Priorities for research in trauma care: creating a bucket list

Trauma represents a major global health burden, yet receives disproportionally less funding compared to other medical conditions. One report found that injury research constituted only 6% of all research grants provided by major funders. Alas, if only there was an endless funding resource for trauma and critical care research. Indeed, only those who have tried to get past the high doors of the federal and institutional research funding programmes (where these even exist) can tell of the intricacies involved, the frustration and pain of rejections, the hard work and relentless hours of tedious reporting to reach an even remotely slim chance for a well-funded research programme on a perceived valuable theme and a well-designed project. Clearly, there is a need to prioritize. The critical questions are what to investigate, what to fund and, what are the clinical implications and for whom? And, hence, how to strengthen the trauma chain of survival?publishedVersio

Priorities for research in trauma care: creating a bucket list

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Dispatch accuracy of physician-staffed emergency medical services in trauma care in south-east Norway: a retrospective observational study

Background Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement. Methods Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times. Results Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74–80% and the range of undertriage was 20–32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was “Police/fire brigade request immediate response” recorded in 4321 (22.7%) of the incidents. Criteria from the groups “Accidents” and “Road traffic accidents” were recorded in 10,875 (57.2%) incidents, and criteria from the groups “Transport reservations” and “Unidentified problem” in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records. Conclusions Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.publishedVersio

Health Care Implications of the COVID-19 Pandemic for Patients with Severe Traumatic Brain Injury-A Nationwide, Observational Cohort Study

Background Containment measures during the coronavirus disease of 2019 (COVID-19) pandemic have resulted in a substantial reduction in treatment of injury. The effect of the COVID-19 pandemic on the epidemiology and mortality of severe traumatic brain injury on a national, population-based level is unknown. Methods Data on all patients with severe traumatic brain injury between 2017 and 2020 were retrieved from the National Trauma Registry of Norway. The study cohort was derived from the pandemic period (March 12 to December 31, 2020) and the control cohort from the prepandemic years 2017 to 2019. The outcome measures were 30-day mortality, in-hospital mortality, and discharge destination. Results This study included 522 trauma patients with severe traumatic brain injury, 387 (74.1%) in the prepandemic and 135 (25.9%) in the pandemic period. Length of stay increased significantly during the pandemic period (4 vs. 3 days; P = 0.014). The 30-day mortality rate was 39% (n = 149) in the prepandemic versus 38% (n = 52) pandemic period (P = 0.998). In-hospital mortality was 33% (n = 128) in the prepandemic versus 33% (n = 44) in the pandemic period (P = 0.920). There were no statistically significant differences in discharge destination besides the number of patients discharged to home in the pandemic period (P = 0.003). When adjusted for clinical relevant factors such as age, gender, and head injury severity, the mortality outcomes did not change during the pandemic period. Conclusions The containment and lockdown measures during the COVID-19 pandemic in Norway did not affect the number of patients or mortality of patients with severe traumatic brain injury.publishedVersio

Impact on radiological practice of active guideline implementation of Musculoskeletal guideline, as measured over a 12-month period

Background An ever-increasing technological development in the field of radiology urges a need for guidelines to provide predictable and just health services. A musculoskeletal guideline was developed in Norway in 2014, without active implementation. Purpose To investigate the impact of active guideline implementation on the use of musculoskeletal diagnostic imaging most frequently encountered in general practice (pain in the neck, shoulders, lower back, and knees). Material and Methods The total number of outpatient radiological examinations across modalities registered at the Norwegian Health Economics Administration between January 2013 and February 2019 was assessed using an interrupted time series design. Results A 12% reduction in the total examination of Magnetic Resonance Imaging shoulder and knee, and x-ray lower back and shoulder was found at a significant level (p = 0.05). Stratified analysis (Magnetic Resonance Imaging examination as one group and x-ray examinations as the other) showed that this reduction mainly was due to the reduction in the use of Magnetic Resonance Imaging examinations (shoulder and knee) which was reduced by 24% at a significant level (p = 0.002), while x-ray examinations had no significant level change (p = 0.71). No other statistically significant changes were found. Conclusion The impact of the implementation on the use of imaging of the neck, shoulder, lower back, and knee is uncertain. Significant reductions were demonstrated in the use of some examinations in the intervention county, but similar effects were not seen when including a control group in the analysis. This indicates a diffusion of the implementation, or other interventions or events that affected both counties and occurred in the intervention period.publishedVersio

Is there a weekend effect on mortality rate and outcome for moderate and severe traumatic brain injury? A population-based, observational cohort study

Purpose The aim of the study was to analyse patient and injury characteristics and the effects of weekend admissions on mortality rate and outcome after moderate and severe traumatic brain injuries. Methods This is an observational cohort study based on data from a prospectively maintained regional trauma registry in South Western Norway. Patients with moderate and severe traumatic brain injury admitted between January 1st, 2004 and December 31st, 2019 were included in this study. Results During the study period 688 patients were included in the study with similar distribution between moderate (n ​= ​318) and severe (n ​= ​370) traumatic brain injury. Mortality rate was 46% in severe and 13% in moderate traumatic brain injury. Two hundred and thirty-one (34%) patients were admitted during weekends. Patients admitted during weekends were significantly younger (median age (IQR) 32.0 (25.5–67.0) vs 47.0 (20.0–55.0), p ​< ​0.001). Pre-injury ASA 1 was significantly more common in patients admitted during weekends (n ​= ​146, 64%, p ​= ​0.001) while ASA 3 showed significance during weekdays compared to weekends (n ​= ​101, 22%, p ​= ​0.013). On binominal logistic regression analysis mortality rate was significantly higher with older age (OR 1.03, 95% CI for OR 1.02–1.04, p ​< ​0.001) and increasing TBI severity (OR 7.08, 95% CI for OR 4.67–10.73, p ​< ​0.001). Conclusions Mortality rate and poor clinical outcome remain high in severe traumatic brain injury. While a higher number of patients are admitted during the weekend, mortality rate does not differ from weekday admissions.publishedVersio

Care pathways and factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe traumatic brain injury: a population-based study from the Norwegian trauma registry

Background Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals. Methods A population-based cohort study from the national Norwegian Trauma Registry (2015–2020) of adult patients (≥16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head≥3, AIS Body<3 and maximum 1 AIS Body=2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability. Results The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P<0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P<0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤13: 55% vs. 27, P<0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients<77 years, and increasing NISSs until the effect was inverted at higher scores. Decreased transfer probability was significantly associated with increasing age and comorbidity, and distance between the acute care trauma hospital and the nearest neurotrauma center, except for extreme NISSs. Conclusions Acute care trauma hospitals managed a substantial burden of isolated moderate-to-severe TBI patients primarily and definitively, highlighting the importance of high-quality neurotrauma care in non-neurosurgical hospitals. The transfer probability declined with increasing age and comorbidity, suggesting that older patients were carefully selected for transfer to specialized care

7. Barnehagetilsynet i den kommunale oppfølginga av rammeplanen

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Incidence, Mechanisms of Injury and Mortality of Severe Traumatic Brain Injury: An Observational Population-Based Cohort Study from New Zealand and Norway

Background Comparing trauma registry data from different countries can help to identify possible differences in epidemiology, which may help to improve the care of trauma patients. Methods This study directly compares the incidence, mechanisms of injuries and mortality of severe TBI based on population-based data from the two national trauma registries from New Zealand and Norway. All patients prospectively registered with severe TBI in either of the national registries for the 4-year study period were included. Patient and injury variables were described and age-adjusted incidence and mortality rates were calculated. Results A total of 1378 trauma patients were identified of whom 751 (54.5%) from New Zealand and 627 (45.5%) from Norway. The patient cohort from New Zealand was significantly younger (median 32 versus 53 years; p < 0.001) and more patients from New Zealand were injured in road traffic crashes (37% versus 13%; p < 0.001). The age-adjusted incidence rate of severe TBI was 3.8 per 100,000 in New Zealand and 2.9 per 100,000 in Norway. The age-adjusted mortality rates were 1.5 per 100,000 in New Zealand and 1.2 per 100,000 in Norway. The fatality rates were 38.5% in New Zealand and 34.2% in Norway (p = 0.112). Conclusions Road traffic crashes in younger patients were more common in New Zealand whereas falls in elderly patients were the main cause for severe TBI in Norway. The age-adjusted incidence and mortality rates of severe TBI among trauma patients are similar in New Zealand and Norway. The fatality rates of severe TBI are still considerable with more than one third of patients dying.publishedVersio

Epidemiology of abdominal trauma: An age- and sex-adjusted incidence analysis with mortality patterns

Purpose Abdominal injuries may occur in up to one-third of all patients who suffer severe trauma, but little is known about epidemiological trends and characteristics in a Northern European setting. This study investigated injury demographics, and epidemiological trends in trauma patients admitted with abdominal injuries. Methods This was an observational cohort study of all consecutive patients admitted to Stavanger University Hospital (SUH) with a documented abdominal injury between January 2004 and December 2018. Injury demographics, age- and sex-adjusted incidence, and mortality patterns are analyzed across three time periods. Results Among 7202 admitted trauma patients, 449 (6.2%) suffered abdominal injuries. The median age was 31 years, and the age increased significantly over time (from a median of 25 years to a median of 38.5 years; p = 0.020). Patients with ASA 2 and 3 increased significantly over time. Men accounted for 70% (316/449). The injury mechanism was blunt in 91% (409/449). Transport-related accidents were the most frequent cause of injury in 57% (257/449). The median Injury Severity Score (ISS) was 21, and the median New Injury Severity Score (NISS) was 25. The annual adjusted incidence of all abdominal injuries was 7.2 per 100,000. Solid-organ injuries showed an annual adjusted incidence of 5.7 per 100,000. The most frequent organ injury was liver injury, found in 38% (169/449). Multiple abdominal injuries were recorded in 44% (197/449) and polytrauma in 51% (231/449) of the patients. Overall 30-day mortality was 12.5% (56/449) and 90-day mortality 13.6% (61/449). Conclusion The overall adjusted incidence rate of abdominal injuries remained stable. Age at presentation increased by over a decade, more often presenting with pre-existing comorbidities (ASA 2 and 3). The proportion of polytrauma patients was significantly reduced over time. Mortality rates were declining, although not statistically significant.publishedVersio