Seasonality in trauma admissions - Are daylight and weather variables better predictors than general cyclic effects?

Trauma is a leading global cause of death, and predicting the burden of trauma admissions is vital for good planning of trauma care. Seasonality in trauma admissions has been found in several studies. Seasonal fluctuations in daylight hours, temperature and weather affect social and cultural practices but also individual neuroendocrine rhythms that may ultimately modify behaviour and potentially predispose to trauma. The aim of the present study was to explore to what extent the observed seasonality in daily trauma admissions could be explained by changes in daylight and weather variables throughout the year.publishedVersio

Mortality after hospital admission for trauma in Norway: A retrospective observational national cohort study

Background - National quality data for trauma care in Norway have not previously been reported. We have therefore assessed crude and risk-adjusted 30-day mortality in trauma cases after primary hospital admission on national and regional levels for 36 acute care hospitals and four regional trauma centres. Methods - All patients in the Norwegian Trauma Registry in 2015–2018 were included. Crude and risk-adjusted 30-day mortality was assessed for the total cohort and for severe injuries (Injury Severity Score ≥16), and individual and combined effects of health region, hospital level, and hospital size were studied. Results - 28,415 trauma cases were included. Crude mortality was 3.1% for the total cohort and 14.5% for severe injuries, with no statistically significant difference between regions. Risk-adjusted survival was lower in acute care hospitals than in trauma centres (0.48 fewer excess survivors per 100 patients, P Conclusion - Differences in risk-adjusted survival for severe injuries can to a large extent be attributed to whether patients are directly admitted to a trauma centre. This should have implications for planning of transport capacity in remote areas

Abdominal injuries in a major Scandinavian trauma center – performance assessment over an 8 year period

INTRODUCTION: Damage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries. The shift towards non-operative management in haemodynamically stable patients suffering blunt abdominal trauma has further contributed to the improved results. However, in many countries, low volume of trauma cases and limited exposure to trauma laparotomies constitute a threat to trauma competence. The aim of this study was to evaluate the institutional patient volume and performance for patients with abdominal injuries over an eight-year period. METHODS: Data from 955 consecutive trauma patients admitted in Oslo University Hospital Ulleval with abdominal injuries during the eight-year period 2002-2009 were retrospectively explored. A separate analysis was performed on all trauma patients undergoing laparotomy during the same period, whether abdominal injuries were identified or not. Variable life-adjusted display (VLAD) was used in order to describe risk-adjusted survival trends throughout the period and the patients admitted before (Period 1) and after (Period 2) the institution of a formal Trauma Service (2005) were compared. RESULTS: There was a steady increase in admitted patients with abdominal injuries, while the number of patients undergoing laparotomy was constant exposing the surgical trauma team leaders to an average of 8 trauma laparotomies per year. No increase in missed injuries or failures of non-operative management was detected. Unadjusted mortality rates decreased from period 1 to period 2 for all patients with abdominal injuries as well as for the patients undergoing laparotomy. However, this apparent decrease was not confirmed as significant in TRISS-based analysis of risk-adjusted mortality. VLAD demonstrated a steady performance throughout the study period. CONCLUSION: Even in a high volume trauma center the exposure to abdominal injuries and trauma laparotomies is limited. Due to increasing NOM, an increasing number of patients with abdominal injuries was not accompanied by an increase in number of laparotomies. However, we have demonstrated a stable performance throughout the study period as visualized by VLAD without an increase in missed injuries or failures of NOM

Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines

<p>Abstract</p> <p>Background</p> <p>Field triage is important for regional trauma systems providing high sensitivity to avoid that severely injured are deprived access to trauma team resuscitation (undertriage), yet high specificity to avoid resource over-utilization (overtriage). Previous informal trauma team activation (TTA) at Ulleval University Hospital (UUH) caused imprecise triage. We have analyzed triage precision after introduction of TTA guidelines.</p> <p>Methods</p> <p>Retrospective analysis of 7 years (2001–07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity).</p> <p>Results</p> <p>Of the 4 659 patients included in the study, 2 221 (48%) were severely injured. TTA occurred 4 440 times, only 2 002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1 508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics.</p> <p>Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6–3.4, p < 0.001) compared to those correctly triaged to TTA.</p> <p>Conclusion</p> <p>Triage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased risk of dying.</p

Increased complement activation 3 to 6 h after trauma is a predictor of prolonged mechanical ventilation and multiple organ dysfunction syndrome: a prospective observational study

Background Complement activation is a central mechanism in systemic inflammation and remote organ dysfunction following major trauma. Data on temporal changes of complement activation early after injury is largely missing. We aimed to describe in detail the kinetics of complement activation in individual trauma patients from admission to 10 days after injury, and the association with trauma characteristics and outcome. Methods In a prospective cohort of 136 trauma patients, plasma samples obtained with high time resolution (admission, 2, 4, 6, 8 h, and thereafter daily) were assessed for terminal complement complex (TCC). We studied individual TCC concentration curves and calculated a summary measure to obtain the accumulated TCC response 3 to 6 h after injury (TCC-AUC3–6). Correlation analyses and multivariable linear regression analyses were used to explore associations between individual patients’ admission TCC, TCC-AUC3–6, daily TCC during the intensive care unit stay, trauma characteristics, and predefined outcome measures. Results TCC concentration curves showed great variability in temporal shapes between individuals. However, the highest values were generally seen within the first 6 h after injury, before they subsided and remained elevated throughout the intensive care unit stay. Both admission TCC and TCC-AUC3–6 correlated positively with New Injury Severity Score (Spearman’s rho, p-value 0.31, 0.0003 and 0.21, 0.02) and negatively with admission Base Excess (− 0.21, 0.02 and − 0.30, 0.001). Multivariable analyses confirmed that deranged physiology was an important predictor of complement activation. For patients without major head injury, admission TCC and TCC-AUC3–6 were negatively associated with ventilator-free days. TCC-AUC3–6 outperformed admission TCC as a predictor of Sequential Organ Failure Assessment score at day 0 and 4. Conclusions Complement activation 3 to 6 h after injury was a better predictor of prolonged mechanical ventilation and multiple organ dysfunction syndrome than admission TCC. Our data suggest that the greatest surge of complement activation is found within the first 6 h after injury, and we argue that this time period should be in focus in the design of future experimental studies and clinical trials using complement inhibitors.publishedVersio

Calculating trauma triage precision: effects of different definitions of major trauma

BACKGROUND: Triage is the process of classifying patients according to injury severity and determining the priority for further treatment. Although the term “major trauma” represents the reference against which over- and undertriage rates are calculated, its definition is inconsistent in the current literature. This study aimed to investigate the effects of different definitions of major trauma on the calculation of perceived over- and undertriage rates in a Norwegian trauma cohort. METHODS: We performed a retrospective analysis of patients included in the trauma registry of a primary, referral trauma centre. Two “traditional” definitions were developed based on anatomical injury severity scores (ISS >15 and NISS >15), one “extended” definition was based on outcome (30-day mortality) and mechanism of injury (proximal penetrating injury), one ”extensive” definition was based on the “extended” definition and on ICU resource consumption (admitted to the ICU for >2 days and/or transferred intubated out of the hospital in ≤2 days), and an additional four definitions were based on combinations of the first four. RESULTS: There were no significant differences in the perceived under- and overtriage rates between the two “traditional” definitions (NISS >15 and ISS >15). Adding “extended” and “extensive” to the “traditional” definitions also did not significantly alter perceived under- and overtriage. Defining major trauma only in terms of the mechanism of injury and mortality, with or without ICU resource consumption (the “extended” and “extensive” groups), drastically increased the perceived overtriage rates. CONCLUSION: Although the proportion of patients who were defined as having sustained major trauma increased when NISS-based definitions were substituted for ISS-based definitions, the outcomes of the triage precision calculations did not differ significantly between the two scales. Additionally, expanding the purely anatomic definition of major trauma by including proximal penetrating injury, 30-day mortality, ICU LOS greater than 2 days and transferred intubated out of the hospital at ≤2 days did not significantly influence the perceived triage precision. We recommend that triage precision calculations should include anatomical injury scaling according to NISS. To further enhance comparability of trauma triage calculations, researchers should establish a consensus on a uniform definition of major trauma

Sudden survival improvement in critical neurotrauma: An exploratory analysis using a stratified statistical process control technique

Background Outcome after trauma depends on patient characteristics, quality of care, and random events. The TRISS model predicts probability of survival (Ps) adjusted for Injury Severity Score (ISS), Revised Trauma Score (RTS), mechanism of injury, and age. Quality of care is often evaluated by calculating the number of “excess” survivors, year by year. In contrast, the Variable Life-Adjusted Display (VLAD) technique allows rapid detection of altered survival. VLAD adjusts each death or survival by the patient's risk status and graphically displays accumulated number of unexpected survivors over time. We evaluated outcome changes and their time relation to trauma service improvements. Methods Observational, retrospective study of the total 2001–2011 trauma population from a Level I trauma centre. Outcome was 30-day survival. Ps was calculated with the TRISS model, 2005 coefficients. VLAD graphs were created for the entire population and for subpopulations stratified by ISS level, ISS body region (Head/Neck, Face, Chest, Abdomen/Pelvic contents, Extremities/Pelvic girdle, External), and maximum Abbreviated Injury Scale (maxAIS) score in each region. Piecewise linear regression identified VLAD graph breakpoints. Results 12,191 consecutive trauma patients (median age 35 years, 72% males, 91% blunt injury, 41% ISS ≥ 16) formed the dataset. Their VLAD graph indicated performance equal to TRISS predicted survival until a sudden improvement in late 2004. From then survival remained improved but unchanged through 2011. Total number of excess survivors was 141. Inspection of subgroup VLAD graphs showed that the increased survival mainly occurred in patients having at least one Head/Neck AIS 5 injury. The effect was present in both isolated and multitraumatised maxAIS 5 Head/Neck trauma. The remaining trauma population showed unchanged survival, superior to TRISS predicted, throughout the study period. Important general and neurotrauma-targeted improvements in our trauma service could underlie our findings: A formalised trauma service, damage control resuscitation protocols, structured training, increased helicopter transfer capacity, consultant-based neurosurgical assessment, a doubling of emergency neurosurgical procedures, and improved neurointensive care. Conclusions Stratified VLAD enables continuous, high-resolution system analysis. We encourage trauma centres to explore their data and to monitor future system changes. Copyright 2014 The Authors. Published by Elsevier Ltd