Using trauma injury severity score (TRISS) variables to predict length of hospital stay following trauma in New Zealand

Aim – To develop and assess the predictive capabilities of a statistical model that relates routinely collected Trauma Injury Severity Score (TRISS) variables to length of hospital stay (LOS) in survivors of traumatic injury. Method – Retrospective cohort study of adults who sustained a serious traumatic injury, and who survived until discharge from Auckland City, Middlemore, Waikato, or North Shore Hospitals between 2002 and 2006. Cubic-root transformed LOS was analysed using two-level mixed-effects regression models. Results – 1498 eligible patients were identified, 1446 (97%) injured from a blunt mechanism and 52 (3%) from a penetrating mechanism. For blunt mechanism trauma, 1096 (76%) were male, average age was 37 years (range: 15-94 years), and LOS and TRISS score information was available for 1362 patients. Spearman’s correlation and the median absolute prediction error between LOS and the original TRISS model was ρ=0.31 and 10.8 days, respectively, and between LOS and the final multivariable two-level mixed-effects regression model was ρ=0.38 and 6.0 days, respectively. Insufficient data were available for the analysis of penetrating mechanism models. Conclusions – Neither the original TRISS model nor the refined model has sufficient ability to accurately or reliably predict LOS. Additional predictor variables for LOS and other indicators for morbidity need to be considered

Contemporary New Zealand coefficients for the Trauma Injury Severity Score: TRISS(NZ)

Aims – To develop local contemporary coefficients for the Trauma Injury Severity Score in New Zealand, TRISS(NZ), and to evaluate their performance at predicting survival against the original TRISS coefficients. Methods – Retrospective cohort study of adults who sustained a serious traumatic injury, and who survived until presentation at Auckland City, Middlemore, Waikato, or North Shore Hospitals between 2002 and 2006. Coefficients were estimated using ordinary and multilevel mixed-effects logistic regression models. Results – 1735 eligible patients were identified, 1672 (96%) injured from a blunt mechanism and 63 (4%) from a penetrating mechanism. For blunt mechanism trauma, 1250 (75%) were male and average age was 38 years (range: 15-94 years). TRISS information was available for 1565 patients of whom 204 (13%) died. Area under the Receiver Operating Characteristic (ROC) curves was 0.901 (95%CI: 0.879-0.923) for the TRISS(NZ) model and 0.890 (95% CI: 0.866-0.913) for TRISS (P<0.001). Insufficient data were available to determine coefficients for penetrating mechanism TRISS(NZ) models. Conclusions – Both TRISS models accurately predicted survival for blunt mechanism trauma. However, TRISS(NZ) coefficients were statistically superior to TRISS coefficients. A strong case exists for replacing TRISS coefficients in the New Zealand benchmarking software with these updated TRISS(NZ) estimates

Surgical Registrars as Primary Operators Have Acceptable Outcomes for Trauma Laparotomy

Background: The literature has suggested that acceptable outcomes in elective general surgery can be achieved with registrars operating but is less clear with trauma surgery. Methods: This was a retrospective study of all laparotomies performed for adult trauma between 2012 and 2020 at a Level 1 Trauma Centre in New Zealand to identify potential differences in clinical outcomes between primary operators. The primary operator of each operation was identified, along with the presence or absence of a consultant and the clinical outcome. Results: During the 9-year study period, a total of 204 trauma laparotomies were performed at Waikato Hospital. The groups of the primary operators were: a registrar with a consultant present (27%), a registrar without a consultant present (22%), a registrar assisting a consultant (48%), and a consultant who operated without a registrar (3%). Direct comparison was made between the three groups where registrars were involved in the laparotomy. There was no significant difference in the clinical outcomes, whether a consultant was present or not. Conclusions: Surgical registrars have acceptable outcomes for trauma laparotomy in the appropriate patients. A consultant surgeon should still operate on patients with more significant physiological derangements

Surgical Registrars as Primary Operators Have Acceptable Outcomes for Trauma Laparotomy

Background: The literature has suggested that acceptable outcomes in elective general surgery can be achieved with registrars operating but is less clear with trauma surgery. Methods: This was a retrospective study of all laparotomies performed for adult trauma between 2012 and 2020 at a Level 1 Trauma Centre in New Zealand to identify potential differences in clinical outcomes between primary operators. The primary operator of each operation was identified, along with the presence or absence of a consultant and the clinical outcome. Results: During the 9-year study period, a total of 204 trauma laparotomies were performed at Waikato Hospital. The groups of the primary operators were: a registrar with a consultant present (27%), a registrar without a consultant present (22%), a registrar assisting a consultant (48%), and a consultant who operated without a registrar (3%). Direct comparison was made between the three groups where registrars were involved in the laparotomy. There was no significant difference in the clinical outcomes, whether a consultant was present or not. Conclusions: Surgical registrars have acceptable outcomes for trauma laparotomy in the appropriate patients. A consultant surgeon should still operate on patients with more significant physiological derangements

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.</p

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 \u3e70% 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 \u3e70% in Round One. Nine recommendations also reached \u3e70% 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

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.</p

Priorities for trauma quality improvement and registry use in Australia and New Zealand

Introduction The Australia New Zealand Trauma Registry enables the collection and analysis of standardised data about trauma patients and their care for quality improvement, injury prevention and benchmarking. Little is known, however, about the needs of providers and clinicians in relation to these data, or their views on trauma quality improvement priorities. As clinical experts, trauma clinicians should have input to these as ultimately their practice may be influenced by report findings. This paper presents the perspectives of multidisciplinary trauma care professionals in Australia and New Zealand about the use of the Australia New Zealand Trauma Registry data and trauma quality improvement priorities. Methods An exploratory survey of trauma professionals from relevant Australia and New Zealand professional organisations was conducted using the Snowballing Method between September 2018 and February 2019. Participants were recruited via a non-random sampling technique to complete an online survey. Descriptive statistical and content analyses were conducted. Results The data use priorities identified by 102 trauma professionals from a range of locations participated were clinical improvement and system/process improvement (86.3%). Participants reported that access to trauma data should primarily be for clinicians (93.1%) and researchers (87.3%). Having a standardised approach to review trauma cases across hospitals was a priority in trauma quality improvement. Conclusion Trauma registry data are under-utilised and their use to drive clinical improvement and system/process improvement is fundamental to trauma quality improvement in Australia and New Zealand