Indicators for the evaluation of musculoskeletal trauma systems: A scoping review and Delphi study

BACKGROUND

Trauma is a leading cause of mortality and morbidity, disproportionately affecting low- and middle-income countries. Musculoskeletal trauma results in the majority of post-traumatic morbidity and disability globally. The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries.

STUDY OBJECTIVES

The purpose of this study was to establish a practical list of performance indicators to evaluate and monitor the quality and equity of musculoskeletal trauma care delivery in health systems worldwide.

METHODS

A scoping review was performed that identified performance indicators related to musculoskeletal trauma care. Indicators were organized by phase of care (general, prevention, pre-hospital, hospital, post-hospital) within a modified Donabedian model (structure, process, outcome, equity). A panel of 21 experts representing 45 countries was assembled to identify priority indicators utilizing a modified Delphi approach.

RESULTS

The scoping review identified 1,206 articles and 114 underwent full text review. We included 95 articles which reported 498 unique performance indicators. Most indicators related to the hospital phase of care (n = 303, 60%) and structural characteristics (n = 221, 44%). Mortality (n = 50 articles) and presence of trauma registries (n = 16 articles) were the most frequently reported indicators. After 3 rounds of surveys our panel reached consensus on a parsimonious list of priority performance indicators. These focused on access to trauma care; processes and key resources for polytrauma triage, patient stabilization, and hemorrhage control; reduction and immobilization of fractures and dislocations; and management of compartment syndrome and open fractures.

CONCLUSIONS

The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries. To create quality and equitable trauma systems, musculoskeletal care must be incorporated into development plans with continuous monitoring and improvement. The performance indicators identified by our expert panel and organized in a modified Donabedian model can serve as a method for evaluating musculoskeletal trauma care.

Parity violation constraints using cosmic microwave background polarization spectra from 2006 and 2007 observations by the QUaD polarimeter

We constrain parity-violating interactions to the surface of last scattering using spectra from the QUaD experiment's second and third seasons of observations by searching for a possible systematic rotation of the polarization directions of cosmic microwave background photons. We measure the rotation angle due to such a possible "cosmological birefringence" to be 0.55 degrees +/-0.82 degrees (random) +/-0.5 degrees (systematic) using QUaD's 100 and 150 GHz temperature-curl and gradient-curl spectra over the spectra over the multipole range 200<l<2000, consistent with null, and constrain Lorentz-violating interactions to <2 x 10;{-43} GeV (68% confidence limit). This is the best constraint to date on electrodynamic parity violation on cosmological scales.

Determination of yeast glycogen content by individual cell spectroscopy using image analysis

A rapid technique has been developed to determine the glycogen content of yeast on an individual cell basis using a combination of image analysis technology and staining of yeast cells with an I(2):KI solution. Changes in mean cellular glycogen content during alcoholic fermentation have been reported using this technique. The glycogen content of stored brewer's yeast is heterogeneous compared to freshly propagated yeast which have a more uniform distribution of glycogen. Analysis of the distribution of yeast glycogen during fermentation indicates that a fraction of yeast cells do not dissimilate glycogen. Therefore, conventional analysis of the mean glycogen content of yeast used to inoculate fermentations is of limited use, unless information regarding the proportion of cells which utilize glycogen is known. Analysis of the distribution of glycogen within a yeast population can serve as a useful indicator of yeast quality.

Vacuum-assisted venous return in pediatric cardiopulmonary bypass

Vacuum-assisted venous return (VAVR) has been reported to offer benefits for adults undergoing cardiopulmonary bypass (CPB), such as improved venous return, lowering priming volume (by eliminating the need to prime the venous line), and the use of smaller venous cannulae. All these benefits would be of particular value in pediatric perfusion because of the unique challenges of these smaller patients and the relatively large components of the CPB circuit. We have been using VAVR in children since the early summer of 1998 after we became comfortable with the technique and convinced of its efficacy in adults. Ours is a medium-sized pediatric caseload of slightly more than 100 CPB cases per year. With that caseload, it is most effective for us to minimize the inventory of different sizes of disposables used. We have opted for an oxygenator/reservoir that has a maximum flow of 4 liters with a priming volume of about 1 liter. We have been unhappy with the large prime volume in infants and earlier, in 1997-1998, were using a smaller prime oxygenator/reservoir until it was recalled. Faced again with a larger priming volume in the infants, we decided to try vacuum to decrease hemodilution and to evaluate other possible benefits. Through the use of VAVR, we have been able to decrease our priming volume, use smaller venous cannulae, and have more consistent return while experiencing no adverse effects of VAVR in our pediatric cardiac surgery patients.

Nonresponsiveness to Mlsd in F1 hybrid mice carrying Mlsa and Mlsc genes

Neither the biological function nor a basic understanding of the enigmatic chromosome 1-encoded Mls locus of the mouse has yet been uncovered despite extensive investigations. The present report is a continuation of our genetic analyses of the Mls locus in an attempt to better define the system. Data presented here indicate that in contrast to cells of mice expressing either the Mlsa or Mlsc allele which respond in mixed leukocyte reactions to cells expressing the Mlsd allelic products, cells from (Mlsa X Mlsc)F1-hybrid mice do not. In addition, the nonresponder phenotype appears to segregate as a single autosomal genetic system in backcross animals. These findings fail to support two recently advanced hypotheses: first, that the Mls locus is nonpolymorphic, or second, that the Mls locus controls differential expression of Ia antigenic determinants. Although the mechanism by which a (responder X responder) converts to a nonresponder remains unknown, three models involving gene complementation are discussed.

Nonresponsiveness to Mlsd in F1 hybrid mice carrying Mlsa and Mlsc genes

Neither the biological function nor a basic understanding of the enigmatic chromosome 1-encoded Mls locus of the mouse has yet been uncovered despite extensive investigations. The present report is a continuation of our genetic analyses of the Mls locus in an attempt to better define the system. Data presented here indicate that in contrast to cells of mice expressing either the Mlsa or Mlsc allele which respond in mixed leukocyte reactions to cells expressing the Mlsd allelic products, cells from (Mlsa X Mlsc)F1-hybrid mice do not. In addition, the nonresponder phenotype appears to segregate as a single autosomal genetic system in backcross animals. These findings fail to support two recently advanced hypotheses: first, that the Mls locus is nonpolymorphic, or second, that the Mls locus controls differential expression of Ia antigenic determinants. Although the mechanism by which a (responder X responder) converts to a nonresponder remains unknown, three models involving gene complementation are discussed.