Implementation of supplemental physiotherapy following hip fracture surgery: a protocol for the process evaluation of a randomised controlled trial

BACKGROUND

Patient outcomes following low-trauma hip fracture are suboptimal resulting in increased healthcare costs and poor functional outcomes at 1 year. Providing early and intensive in-hospital physiotherapy could help improve patient outcomes and reduce costs following hip fracture surgery. The HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER) trial will compare usual care physiotherapy to intensive in-hospital physiotherapy for patients following hip fracture surgery. The complex environments in which the intervention is implemented present unique contextual challenges that may impact intervention effectiveness. This study aims to complete a process evaluation to identify barriers and facilitators to implementation and explore the patient, carer and clinician experience of intensive therapy following hip fracture surgery.

METHODS AND ANALYSIS

The process evaluation is embedded within a two-arm randomised, controlled, assessor-blinded trial recruiting 620 participants from eight Australian hospitals who have had surgery for a hip fracture sustained via a low-trauma injury. A theory-based mixed method process evaluation will be completed in tandem with the HIPSTER trial. Patient and carer semi-structured interviews will be completed at 6 weeks following hip fracture surgery. The clinician experience will be explored through online surveys completed pre- and post-implementation of intensive therapy and mapped to domains of the Theoretical Domains Framework (TDF). Translation and behaviour change success will be assessed using the Reach Effectiveness-Adoption Implementation Maintenance (RE-AIM) framework and a combination of qualitative and quantitative data collection methods. These data will assist with the development of an Implementation Toolkit aiding future translation into practice.

DISCUSSION

The embedded process evaluation will help understand the interplay between the implementation context and the intensive therapy intervention following surgery for low-trauma hip fracture. Understanding these mechanisms, if effective, will assist with transferability into other contexts and wider translation into practice.

TRIAL REGISTRATION

ACTRN 12622001442796.

Follow-up after major traumatic injury: a survey of services in Australian and New Zealand public hospitals

BACKGROUND

Increased survival from traumatic injury has led to a higher demand for follow-up care when patients are discharged from hospital. It is currently unclear how follow-up care following major trauma is provided to patients, and how, when, and to whom follow-up services are delivered. The aim of this study was to describe the current follow-up care provided to patients and their families who have experienced major traumatic injury in Australia and New Zealand (ANZ).

METHODS

Informed by Donabedian's 'Evaluating the Quality of Medical Care' model and the Institute of Medicine's Six Domains of Healthcare Quality, a cross-sectional online survey was developed in conjunction with trauma experts. Their responses informed the final survey which was distributed to key personnel in 71 hospitals in Australia and New Zealand that (i) delivered trauma care to patients, (ii) provided data to the Australasian Trauma Registry, or (iii) were a Trauma Centre.

RESULTS

Data were received from 38/71 (53.5%) hospitals. Most were Level 1 trauma centres (n = 23, 60.5%); 76% (n = 16) follow-up services were permanently funded. Follow-up services were led by a range of health professionals with over 60% (n = 19) identifying as trauma specialists. Patient inclusion criteria varied; only one service allowed self-referral (3.3%). Follow-up was within two weeks of acute care discharge in 53% (n = 16) of services. Care activities focused on physical health; psychosocial assessments were the least common. Most services provided care for adults and paediatric trauma (60.5%, n = 23); no service incorporated follow-up for family members. Evaluation of follow-up care was largely as part of a health service initiative; only three sites stated evaluation was specific to trauma follow-up.

CONCLUSION

Follow-up care is provided by trauma specialists and predominantly focuses on the physical health of the patients affected by major traumatic injury. Variations exist in terms of patient selection, reason for follow-up and care activities delivered with gaps in the provision of psychosocial and family health services identified. Currently, evaluation of trauma follow-up care is limited, indicating a need for further development to ensure that the care delivered is safe, effective and beneficial to patients, families and healthcare organisations.

Review article: Pre-hospital trauma guidelines and access to lifesaving interventions in Australia and Aotearoa/New Zealand

The centralisation of trauma services in western countries has led to an improvement in patient outcomes. Effective trauma systems include a pre-hospital trauma system. Delivery of high-level pre-hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs) and timely transport to definitive care. Globally, many nations endorse nationwide pre-hospital major trauma triage guidelines, to ensure a universal approach to patient care. This paper examined clinical guidelines from all 10 EMS in Australia and Aotearoa/New Zealand. All relevant trauma guidelines were included, and key information was extracted. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care. The identification of major trauma patients varied between all 10 EMS, with no universal criteria. The most common approach to trauma triage included a three-step assessment process: physiological criteria, identified injuries and mechanism of injury. Disparity between physiological criteria, injuries and mechanism was found when comparing guidelines. All 10 EMS had fundamental LSI included in their trauma guidelines. Fundamental LSI included haemorrhage control (arterial tourniquets, pelvic binders), non-invasive airway management (face mask ventilation, supraglottic airway devices) and pleural wall needle decompression. Variation in more advanced LSI was evident between EMS. Optimising trauma triage guidelines is an important aspect of a robust and evidence driven trauma system. The lack of consensus in trauma triage identified in the present study makes benchmarking and comparison of trauma systems difficult.

Social determinants of health and disparities in pediatric trauma care: protocol for a systematic review and meta-analysis

BACKGROUND

Social determinants of health (SDH), including "the conditions in which individuals are born, grow, work, live and age" affect child health and well-being. Several studies have synthesized evidence about the influence of SDH on childhood injury risks and outcomes. However, there is no systematic evidence about the impact of SDH on accessing care and quality of care once a child has suffered an injury. We aim to evaluate the extent to which access to care and quality of care after injury are affected by children and adolescents' SDH.

METHODS

Using Cochrane methodology, we will conduct a systematic review including observational and experimental studies evaluating the association between social/material elements contributing to health disparities, using the PROGRESS-Plus framework: place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital and care received by children and adolescents (≤ 19 years of age) after injury. We will consult published literature using PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, and Academic Search Premier and grey literature using Google Scholar from their inception to a maximum of 6 months prior to submission for publication. Two reviewers will independently perform study selection, data extraction, and risk of bias assessment for included studies. The risk of bias will be assessed using the ROBINS-E and ROB-2 tools respectively for observational and experimental study designs. We will analyze data to perform narrative syntheses, and if enough studies are identified, we will conduct a meta-analysis using random effects models.

DISCUSSION

This systematic review will provide a synthesis of evidence on the association between SDH and pediatric trauma care (access to care and quality of care) that clinicians and policymakers can use to better tailor care systems and promote equitable access and quality of care for all children. We will share our findings through clinical rounds, conferences, and publication in a peer-reviewed journal.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023408467.

A scoping review of models of care for the management of older trauma patients

INTRODUCTION

The number of older people hospitalised with major trauma is rapidly increasing. New models of care have emerged, such as co-management, and trauma centres dedicated to delivering geriatric trauma care. The aim of this scoping review was to explore in-hospital models of care for older adults who experience physical trauma.

PATIENTS AND METHODS

The search was conducted in accordance with the PRISMA- SC (preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews) reporting guidelines. The National Heart Lung, and Blood Institute (NIH) study quality assessment tool was used to evaluate risk of bias in before and after non-randomised experimental studies.

RESULTS

Of 2127 records returned from the database search, 43 papers were included. We identified five types of care models investigated in the reviewed studies: centralised trauma management, consultation services, co-management, patient care protocols, and alert and triage systems. The majority of patients were admitted under a specialised trauma service, intervention teams were for the most part multidisciplinary, and follow-up of patients post-discharge was seldom reported. Consultation services more often had advanced care and discharge planning as treatment objectives. In contrast, patient care protocol and alert systems commonly had management of anticoagulation as a treatment objective. Overall, the impact of the five models of care on patient outcomes was mixed.

DISCUSSION

Given the variability in patient characteristics and capabilities of health services, models of care need to be matched to the local profile of older trauma patients. However, some standards should be incorporated into a care model, including identifying goals of care, medication review and follow up post-discharge.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review

BACKGROUND

Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations.

METHODS

We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework.

RESULTS

We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence.

CONCLUSIONS

We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma.

LEVEL OF EVIDENCE

Level II-therapeutic study.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Biases in the collection of blood alcohol data for adult major trauma patients in Victoria, Australia

BACKGROUND

In-hospital alcohol testing provides an opportunity to implement prevention strategies for patients with high risk of experiencing repeated alcohol-related injuries. However, barriers to alcohol testing in emergency settings can prevent patients from being tested. In this study, we aimed to understand potential biases in current data on the completion of blood alcohol tests for major trauma patients at hospitals in Victoria, Australia.

METHODS

Victorian State Trauma Registry data on all adult major trauma patients from 1 January 2018 to 31 December 2021 were used. Characteristics associated with having a blood alcohol test recorded in the registry were assessed using logistic regression models.

RESULTS

This study included 14 221 major trauma patients, of which 4563 (32.1%) had a blood alcohol test recorded. Having a blood alcohol test completed was significantly associated with age, socioeconomic disadvantage level, preferred language, having pre-existing mental health or substance use conditions, smoking status, presenting during times associated with heavy community alcohol consumption, injury cause and intent, and Glasgow Coma Scale scores (p<0.05). Restricting analyses to patients from a trauma centre where blood alcohol testing was part of routine clinical care mitigated most biases. However, relative to patients injured while driving a motor vehicle/motorcycle, lower odds of testing were still observed for patients with injuries from flames/scalds/contact burns (adjusted OR (aOR)=0.33, 95% CI 0.18 to 0.61) and low falls (aOR=0.17, 95% CI 0.12 to 0.25). Higher odds of testing were associated with pre-existing mental health (aOR=1.39, 95% CI 1.02 to 1.89) or substance use conditions (aOR=2.33, 95% CI to 1.47-3.70), and living in a more disadvantaged area (most disadvantaged quintile relative to least disadvantaged quintile: aOR=2.30, 95% CI 1.52 to 3.48).

CONCLUSION

Biases in the collection of blood alcohol data likely impact the surveillance of alcohol-related injuries. Routine alcohol testing after major trauma is needed to accurately inform epidemiology and the subsequent implementation of strategies for reducing alcohol-related injuries.

Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis

Importance

Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking.

Objective

To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma.

Data Sources

MEDLINE, Embase, and Web of Science through March 2023.

Study Selection

Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years).

Data Extraction and Synthesis

This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence.

Main Outcome(s) and Measure(s)

Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI).

Results

A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes.

Conclusions and Relevance

In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review

BACKGROUND

Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs.

METHODS

We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria.

RESULTS

We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries.

CONCLUSION

We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level III.

The Translated Proximal Humerus Fracture: A Comparison of Operative and Nonoperative Management

OBJECTIVES

To report on the long-term outcomes of the management of translated proximal humerus fractures.

DESIGN

A prospective cohort study was conducted from January 2010 to December 2018.

SETTING

Academic Level 1 trauma center.

PARTICIPANTS/PATIENTS

A total of 108 patients with a proximal humerus fracture with ≥100% translation, defined as no cortical bony contact between the shaft and humeral head fragments, were included.

INTERVENTION

Patients were managed nonoperatively with sling immobilization or with operative management as determined by the treating surgeon.

MAIN OUTCOME MEASURES

Outcome measures were the Oxford Shoulder Score, EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, nonunion/malunion, and avascular necrosis.

RESULTS

Of the 108 patients, 76 underwent operative intervention and 32 were managed nonoperatively. The mean (SD) age in the operative group was 54.3 (±20.2) years and in the nonoperative group was 73.3 (±15.3) years ( P < 0.001). There was no association between Oxford Shoulder Score and management options (mean 38.5 [±9.5] operative versus mean 41.3 [±8.5] nonoperative, P = 0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference was 0.16 (95% CI, 0.04-0.27; P = 0.008); EQ-5D VAS adjusted mean difference was 19.2 (95% CI, 5.2-33.2; P = 0.008). Operative management was associated with a lower odds of nonunion (adjusted OR 0.30; 95% CI, 0.09-0.97; P = 0.04), malunion (adjusted OR 0.14; 95% CI, 0.04-0.51; P = 0.003), and complications (adjusted OR 0.07; 95% CI, 0.02-0.32; P = 0.001).

CONCLUSION

Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes after surgical fixation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial

BACKGROUND

While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care.

METHODS

We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios.

DISCUSSION

On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm.

TRIAL REGISTRATION

This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).

A qualitative descriptive study exploring clinicians' perspectives of the management of older trauma care in rural Australia

BACKGROUND

For older trauma patients who sustain trauma in rural areas, the risk of adverse outcomes associated with advancing age, is compounded by the challenges encountered in rural healthcare such as geographic isolation, lack of resources, and accessibility. Little is known of the experience and challenges faced by rural clinicians who manage trauma in older adults. An understanding of stakeholders' views is paramount to the effective development and implementation of a trauma system inclusive of rural communities. The aim of this descriptive qualitative study was to explore the perspectives of clinicians who provide care to older trauma patients in rural settings.

METHOD

We conducted semi-structured interviews of health professionals (medical doctors, nurses, paramedics, and allied health professionals) who provide care to older trauma patients in rural Queensland, Australia. A thematic analysis consisting of both inductive and deductive coding approaches, was used to identify and develop themes from interviews.

RESULTS

Fifteen participants took part in the interviews. Three key themes were identified: enablers of trauma care, barriers, and changes to improve trauma care of older people. The resilience of rural residents, and breadth of experience of rural clinicians were strengths identified by participants. The perceived systemic lack of resources, both material and in the workforce, and fragmentation of the health system across the state were barriers to the provision of trauma care to older rural patients. Some changes proposed by participants included tailored education programs that would be taught in rural centres, a dedicated case coordinator for older trauma patients from rural areas, and a centralised system designed to streamline the management of older trauma patients coming from rural regions.

CONCLUSIONS

Rural clinicians are important stakeholders who should be included in discussions on adapting trauma guidelines to the rural setting. In this study, participants formulated pertinent and concrete recommendations that should be weighed against the current evidence, and tested in rural centres.

Prevalence of psychoactive drugs in injured patients presenting to an emergency department

OBJECTIVE

The aim of the present study was to obtain an unbiased understanding of the prevalence of psychoactive drugs in trauma patients presenting to a large ED.

METHODS

Consecutive adult patients presenting to the ED with an injury resulting in a trauma call had an anonymised, additional blood test taken for detection of over 2000 drugs. Laboratory testing was to judicial standards. Drugs given by ambulance pre-hospital were detected but excluded from the analysis.

RESULTS

Over 6 months 276 (74.7%) of 371 patients were tested. Of the 276 patients tested, 158 (57.2%) had one or more psychoactive drug present. Recreational drugs were detected in 101 (36.6%) patients and medicinal drugs in 88 (31.8%) patients, with a combination of both detected in 31 (11.2%) patients. The most common drugs detected were cannabis (22.1%), antidepressants (18.4%), alcohol (15.5%), opioids (10.1%), benzodiazepine/z-drugs (9.4%) and methamphetamine (7.2%). The prevalence of psychoactive drugs differed by age group, sex and cause of injury.

CONCLUSIONS

The prevalence of psychoactive drugs in injury presentations to an ED is high, and provides an opportunity to reduce harm. The present study demonstrates the feasibility of an approach which limits bias and obtains results that accurately reflect the drug prevalence in injured cohorts. Systematic testing of injured patients is an important contribution to the epidemiology of injury.

Long-term outcomes of major trauma patients with concussion

INTRODUCTION

Concussion may be sustained in the setting of injuries to multiple body regions and persistent effects of concussion may impact recovery. This project aimed to evaluate the association between concussion and 6-month and 12-month functional outcomes in survivors after major trauma.

METHODS

This was a registry-based cohort study that included adult patients with major trauma who presented to hospital between 01 Jan 2008 and 31 Dec 2017 and survived to hospital discharge. We excluded patients presenting with a Glasgow Coma Scale score <13 and those diagnosed with other intracranial injuries. Additionally, from the non-concussed group, patients with fractured skull and/or face were excluded, with the assumption that such patients may have had undiagnosed concussion. A good recovery was considered for Glasgow Outcome Scale-Extended (GOS-E) scores of 7 or 8. In addition, we assessed for patient reported anxiety and/or depression measured using the 3-level EuroQol 5 dimensions questionnaire. A modified mixed effects Poisson models with random intercepts for participant was used to assess the association between concussion and outcome.

RESULTS

There were 28,161 eligible patients and 12,822 met inclusion criteria. Concussion was diagnosed in 1860 patients (14.5%; 95%CI: 13.9-15.1). There was no association between concussion and good recovery at 12 months (aRR 1.05 (95%CI: 0.99-1.11). There was no association between concussion and anxiety and/or depression at 12 months (aRR 1.03; 95%CI: 0.99-1.07).

CONCLUSIONS

Concussion was sustained among 14.5% of included patients in the setting of major trauma but not associated with longer-term adverse outcomes using GOS-E. Concussed patients did not report differential rates of anxiety and/or depression.

Older trauma patients with isolated chest injuries have low rates of complications

INTRODUCTION

The number of older adults hospitalised for injury is growing rapidly. The population-adjusted incidence of isolated thoracic injuries in older adults is also growing. While some older adults are at high risk of post-traumatic complications, not all older adults will need treatment in a major trauma service (MTS). The aim of this study was to characterise older patients with isolated chest injuries, determine the rates of post-traumatic complications, including respiratory failure and pneumonia, and the factors associated with the risk of developing these complications.

PATIENTS AND METHODS

This was a retrospective review of patients aged 65 years and over with isolated chest trauma, from January 2007 to June 2017, using data from the Victorian State Trauma Registry. Patient characteristics and rates of complications were compared between patients with 1. isolated rib fractures, and 2. complex chest injury. Multivariable logistic regression was used to identify predictors of respiratory failure, and pneumonia.

RESULTS

The study population comprised 5401 patients aged 65 years or more, with isolated chest injuries. Two-thirds (65%) of all patients had isolated rib fractures, and 58% of patients (n = 3156) were directly admitted to a non-major trauma centre. Complications were uncommon, with 5.45% of all patients (n = 295) having pneumonia and 3.2% (n = 175) having respiratory failure. Factors associated with increased risk of pneumonia and respiratory failure included advancing age, smoking, chronic obstructive pulmonary disease, congestive heart failure, and more severe and complex chest injury. The adjusted odds of complications were lowest amongst patients not classified as major trauma and receiving definitive treatment in non-MTS.

DISCUSSION

Our findings suggest that rates of complications in older patients with isolated chest trauma in this study were low, and that there is a large group of patients with isolated, uncomplicated rib fractures, who may not need to be treated in a major trauma centre. Further work should be undertaken to appropriately risk stratify and manage older adults with isolated chest trauma.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

BACKGROUND

In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes.

METHODS

Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions.

CONCLUSION

This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Long-term health and mobility of older adults following traumatic injury: a qualitative longitudinal study

PURPOSE

The aim of this study was to explore older adults' experiences of and approaches to managing their long-term health and mobility after traumatic injury.

METHODS

A longitudinal qualitative study was undertaken with older adults following traumatic injury in Victoria, Australia. Fifteen participants (≥65 years) were interviewed at three years post-injury (n = 15), and re-interviewed at four (n = 14) and five years (n = 12) post-injury. Using a framework approach, a longitudinal thematic analysis was performed.

RESULTS

Older age at the time of injury was identified by participants as a key factor influencing their recovery. Many participants reported actively attempting to regain their strength and fitness in the first five years following injury. However, their age, injury impacts, other health conditions, and weight gain made it difficult to achieve recovery goals. Many older adults reported a decline in their physical function over time. While these experiences and persistent disability constrained or changed the quality of social relationships, community participation, and independence, several participants described adapting to their functional limitations, and managing their secondary conditions over time.

CONCLUSION

In our cohort, the intertwined combination of ageing, injury, and comorbid conditions negatively affected health and mobility, reinforcing the need for preventative strategies.Implications for rehabilitationOlder adults recovering from traumatic injury may benefit from specialised care pathways that offer long-term and tailored therapies, with programs and services specific to their needs and goals.An integrated service approach by injury insurers, health care, primary care, disability, and aged care could more clearly identify and effectively address the individual needs and goals of older adults with complex conditions.Health and social services that work with people with injuries to develop personalised coping strategies can reduce anxiety related to uncertainty about the future, promote well-being, and support participation in valued activities.

Serious Injury in Metropolitan and Regional Victoria: Exploring Travel to Treatment and Utilisation of Post-Discharge Health Services by Injury Type

This study aimed to describe regional variations in service use and distance travelled to post-discharge health services in the first three years following hospital discharge for people with transport-related orthopaedic, brain, and spinal cord injuries. Using linked data from the Victorian State Trauma Registry (VSTR) and Transport Accident Commission (TAC), we identified 1597 people who had sustained transport-related orthopaedic, brain, or spinal cord injuries between 2006 and 2016 that met the study inclusion criteria. The adjusted odds of GP service use for regional participants were 76% higher than for metropolitan participants in the orthopaedic and traumatic brain injury (TBI) groups. People with spinal cord injury (SCI) living in regional areas had 72% lower adjusted odds of accessing mental health, 76% lower adjusted odds of accessing OT services, and 82% lower adjusted odds of accessing physical therapies compared with people living in major cities. People with a TBI living in regional areas on average travelled significantly further to access all post-discharge health services compared with people with TBI in major cities. For visits to medical services, the median trip distance for regional participants was 76.61 km (95%CI: 16.01-132.21) for orthopaedic injuries, 104.05 km (95% CI: 51.55-182.78) for TBI, and 68.70 km (95%CI: 8.34-139.84) for SCI. Disparities in service use and distance travelled to health services exist between metropolitan Melbourne and regional Victoria following serious injury.

Validation of Quality Indicators Targeting Low-Value Trauma Care

Importance

Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences.

Objective

To assess the validity of quality indicators on low-value trauma care using trauma registry data.

Design, Setting, and Participants

Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts.

Main Outcomes and Measures

Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time).

Results

The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs.

Conclusions and Relevance

This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.

International comparison of injury care structures, processes, and outcomes between integrated trauma systems in Québec, Canada, and Victoria, Australia

BACKGROUND

Quality improvement activities in trauma systems are widely based on comparisons between trauma centers within the same system. Comparisons across different trauma systems may reveal further opportunities for quality improvement.

OBJECTIVES

This study aimed to compare the integrated trauma systems in Québec, Canada and in Victoria, Australia, regarding their structures, care processes and patient outcomes.

METHODOLOGY

The elements recommended by the American College of Surgeons were used to compare trauma systems structures. Comparisons of care processes and patient outcomes were based on data from major trauma admissions extracted from trauma registries (2013 and 2017). Care processes included time to reach a definitive care facility, time spent in the emergency department, and time lapsed before the first head computed tomography (CT) scan. These care processes were compared using a z-test of log-transformed times. Hospital mortality and hospital length of stay (LOS) were compared using indirect standardization based on multiple logistic and linear regression.

RESULTS

Major differences in trauma system structure were Advanced Trauma Life Support at the scene of injury (Victoria), the use of validated prehospital triage tools (Québec), and mandatory accreditation of all trauma centers (Québec). Patients in Québec arrived at their definitive care hospital earlier than their counterparts in Victoria (median: 1.93 vs. 2.13 h, p = 0.002), but spent longer in the emergency department (median: 8.23 vs. 5.15 h, p<0.0001) and waited longer before having their first head CT (median: 1.90 vs. 1.52 h, p<0.0001). In-hospital mortality and hospital LOS were higher in Québec than in Victoria (standardized mortality ratio: 1.15, 95% CI: 1.09 - 1.20; standardized LOS ratio: 1.10, 95% CI: 1.09 - 1.11).

CONCLUSION

We observed important differences in the structural components and care processes in Québec and Victoria's trauma systems, which might explain some of the observed differences in patient outcomes. This study shows the potential value of international comparisons in trauma care and identifies possible opportunities for quality improvement.

Factors associated with long term work incapacity following a non-catastrophic road traffic injury: analysis of a two-year prospective cohort study

Background

Road traffic injuries (RTIs), primarily musculoskeletal in nature, are the leading cause of unintentional injury worldwide, incurring significant individual and societal burden. Investigation of a large representative cohort is needed to validate early identifiable predictors of long-term work incapacity post-RTI. Therefore, up until two years post-RTI we aimed to: evaluate absolute occurrence of return-to-work (RTW) and occurrence by injury compensation claimant status; evaluate early factors (e.g., biopsychosocial and injury-related) that influence RTW longitudinally; and identify factors potentially modifiable with intervention (e.g., psychological distress and pain).

Methods

Prospective cohort study of 2019 adult participants, recruited within 28 days of a non-catastrophic RTI, predominantly of mild-to-moderate severity, in New South Wales, Australia. Biopsychosocial, injury, and compensation data were collected via telephone interview within one-month of injury (baseline). Work status was self-reported at baseline, 6-, 12-, and 24-months. Analyses were restricted to participants who reported paid work pre-injury (N = 1533). Type-3 global p-values were used to evaluate explanatory factors for returning to ‘any’ or ‘full duties’ paid work across factor subcategories. Modified Poisson regression modelling was used to evaluate factors associated with RTW with adjustment for potential covariates.

Results

Only ~ 30% of people with RTI returned to full work duties within one-month post-injury, but the majority (76.7%) resumed full duties by 6-months. A significant portion of participants were working with modified duties (~ 10%) or not working at all (~ 10%) at 6-, 12-, and 24-months. Female sex, low education, low income, physically demanding occupations, pre-injury comorbidities, and high injury severity were negatively associated with RTW. Claiming injury compensation in the fault-based scheme operating at the time, and early identified post-injury pain and psychological distress, were key factors negatively associated with RTW up until two years post-injury.

Conclusions

Long-term work incapacity was observed in 20% of people following RTI. Our findings have implications that suggest review of the design of injury compensation schemes and processes, early identification of those at risk of delayed RTW using validated pain and psychological health assessment tools, and improved interventions to address risks, may facilitate sustainable RTW.

Trial registration

This study was registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12613000889752).

Effect of Psychological Distress on Long-Term Health-Related Quality of Life After Road Traffic Injury

OBJECTIVE

A prospective cohort study to investigate how injury and early post-injury psychosocial factors influence health outcomes 12 months after road traffic injury.

METHODS

Residents of New South Wales, Australia, with road traffic injury in the period 2013-16 were recruited. Explanatory factors were evaluated for outcomes over 12 months using 12-Item Short Form Survey (SF-12) Physical and Mental Component Scores (PCS and MCS). Path models and mediation analysis were used to examine the effect of injury severity and explanatory factors.

RESULTS

SF-12 PCS and MCS outcomes were poorer among participants with baseline psychological distress, for all injury severities (β coefficients -3.3 to -9.3, p < 0.0001). Baseline pain and psychological distress, and baseline PCS and MCS were each involved in indirect effects of injury severity on 12-month PCS and MCS. Injury severity, baseline PCS and MCS, and baseline psychological distress were also associated with the likelihood of a compulsory third-party insurance claim, and claiming was negatively associated with 12-month PCS and MCS outcomes (beta coefficients -0.22 and -0.14, respectively, for both, p < 0.01).

CONCLUSION

Baseline factors, including pain, psychological distress and lodging a compulsory third-party insurance claim, negatively impact long-term physical and mental health status following road traffic injury, emphasizing the importance of early screening and intervention.

TRIAL REGISTRATION

Australia New Zealand Clinical trial registry identification number: ACTRN12613000889752.

AUS-TBI: The Australian Health Informatics Approach to Predict Outcomes and Monitor Intervention Efficacy after Moderate-to-Severe Traumatic Brain Injury

Predicting and optimizing outcomes after traumatic brain injury (TBI) remains a major challenge because of the breadth of injury characteristics and complexity of brain responses. AUS-TBI is a new Australian Government–funded initiative that aims to improve personalized care and treatment for children and adults who have sustained a TBI. The AUS-TBI team aims to address a number of key knowledge gaps, by designing an approach to bring together data describing psychosocial modulators, social determinants, clinical parameters, imaging data, biomarker profiles, and rehabilitation outcomes in order to assess the influence that they have on long-term outcome. Data management systems will be designed to track a broad range of suitable potential indicators and outcomes, which will be organized to facilitate secure data collection, linkage, storage, curation, management, and analysis. It is believed that these objectives are achievable because of our consortium of highly committed national and international leaders, expert committees, and partner organizations in TBI and health informatics. It is anticipated that the resulting large-scale data resource will facilitate personalization, prediction, and improvement of outcomes post-TBI.

Economic Evaluation of In-Hospital Clinical Practices in Acute Injury Care: A Systematic Review

OBJECTIVES

Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. To achieve value-based care, guidelines and recommendations should target both underuse and overuse and be supported by evidence from economic evaluations. We aimed to conduct a systematic review of the economic value of in-hospital clinical practices in acute injury care to advance knowledge on value-based care in this patient population.

METHODS

Pairs of independent reviewers systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central Register for full economic evaluations of in-hospital clinical practices in acute trauma care published from 2009 to 2019 (last updated on June 17, 2020). Results were converted into incremental net monetary benefit and were summarized with forest plots. The protocol was registered with PROSPERO (CRD42020164494).

RESULTS

Of 33 910 unique citations, 75 studies met our inclusion criteria. We identified 62 cost-utility, 8 cost-effectiveness, and 5 cost-minimization studies. Values of incremental net monetary benefit ranged from international dollars -467 000 to international dollars 194 000. Of 114 clinical interventions evaluated (vs comparators), 56 were cost-effective. We identified 15 cost-effective interventions in emergency medicine, 6 in critical care medicine, and 35 in orthopedic medicine. A total of 58 studies were classified as high quality and 17 as moderate quality. From studies with a high level of evidence (randomized controlled trials), 4 interventions were clearly dominant and 8 were dominated.

CONCLUSIONS

This research advances knowledge on value-based care for injury admissions. Results suggest that almost half of clinical interventions in acute injury care that have been studied may not be cost-effective.

Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care

Importance

The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators.

Objective

To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care.

Design, Setting, and Participants

This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners.

Main Outcomes and Measures

Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability.

Results

Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery).

Conclusions and Relevance

In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

Risk Factors and Prognosis of Early Posttraumatic Seizures in Moderate to Severe Traumatic Brain Injury

IMPORTANCE

Early posttraumatic seizures (EPS) that may occur following a traumatic brain injury (TBI) are associated with poorer outcomes and development of posttraumatic epilepsy (PTE).

OBJECTIVE

To evaluate risk factors for EPS, associated morbidity and mortality, and contribution to PTE.

DESIGN, SETTING, AND PARTICIPANTS

Data were collected from an Australian registry-based cohort study of adults (age ≥18 years) with moderate to severe TBI from January 2005 to December 2019, with 2-year follow-up. The statewide trauma registry, conducted on an opt-out basis in Victoria (population 6.5 million), had 15 152 patients with moderate to severe TBI identified via Abbreviated Injury Scale (AIS) head severity score, with an opt-out rate less than 0.5% (opt-out n = 136).

MAIN OUTCOMES AND MEASURES

EPS were identified via International Statistical Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) codes recorded after the acute admission. Outcome measures also included in-hospital metrics, 2-year outcomes including PTE, and post-discharge mortality. Adaptive least absolute shrinkage and selection operator (LASSO) regression was used to build a prediction model for risk factors of EPS.

RESULTS

Among the 15 152 participants (10 457 [69%] male; median [IQR] age, 60 [35-79] y), 416 (2.7%) were identified with EPS, including 27 (0.2%) with status epilepticus. Significant risk factors on multivariable analysis for developing EPS were younger age, higher Charlson Comorbidity Index, TBI sustained from a low fall, subdural hemorrhage, subarachnoid hemorrhage, higher Injury Severity Score, and greater head injury severity, measured using the AIS and Glasgow Coma Score. After adjustment for confounders, EPS were associated with increased ICU admission and ICU length of stay, ventilation and duration, hospital length of stay, and discharge to inpatient rehabilitation rather than home, but not in-hospital mortality. Outcomes in TBI admission survivors at 24 months, including mortality (relative risk [RR] = 2.14; 95% CI, 1.32-3.46; P = .002), development of PTE (RR = 2.91; 95% CI, 2.22-3.81; P < .001), and use of antiseizure medications (RR = 2.44; 95% CI, 1.98-3.02; P < .001), were poorer for cases with EPS after adjustment for confounders. The prediction model for EPS had an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.66-0.79), sensitivity of 66%, and specificity of 73% in the validation set.

DISCUSSION

We identified important risk factors for EPS following moderate to severe TBI. Early posttraumatic seizures were associated with longer ICU and hospital admissions, ICU ventilation, and poorer 24-month outcomes including mortality and development of PTE.

A Randomized Controlled Trial of the Prevent Alcohol and Risk-Related Trauma in Youth Program in Reducing Alcohol-Related Harms in Young Naval Trainees

BACKGROUND

The aim of this study was to test whether participation in an alcohol risk reduction program known as Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y.) is effective in reducing the prevalence of risky drinking at 12 months' post-intervention in a sample of Royal Australian Navy (RAN) trainees.

METHODS

A non-blinded randomized controlled trial of 952 RAN trainees comparing two forms of P.A.R.T.Y. plus RAN annual alcohol and other drug awareness training with annual alcohol and other drugs awareness training only (Control). Participants were screened at baseline and at 12-month follow-up using the Alcohol Use Disorders Identification Test (AUDIT). Participants were randomized to one of three arms: (1) in-hospital P.A.R.T.Y program, (2) on-base P.A.R.T.Y. program, or (3) control.The primary outcome measure was the percentage of participants reporting an AUDIT score of 8 or above at 12 months in each group. A secondary outcome considered was reports of alcohol-related incidents in the 12-month follow-up.

RESULTS

There was no difference in the risk of reporting an AUDIT score of 8 or above in either the in-hospital (Relative Risk (RR) 0.96, 95% CI: 0.75-1.23; P = .75) or on-base (RR 1.11, 95% CI: 0.89-1.369; P = 0.35) intervention groups, compared to the control group. Compared to the on-base group, there was no difference in the risk of reporting an AUDIT score of 8 or above in the in-hospital group (RR 1.16, 95% CI: 0.90-1.48; P = .24). The rate of reporting an alcohol-related incident was not different for the in-hospital (Hazard Ratio (HR) 0.60, 95% CI: 0.27-1.33; P = .21) or on-base (HR 0.50, 95% CI: 0.21-1.16; P = .11) intervention groups when compared to the control group.

CONCLUSION

Participation in either an on-base or an in-hospital P.A.R.T.Y. program did not affect the proportion of naval trainee participants screening positive for risky drinking on the AUDIT.

Injury profiles and clinical management of older patients with major trauma

OBJECTIVES

This study aimed to characterise the most common injury profiles and interventions in older major trauma patients, and how they change with age.

METHODS

This is a retrospective review of interventions, injury profiles and outcomes of major trauma patients aged 65 years and older from 2007 to 2018, using data from the Victorian State Trauma Registry. A latent class analysis (LCA) was used to identify homogenous injury groups.

RESULTS

The LCA identified five injury profiles: isolated head injury; chest/upper limb injuries; multi-trauma; isolated spine; and head/chest/upper limb. Among 10,001 patients, 50% had an isolated head injury, and 83% of patients received definitive treatment at a major trauma centre. 50% of patients received a surgical or non-surgical intervention, and 36% underwent surgery. These proportions declined with increasing age.

CONCLUSIONS

Older patients with major trauma are a heterogeneous group, whose mechanisms and patterns of injury, and clinical management change with increasing age.

Association between anticoagulants and mortality and functional outcomes in older patients with major trauma

BACKGROUND

The number of trauma patients taking anticoagulants and antiplatelet agents is increasing as society ages. However, there have been limited and inconsistent reports of the association between anticoagulants and mortality and functional outcomes. This study aimed to quantify the association between anticoagulant/antiplatelet medication at the time of injury and both short-term and longer-term outcomes in older major trauma patients.

METHODS

This was a population-based registry study using data from the Victorian State Trauma Registry from July 2017 to June 2018. We included patients with major trauma aged 65 years and older. The outcomes of interest were in-hospital mortality, hospital length of stay, intensive care unit length of stay and the Extended Glasgow Outcome Scale (GOS-E) at 6 months after injury. We examined the association between the outcomes and anticoagulants/antiplatelet agents at the time of injury and used multivariable logistic regression models to account for known confounders.

RESULTS

There were 1323 older adults eligible for inclusion in the study, of which 249 (18.8%) were taking anticoagulants (n=8 were taking both anticoagulants and antiplatelet agents), 380 (28.7%) were taking antiplatelet agents and 694 (52.5%) were not using either. Any anticoagulant use was associated with higher odds of in-hospital mortality (adjusted OR (AOR), 2.38; 95% CI 1.58 to 3.59) compared with not using anticoagulants. No differences were observed in the GOS-E at 6 months after injury between any anticoagulants use, antiplatelet use and no anticoagulant use (anticoagulant AOR, 0.71; 95% CI 0.48 to 1.05, antiplatelet AOR, 1.02; 95% CI 0.73 to 1.42).

CONCLUSION

Anticoagulant use at the time of injury was associated with higher odds of in-hospital mortality but did not adversely impact functional outcomes at 6 months after injury. These findings demonstrate the importance of seeking an accurate history of anticoagulant use and its indication, as well as the immediate initiation of reversal therapies.

Low-value injury admissions in an integrated Canadian trauma system: A multicentre cohort study

BACKGROUND

Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation.

METHODS

We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years).

RESULTS

The prevalence of low-value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16-64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC = 37%).

CONCLUSION

One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.

Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients

INTRODUCTION

Amongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality.

METHODS

The Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury.

RESULTS

Overall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults.

CONCLUSION

In ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.

Accuracy of injury coding in a trauma registry

Introduction

Abbreviated Injury Scale has significant advantages over administrative coding systems for trauma analytics as it was developed specifically for injury, provides greater depth of characterisation of injury and has an integrated severity measure. It is used by trauma registries globally as it allows benchmarking between registries and is used to drive quality improvement. However, the consistency of scoring between individuals is not well understood. An audit was undertaken in six tertiary trauma centres in New Zealand to determine variation between AIS coders.

Methods

Each of six sites was audited by two experienced auditors. A random selection of case was identified in ISS categories 13–24, 25–44 and 45+. The case notes were pulled, and the auditors independently audited the notes,and then compared their results for a consensus result. The consensus result was then compared with the original coders.

Results

111 cases were audited. Coding concordance was found in 31% of cases. Of the 69% of cases where discordant coding was observed, the discordance was attributed to incorrect coding (49%), missed injuries (43%) and other reasons (7%). Head and chest body regions were associated with the greatest number, and largest differences in coding scores. The overall mean difference across all cases was an ISS score of 1.

Conclusions

The overall accuracy of data held in the New Zealand Trauma Registry (NZTR) is suitable for quality improvement and benchmarking purposes, but more work is needed to improve the accuracy of individual cases, particularly those with head/neck and chest injury. Standardised tools to ensure the accuracy of data in a trauma registry is a gap which needs to be addressed to maintain confidence in a contemporary trauma system.

Impacts of injury severity on long-term outcomes following motor vehicle crashes

Background

There is growing evidence that a range of pre-injury, injury related and post-injury factors influence social and health outcomes across the injury severity spectrum. This paper documents health related outcomes for people with mild, moderate and severe injury after motor vehicle crash (MVC) injuries in New South Wales, Australia.

Methods

This inception cohort study followed 2019 people injured in MVCs, for 6 and 12 months post-injury. We categorised moderate injury as hospital length-of-stay (LOS) of 2–6 days and Injury Severity Score (ISS) of 4–11, while severe injury as LOS ≥7 days or ISS ≥ 12. We examined differences in paid work status, 12-Item Short Form Survey (SF12), EQ-5D and World Health Organisation Disability Assessment Schedule II (WHODAS) outcomes longitudinally from baseline to 12 months between levels of injury severity using linear mixed models for repeated measures. We first considered minimally sufficient adjustment factors (age, sex, crash role, perceived danger in crash, pre-injury health, pre-injury EQ-5D, recruitment source), and then more extensive adjustments including post-injury factors. The presence of mediating pathways for SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) via post-injury factors was evaluated.

Results

Based on hospital length of stay (LOS), 25 and 10% of participants sustained moderate and severe injuries, respectively, while 43 and 4% had these injuries based on ISS. Twelve months post-injury LOS ≥7 days versus ≤1 day was associated with an estimated 9 units lower mean SF12 PCS using a minimally sufficient adjustment model, and LOS ≥ 7 days was associated with a 3 units lower mean SF12 MCS score. Mediation analyses (LOS ≥ 7 days vs ≤1 day) found for SF12 MCS outcomes, effects of injury severity were small and mostly indirect (direct effect − 0.03, indirect effect − 0.22). Whereas for SF12 PCS outcomes the effect of having a more severe injury rather than mild were both direct and indirect (direct effect − 0.50, indirect effect − 0.38).

Conclusions

Individuals with severe injuries (those with LOS ≥ 7 days and ISS 12+) had poorer recovery 12 months after the injury. In addition, post-injury mediators have an important role in influencing long-term health outcomes.

Trial registration

Australia New Zealand Clinical trial registry identification number - ACTRN12613000889752.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10638-7.

A cross-sectional study reporting concussion exposure, assessment and management in Western Australian general practice

Background

General Practitioners (GPs) may be called upon to assess patients who have sustained a concussion despite limited information being available at this assessment. Information relating to how concussion is actually being assessed and managed in General Practice is scarce. This study aimed to identify characteristics of current Western Australian (WA) GP exposure to patients with concussion, factors associated with GPs’ knowledge of concussion, confidence of GPs in diagnosing and managing patients with concussion, typical referral practices and familiarity of GPs with guidelines.

Methods

In this cross-sectional study, GPs in WA were recruited via the RACGP WA newsletter and shareGP and the consented GPs completed an electronic survey. Associations were performed using Chi-squared tests or Fisher’s Exact test.

Results

Sixty-six GPs in WA responded to the survey (response rate = 1.7%). Demographics, usual practice, knowledge, confidence, identification of prolonged recovery as well as guideline and resource awareness of GPs who practised in regional and metropolitan areas were comparable (p > 0.05). Characteristics of GPs were similar between those who identified all symptoms of concussion and distractors correctly and those who did not (p > 0.05). However, 84% of the respondents who had never heard of concussion guidelines were less likely to answer all symptoms and distractors correctly (p = 0.039). Whilst 78% of the GPs who were confident in their diagnoses had heard of guidelines (p = 0.029), confidence in managing concussion was not significantly associated with GPs exposure to guidelines. It should be noted that none of the respondents correctly identified signs of concussion and excluded the distractors.

Conclusions

Knowledge surrounding concussion guidelines, diagnosis and management varied across GPs in WA. Promotion of available concussion guidelines may assist GPs who lack confidence in making a diagnosis. The lack of association between GPs exposure to guidelines and confidence managing concussion highlights that concussion management may be an area where GPs could benefit from additional education and support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01384-1.

The psychometric properties and minimal clinically important difference for disability assessment using WHODAS 2.0 in critically ill patients

Objectives: The 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) provides a standardised method for measuring health and disability. This study aimed to determine its reliability, validity and responsiveness and to establish the minimum clinically important difference (MCID) in critically ill patients. Design: Prospective, multicentre cohort study. Setting: Intensive care units of six metropolitan hospitals. Participants: Adults mechanically ventilated for > 24 hours. Main outcome measures: Reliability was assessed by measuring internal consistency. Construct validity was assessed by comparing WHODAS 2.0 scores at 6 months with the EuroQoL visual analogue scale (EQ VAS) and Lawton Instrumental Activities of Daily Living (IADL) scale scores. Responsiveness was evaluated by assessing change over time, effect sizes, and percentage of patients showing no change. The MCID was calculated using both anchor and distribution-based methods with triangulation of results. Main results: A baseline and 6-month WHODAS 2.0 score were available for 448 patients. The WHODAS 2.0 demonstrated good correlation between items with no evidence of item redundancy. Cronbach α coefficient was 0.91 and average split-half coefficient was 0.91. There was a moderate correlation between the WHODAS 2.0 and the EQ VAS scores (r = -0.72; P < 0.001) and between the WHODAS 2.0 and the Lawton IADL scores (r = -0.66; P < 0.001) at 6 months. The effect sizes for change in the WHODAS 2.0 score from baseline to 3 months and from 3 to 6 months were low. Ceiling effects were not present and floor effects were present at baseline only. The final MCID estimate was 10%. Conclusion: The 12-item WHODAS 2.0 is a reliable, valid and responsive measure of disability in critically ill patients. A change in the total WHODAS 2.0 score of 10% represents the MCID.

Risk factors for surgical site infections following spinal column trauma in an Australian trauma hospital

BACKGROUND

There is limited, and often conflicting, data in the literature about the prevalence and risk factors for surgical site infections (SSI) in spine surgery patients, with the majority consisting of elective spine surgery cohorts. Furthermore, there is no reported Australian data regarding rates of SSI in a spinal trauma cohort. The aim of this study is to identify factors associated with SSI following spinal column trauma.

METHODS

Adult (16+ years) patients that underwent surgery following emergency admission for spinal trauma between January 2010 and December 2016 at a major trauma centre in Melbourne, Australia, were identified through the Victorian Orthopaedic Trauma Outcomes Registry. The presence of an SSI was confirmed from the electronic medical record. Patient and clinical factors were analysed by SSI status. Generalized Estimating Equations were used to model predictors of SSI, with a P-value <0.05 deemed significant.

RESULTS

Data for 458 patients and 520 surgical wounds were collected. Twenty-six (5.7%) patients developed an SSI. Staphylococcus aureus was the most common microorganism with methicillin-sensitive S. aureus found in 46% of SSI cases. A posterior surgical approach and same site reoperation were predictors of SSI with adjusted odds ratios (95% confidence intervals) of 4.26 (1.22-14.80, P = 0.02) and 4.99 (1.10-22.58, P = 0.04), respectively.

CONCLUSIONS

A posterior surgical approach and same site reoperation increased the risk of SSI after spinal trauma. Further research into modifiable associations within these and other factors will help mitigate the risk of SSI and hence decrease the personal and financial costs of this potentially devastating complication.

Outcomes of surgical site infections following spinal column trauma

BACKGROUND

Surgical site infections (SSI) are an undesirable outcome of spinal surgery for both the patient and healthcare system. To date, few studies have investigated the impact of SSI on patient-reported and clinical outcomes. Sepsis and readmission are potential sequelae of SSI, with sepsis potentially being life threatening. This study aimed to assess the association between SSI and patient outcomes in a spinal trauma cohort.

METHODS

Adult (16+ years) patients who underwent emergency spinal surgery due to trauma between January 2010 and December 2016 at a major trauma centre in Melbourne, Australia, were identified through the Victorian Orthopaedic Trauma Outcomes Registry. The presence of an SSI was abstracted from the electronic medical record and outcomes were compared between patients with and without an SSI. Clinical outcomes were obtained from the medical record, and patient-reported outcomes at 6 and 12 months were obtained from the Victorian Orthopaedic Trauma Outcomes Registry. Chi-squared tests were used to compare patient outcomes between groups.

RESULTS

Of the 458 included patients, 26 (5.7%) developed an SSI. Patient-reported outcomes at 6 and 12 months were not different between the groups. An SSI was associated with sepsis (χ² ₁ = 24.20, P < 0.01), readmission (χ² ₁ = 215.34, P < 0.01), revision surgery (χ² ₁ = 171.21, P < 0.01) and removal of implants (χ² ₁ = 4.31, P = 0.04) within 12 months of discharge.

CONCLUSION

These findings indicate that spine trauma SSIs are not associated with patient-reported outcomes and may not have lasting effects on patients. Larger studies are required to assess further follow-up and support our findings and possibly distinguish outcomes between superficial and deep SSI.

Identify the key characteristics of pedestrian collisions through in-depth interviews: a pilot study

This study aimed to assess the feasibility of recruiting injured pedestrians from the emergency department of a major trauma centre, using an in-depth interview shortly post collision. Convenience sampling was used to prospectively recruit injured pedestrians from the Alfred Hospital Emergency and Trauma Centre. Of the 102 injured pedestrians, 39 met eligibility criteria and of these, 30 (77%) consented and completed the questionnaire. Over half of the collisions occurred at an intersection (57%), and of these the most common pre-impact vehicle manoeuvre was a vehicle turning into the street the pedestrian was crossing. In-depth interview during the early post-crash period was a feasible and effective method of collecting detailed data in an accessible sample. However, only 38% of patients met eligibility criteria. To enhance representativeness, supplementing interview data with police-reported crash data, recruiting from hospital wards and crash location assessment is recommended.

Workplace intervention programmes for decreasing alcohol use in military personnel: a systematic review

INTRODUCTION

Harmful or risky-single occasion drinking (RSOD) alcohol use in the military is a significant problem. However, most studies of interventions have focused on veterans, representing a missed opportunity for intervention with active military personnel. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, the aim of this systematic review was to analyse and synthesise the evidence related to workplace-based interventions for reducing alcohol use in active-duty military personnel.

METHODS

Four electronic databases and reference lists of relevant articles were searched from database inception until 20 January 2020. This review focused on experimental and quasi-experimental studies of active-duty military personnel. Data extraction and methodological quality assessment were independently performed by two reviewers using a standardised checklist. A third reviewer was used to arbitrate the disputed studies for final selection.

RESULTS

The search yielded seven studies from an initial 1582 records identified. A range of interventions were used in these studies (four randomised controlled trials, two non-randomised trials and one before and after cohort study), including web-based approaches, telephone-delivered interventions and individual and group-based face-to-face interventions. Seven studies found decreased drinking, measured using a range of outcomes, following the intervention. However, this was not sustained in the longer term in any of the studies.

CONCLUSIONS

The low methodological rigour of most studies limited the capacity to demonstrate the efficacy of the interventions studied. Given the importance of reducing harmful or RSOD use of alcohol in the military, future studies would benefit from improved methodological rigour including ensuring adequate study power, randomisation, selection of validated outcome measures, including measures other than consumption (eg, attitudinal measures), and longer-term follow-up. There is also a need to develop methods that ensure participant loss to follow-up is minimised.

Management of Australian Patients with Severe Traumatic Brain Injury: Are Potentially Harmful Treatments Still Used?

Clinical trials have shown that intravenous albumin and decompressive craniectomy to treat early refractory intracranial hypertension can cause harm in patients with severe traumatic brain injury (TBI). The extent to which these treatments remain in use is unknown. We conducted a multi-center retrospective cohort study of adult patients with severe TBI admitted to five neurotrauma centers across Australia between April 2013 and March 2015. Patients were identified from local trauma and intensive care unit (ICU) registries and followed until hospital discharge. Main outcome measures were the administration of intravenous albumin, and decompressive craniectomy for intracranial hypertension. Analyses were predominantly descriptive. There were 303 patients with severe TBI, of whom a minority received albumin (6.9%) or underwent early decompressive craniectomy for treatment of refractory intracranial hypertension complicating diffuse TBI (2.3%). The median (intequartile range [IQR]) age was 35 (24, 58), and most injuries were caused by road traffic accidents (57.4%) or falls (25.1%). Overall, 34.3% of patients died while in the hospital and the remainder were discharged to rehabilitation (44.6%), other health care facilities (4.6%), or home (16.5%). There were no patient characteristics significantly associated with use of albumin or craniectomy. Intravenous albumin and craniectomy for treatment of intracranial hypertension were used infrequently in Australian neurotrauma centers, indicating alignment between best available evidence and practice.

Patient-specific record linkage between emergency department and hospital admission data for a cohort of people who inject drugs: methodological considerations for frequent presenters

Background

People who inject drugs (PWID) have been identified as frequent users of emergency department (ED) and hospital inpatient services. The specific challenges of record linkage in cohorts with numerous administrative health records occurring in close proximity are not well understood. Here, we present a method for patient-specific record linkage of ED and hospital admission data for a cohort of PWID.

Methods

Data from 688 PWID were linked to two state-wide administrative health databases identifying all ED visits and hospital admissions for the cohort between January 2008 and June 2013. We linked patient-specific ED and hospital admissions data, using administrative date-time timestamps and pre-specified linkage criteria, to identify hospital admissions stemming from ED presentations for a given individual. The ability of standalone databases to identify linked ED visits or hospital admissions was examined.

Results

There were 3459 ED visits and 1877 hospital admissions identified during the study period. Thirty-four percent of ED visits were linked to hospital admissions. Most links had hospital admission timestamps in-between or identical to their ED visit timestamps (n = 1035, 87%). Allowing 24-h between ED visits and hospital admissions captured more linked records, but increased manual inspection requirements. In linked records (n = 1190), the ED ‘departure status’ variable correctly reflected subsequent hospital admission in only 68% of cases. The hospital ‘admission type’ variable was non-specific in identifying if a preceding ED visit had occurred.

Conclusions

Linking ED visits with subsequent hospital admissions in PWID requires access to date and time variables for accurate temporal sorting, especially for same-day presentations. Selecting time-windows to capture linked records requires discretion. Researchers risk under-ascertainment of hospital admissions if using ED data alone.

Health and return to work in the first two years following road traffic injury: a comparison of outcomes between compensation claimants in Victoria and New South Wales, Australia

BACKGROUND

People who sustain road traffic injuries often have poor health outcomes. While outcomes are often worse in people with a compensation claim, especially in fault-based schemes versus no-fault schemes, few studies have directly compared outcomes across scheme types.

OBJECTIVE

To compare health and work outcomes between people who had no compensation claim, a fault-based claim, or "no-fault" transport or workers compensation claim after hospitalisation for a road traffic injury.

METHODS

Participants aged >=18 years admitted to hospital in New South Wales or Victoria for >24 hours were recruited in two separate prospective cohort studies (N=1,034). People who died or sustained minor or very severe injuries were excluded. Groups included Compulsory Third Party (fault-based, n=128), no-fault Transport Accident Commission (TAC; n=454) and workers compensation claimants (n=73), or no claim (n=226). Outcomes at six, 12- and 24-months post-injury included health [SF-12 Mental Component Score (MCS) and Physical Component Score (PCS)], and return to work for people working pre-injury. Multivariable mixed effects linear and logistic regressions, adjusting for demographic and injury covariates, examined differences in health and work outcomes between claimant groups, with fixed effects of time and random effects of participant ID.

RESULTS

Health status was better in people with a no-fault TAC claim (MCS: m=50.62, 95%CI:49.62,51.62; PCS: m=40.49, 95%CI:39.46,41.52) or no claim (MCS: m=49.99, 95%CI:49.62,51.62; PCS: m=44.36, 95%CI:43.00,45.72), than people with a workers compensation (MCS: m=45.73, 95%CI:43.46,48.00; PCS: m=38.94, 95%CI:36.59,41.30) or fault-based CTP claim (MCS: m=41.34, 95%CI:39.54,43.13; PCS: m=35.64, 95%CI:33.78,37.49). Relative to fault-based CTP claimants, the odds of returning to work were higher for people with no claim (AOR=6.84, 95%CI:1.73,27.05) but did not differ for no-fault TAC (AOR=1.21, 95%CI:0.36,4.05) or workers compensation claimants (AOR=0.83,95%CI: 0.17,3.99). While people with a fault-based CTP claim had poorer mental and physical health and return to work after injury, they showed greater improvements in mental health, and similar levels of improvement in physical health and work participation over time to the other groups.

CONCLUSION

The patterns of health and work across scheme types provide important insights against which we can contrast the effects of future scheme designs on client outcomes.

Low-Value Clinical Practices in Adult Traumatic Brain Injury: An Umbrella Review

Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias.

Identifying the priority challenges in trauma care delivery for Australian and New Zealand trauma clinicians

INTRODUCTION

Injury is a leading cause of death and disability world-wide. Little is known about the day-to-day challenges the trauma clinicians face in their practice that they feel could be improved through an increased evidence base. This study explored and ranked the trauma clinical practice research priorities of trauma care professionals across Australia and New Zealand.

METHODS

A modified-Delphi study was conducted between September 2019 and January 2020. The study employed two rounds of online survey of trauma professionals from relevant Australia and New Zealand professional organisations using snowballing method. Participants were asked to rank the importance of 29 recommendations, each corresponding to a key challenge in trauma care delivery. Decisions on the priorities of the challenges were determined by a consensus of >70% of respondents ranking the challenge as important or very important.

RESULTS

One hundred and fifty-five participants completed Round One, and 106 participants completed Round Two. A total of 15 recommendations reached >70% in Round One. Nine recommendations also reached >70% consensus in Round Two. Recommendations ranked highest were 'Caring for elderly trauma patients', 'Identifying and validating key performance indicators for trauma system benchmarking and improvement', and 'Management of traumatic brain injury'.

CONCLUSION

This study identified the priority areas for trauma research as determined by clinician ranking of the most important for informing and improving their practice. Addressing these areas generates potential to improve the quality and safety of trauma care in Australian and New Zealand.

Functional Outcomes in Patients Admitted to the Intensive Care Unit with Traumatic Brain Injury and Exposed to Hyperoxia: A Retrospective Multicentre Cohort Study

Background

Supplemental oxygen administration to critically ill patients is ubiquitous in the intensive care unit (ICU). Uncertainty persists as to whether hyperoxia is benign in patients with traumatic brain injury (TBI), particularly in regard to their long-term functional neurological outcomes.

Methods

We conducted a retrospective multicenter cohort study of invasively ventilated patients with TBI admitted to the ICU. A database linkage between the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS-APD) and the Victorian State Trauma Registry (VSTR) was utilized. The primary exposure variable was minimum acute physiology and chronic health evaluation (APACHE) III P_aO₂ in the first 24 h of ICU. We defined hypoxia as P_aO₂ < 60 mmHg, normoxia as 60–299 mmHg, and hyperoxia as ≥ 300 mmHg. The primary outcome was a Glasgow Outcome Scale-Extended (GOSE) < 5 at 6 months while secondary outcomes included 12 and 24 months GOSE and mortality at each of these timepoints. Additional sensitivity analyses were undertaken in the following subgroups: isolated head injury, patients with operative intervention, head injury severity, and P_aO₂ either subcategorized by increments of 60 mmHg or treated as a continuous variable.

Results

A total of 3699 patients met the inclusion criteria. The mean age was 42.8 years, 77.7% were male and the mean acute physiology and chronic health evaluation (APACHE) III score was 60.1 (26.3). 2842 patients experienced normoxia, and 783 hyperoxia. The primary outcome occurred in 1470 (47.1%) of patients overall with 1123 (47.1%) from the normoxia group and 312 (45.9%) from the hyperoxia group—odds ratio 0.99 (0.78–1.25). No significant differences in outcomes between groups at 6, 12, and 24 months were observed. Sensitivity analyses did not identify subgroups that were adversely affected by exposure to hyperoxia.

Conclusions

No associations were observed between hyperoxia in ICU during the first 24 h and adverse neurological outcome at 6 months in ventilated TBI patients.

Electronic supplementary material

The online version of this article (10.1007/s12028-020-01033-y) contains supplementary material, which is available to authorized users.

Challenges to trauma care delivery for Australian and New Zealand trauma clinicians

INTRODUCTION

The availability and implementation of evidence-based care is essential to achieving safe, quality trauma patient outcomes. Little is documented, however, about the challenges trauma clinicians face in their day-to day practice, or their views on the availability of evidence. This paper presents the most significant clinical practice challenges reported by multidisciplinary trauma care professionals in Australia and New Zealand, in particular those that may be resolved with focussed research or enhanced implementation activity.

METHODS

An exploratory survey of trauma professionals from relevant Australia and New Zealand professional organisations was conducted between September 2018 and February 2019 using the Snowballing Method. Participants were recruited via a non-random sampling technique to complete an online survey. Thematic analyses were conducted.

RESULTS

There were nine significant clinical practice challenge themes in trauma care, arising from 287 individual clinical practice challenges reported. The most reported being clinical management (bleeding, spinal, older patients) and operationalisation of the trauma system. There was no consensus as to the availability of evidence to guide each theme.

CONCLUSION

Future research should seek to address the clinical practice challenge of Australian and New Zealand trauma community to enable safe, quality trauma patient outcomes.

Factors facilitating recovery following severe traumatic brain injury: A qualitative study

Given the significant impact of severe traumatic brain injury (TBI), understanding factors influencing recovery is critical to inform prognostication and treatment planning. Previous research has focussed primarily on factors negatively associated with outcome, with less focus on factors facilitating the recovery process. The current qualitative study examined positive factors identified for recovery by individuals who had sustained severe TBI three years earlier. Semi-structured interviews were conducted with nine participants with TBI and 16 close-others. Participants were asked to identify factors about themselves (or the injured individual), those around them, and the care they received that they felt were positive for recovery. Using reflexive thematic analysis, three themes were identified as positive for recovery after a TBI. Having a support network included social supports such as family and friends, and receiving other funded/non-funded assistance towards improving independence and participation. Being positive and engaged included being able to participate, being positive, using compensatory strategies, and becoming fit, healthy and happy. Getting good care included patients perceiving they had a comprehensive and good quality hospital experience, and access to multidisciplinary outpatient services. A focus on enhancing these positive environmental, personal and service factors in service provision may enhance outcomes following severe TBI.