Jeffrey Petchell

Trauma teams in Australia: a national survey

Background:  Trauma teams have been associated with improved trauma patient outcomes. The present study seeks to estimate the use of trauma teams in Australian hospitals and describe their medical composition, leadership and criteria for activation.

Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital

OBJECTIVE To evaluate a two-tiered trauma activation protocol in a major trauma referral hospital in Australia. METHODS A prospective study performed over a 12-month period of all consecutive trauma activations in a major trauma referral hospital. The triage tool assigned patients into two tiers of trauma activation. The full trauma activation was initiated where physiological or anatomical criteria were present. These patients were assessed by a multispecialty trauma team. A consult trauma activation was initiated where only mechanism of injury criteria was present. These patients were assessed by the Emergency Department Registrar and Surgical Registrar. The primary endpoint was major trauma outcome defined as either injury severity score (ISS) greater than 15, requirement for High Dependency Unit or Intensive Care Unit (HDU/ICU) admission, need for urgent operative intervention, or in hospital mortality. RESULTS Of 1144 trauma activations, 468 (41%) were full trauma and 676 (59%) were consult trauma activations. The full trauma activation group had a significantly higher proportion of the major trauma outcome (34% vs. 5%, p<0.01) and all 18 patients (2%) who died were in the full trauma activation group. Sensitivity of the triage tool for the major trauma outcome was 83%, specificity was 68%, undertriage was 3% and overtriage was 27%. CONCLUSIONS The two-tiered trauma activation protocol is effective in identifying patients with major trauma from those with minor trauma. There were no deaths in undertriaged patients.

SEVERE TRAUMA CAUSED BY STABBING AND FIREARMS IN METROPOLITAN SYDNEY, NEW SOUTH WALES, AUSTRALIA

Background:  Stabbing and firearm trauma causing severe injuries (injury severity score (ISS) >15) and death is uncommon in Australia. The present study describes the experience with stabbings and firearm trauma causing severe injuries at a major Australian urban trauma centre.

Growing trend in older patients with severe injuries: mortality and mechanisms of injury between 1991 and 2010 at an inner city major trauma centre

Elderly patients with major trauma are an increasingly important public health concern. The objective of the study was to describe the long term trend in patients aged 65 years and older with major trauma.

The utility of Advanced Trauma Life Support (ATLS) clinical shock grading in assessment of trauma

Background Acute haemorrhage is a major contributor to trauma related morbidity and mortality. Quantifying blood loss acutely and accurately is a difficult task and no currently accepted standard exists. We introduce a simple shock grading tool incorporating vital signs, fluid response and estimated blood loss to describe shock grade during the primary survey based on the original Advanced Trauma Life Support (ATLS) classification. Methods We performed a prospective cohort study of all trauma patients admitted to our emergency room over a 1-year period to evaluate the utility of this tool for emergency physicians to detect significant haemorrhage in the trauma patient. Shock grades were prospectively assigned to patients by the trauma team as part of the primary survey, and followed up to assess for outcomes. The primary outcome was a composite endpoint of clinical, radiological and operative findings consistent with significant haemorrhage. Data were analysed using linear and logistic regression to assess predictive ability and receiver operator characteristic curve to assess overall diagnostic accuracy. Results The overall sensitivity of the shock grading tool was 83%. The diagnostic accuracy based on area under receiver operator characteristic curve was 0.86. There was also a significant association between increasing shock grade and both injury severity score (β coefficient 7.0, p<0.001, 95% CI 6.2 to 7.8) and the presence of significant haemorrhage (OR 5.1, p<0.001, 95% CI 3.6 to 7.3). Conclusions We conclude that a simple ATLS based clinical tool that objectively categorises haemorrhagic shock is a useful part of the primary survey of the trauma patient, although a larger study with higher statistical power is required to evaluate this conclusion further.

A trauma quality improvement programme associated with improved patient outcomes: 21 years of experience at an Australian Major Trauma Centre

INTRODUCTION Quality improvement programmes are an important part of care delivery in trauma centres. The objective was to describe the effect of a comprehensive quality improvement programme on long term patient outcome trends at a low volume major trauma centre in Australia. METHODS All patients aged 15 years and over with major trauma (Injury Severity Score>15) admitted to a single inner city major trauma centre between 1992 and 2012 were studied. The outcomes of interest were in-hospital mortality and transfer to rehabilitation. Time series analysis using integer valued autoregressive Poisson models was used to determine the reduction in adjusted monthly count data associated with the intervention period (2007-2012). Risk adjusted odds ratios for mortality over three yearly intervals was also obtained using multivariable logistic regression. Crude and risk adjusted mortality was compared before and after the implementation period. RESULTS 3856 patients were analysed. Crude in-hospital mortality fell from 16% to 10% after implementation (p<0.001). The intervention period was associated with a 25% decrease in monthly mortality counts. Risk adjusted mortality remained stable from 1992 to 2006 and did not fall until the intervention period. Crude and risk adjusted transfer to in-patient rehabilitation after major trauma also declined during the intervention period. CONCLUSION In this low volume major trauma centre, the implementation of a comprehensive quality improvement programme was associated with a reduction in crude and risk adjusted mortality and risk adjusted discharge to rehabilitation in severely injured patients.

Resources for managing trauma in rural New South Wales, Australia

Background:  Trauma bypass is not always appropriate in the management of rural trauma because of the large distances and travel times. Rural hospitals in New South Wales, Australia are an essential component of the statewide integrated trauma system. The present study profiles the trauma resources of base hospitals in rural New South Wales.

Paediatric trauma teams in Australia

Background:  Trauma teams have been associated with improved survival probability of paediatric trauma patients. The present study seeks to estimate the use of trauma teams in Australian paediatric tertiary referral centres and describe their medical composition, leadership and criteria for activation.

Predictors of transfer to rehabilitation for trauma patients admitted to a level 1 trauma centre—A model derivation and internal validation study

OBJECTIVE Determine the predictors of transfer to rehabilitation in a cohort of trauma patients and derive a risk score based clinical prediction tool to identify such patients during the acute phase of injury management. METHODS Trauma registry data at a single level one trauma centre were obtained for all patients aged between 15 and 65 years admitted due to injury between 2007 and 2011. Multivariable logistic regression with stepwise selection was performed to derive a prediction model for transfer to rehabilitation. The model was tested on a validation dataset using receiver operator characteristic analyses and bootstrap cross validation on the entire dataset. A clinical prediction risk score was developed based on the final model. RESULTS There were 4900 patients included in the study. Variables found to be the strongest predictors of rehabilitation after logistic regression with stepwise selection were pelvic injuries (OR 12.6 95% CI 6.2, 25.2 p<0.001), need for intensive care unit admission (OR 7.2 95% CI 4.2, 12.3 p<0.001) and neurosurgical operation (OR 10.5 95% CI 4.7, 23.1 p<0.001). After bootstrap cross validation the mean AUC was 0.86 (95% CI 0.84, 0.89). The model had a sensitivity of 89% and specificity of 64%. CONCLUSION Intensive unit admission, neurosurgical operation, pelvic injuries and other lower limb injuries were the most important predictors of the need for rehabilitation after trauma. The prediction model has good overall sensitivity, discrimination and could be further validated for use in clinical practice.