Revised Functional Capacity Index as a predictor of outcome following injury.

BACKGROUND: Assessment of functional outcomes in survivors of severe injury is an identified priority for trauma systems. The predictive Functional Capacity Index (pFCI) within the 2008 Abbreviated Injury Scale dictionary (pFCI08) offers a widely available tool for predicting functional outcomes without requiring long-term follow-up. This study aimed to assess the 12-month functional outcome predictions of pFCI08 in a major trauma population, and to test the assumptions made by its developers to ensure population homogeneity. METHODS: Patients with major trauma from Victoria, Australia, were followed up using routine telephone interviews. Assessment of survivors 12 months after injury included the Glasgow Outcome Scale - Extended (GOS-E). κ scores were used to measure agreement between pFCI08 and assessed GOS-E scores. RESULTS: Of 20 098 patients with severe injury, 12 417 had both pFCI08 and GOS-E scoring available at 12 months. The quadratic weighted κ score across this population was 0·170; this increased to 0·244 in the subgroup of 1939 patients who met all pFCI assumptions. However, expanding the age range used in this group did not significantly affect κ scores until patients over the age of 70 years were included. DISCUSSION: The pFCI08 has only a slight agreement with outcomes following major trauma. However, the age limits in the pFCI development assumptions are unnecessarily restrictive. The pFCI08 may be able to contribute to future systems predicting functional outcomes following severe injury, but is likely to explain only a small proportion of the variability in patient outcomes.

Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry.

BACKGROUND AND OBJECTIVES: Critically bleeding patients requiring massive transfusion (MT) are clinically challenging, and limited data exist to support management decisions. This study describes patient characteristics, transfusion support and clinical outcomes from the Australian and New Zealand (NZ) Massive Transfusion Registry (ANZ-MTR). MATERIALS AND METHODS: Retrospective, cohort study of all adult patients receiving MT (≥5 units red blood cells [RBC] in 4 h) at participating ANZ-MTR hospitals, 2011-2015. Mortality information was collected from the Australian National Death Index and NZ Ministry of Health. Associations between patient characteristics and outcomes were modelled using logistic regression. RESULTS: A total of 3560 MT cases were identified. For in-hospital deaths, cardiothoracic surgery was the most frequent bleeding context (24·5%) followed by trauma (18·3%). Age (OR = 1·03; 95% CI: 1·02-1·04), more comorbidities (OR = 1·14; 95% CI: 1·09-1·21), larger volume of RBC in first 24 h from MT onset (OR = 1·04; 95% CI: 1·02-1·06), higher platelet to RBC ratio at 4 h (OR = 2·76; 95% CI: 1·14-6·65) and higher activated partial thromboplastin time (OR = 1·02; 95% CI: 1·01-1·03) were associated with in-hospital mortality. CONCLUSION: Patients with more comorbidities, older age, traumatic or surgical bleeding or requiring more blood components had higher in-hospital mortality. These findings provide a basis to evaluate and monitor practice relating to optimal use of blood products, variation in transfusion practices and patient outcomes, and also enable benchmarking of hospital performance for management of MT in specific patient groups.

Evaluation of clinical coding data to determine causes of critical bleeding in patients receiving massive transfusion: a bi-national, multicentre, cross-sectional study.

OBJECTIVES: To evaluate the use of routinely collected data to determine the cause(s) of critical bleeding in patients who receive massive transfusion (MT). BACKGROUND: Routinely collected data are increasingly being used to describe and evaluate transfusion practice. MATERIALS/METHODS: Chart reviews were undertaken on 10 randomly selected MT patients at 48 hospitals across Australia and New Zealand to determine the cause(s) of critical bleeding. Diagnosis-related group (DRG) and International Classification of Diseases (ICD) codes were extracted separately and used to assign each patient a cause of critical bleeding. These were compared against chart review using percentage agreement and kappa statistics. RESULTS: A total of 427 MT patients were included with complete ICD and DRG data for 427 (100%) and 396 (93%), respectively. Good overall agreement was found between chart review and ICD codes (78·3%; κ = 0·74, 95% CI 0·70-0·79) and only fair overall agreement with DRG (51%; κ = 0·45, 95% CI 0·40-0·50). Both ICD and DRG were sensitive and accurate for classifying obstetric haemorrhage patients (98% sensitivity and κ > 0·94). However, compared with the ICD algorithm, DRGs were less sensitive and accurate in classifying bleeding as a result of gastrointestinal haemorrhage (74% vs 8%; κ = 0·75 vs 0·1), trauma (92% vs 62%; κ = 0·78 vs 0·67), cardiac (80% vs 57%; κ = 0·79 vs 0·60) and vascular surgery (64% vs 56%; κ = 0·69 vs 0·65). CONCLUSION: Algorithms using ICD codes can determine the cause of critical bleeding in patients requiring MT with good to excellent agreement with clinical history. DRG are less suitable to determine critical bleeding causes.

RESPOND--A patient-centred programme to prevent secondary falls in older people presenting to the emergency department with a fall: protocol for a multicentre randomised controlled trial.

INTRODUCTION: Participation in falls prevention activities by older people following presentation to the emergency department (ED) with a fall is suboptimal. This randomised controlled trial (RCT) will test the RESPOND programme, an intervention designed to improve older persons' participation in falls prevention activities through delivery of patient-centred education and behaviour change strategies. DESIGN AND SETTING: A RCT at two tertiary referral EDs in Melbourne and Perth, Australia. PARTICIPANTS: 528 community-dwelling people aged 60-90 years presenting to the ED with a fall and discharged home will be recruited. People who require an interpreter or hands-on assistance to walk; live in residential aged care or >50 km from the trial hospital; have terminal illness, cognitive impairment, documented aggressive behaviour or a history of psychosis; are receiving palliative care or are unable to use a telephone will be excluded. METHODS: Participants will be randomly allocated to the RESPOND intervention or standard care control group. RESPOND incorporates (1) a home-based risk factor assessment; (2) education, coaching, goal setting and follow-up telephone support for management of one or more of four risk factors with evidence of effective interventions and (3) healthcare provider communication and community linkage delivered over 6 months. Primary outcomes are falls and fall injuries per person-year. DISCUSSION: RESPOND builds on prior falls prevention learnings and aims to help individuals make guided decisions about how they will manage their falls risk. Patient-centred models have been successfully trialled in chronic and cardiovascular disease; however, evidence to support this approach in falls prevention is limited. TRIAL REGISTRATION NUMBER: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000336684).

Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion.

BACKGROUND AND OBJECTIVES: The type and clinical characteristics of patients identified with commonly used definitions of massive transfusion (MT) are largely unknown. The objective of this study was to define the clinical characteristics of patients meeting different definitions of MT for the purpose of patient recruitment in observational studies. MATERIALS AND METHODS: Data were extracted on all patients who received red blood cell (RBC) transfusions in 2010 at three tertiary Australian hospitals. MT patients were identified according to three definitions: ≥10 units RBC in 24 h (10/24 h), ≥6 units RBC in 6 h (6/6 h) and ≥5 units RBC in 4 h (5/4 h). Clinical coding data were used to assign bleeding context. Data on in-hospital mortality were also extracted. RESULTS: Five hundred and forty-two patients met at least one MT definition, with 236 (44%) included by all definitions. The most inclusive definition was 5/4 h (508 patients, 94%) followed by 6/6 h (455 patients, 84%) and 10/24 h (251 patients, 46%). Importantly, 40-55% of most types of critical bleeding events and 82% of all obstetric haemorrhage cases were excluded by the 10/24 h definition. Patients who met both the 5/4 h and 10/24 h definitions were transfused more RBCs (19 vs. 8 median total RBC units; P < 0·001), had longer ventilation time (120 vs. 55 h; P < 0·001), median ICU (149 vs. 99 h; P < 0·001) and hospital length of stay (23 vs. 18 h; P = 0·006) and had a higher in-hospital mortality rate (23·3% vs. 16·4%; P = 0·050). CONCLUSION: The 5/4 h MT definition was the most inclusive, but combination with the 10/24 h definition appeared to identify a clinically important patient cohort.

Triaging the right patient to the right place in the shortest time.

Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.

Investigation of outcomes following recombinant activated FVII use for refractory bleeding during abdominal aortic aneurysm repair.

OBJECTIVE: To evaluate the outcomes following recombinant activated factor VII (rFVIIa) use during abdominal aortic aneurysms (AAA) repair. DESIGN: AAA patients were selected from the Australian and New Zealand Haemostasis Registry (ANZHR) who received off-licence rFVIIa to control critical bleeding. METHODS: Patient characteristics and outcomes were compared between responders (bleeding stopped/attenuated) and non-responders (bleeding continued) to rFVIIa, stratified by aneurysm status (ruptured (r-AAA) vs. non-ruptured (nr-AAA)). Patients were also scored using POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) and Hardman Index mortality predictive models. RESULTS: In total, 77 AAA patients were included in the analysis. Approximately 73% (n = 56) of them had ruptured aneurysms and about 50% (n = 35/70 with known data) responded positively to rFVIIa. Eleven incidents of thromboembolic adverse events were reported in 9 patients (6 r-AAA and 3 nr-AAA). Responders in both ruptured and non-ruptured groups had significantly lower 28-day mortality than non-responders (r-AAA: 40% (10/25) vs. 92% (24/26); P < 0.001; nr-AAA: 30% (3/10) vs. 67% (6/9); P < 0.01). Mortality predictive models did not show any difference between overall observed and expected mortality in ANZHR patients. CONCLUSION: Patients who responded to rFVIIa had a lower mortality than those who did not respond to the treatment.

Reducing the length of stay for acute hospital patients needing admission into inpatient rehabilitation: a multicentre study of process barriers.

BACKGROUND: Patient flow is a major problem in hospitals. Delays in accessing inpatient rehabilitation have not been well studied. AIMS: Measure the time taken for key processes in the patient journey from acute hospital admission through to inpatient rehabilitation admission in order to identify opportunities for improvement. METHODS: Retrospective open cohort study. All patients admitted over 8- and 10-month periods during 2008 into two inpatient rehabilitation units in Melbourne, Australia. Main outcome measures were the duration of the following key processes: acute hospital admission until referral for rehabilitation, referral until assessment by the rehabilitation service, assessment until deemed ready for transfer to rehabilitation, ready for transfer until rehabilitation admission. RESULTS: Three hundred and sixty patients were in the study sample (females = 186; 51.7%); mean age = 58.4 (standard deviation = 15.0) years. There was a median of 7 (interquartile range [IQR] 4-13) days from acute hospital admission till referral for rehabilitation, a median of 1 (IQR 0-1) day from referral till assessment, a median of 0 (IQR 0-2) days from assessment till deemed ready for transfer and a median of 1 (IQR 0-3) day from ready till admission into rehabilitation. Overall, patients spent 12.0% (804/6682) of their acute hospital admission waiting for a rehabilitation bed. CONCLUSIONS: There are opportunities to improve the efficiency of key processes in the acute hospital journey for patients subsequently admitted to inpatient rehabilitation; in particular, reducing the time from acute hospital admission till referral for rehabilitation and from being deemed ready for transfer to rehabilitation till admission.

Why older patients of lower clinical urgency choose to attend the emergency department.

BACKGROUND/AIMS: To examine non-clinical factors associated with emergency department (ED) attendance by lower urgency older patients. METHODS: An exploratory descriptive study comprising structured interviews with lower urgency community-dwelling patients aged ≥70 years presenting to a tertiary metropolitan Melbourne public hospital ED. Demographical and clinical characteristics, self-reported feelings of social connectedness, perceived accessibility to primary care, reason for attending ED were measured. RESULTS: One hundred patients were interviewed: mean age 82 years, 56% female, 57% lived alone; 73% presented during business hours, 58% arrived by ambulance, 80% presented for illness, and 65% were discharged home within 48 h. Fifty-six per cent of patients reported feeling socially disconnected, comprising 49% living alone compared with 65% who lived with their spouse/family. All patients attended a regular general practitioner, 31% reporting regular review appointments. Thirty-five per cent reported waiting times >2-3 days for urgent problems; 59% stated accessing care 'after hours' without attending ED as difficult, with 20% having attended ED 3-6 times in the previous 12 months. Reasons for attending ED were referral by a third party, difficulty with accessibility to primary care, patient preferences for timely care and fast-track access to specialist care. CONCLUSIONS: Most older patients of lower clinical urgency presented to ED because of perceived access block to primary or specialist services, alongside an expectation of more timely and specialised care. This suggests that EDs should be redesigned and/or integrated community-based models of care developed to meet the specific needs of this age group who have growing demand for acute care.

Indicators of the quality of trauma care and the performance of trauma systems.

BACKGROUND: Valid and reliable measures of trauma system performance are needed to guide improvement activities, benchmarking and public reporting, future investment and research. Traditional measures of in-hospital mortality fail to take into account prehospital and posthospital care, recovery after discharge, and the nature and costs of long-term disability. METHODS: Drawing on recent systematic reviews, an overview was conducted of existing and emerging trauma care performance indicators. Changes in the nature and purpose of indicators were assessed. RESULTS: Among a large number of existing, mostly locally developed performance indicators, only peer review of deaths has evidence of validity or reliability. The usefulness of the traditional performance measure of in-hospital mortality has been challenged. There is an emerging shift in focus from mortality to non-mortality outcomes, from hospital-based to long-term community-based outcome assessment, and from single measures of trauma centre performance to measures better suited to monitoring the performance of systems of care spanning the entire patient journey. As a result, a new generation of indicators is emerging that are both feasible and potentially more useful for commissioners and payers of population-based services. CONCLUSION: A global endeavour is now under way to agree on a set of standardized performance indicators that are meaningful to patients, carers, clinicians, managers and service funders, are likely to contribute to desired outcomes, and are valid, reliable and have a strong evidence base.

Predicting massive blood transfusion using clinical scores post-trauma.

BACKGROUND AND OBJECTIVES: Early prediction of massive transfusion (MT) post-trauma may reduce mortality by earlier delivery of blood products. A clinical prediction tool (PWH score) for this purpose was developed at the Prince of Wales Hospital, Hong Kong. The aims of this study were to apply this tool to major trauma patients in Victoria, Australia and compare the score to the Assessment of Blood Consumption (ABC) score and the Trauma-Associated Severe Haemorrhage (TASH) score. METHODS: A retrospective review of patients entered into the The Alfred Trauma Registry between January 2006 and December 2009 was conducted. The performance of the PWH score to predict MT defined by 5 units of packed red blood cells in 4 h was compared with the ABC and TASH scores. Included patients presented to the Emergency & Trauma Centre from the scene and had had complete datasets with respect to the components of the three scores. RESULTS: There were 1234 patients included in the study with 195 (15·8%) receiving a MT and an overall mortality of 14·0%. The PWH score had an area under the receiver operating characteristics (ROC) curve of 0·842 (95% CI: 0·820-0·862). The area under the ROC curve of the PWH score was significantly less than that of the TASH score (χ(2)=19·8, P<0·001) and significantly greater than that of the ABC score (χ(2)=9·3, P=0·002). CONCLUSIONS: The PWH score performs with similar accuracy when applied to an Australian population as in its derivation population. The relative simplicity of the PWH score makes it a viable tool for clinical use, although utility of such tools may be more suited for research in determining inclusion or exclusion criteria for comparative outcome studies.

The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients.

BACKGROUND: A perceived risk of time-limited emergency department (ED) assessment of patients is inadequate workup leading to inappropriate disposition. The aim of this study was to examine the association of time to disposition plan (TDP) on ED length of stay (LOS) and correlate this to mortality. METHODS: A retrospective review of data collected from ED information systems at three hospitals was conducted between June 2008 and October 2009. Included patients were admitted to a general medical unit. Patients were excluded if admitted to intensive care, coronary care, a cardiac monitored bed or required surgery in first 24 h or had an expected LOS of <48 h. Multivariate regression analysis was used to identify independent associations with mortality. RESULTS: A total of 10,107 patient episodes was analysed, of which 6768 patients (67.0%) had an ED LOS of ≥8 h. There was significant effect modification by ED LOS in the association of TDP and mortality. In the setting of longer ED LOS, a TDP of <4 h was associated with significantly higher mortality (OR 1.57, 95% CI: 1.28-1.92, P < 0.001), corrected for age, gender and triage category. This association was not significant when ED LOS was <8 h (OR 0.88, 95% CI: 0.60-1.27, P = 0.49). CONCLUSIONS: In the setting of prolonged ED LOS, completing ED assessment and management within 4 h of presentation was associated with significantly higher mortality. Further prospective studies are required to understand the relationship between rapid decision making in the ED and patient safety.

A survey of Australian clinical registries: can quality of care be measured?

BACKGROUND: Clinical quality registries gather and analyse information to monitor and enhance the quality of care received by patients. The aim of the present study was to determine the attributes of Australian clinical registries to identify their capacity to accurately assess quality of care. METHODS: A survey was distributed to registry custodians managing multi-site clinical outcome registries. They were asked to self-report on general aspects of registries, including coverage, length of operation, data collection process, data management, quality of data and registry governance structures. RESULTS: A total of 28 registries were identified and all provided responses to the survey. The majority of the registries require modifications to their procedures in order to provide useful and reliable information for quality improvement purposes. Thirteen registries (46%) did not assess or recruited fewer than 80% of the eligible population and 23 (82%) did not formally audit reliability of coding at the clinical level. Five (18%) did not collect the information required for basic risk adjustment of outcome measures. While most registries produced reports for providers and interested parties, the approach to disseminating this information was highly variable. CONCLUSION: Clinical registries provide the most credible information about quality of care. However, most key registries in Australia require some adaptation of procedures in order to accomplish this task. Funding should be provided to enable registries to make the necessary changes.

Variation in the use of recombinant activated factor VII in critical bleeding.

BACKGROUND: Recombinant activated factor VII (rFVIIa) is being increasingly used as a treatment option in settings of uncontrolled bleeding. Despite this, national practice guidelines are lacking, resulting in widespread practice variation between providers. This investigation aimed to describe the differences in use of rFVIIa across Australian and New Zealand hospitals. METHODS: Data were extracted from the Haemostasis Registry that collects both contemporaneous and retrospective cases of off-licence (i.e. in non-haemophilia patients) rFVIIa use in participating institutions. Hospitals were classified according to geographical location and service provision. RESULTS: 2075 cases from 87 hospitals were recorded on the Haemostasis Registry. Across all hospital categories, over 41% of cases received rFVIIa in relation to cardiac surgery. Case complexity varied between providers, with large urban centres treating more severely ill patients. This was reflected in significant differences in the use of blood components and products before rFVIIa administration. Despite differences in patient complexity and use of blood products between hospital categories, response to treatment and patient outcomes remained similar across providers, with survival rates ranging from 68.29% to 70.41%. CONCLUSION: This is the largest study of off-licence use of rFVIIa. There is significant regional variation in the administration of rFVIIa in Australian and New Zealand hospitals, with little documentation of adherence to guidelines. National consensus guidelines based on available evidence should be developed and promulgated to ensure optimal outcomes.

Over view of major traumatic injury in Australia--Implications for trauma system design.

BACKGROUND: Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia. METHODS: The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS). RESULTS: There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28-68) years. Median (IQR) ISS was 17 (14-25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03-2.12) h to reach hospital and spent 7.10 (3.64-15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups. CONCLUSION: Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.

Prioritizing quality indicator development across the healthcare system: identifying what to measure.

Measuring healthcare quality has become an increasingly important task for regulating bodies and healthcare institutions. Strategically chosen quality indicators provide a means of understanding the quality and safety of the healthcare system. Current frameworks developed to determine aspects of care to be measured do not provide the level of precision required to ensure that indicators are best selected to enable focused action to improve health. We propose a clearly structured process for selecting indicators at a national and local level based on six steps: (i) identify the problem for which measurement is needed, (ii) identify the perspective from which to measure, (iii) focus measurement on transition points through the health system, (iv) identify the type of probe required, (v) apply evaluation criteria to prioritize indicator selection and action and (vi) test the indicator in the clinical setting to which it will be applied. These steps should form the basis of a framework to drive quality indicator development.

Measuring the quality of hospital care: an inventory of indicators.

BACKGROUND: Development of indicators to measure health-care quality has progressed rapidly. This development has, however, rarely occurred in a systematic fashion, and some aspects of care have received more attention than others. The aim of this study is to identify and classify indicators currently in use to measure the quality of care provided by hospitals, and to identify gaps in current measurement. METHODS: A literature search was undertaken to identify indicator sets. Indicators were included if they related to hospital care and were clearly being collected and reported to an external body. A two-person independent review was undertaken to classify indicators according to aspects of care provision (structure, process or outcome), dimensions of quality (safety, effectiveness, efficiency, timeliness, patient-centredness and equity), and domain of application (hospital-wide, surgical and non-surgical clinical specialities). RESULTS: 383 discrete indicators were identified from 22 source organizations or projects. Of these, 27.2% were relevant hospital-wide, 26.1% to surgical patients and 46.7% to non-surgical specialities, departments or diseases. Cardiothoracic surgery, cardiology and mental health were the specialities with greatest coverage, while nine clinical specialities had fewer than three specific indicators. Processes of care were measured by 54.0% of indicators and outcomes by 38.9%. Safety and effectiveness were the domains most frequently represented, with relatively few indicators measuring the other dimensions. CONCLUSION: Despite the large number of available indicators, significant gaps in measurement still exist. Development of indicators to address these gaps should be a priority. Work is also required to evaluate whether existing indicators measure what they purport to measure.

A checklist for trauma quality improvement meetings: A process improvement study.

BACKGROUND: Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM. METHODS: This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop. RESULTS: There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001). CONCLUSION: This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

Prevalence of sleepiness in surviving drivers of motor vehicle collisions.

BACKGROUND: Although alcohol and recreational drugs are recognized as significant risk factors for motor vehicle collisions (MVC), the contribution of sleepiness alone is less clear. We therefore sought to identify the contribution of sleepiness to the risk of a MVC in injured drivers, independent of drugs and alcohol. METHODS: A prospective questionnaire and examination of sleep-related risk factors in drivers surviving MVC in a major hospital-based trauma centre was carried out. RESULTS: Forty of 112 injured drivers screened were interviewed, of whom approximately 50% had at least one sleep-related risk factor, 20% having two or more. Of the MVC deemed sleep-related by questionnaire, only 25% were identified by the Australian Transport Safety Bureau definitions. Shift work was the greatest sleep-related factor identified contributing to MVC. CONCLUSION: Sleepiness, particularly related to shift work, needs to be emphasized as a risk factor for MVC. Australian Transport Safety Bureau definitions of sleep-related MVC are too lenient.