Gerard O’Reilly

Trauma registries in developing countries: A review of the published experience ☆

BACKGROUND The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries. METHODS A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis. RESULTS There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the Kampala Trauma Score (KTS). CONCLUSION Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed.

Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with high mortality and poor outcomes. The aim of this systematic review was to examine the incidence and outcome of patients with ATC in the setting of iTBI. METHODS We conducted a search of the MEDLINE database and Cochrane library, focused on subject headings and keywords involving coagulopathy and TBI. Design and results of each study were described. Studies were assessed for heterogeneity and the pooled incidence of ATC in the setting of iTBI determined. Reported outcomes were described. RESULTS There were 22 studies selected for analysis. A statistically significant heterogeneity among the studies was observed (p<0.01). Using the random effects model the pooled proportion of patients with ATC in the setting of iTBI was 35.2% (95% CI: 29.0-41.4). Mortality of patients with ATC and iTBI ranged between 17% and 86%. Higher blood transfusion rates, longer hospital stays, longer ICU stays, decreased ventilator free days, higher rates of single and multiple organ failure and higher incidence of delayed injury and disability at discharge were reported among patients with ATC. CONCLUSIONS ATC is commonly associated with iTBI and almost uniformly associated with worse outcomes. Any disorder of coagulation above the normal range appears to be associated with worse outcomes and therefore a clinically important target for management. Earlier identification of patients with ATC and iTBI, for recruitment into prospective trials, presents avenues for further research.

Early coagulopathy of major burns

INTRODUCTION AND AIMS The pathophysiology and time-course of coagulopathy post major burns are inadequately understood. The aims of this study were to review the incidence of acute coagulopathy post major burns, potential contributing factors associated with this coagulopathy and outcome of patients who developed early coagulopathy. METHODS A retrospective review of all patients with major burns (≥20% total body surface area (TBSA)) presenting to a tertiary burns referral centre was conducted. Data on demographic, injury characteristics and fluid resuscitation practices were recorded and tested for association with coagulopathy (INR>1.5 or aPTT>60 s) at hospital presentation and within 24 h of burns injury. Mortality, intensive care unit (ICU) admission, mechanical ventilation and blood and blood product usage were primary endpoints. RESULTS There were 99 patients who met the inclusion criteria with 36 (16) %TBSA burns. Coagulopathy was present in only three patients on presentation, but 37 (37%) patients developed early onset (within 24 h of injury) coagulopathy. Early onset coagulopathy was independently associated with %TBSA burnt (p<0.001) and volume of fluid administered (p=0.005). Early onset coagulopathy was associated with higher volumes of blood and blood product administration, ICU admission and prolonged mechanical ventilation. CONCLUSIONS Post major burns, a very low proportion of patients presented with coagulopathy, but a substantial proportion of patients developed coagulopathy within 24 h. This and the association of coagulopathy with the volume of fluid resuscitation suggest dilution as a major cause of the early coagulopathy of major burns.

Which patients have missing data? An analysis of missingness in a trauma registry

BACKGROUND Trauma registry data are almost always incomplete. Multiple imputation can reduce bias in registry analyses but the ideal approach would be to improve data capture. The aim of this study was to identify, using multiple imputation, which type of patients were most likely to have incomplete data. METHODS An analysis of prospectively collected regional trauma registry data over one year was performed. Analyses were conducted following complete data estimation using multiple imputation. Variables necessary for TRISS analysis and with incomplete data were analysed. For each variable, logistic regression analyses were performed to identify predictors of missingness. A p-value of less than 0.05 was considered to be statistically significant. RESULTS There were 2520 cases. The variables with the greatest proportion of missing observations were respiratory rate, GCS, Qualifier (of GCS and respiratory rate) and systolic blood pressure. The Qualifier variable described whether or not the patient was intubated and mechanically ventilated at the time the first hospital GCS and respiratory rate were recorded. GCS and respiratory rate were more likely to be missing (imputed) when abnormal (unadjusted ORs: 8.6 (p<0.001) and 2.1 (p=0.02), respectively). The most important determinant of a valid GCS or respiratory rate was the Qualifier. There was no association between whether the systolic blood pressure and Qualifier were missing (imputed) and whether they were estimated to be abnormal. Following multivariable analysis, data for all four variables were more likely to be missing when the patient died in hospital. Additional independent predictors of a missing GCS or respiratory rate were an abnormal pre-hospital GCS and severe chest injury. The Qualifier and systolic blood pressure were more likely to be missing where the patient was transferred from the primary hospital. CONCLUSION The major independent predictor of missing primary hospital physiological variables was death in hospital. An abnormal GCS was more likely to be missing from the regional trauma registry dataset. Predictors of a missing GCS or respiratory rate included whether the patient was intubated, an abnormal pre-hospital GCS and severe chest injury. Augmenting resources to record the initial observations of the more severely injured patients would improve data quality. Multiple imputation can be used to inform data capture.

Trauma registry methodology: A survey of trauma registry custodians to determine current approaches

INTRODUCTION The global burden of injury is enormous, especially in developing countries. Trauma systems in highincome countries have reduced mortality and disability. An important component of trauma quality improvement programmes is the trauma registry which monitors the epidemiology, processes and outcomes of trauma care. There is a severe deficit of trauma registries in developing countries and there are few resources to support the development of trauma registries. Specifically, publicly available information of trauma registry methodology in developed trauma registries is sparse. The aim of this study was to describe and compare trauma registries globally. METHODS A survey of trauma registry custodians was conducted. Purposive sampling was used to select trauma registries following a structured review of the literature. Registries for which there were at least two included abstracts over the five-year period were defined as active and selected. Following piloting and revision, a detailed survey covering physical and human resources, administration and methodology was distributed. The survey responses were analysed; single hospital and multi-hospital registries were compared. RESULTS Eighty-four registries were emailed the survey. Sixty-five trauma registries participated, giving a response rate of 77%. Of the 65 participating registries, 40 were single hospital registries and 25 were multi-hospital registries. Fifteen countries were represented; more than half of the participating registries were based in the USA. There was considerable variation in resourcing and methodology between registries. A trauma registry most commonly had at least three staff, reported to both the hospital and government, included more than 1000 cases annually, listed admission, death and transfer amongst inclusion criteria, mandated collection of more than 100 data elements, used AIS Version 2005 (2008 update) and used age, the Glasgow Coma Scale and the Injury Severity Score for injury severity adjustment. CONCLUSION Whilst some characteristics were common across many trauma registries, the resourcing and methodology varied markedly. The common features identified may serve as a guide to those looking to establish a trauma registry. However much remains to be done for trauma registries to determine the best standardised approach.

Management of haemodynamically stable patients with abdominal stab wounds

Objectives:  Australasian trauma centres receive relatively low numbers of penetrating injuries from stabbings. There is limited agreement regarding protocols to guide the management of haemodynamically stable patients with penetrating injuries. This has resulted in a wide variation in practice with anecdotally high negative laparotomy rates. The aim of the present study was to review the ED procedures, investigations and disposition of this group of patients.

Evaluating patient presentations for care delivered by emergency nurse practitioners : a retrospective analysis of 12 months

BACKGROUND The delivery of quality patients care in the emergency department (ED) is emerging as one of the most important service indicators to be measured in health services today. The emergency nurse practitioner role was implemented as a service innovation in one Melbourne, ED, Australia, in July 2004. The primary aim of the role was intended to enhance healthcare services, improve the efficiency and timely delivery of high quality care to patients. AIM To conduct a retrospective study of patient presentations at the ED to obtain a profile of the characteristics of patients managed by emergency nurse practitioners. Specifically the objectives of the study were to: (1) examine the demographics of the patient population and (2) evaluate data on emergency department service indicators for this patient cohort. METHOD A descriptive exploratory design was used. All patients presenting to the ED from January 01, 2011 to December 31, 2011 and managed by emergency nurse practitioners were included in the review. Data collection included baseline demographics, waiting times to be seen, length of stay, ED discharge diagnoses and referral patterns. Data were extracted and imported directly from the ED patient information system (Cerner log), for the specified time frame. RESULTS A total of 5212 patients were reviewed in the study period. The median age of patients was 35 years and 61% of patients were male. The most common discharge diagnosis was open wounds to hand/wrist. Waiting times to be seen by the emergency nurse practitioner were 14 min and length of stay for patients with a discharge disposition of home were 122 min. CONCLUSIONS This study has provided information on patient baseline characteristics and performance on important service indicators for this patient sample that will inform further research to evaluate specific outcomes of the emergency nurse practitioner service.

A procedural check list for pleural decompression and intercostal catheter insertion for adult major trauma

BACKGROUND Intercostal catheter (ICC) insertion is the standard pleural decompression and drainage technique for blunt and penetrating traumatic injury. Potentially high complication rates are associated with the procedure, with the literature quoting over 20% in some cases (1-4). Empyema in particular is a serious complication. Risk adverse industries such as the airline industry and military services regularly employ checklists to standardise performance and decrease human errors. The use of checklists in medical practice is exemplified by introduction of the WHO Surgical Safety checklist. METHODS The Alfred Hospital in Melbourne, Australia is an Adult Level 1 Trauma Centre. In August 2009 The Alfred Trauma Service introduced an evidence-based checklist system for the insertion of ICCs, combined with standardised formal training for resident medical staff, in an attempt to minimise the incidence of ICC related empyema. RESULTS Between January 2003 and July 2009 the incidence of empyema was 1.44% (29 in 2009 insertions). This decreased to 0.57% between August 2009 and December 2011 (6 in 1060 insertions) when the measures described above were introduced [p=0.038 Fishers exact test, 2-tailed]. CONCLUSION Quality control checklists - such as the ICC checklist described - are a sensible and functional means to standardise practice, to decrease procedural error and to reduce complication rates during trauma resuscitation.

Impact of trauma system structure on injury outcomes: a systematic review protocol.

BackgroundInjury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization.MethodsWe will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool.DiscussionWe expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts.Systematic review registrationThis protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041336.

The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients

BACKGROUND AND OBJECTIVE The National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients. METHODS Patients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated. RESULTS Over the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%-96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%-97.2%]. CONCLUSION Compared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.