The health status of people claiming compensation for musculoskeletal injuries following road traffic crashes is not altered by an early intervention programme: a comparative study.

OBJECTIVE: To compare health outcomes among claimants compared to those who were ineligible or choose not to lodge a compensation claim. We also evaluated the effect of an early intervention programme on the health outcomes of the participants. DESIGN: Prospective comparative study using sequential cohorts. SUBJECTS: People presenting to hospital emergency departments with mild to moderate musculoskeletal injuries following road traffic crashes. INTERVENTION: referral to an early intervention programme for assessment by musculoskeletal physician, pain management education, promotion of self-management and encouragement of early activity. MAIN OUTCOMES: The 36-Item Short-Form Survey (SF-36); Hospital Anxiety and Depression Scale (HADS) and Functional Rating Index (FRI) scores were assessed at post-crash and at 12 months. RESULTS: At 12 months, mean scores in six and five of the SF-36 domains were significantly lower among participants who claimed compensation versus those who chose not to claim or were ineligible, respectively. Differences in mean SF-36 scores ranged from 3.0 ('general health perception') to 8.0 units ('role limitations due to physical problems'). Participants who claimed compensation had 6.3- and 4.6-units lower SF-36 physical component score compared to those who were ineligible (p=0.001) or chose not to claim (p=0.01), respectively. Participants who claimed compensation reported a worse HADS-depression score of 6.46 versus 4.97 and 4.69 observed in those who were ineligible (p=0.04) or did not claim (p=0.01). Claimants had worse FRI scores compared to non-claimants (p=0.01) and those who were ineligible (p=0.01). The early intervention did not improve health outcomes, 12 months after injury. CONCLUSIONS: Claiming compensation was associated with a worse health status for people with soft tissue injuries caused by road traffic crashes. The health status in people claiming compensation was not altered by an early intervention programme.

An early intervention programme had no detectable influence on the health status of people with musculoskeletal injuries following road traffic crashes: comparative study.

OBJECTIVE: To compare the health status of people with minor injuries from road traffic crashes that are exposed to an early, active intervention programme (intervention group) with those receiving usual care (control group) over a 12 month period. DESIGN: Prospective comparative study using sequential cohorts. SUBJECTS: People presenting to hospital emergency departments with mild to moderate musculoskeletal injuries following road traffic crashes. MAIN OUTCOME MEASURES: Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI) recorded immediately post-crash, at 6 months and at 12 months after injury. RESULTS: There were 95 participants allocated to the control group and 98 allocated to the intervention group. Participants were enrolled at a mean of 9.3 days following the crash. There were no significant differences in baseline health measures between the groups. Apart from a small improvement in anxiety for the intervention group, there were no significant differences in health status between the groups. Twenty percent of participants in the intervention group received treatment from external healthcare providers that was inconsistent with the recommendations of the intervention programme. CONCLUSIONS: The intervention programme failed to result in a clinically significant improvement in health outcomes compared with usual care. There is some evidence to suggest that the intervention had some psychological benefits, as evidenced by the small improvement in anxiety levels. Limited adherence, frequent use of co-interventions, or other factors (such as intervention content or intensity) may have reduced its effect.

The influence of fault on health in the immediate post-crash period following road traffic crashes.

OBJECTIVE: To compare the early health status of people who sustained injuries during road traffic crashes (RTC) in which they were at fault (AF), with people who sustained injuries in RTC in which they were not at fault (NAF). DESIGN: Prospective cohort study. SUBJECTS: People presenting to the emergency department with mild to moderate musculoskeletal injuries following RTC. MAIN OUTCOME MEASURES: Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure; Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI) recorded immediately post-crash. RESULTS: 193 people participated in the study and were enrolled a mean of 9.3 days following the crash. The mean age was 37 years and 60% were female. 71% were NAF. There was a significantly higher number of females in the NAF group (65% compared with 35% males; p<0.001). Neck and back injuries were reported by 90.4% of the NAF group compared to 69.1% of the AF group (p<0.001). There were no significant differences in PCS, FRI or pain intensity between the two groups at a mean of 9.3 days after the crash. The mean MCS for the NAF group was significantly worse than for the AF group (31.4 compared to 37.3; p = 0.005). The SF-36 domain revealed a significantly worse adjusted mean role emotional score for the NAF group (23.4 compared to 32.5, p = 0.002). Females had significantly worse MCS score than males (30.6 and 38.1 respectively; p<0.001) and worse adjusted mean anxiety and depression scores (10 compared to 7.8; p = 0.002 and 7.6 compared to 5.5; p = 0.002 respectively). CONCLUSIONS: Despite there being no difference in physical health status, the NAF group demonstrated more emotional and mental disturbance than the AF group; and this was significantly worse for females. Treatment strategies should focus on addressing early pain and disability as well as providing appropriate psychological interventions, particularly for people not at fault following RTC.

The association of compensation on longer term health status for people with musculoskeletal injuries following road traffic crashes: emergency department inception cohort study.

OBJECTIVE: To compare the health status of people claiming compensation for injuries sustained in road traffic crashes (RTC), with people who do not claim compensation. DESIGN: Prospective cohort study. SETTING: Australian Capital Territory, Australia and a fault based common law compensation scheme. SUBJECTS: People presenting to the emergency department with mild to moderate musculoskeletal injury following RTC. MAIN OUTCOME MEASURES: Physical Component Score (PCS) and Mental Component Score (MCS) of the Short Form 36 (SF-36) health status measure, Hospital Anxiety and Depression Scale (HADS) and the Functional Rating Index (FRI). These measures are recorded immediately post crash, at 6 and 12 months post crash. RESULTS: 95 people participated in the study and were enrolled a mean of 8.6 (median 8) days following the crash. 86% were followed up to 12 months after injury. Mean age was 37 years, 61% were female and 91% were employed at the time of their injury.33%ultimately claimed compensation, and 25% engaged a lawyer. There were no major differences in baseline personal characteristics or injury related factors between the groups. As expected, involvement as a passenger and in multiple vehicle crashes, were more frequent in the group claiming compensation. Over the duration of the study claiming compensation was associated with lower SF-36 PCS (5.5 (95%CI 8.6 to 2.4), p = 0.001), greater HADS-Anxiety (1.7 (95%CI 0.2­3.3), p = 0.048), and worse FRI (11.2 (95%CI 3.9­18.5), p = 0.003). There was a highly significant improvement in health status between baseline and 6 months after injury, but no further significant change between 6 and 12 months after injury. There was no difference in rate of improvement between the groups. Claiming compensation and psychological factors were independent predictors of worse health status at 12 months. CONCLUSION: In this study the group claiming compensation had overall worse health status following mild to moderate musculoskeletal injuries over the course of the study. There was no difference in rate of improvement between the groups. However, it is not possible to determine whether this negative effect was due to claiming compensation itself or the presence of other unmeasured factors.

Complications and mortality in older surgical patients in Australia and New Zealand (the REASON study): a multicentre, prospective, observational study.

We conducted a prospective study of non-cardiac surgical patients aged 70 years or more in 23 hospitals in Australia and New Zealand. We studied 4158 consecutive patients of whom 2845 (68%) had pre-existing comorbidities. By day 30, 216 (5%) patients had died, and 835 (20%) suffered complications; 390 (9.4%) patients were admitted to the Intensive Care Unit. Pre-operative factors associated with mortality included: increasing age (80-89 years: OR 2.1 (95% CI 1.6-2.8), p < 0.001; 90+ years: OR 4.0 (95% CI 2.6-6.2), p < 0.001); worsening ASA physical status (ASA 3: OR 3.1 (95% CI 1.8-5.5), p < 0.001; ASA 4: OR 12.4 (95% CI 6.9-22.2), p < 0.001); a pre-operative plasma albumin < 30 g.l⁻¹ (OR: 2.5 (95% CI 1.8-3.5), p < 0.001); and non-scheduled surgery (OR 1.8 (95% CI 1.3-2.5), p < 0.001). Complications associated with mortality included: acute renal impairment (OR 3.3 (95% CI 2.1-5.0), p < 0.001); unplanned Intensive Care Unit admission (OR 3.1 (95% CI 1.9-4.9), p < 0.001); and systemic inflammation (OR 2.5 (95% CI 1.7-3.7), p < 0.001). Patient factors often had a stronger association with mortality than the type of surgery. Strategies are needed to reduce complications and mortality in older surgical patients.

Effect of pump prime on acidosis, strong-ion-difference and unmeasured ions during cardiopulmonary bypass.

We tested the hypothesis that a cardiopulmonary bypass prime with lactate would be associated with less acidosis than a prime with only chloride anions because of differences in the measured strong-ion-difference. We randomised 20 patients to a 1500 ml bypass prime with either a chloride-only solution (Ringer's Injection; anions: chloride 152 mmol/l) or a lactated solution (Hartmann's solution; anions: chloride 109 mmol/l, lactate 29 mmol/l). Arterial blood was sampled before bypass and then two, five, 15 and 30 minutes after initiating bypass. We used repeated measures analysis of variance to compare groups. In both groups, the base-excess and measured strong-ion-difference decreased markedly from baseline after two minutes of bypass. The chloride-only group had greater acidosis with lower base-excess and pH (P < 0.05), greatest after five minutes of bypass (C5). Contrary to our hypothesis, however, the difference between the groups was not due to a difference in the measured strong-ion-difference, P = 0.88. At C5 when the difference in standard base-excess between the groups was greatest, 1.9 mmol/l (95% confidence interval: 0.1 to 3.6 mmol/l, P < 0.05), the difference in the measured strong-ion-difference was only 0.2 mmol/l (95% confidence interval: -2.4 to 2.7 mmol/l, P > 0.05). There was, however a difference in the net-unmeasured-ions (strong-ion-gap). We conclude that acid-base changes with cardiopulmonary bypass may differ with the prime but that the early differences between chloride-only and lactated primes appear not to be due to differences in the measured strong-ion-difference. We suggest future studies examine other possible mechanisms including unmeasured ions.

Effect of an anaesthesia department led critical care outreach and acute pain service on postoperative serious adverse events.

UNLABELLED: We examined whether a combined critical care outreach and acute pain service comprising both medical and nursing staff from the Department of Anaesthesia would decrease the incidence of postoperative serious adverse events in a hospital with an established Medical Emergency Team. We called this combined service IMPACT: Inpatient Management of acute Pain and Advice on Clinical Treatment. We conducted a prospective, before-and-after trial with a baseline phase (319 patients) of standard acute pain management followed by the IMPACT phase (271 patients), during which the IMPACT team systematically reviewed high-risk postoperative patients for the first three days after their return to the general wards. The incidence of serious adverse events decreased from 23 events per 100 patients to 16 events per 100 patients. The 30-day mortality decreased from 9% to 3%, p = 0.004. An acute pain service providing critical care outreach may improve postoperative outcome but the workload is considerable.

The effect of critical care outreach on postoperative serious adverse events.

We proposed that critical care outreach would decrease the incidence of postoperative serious adverse events and so conducted a sequential cohort study with a surveillance-only phase (baseline) followed by an intervention phase. We studied high-risk patients in a large Australian hospital. A critical care qualified nurse reviewed patients for the first three days after return to the general wards. During the intervention phase the nurse intervened in patient care where appropriate. We examined the incidence of 11 categories of serious adverse events per 100 patients during the first three days on the general wards during the surveillance and intervention phases. The surveillance phase had 319 patients and the intervention phase 345 patients. In a subgroup analysis, there were four myocardial infarctions per 100 patients in the surveillance phase and seven per 100 patients during the intervention phase (95% confidence interval: 1-7 infarctions per 100 patients increase). For the other 10 serious adverse events there were 19 per 100 patients in the surveillance phase and 11 per 100 patients in the intervention phase (95% confidence interval: 4-11 serious adverse events per 100 patients decrease). Outreach may have led to greater detection of myocardial infarctions while reducing the incidence of other serious adverse events.