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Haslam NR, Bouamra O, Lawrence T, Moran CG, Lockey DJ. Time to definitive care within major trauma networks in England. BJS Open 2020; 4:963-969. [PMID: 32644299 PMCID: PMC7528529 DOI: 10.1002/bjs5.50316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 05/26/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016. METHODS An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death. RESULTS Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001). CONCLUSION Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.
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Affiliation(s)
- N. R. Haslam
- Barts and The London School of Anaesthesia, Barts Health NHS TrustLondonUK
| | - O. Bouamra
- Trauma Research and Audit NetworkUniversity of ManchesterSalfordUK
| | - T. Lawrence
- Trauma Research and Audit NetworkUniversity of ManchesterSalfordUK
| | - C. G. Moran
- Trauma and Orthopaedic SurgeryQueen's Medical CentreNottinghamUK
| | - D. J. Lockey
- Centre for Trauma Sciences, Blizard InstituteQueen Mary University of LondonLondonUK
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2
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Green PA, Wilkinson DJ, Bouamra O, Fragoso M, Farrelly PJ. Variations in the management of adolescents with blunt splenic trauma in England and Wales: are we preserving enough? Ann R Coll Surg Engl 2020; 102:488-492. [PMID: 32326736 DOI: 10.1308/rcsann.2020.0053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Management of blunt splenic injury has changed drastically with non-operative management increasingly used in paediatric and adult patients. Studies from America and Australia demonstrate disparities in care of patients treated at paediatric and adult centres. This study assessed management of splenic injuries in UK adolescents. MATERIALS AND METHODS Data were acquired from the Trauma Audit and Research Network on isolated blunt splenic injuries reported 2006-2015. Adolescents were divided into age groups of 11-15 years and 16-20 years, and injuries classified as minor (grades 1/2) or major (3+). Primary outcomes were needed for splenectomy and blood transfusion. RESULTS A total of 445 adolescents suffered isolated blunt splenic injuries. Road traffic collisions were the most common mechanism. There were no deaths as a result of isolated blunt splenic injuries, but 49 (11%) adolescents needed transfusions and 105 (23.6%) underwent splenectomies. There was no significant difference observed in the management of adolescents with minor trauma. In major trauma, 11-15-year-olds were more likely to have splenectomies when managed at local trauma units compared with major trauma centres (31% vs 4%, odds ratio 11.5; 95% confidence interval 3.82-34.38, p < 0.0001). Within major trauma centres, older adolescents were more likely to have splenectomies than younger adolescents (35.5% vs 3.8%, odds ratio 14; 95% confidence interval 4.55-43.26, p < 0.0001). There were no significant differences in haemodynamic status, transfusion requirement or embolisation rates. CONCLUSIONS There appears to be a large variation in the management of isolated blunt splenic injuries in the UK. The reasons for this remain unclear however non-operative management is safe and should be first line management in the haemodynamically stable adolescent, even with major splenic injuries.
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Affiliation(s)
- P A Green
- Royal Manchester Children's Hospital, Manchester, UK
| | - D J Wilkinson
- Royal Manchester Children's Hospital, Manchester, UK
| | - O Bouamra
- Trauma Audit and Research Network, Salford, UK
| | - M Fragoso
- Trauma Audit and Research Network, Salford, UK
| | - P J Farrelly
- Royal Manchester Children's Hospital, Manchester, UK
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Hepple DJ, Durrand JW, Bouamra O, Godfrey P. Impact of a physician-led pre-hospital critical care team on outcomes after major trauma. Anaesthesia 2018; 74:473-479. [DOI: 10.1111/anae.14501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2018] [Indexed: 01/22/2023]
Affiliation(s)
- D. J. Hepple
- Northern School of Anaesthesia and Intensive Care Medicine; Newcastle UK
| | - J. W. Durrand
- Northern School of Anaesthesia and Intensive Care Medicine; Newcastle UK
| | - O. Bouamra
- The Trauma Audit and Research Network; Faculty of Biology Medicine and Health; The University of Manchester; UK
| | - P. Godfrey
- Department of Anaesthesia; James Cook University Hospital; Middlesbrough UK
- Great North Air Ambulance Service; Darlington UK
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Morrow L, Nutbeam T, Bouamra O. 1 Simultaneous trauma patients in emergency departments: a difference in mortality? J ROY ARMY MED CORPS 2018. [DOI: 10.1136/jramc-2018-000959.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundThe presentation of multiple simultaneous trauma patients to an Emergency Department is likely to place significant stress and strain on trauma care resources. Currently there is limited literature and no UK or multicentre data available to understand this impact. The aim of this study was to identify patient outcomes when there are simultaneous major trauma patients. We hypothesised that with increasing numbers of simultaneous trauma patients an increase in mortality may be seen.MethodsThe Trauma Audit and Research Network (TARN) database was interrogated from 2010–2015 to identify simultaneous major trauma patients. We defined simultaneous trauma as occurring when there was more than one trauma patient within an Emergency Department at any one time.Patient age, sex, Glasgow Coma Scale and Injury Severity Score (ISS) were recorded. A standardised comparison using a stratified Ws statistic was conducted to compare mortality between groups. Secondary outcomes included length of hospital and intensive care (ICU) stay.ResultsOf 2 07 094 patients, 33.7% were eligible simultaneous trauma patients. 55.7% of patients were male, median age was 61 and median ISS was 9. No increase in mortality was seen with increasing patient numbers (table 1).Abstract 1 Table 1 Ws statistic with increasing simultaneous patient numbersIsolated2 patients3 patients4 patients5 patients6+patientsTotal1 37 360 51 466 13 820 3539 671 185 Ws statistic0.05 0.38 0.72 0.53 0.39 2.70 A statistically significant increase in length of ICU stay was observed for the 6+patient category (p=0.047) but no difference was reported in hospital stay.ConclusionThe impact of simultaneous trauma patients on patient outcomes within the UK has not been previously defined. Simultaneous trauma patients do not appear to have an impact on mortality (as measured by Ws statistic).
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Cook A, Osler T, Glance L, Lecky F, Bouamra O, Weddle J, Gross B, Ward J, Moore FO, Rogers F, Hosmer D. Comparison of two prognostic models in trauma outcome. Br J Surg 2018; 105:513-519. [PMID: 29465764 DOI: 10.1002/bjs.10764] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/01/2017] [Accepted: 10/22/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Trauma Audit and Research Network (TARN) in the UK publicly reports hospital performance in the management of trauma. The TARN risk adjustment model uses a fractional polynomial transformation of the Injury Severity Score (ISS) as the measure of anatomical injury severity. The Trauma Mortality Prediction Model (TMPM) is an alternative to ISS; this study compared the anatomical injury components of the TARN model with the TMPM. METHODS Data from the National Trauma Data Bank for 2011-2015 were analysed. Probability of death was estimated for the TARN fractional polynomial transformation of ISS and compared with the TMPM. The coefficients for each model were estimated using 80 per cent of the data set, selected randomly. The remaining 20 per cent of the data were used for model validation. TMPM and TARN were compared using calibration curves, measures of discrimination (area under receiver operating characteristic curves; AUROC), proximity to the true model (Akaike information criterion; AIC) and goodness of model fit (Hosmer-Lemeshow test). RESULTS Some 438 058 patient records were analysed. TMPM demonstrated preferable AUROC (0·882 for TMPM versus 0·845 for TARN), AIC (18 204 versus 21 163) and better fit to the data (32·4 versus 153·0) compared with TARN. CONCLUSION TMPM had greater discrimination, proximity to the true model and goodness-of-fit than the anatomical injury component of TARN. TMPM should be considered for the injury severity measure for the comparative assessment of trauma centres.
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Affiliation(s)
- A Cook
- Department of Surgery, Chandler Regional Medical Center, Chandler, Arizona, USA.,Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - T Osler
- Department of Surgery, University of Vermont, Burlington, Vermont, USA
| | - L Glance
- Department of Anesthesiology, University of Rochester, Rochester, New York, USA
| | - F Lecky
- Department of Emergency Medicine, University of Sheffield, Sheffield, UK
| | - O Bouamra
- Institute of Population Health, University of Manchester, Manchester, UK
| | - J Weddle
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - B Gross
- College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - J Ward
- Department of Surgery, Chandler Regional Medical Center, Chandler, Arizona, USA
| | - F O Moore
- Department of Surgery, Chandler Regional Medical Center, Chandler, Arizona, USA
| | - F Rogers
- Department of Surgery, Lancaster General Hospital, Lancaster, Pennsylvania, USA
| | - D Hosmer
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts, USA
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Talbot C, Davis N, Majid I, Young M, Bouamra O, Lecky FE, Jones S. Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks. Bone Joint J 2018; 100-B:109-118. [PMID: 29305459 DOI: 10.1302/0301-620x.100b1.bjj-2016-1315.r3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.
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Affiliation(s)
- C Talbot
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - N Davis
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - I Majid
- Royal Manchester Children's Hospital
| | - M Young
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - O Bouamra
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - F E Lecky
- University of Sheffield, School of Health and Related Research, Western Bank, Sheffield S10 2TN, UK
| | - S Jones
- Royal Manchester Children's Hospital
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Herron J, Hutchinson R, Lecky F, Bouamra O, Edwards A, Woodford M, Eardley WGP. The impact of age on major orthopaedic trauma: an analysis of the United Kingdom Trauma Audit Research Network database. Bone Joint J 2017; 99-B:1677-1680. [PMID: 29212692 DOI: 10.1302/0301-620x.99b12.bjj-2016-1140.r2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 06/26/2017] [Indexed: 11/05/2022]
Abstract
AIMS To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries. PATIENTS AND METHODS The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients. RESULTS Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures. CONCLUSION Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. Cite this article: Bone Joint J 2017;99-B:1677-80.
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Affiliation(s)
- J Herron
- James Cook University Hospital, Middlesbrough TS4 3BW, UK
| | - R Hutchinson
- James Cook University Hospital, Middlesbrough TS4 3BW, UK
| | - F Lecky
- Trauma Audit Research Network, University of Manchester, Salford Royal Hospital, Salford, UK and Centre for Urgent and Emergency Care Research and (CURE), School of Health and Related Research and University of Sheffield, UK
| | - O Bouamra
- University of Manchester, Hope Hospital, Salford, UK
| | - A Edwards
- University of Manchester, Hope Hospital, Salford, UK
| | - M Woodford
- University of Manchester, Hope Hospital, Salford, UK
| | - W G P Eardley
- University of York Seebohm Rowntree Building, York, YO10 5DD, UK
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Barrie J, Jamdar S, Iniguez MF, Bouamra O, Jenks T, Lecky F, O'Reilly DA. Improved outcomes for hepatic trauma in England and Wales over a decade of trauma and hepatobiliary surgery centralisation. Eur J Trauma Emerg Surg 2017; 44:63-70. [PMID: 28204851 PMCID: PMC5808051 DOI: 10.1007/s00068-017-0765-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/20/2017] [Indexed: 11/30/2022]
Abstract
Background Over the last decade trauma services have undergone a reconfiguration in England and Wales. The objective is to describe the epidemiology, management and outcomes for liver trauma over this period and examine factors predicting survival. Methods Patients sustaining hepatic trauma were identified using the Trauma Audit and Research Network database. Demographics, management and outcomes were assessed between January 2005 and December 2014 and analysed over five, 2-year study periods. Independent predictor variables for the outcome of liver trauma were analysed using multiple logistic regression. Results 4368 Patients sustained hepatic trauma (with known outcome) between January 2005 and December 2014. Median age was 34 years (interquartile range 23–49). 81% were due to blunt and 19% to penetrating trauma. Road traffic collisions were the main mechanism of injury (58.2%). 241 patients (5.5%) underwent liver-specific surgery. The overall 30-day mortality rate was 16.4%. Improvements were seen in early consultant input, frequency and timing of computed tomography (CT) scanning, use of tranexamic acid and 30-day mortality over the five time periods. Being treated in a unit with an on-site HPB service increased the odds of survival (odds ratio 3.5, 95% confidence intervals 2.7–4.5). Conclusions Our study has shown that being treated in a unit with an on-site HPB service increased the odds of survival. Further evaluation of the benefits of trauma and HPB surgery centralisation is warranted.
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Affiliation(s)
- J Barrie
- Department of Hepato-pancreatobiliary Surgery, Manchester Royal Infirmary, Central Manchester Foundation Trust, Oxford Rd, Manchester, M13 9WL, UK
| | - S Jamdar
- Department of Hepato-pancreatobiliary Surgery, Manchester Royal Infirmary, Central Manchester Foundation Trust, Oxford Rd, Manchester, M13 9WL, UK
| | - M F Iniguez
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK
| | - O Bouamra
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK
| | - T Jenks
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK
| | - F Lecky
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK.,EMRiS Group, HSR Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - D A O'Reilly
- Department of Hepato-pancreatobiliary Surgery, Manchester Royal Infirmary, Central Manchester Foundation Trust, Oxford Rd, Manchester, M13 9WL, UK. .,School of Medical Sciences, The University of Manchester, Manchester, UK.
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Metcalfe D, Perry DC, Bouamra O, Salim A, Woodford M, Edwards A, Lecky FE, Costa ML. Regionalisation of trauma care in England. Bone Joint J 2017; 98-B:1253-61. [PMID: 27587529 DOI: 10.1302/0301-620x.98b9.37525] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 05/09/2016] [Indexed: 02/03/2023]
Abstract
AIMS We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England. PATIENTS AND METHODS An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital. RESULTS AND CONCLUSION A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.
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Affiliation(s)
- D Metcalfe
- University of Oxford, NDORMS, Oxford, OX3 7HE, UK
| | - D C Perry
- University of Liverpool, Liverpool, Institute of Translational Medicine, Liverpool, L12 2AP, UK
| | - O Bouamra
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester, M6 8HD, UK
| | - A Salim
- Harvard Medical School, Center for Surgery and Public Health, Boston, MA 02115, USA
| | - M Woodford
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester, M6 8HD, UK
| | - A Edwards
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester, M6 8HD, UK
| | - F E Lecky
- University of Sheffield, School of Health and Related Research, Sheffield, S1 4DA, UK
| | - M L Costa
- University of Oxford, NDORMS, Oxford, OX3 7HE, UK
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Yiannoullou P, Hall C, Newton K, Pearce L, Bouamra O, Jenks T, Scrimshire AB, Hughes J, Lecky F, Macdonald A. A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes? Ann R Coll Surg Engl 2017; 99:63-69. [PMID: 27791418 PMCID: PMC5392813 DOI: 10.1308/rcsann.2016.0325] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2016] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION The spleen remains one of the most frequently injured organs following blunt abdominal trauma. In 2012, regional trauma networks were launched across England and Wales with the aim of improving outcomes following trauma. This retrospective cohort study investigated the management and outcomes of blunt splenic injuries before and after the establishment of regional trauma networks. METHODS A dataset was drawn from the Trauma Audit Research Network database of all splenic injuries admitted to English and Welsh hospitals from 1 April 2010 to 31 March 2014. Demographic data, injury severity, treatment modalities and outcomes were collected. Management and outcomes were compared before and after the launch of regional trauma networks. RESULTS There were 1457 blunt splenic injuries: 575 between 2010 and 2012 and 882 in 2012-14. Following the introduction of the regional trauma networks, use of splenic artery embolotherapy increased from 3.5% to 7.6% (P = 0.001) and splenectomy rates decreased from 20% to 14.85% (P = 0.012). Significantly more patients with polytrauma and blunt splenic injury were treated with splenic embolotherapy following 2012 (61.2% vs. 30%, P < 0.0001). Increasing age, injury severity score, polytrauma and Charlson Comorbidity Index above 10 were predictors of increased mortality (P < 0.001). Increasing systolic blood pressure (odds ratio, OR, 0.757, 95% confidence interval, CI, 0.716-0.8) and Glasgow Coma Scale (OR 0.988, 95% CI 0.982-0.995) were protective. CONCLUSIONS This study demonstrates a reduction in splenectomy rate and an increased use of splenic artery embolotherapy since the introduction of the regional trauma networks. This may have resulted from improved access to specialist services and reduced practice variation since the establishment of these networks.
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Affiliation(s)
- P Yiannoullou
- Department of General Surgery, Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK
- North West Research Collaborative , Manchester , UK
| | - C Hall
- Department of General Surgery, Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK
- North West Research Collaborative , Manchester , UK
| | - K Newton
- Department of General Surgery, Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK
- North West Research Collaborative , Manchester , UK
| | - L Pearce
- Department of General Surgery, Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK
- North West Research Collaborative , Manchester , UK
| | - O Bouamra
- Trauma Audit Research Network, Salford Royal NHS Foundation Trust, University of Manchester , Manchester , UK
| | - T Jenks
- Trauma Audit Research Network, Salford Royal NHS Foundation Trust, University of Manchester , Manchester , UK
| | | | - J Hughes
- Department of General Surgery, Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK
- North West Research Collaborative , Manchester , UK
| | - F Lecky
- Trauma Audit Research Network, Salford Royal NHS Foundation Trust, University of Manchester , Manchester , UK
- Emergency Medicine Research in Sheffield Group, Health Services Research Section, School of Health and Related Research, University of Sheffield , Manchester , UK
| | - Adh Macdonald
- North West Research Collaborative , Manchester , UK
- Department of General Surgery, University Hospital South Manchester , Manchester , UK
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Mynors-Wallis D, Lecky F, Bouamra O, Burke D. PAEDIATRIC OUT-OF-HOSPITAL TRAUMATIC CARDIAC ARREST: A REVIEW OF THE PS14 SURVIVAL PREDICTION MODEL. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206402.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
OBJECTIVES To provide a comprehensive assessment of the management of traumatic brain injury (TBI) relating to epidemiology, complications and standardised mortality across specialist units. DESIGN The Trauma Audit and Research Network collects data prospectively on patients suffering trauma across England and Wales. We analysed all data collected on patients with TBI between April 2014 and June 2015. SETTING Data were collected on patients presenting to emergency departments across 187 hospitals including 26 with specialist neurosurgical services, incorporating factors previously identified in the Ps14 multivariate logistic regression (Ps14n) model multivariate TBI outcome prediction model. The frequency and timing of secondary transfer to neurosurgical centres was assessed. RESULTS We identified 15 820 patients with TBI presenting to neurosurgical centres directly (6258), transferred from a district hospital to a neurosurgical centre (3682) and remaining in a district general hospital (5880). The commonest mechanisms of injury were falls in the elderly and road traffic collisions in the young, which were more likely to present in coma. In severe TBI (Glasgow Coma Score (GCS) ≤8), the median time from admission to imaging with CT scan is 0.5 hours. Median time to craniotomy from admission is 2.6 hours and median time to intracranial pressure monitoring is 3 hours. The most frequently documented complication of severe TBI is bronchopneumonia in 5% of patients. Risk-adjusted W scores derived from the Ps14n model indicate that no neurosurgical unit fell outside the 3 SD limits on a funnel plot. CONCLUSIONS We provide the first comprehensive report of the management of TBI in England and Wales, including data from all neurosurgical units. These data provide transparency and suggests equity of access to high-quality TBI management provided in England and Wales.
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Affiliation(s)
- T Lawrence
- Trauma Audit and Research Network, Manchester Medical Academic Health Sciences Centre, Institute of Population Health, University of Manchester, Salford Royal Hospital, Salford, UK
| | - A Helmy
- Division of Neurosurgery, Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - O Bouamra
- Trauma Audit and Research Network, Manchester Medical Academic Health Sciences Centre, Institute of Population Health, University of Manchester, Salford Royal Hospital, Salford, UK
| | - M Woodford
- Trauma Audit and Research Network, Manchester Medical Academic Health Sciences Centre, Institute of Population Health, University of Manchester, Salford Royal Hospital, Salford, UK
| | - F Lecky
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - P J Hutchinson
- Division of Neurosurgery, Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
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Kehoe A, Smith JE, Bouamra O, Edwards A, Yates D, Lecky F. Older patients with traumatic brain injury present with a higher GCS score than younger patients for a given severity of injury. Emerg Med J 2016; 33:381-5. [DOI: 10.1136/emermed-2015-205180] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/29/2015] [Indexed: 11/03/2022]
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Hunt P, Bouamra O, Jenks T, Lecky FE, Edwards A, Woodford M, Yates D, Han K. EARLY WHOLE BODY VERSUS FOCUSED COMPUTED TOMOGRAPHY IMAGING FOLLOWING MAJOR TRAUMA: EXISTING EVIDENCE AND ANALYSIS OF 10 YEARS OF TARN DATA. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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O’Reilly DA, Bouamra O, Kausar A, Dickson EJ, Lecky F. The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989-2013. Ann R Coll Surg Engl 2015; 97:125-30. [PMID: 25723689 PMCID: PMC4473389 DOI: 10.1308/003588414x14055925060712] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2014] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989-2013. METHODS The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both. RESULTS Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14-35) for blunt trauma and 14 (IQR: 9-18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation. CONCLUSIONS Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.
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Affiliation(s)
- DA O’Reilly
- Department of HPB Surgery, North Manchester General Hospital, Manchester, UK
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - O Bouamra
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- EMRiS, Health Service Research, School of Health and Related Research, University of Sheffield
| | - A Kausar
- Department of HPB Surgery, North Manchester General Hospital, Manchester, UK
| | - EJ Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, UK
| | - F Lecky
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- EMRiS, Health Service Research, School of Health and Related Research, University of Sheffield
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Metcalfe D, Bouamra O, Parsons NR, Aletrari MO, Lecky FE, Costa ML. Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres. Br J Surg 2014; 101:959-64. [PMID: 24915789 DOI: 10.1002/bjs.9498] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Centralization of complex healthcare services into specialist high-volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients. METHODS A retrospective before-after study was undertaken of severely injured patients attending four hospitals that became major trauma centres (MTCs) in March 2012. Consecutive patients with major trauma were identified from a national registry and divided into two groups according to injury before or after the launch of a new trauma network. The two cohorts were compared for differences in case mix, demand on hospital resources, and outcomes. RESULTS Patient volume increased from 442 to 1326 (200 per cent), operations from 349 to 1231 (253 per cent), critical care bed-days from 1100 to 3704 (237 per cent), and total hospital bed-days from 7910 to 22,772 (188 per cent). Patient age increased on MTC designation from 45.0 years before March 2012 to 48.2 years afterwards (P = 0.021), as did the proportion of penetrating injuries (1.8 versus 4.1 per cent; P = 0.025). Injury severity fell as measured by median Injury Severity Score (16 versus 14) and Revised Trauma Score (4.1 versus 7.8). Fewer patients required secondary transfer to a MTC from peripheral hospitals (19.9 versus 16.1 per cent; P = 0.100). There were no significant differences in total duration of hospital stay, critical care requirements or mortality. However, there was a significant increase, from 55.5 to 62.3 per cent (P < 0.001), in the proportion of patients coded as having a 'good recovery' at discharge after institution of the trauma network. CONCLUSION MTC designation leads to an increased case volume with considerable implications for operating theatre capacity and bed occupancy. Although no mortality benefit was demonstrated within 6 months of establishing this trauma network, early detectable advantages included improved functional outcome at discharge.
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Affiliation(s)
- D Metcalfe
- Warwick Medical School, University of Warwick, Coventry, UK; College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Lyttle MD, Ardolino A, Berry K, Bouamra O, Cheung R, Lawrence T, Lecky F, Maconochie IK. USING EXISTING PAEDIATRIC PRE-HOSPITAL TRAUMA TRIAGE TOOLS TO IDENTIFY CHILDREN WITH SEVERE TRAUMATIC BRAIN INJURY–AN ANALYSIS OF NATIONAL TRAUMA REGISTRY DATA. Arch Emerg Med 2013. [DOI: 10.1136/emermed-2013-203113.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cheung R, Ardolino A, Lawrence T, Bouamra O, Lecky FE, Berry K, Chaudhury A, Issa S, Koralage N, Lyttle MD, Maconochie IK. THE ACCURACY OF EXISTING PRE-HOSPITAL TRIAGE TOOLS FOR INJURED CHILDREN IN ENGLAND–AN ANALYSIS USING TRAUMA REGISTRY AND EMERGENCY DEPARTMENT DATA. Arch Emerg Med 2013. [DOI: 10.1136/emermed-2013-203113.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hunt PA, Lecky F, Bouamra O. Whole body computed tomography scanning for severe blunt polytrauma: analysis of Trauma Audit and Research Network database 2005 to 2010. Crit Care 2012. [PMCID: PMC3363875 DOI: 10.1186/cc11064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Fuller G, Lecky F, Woodford M, Bouamra O, Jenks T, Coats T, Hutchinson P. 015 Temporal trends in head injury outcomes from 2003 to 2010 in England and Wales, and the effect of specialist neurosciences care: a Cohort Study. Arch Emerg Med 2011. [DOI: 10.1136/emermed-2011-200617.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Fuller G, Bouamra O, Woodford M, Jenks T, Patel H, Coats TJ, Oakley P, Mendelow A, Pigott T, Hutchinson PJ, Lecky F. Temporal trends in head injury outcomes from 2003 to 2009 in England and Wales. Br J Neurosurg 2011; 25:414-21. [DOI: 10.3109/02688697.2011.570882] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gabbe BJ, Lyons RA, Lecky FE, Bouamra O, Woodford M, Coats TJ, Cameron PA. Comparison of mortality following hospitalisation for isolated head injury in the UK and Victoria, Australia. Inj Prev 2010. [DOI: 10.1136/ip.2010.029215.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Davenport RA, Tai N, West A, Bouamra O, Aylwin C, Woodford M, McGinley A, Lecky F, Walsh MS, Brohi K. A major trauma centre is a specialty hospital not a hospital of specialties. Br J Surg 2009; 97:109-17. [PMID: 20013932 DOI: 10.1002/bjs.6806] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND High estimates of preventable death rates have renewed the impetus for national regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance improvement programme was hypothesized to have resulted in improved outcomes for severely injured patients. METHODS This was a comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma Audit and Research Network (England and Wales), 2000-2005. Preventable mortality was evaluated by prospective analysis of the RLH performance improvement programme. RESULTS Mortality from critical injury at the RLH was 48 per cent lower in 2005 than 2000 (17.9 versus 34.2 per cent; P = 0.001). Overall mortality rates were unchanged for acute hospitals (4.3 versus 4.4 per cent) and other multispecialty hospitals (8.7 versus 7.3 per cent). Secondary transfer mortality in critically injured patients was 53 per cent lower in the regional network than the national average (5.2 versus 11.0 per cent; P = 0.001). Preventable death rates fell from 9 to 2 per cent (P = 0.040) and significant gains were made in critical care and ward bed utilization. CONCLUSION Institution of a specialist trauma service and performance improvement programme was associated with significant improvements in outcomes that exceeded national variations.
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Affiliation(s)
- R A Davenport
- Trauma Clinical Academic Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Royal London Hospital, London, UK
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Loizou E, Bouamra O, Dark P, Lecky F. Comparing the initial cardiovascular response in injured children with and without traumatic brain injury. Arch Emerg Med 2009; 26 Suppl 1:1-35. [DOI: 10.1136/emj.2009.082081a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
OBJECTIVE Trauma accounts for a large proportion of childhood deaths. No data exist about injury patterns within paediatric trauma in the UK. Identification of specific high-risk injury patterns may lead to improved care and outcome. METHODS Data from 24 218 paediatric trauma cases recorded by the Trauma Audit and Research Network (TARN) from 1990 to 2005 were analysed. Main injury, injury patterns and outcome were analysed. Mortality at 93 days' post-injury was the major outcome measure. RESULTS Limb injuries occurred in 65.0% of patients. In infants 81.4% of head injuries were isolated, compared with 46.5% in 11-15-year-old children. Thoracic injuries were associated with other injuries in 68.4%. The overall mortality rate was 3.7% (n = 893). Mortality decreased from 4.2% to 3.1%; this was most evident in non-isolated head injuries. It was low in isolated injuries: 1.5% (n = 293). In children aged 1-15 years the highest mortalities occurred in multiple injuries including head/thoracic (47.7%) and head/abdominal injuries (49.9%). Having a Glasgow Coma Scale of <15 on presentation to hospital was associated with a mortality of 16%. CONCLUSIONS Differences in injury patterns and mortality exist between different age groups and high-risk injury patterns can be identified. With increasing age, a decline in the proportion of children with head injury and an increase in the proportion with limb injury were observed. This information is useful for directing ongoing care of severely injured children. Future analyses of the TARN database may help to evaluate the management of high-risk children and to identify the most effective care.
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Affiliation(s)
- J Bayreuther
- Paediatric A+E, Fulham Road, Chelsea and Westminster Hospital, London, UK.
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Guly HR, Bouamra O, Lecky FE. The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department. Resuscitation 2008; 76:57-62. [PMID: 17688997 DOI: 10.1016/j.resuscitation.2007.06.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 06/05/2007] [Accepted: 06/11/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) is recognised to cause hypotension and bradycardia (neurogenic shock). Previous studies have shown that the incidence of this in the emergency department (ED) may be low. However these studies are relatively small and have included a mix of blunt and penetrating injuries with measurements taken over different time frames. The aim was to use a large database to determine the incidence of neurogenic shock in patients with isolated spinal cord injuries. METHODS The Trauma Audit and Research Network (TARN) collects data on patients attending participating hospitals in England and Wales. The database between 1989 and 2003 was searched for patients aged over 16 who had sustained an isolated spinal cord injury. The heart rate (HR) and systolic blood pressure (SBP) on arrival at the ED were determined as was the number and percentage of patients who had both a SBP<100mm Hg and a HR<80 beats per minute (BPM) (the classic appearance of neurogenic shock). RESULTS Four hundred and ninety patients had sustained an isolated spinal cord injury (SCI) with no other injury with an abbreviated injury scale (AIS) of greater than 2. The incidence of neurogenic shock in cervical cord injuries was 19.3% (95% CI 14.8-23.7%). The incidence in thoracic and lumbar cord injuries was 7% (3-11.1%) and 3% (0-8.85%). CONCLUSIONS Fewer than 20% of patients with a cervical cord injury have the classical appearance of neurogenic shock when they arrive in the emergency department. It is uncommon in patients with lower cord injuries. The heart rate and blood pressure changes in patients with a SCI may develop over time and we hypothesise that patients arrive in the ED before neurogenic shock has become manifest.
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Affiliation(s)
- H R Guly
- Derriford Hospital, Plymouth, PL6 8DH, UK.
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Abstract
AIM To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures. METHODS A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39,073 patients with major trauma. RESULTS Of the 39,073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs). CONCLUSION The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.
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Affiliation(s)
- C M Guly
- Taunton and Somerset NHS Trust, Taunton, UK.
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Abstract
OBJECTIVE To determine whether being admitted with major trauma to an emergency department outside rather than within working hours results in an adverse outcome. METHODS The data were collected from hospitals in England and Wales participating in the Trauma Audit and Research Network (TARN). Data from the TARN database were used. Admission time and discharge status were cross matched, and this was repeated while controlling for Injury Severity Score (ISS) values. Logistic regression was carried out, calculating the effects of Revised Trauma Score (RTS), ISS, age, and time of admission on outcome from major trauma. This allowed observed versus expected mortality rates (Ws) scores to be compared within and outside working hours. As much of the RTS data were missing, this was repeated using the Glasgow Coma Score instead of RTS. RESULTS In total, 5.2% of people admitted "out of hours" died, compared with 5.3% of people within working hours, and 12.2% of people admitted outside working hours had an ISS score greater than 15, compared with 10.1% admitted within working hours. Outcome in cases with comparable ISS values were very similar (31.1% of cases with ISS >15 died out of hours, compared with 33.5% inside working hours.) The subgroup of data with missing RTS values had a significantly increased risk of death. Therefore, GCS was used to calculate severity adjusted odds of death instead of RTS. However, with either model, Ws scores were identical (both 0%) within and outside working hours. CONCLUSIONS Out of hours admission does not in itself have an adverse effect on outcome from major trauma.
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Affiliation(s)
- H R Guly
- Derriford Hospital, Plymouth, Cornwall, UK.
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Hassan Z, Smith M, Littlewood S, Bouamra O, Hughes D, Biggin C, Amos K, Mendelow AD, Lecky F. Head injuries: a study evaluating the impact of the NICE head injury guidelines. Emerg Med J 2006; 22:845-9. [PMID: 16299190 PMCID: PMC1726640 DOI: 10.1136/emj.2004.021717] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The NICE head injury guidelines recommend a different approach in the management of head injury patients. It suggests that CT head scan should replace skull x ray (SXR) and observation/admission as the first investigation. We wished to determine the impact of NICE on SXR, CT scan, and admission on all patients with head injury presenting to the ED setting and estimate the cost effectiveness of these guidelines, which has not been quantified to date. DESIGN Study of head injury patients presenting to two EDs before and after implementation of NICE guidelines METHODS The rate of SXR, CT scan, and admission were determined six months before and one month after NICE implementation in both centres. The before study also looked at predicted rates had NICE been applied. This enabled predicted and actual cost effectiveness to be determined. RESULT 1130 patients with head injury were studied in four 1 month periods (two in each centre). At the teaching hospital, the CT head scan rate more than doubled (3% to 7%), the SXR declined (37% to 4%), while the admission rate more than halved (9% to 4%). This represented a saving of 3381 pounds sterling per 100 head injury PATIENTS greater than predicted with no adverse events. At the District General Hospital, the CT head scan rate more than quadrupled (1.4% to 9%), the SXR dropped (19 to 0.57%), while the admission rate declined (7% to 5%). This represented a saving of 290 pounds sterling per 100 head injury patients: less than predicted. CONCLUSION The implementation of the NICE guidelines led to a two to fivefold increase in the CT head scan rate depending on the cases and baseline departmental practice. However, the reduction in SXR and admission appears to more than offset these costs without compromising patient outcomes.
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MESH Headings
- Adolescent
- Adult
- Child
- Cost-Benefit Analysis
- Craniocerebral Trauma/diagnostic imaging
- Craniocerebral Trauma/economics
- Emergency Service, Hospital/economics
- Emergency Service, Hospital/standards
- England
- Female
- Guideline Adherence
- Health Services Research
- Hospitalization/statistics & numerical data
- Hospitals, District/economics
- Hospitals, District/standards
- Hospitals, General/economics
- Hospitals, General/standards
- Hospitals, Teaching/economics
- Hospitals, Teaching/standards
- Humans
- Male
- Outcome Assessment, Health Care
- Practice Guidelines as Topic
- Tomography, X-Ray Computed/economics
- Tomography, X-Ray Computed/statistics & numerical data
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Affiliation(s)
- Z Hassan
- Emergency Medicine, Hope Hospital Salford,Urmston, Manchester.
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Abstract
BACKGROUND Case fatality rates after all types of blunt injury have not improved since 1994 in England and Wales, possibly because not all patients with severe head injury are treated in a neurosurgical centre. Our aims were to investigate the case fatality trends in major trauma patients with and without head injury, and to establish the effect of neurosurgical care on mortality after severe head injury. METHODS We analysed prospectively collected data from the Trauma Audit and Research Network database for patients presenting between 1989 and 2003. Mortality and odds of death adjusted for case mix were compared for patients with and without head injury, and for those treated in a neurosurgical versus a non-neurosurgical centre. FINDINGS Patients with head injury (n=22,216) had a ten-fold higher mortality and showed less improvement in the adjusted odds of death since 1989 than did patients without head injury (n=154,231). 2305 (33%) of patients with severe head injury (presenting between 1996 and 2003) were treated only in non-neurosurgical centres; such treatment was associated with a 26% increase in mortality and a 2.15-fold increase (95% CI 1.77-2.60) in the odds of death adjusted for case mix compared with patients treated at a neurosurgical centre. INTERPRETATION Since 1989 trauma system changes in England and Wales have delivered greater benefit to patients without head injury. Our data lend support to current guidelines, suggesting that treatment in a neurosurgical centre represents an important strategy in the management of severe head injury.
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Affiliation(s)
- H C Patel
- Department of Neurosurgery, Hope Hospital, Salford, UK
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Buishi IE, Njoroge EM, Bouamra O, Craig PS. Canine echinococcosis in northwest Libya: assessment of coproantigen ELISA, and a survey of infection with analysis of risk-factors. Vet Parasitol 2005; 130:223-32. [PMID: 15905032 DOI: 10.1016/j.vetpar.2005.03.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Revised: 03/10/2005] [Accepted: 03/10/2005] [Indexed: 12/22/2022]
Abstract
In order to determine the prevalence and risk factors for canine echinococcosis in different endemic localities in the Tripoli area of northwest Libya, stray dogs were examined post-mortem, and owned dogs screened for Echinococcus granulosus infection using a standardised genus specific coproantigen ELISA. The prevalence of E. granulosus infection at necropsy in stray-dogs was 25.8% (15/58, 95% CI 15.3-39.0%), and 21.6% (72/334, 95% CI 17.3-26.4%) of owned dogs tested were positive by coproantigen ELISA. Sheepdogs appeared to have a significantly higher copro-positive prevalence (19/19 positive, p=0.003), compared to 23.6% of other dog classes (e.g. 52/220 guard dogs and household pets). Worm burdens in necropsied dogs ranged from 29 to 2900 (mean 1064) and were positively correlated to coproantigen ELISA OD values (r(s)=0.87, p<0.001), but negatively correlated with dog age (r(s)=-0.69, p=0.001). Dog age was a significant factor in copro-prevalence as there was an increasing coproantigen-positive tendency in younger dogs (< or =5 years, p=0.04). A total of 45/132 (34%, 95% CI 25.9-42.1%) of farms/homestead had at least one dog that was coproantigen positive. Overall copro-prevalence in dogs by locality varied, with Alkhums (Leptis-Magna) district having the highest copro-prevalence at 38.7% (24/62, 95% CI 26.6-50.8%) (p=0.001). Coproantigen testing of a cohort of owned dogs before and approximately 15 months after praziquantel treatment showed a significant decrease in the coproantigen positive rate from 21.6% (72/334) to 9% (21/233) post-treatment. The overall E. granulosus coproantigen positive rate ('re-infection rate') within the same cohort of dogs was 22 % (10/45) by 15 months post-treatment. Significant risk factors for a copro-positive owned dog were associated with non-restraint of dogs, and owners that did not de-worm their dogs. Home slaughtering of livestock and lack of knowledge about E. granulosus transmission were also significant risk factors for a canine coproantigen positive result.
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Affiliation(s)
- I E Buishi
- Cestode Zoonoses Research Group, Bioscience Research Institute and School of Environment and Life Sciences, University of Salford, Greater Manchester M5 4WT, UK.
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Abstract
UNLABELLED To demonstrate trends in trauma care in England and Wales from 1989 to 2000. STUDY POPULATION Database of the Trauma Audit and Research Network that includes hospital patients admitted for three days or more, those who died, were transferred or admitted to an intensive care or high dependency area. METHOD To demonstrate trends in outcome, severity adjusted odds of death per year of admission to hospital were calculated for all hospitals (n=99) and 20 hospitals who had participated since 1989 (adjustments are for Injury Severity Score, age, and Revised Trauma Score). The grade of doctor initially seeing the injured patient in accident and emergency and median prehospital times per year of admission were calculated to demonstrate trends in the process of care. Trend analyses were carried out using simple linear regression (odds ratio versus year). RESULTS The analysis shows a significant reduction in the severity adjusted odds of death of 3% per year over the 1989-2000 time period (p=0.001). During the period 1989-1994 the odds of death declined most steeply (on average 6% per year p=0.004). Between 1994 to 2000 no significant change occurred (p=0.35). This pattern was mirrored by the 20 permanent members where the odds of death also declined more steeply over the 1989-1994 period. The percentage of severely injured patients (ISS >15) seen by a consultant increased from 29 to 40 from 1989-1994 but has remained static subsequently. Median prehospital times for severely injured patients have not changed significantly since 1994 (51 to 45 minutes). CONCLUSION Most of the case fatality reduction for trauma patients reaching hospital over the 1989-2000 time period occurred before 1995 when there was most marked change in the initial care of severely injured patients.
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Affiliation(s)
- F E Lecky
- Trauma Audit and Research Network, University of Manchester, Salford, Manchester, UK.
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