Major trauma mortality in rural and metropolitan NSW, 2009-2014: a retrospective analysis of trauma registry data.

OBJECTIVE: To determine trends in crude and risk-adjusted mortality for major trauma patients injured in rural or metropolitan New South Wales, 2009-2014. DESIGN: A retrospective analysis of NSW statewide trauma registry data. PARTICIPANTS: Adult patients (aged 16 years or more) who presented with major trauma (Injury Severity Scores greater than 15) to a NSW hospital during 2009-2014. MAIN OUTCOME MEASURES: The main covariate of interest was geographic location of injury (metropolitan v rural/regional areas). Inpatient mortality was analysed by multivariable logistic regression. RESULTS: Data for 11 423 eligible patients were analysed. Inpatient mortality for those injured in metropolitan locations was 14.7% in 2009 and 16.1% in 2014 (P = 0.45). In rural locations, there was a statistically significant decline in in-hospital mortality over the study period, from 12.1% in 2009 to 8.7% in 2014 (P = 0.004). Risk-adjusted mortality for those injured in a rural location was lower in 2013 than during 2009, but remained stable for those injured in metropolitan locations. CONCLUSION: Crude and risk-adjusted mortality after major trauma have remained stable in those injured in metropolitan areas of NSW between 2009 and 2014. The apparent downward trend in mortality associated with severe trauma in rural/regional locations requires further analysis.

Prehospital times and outcomes of patients transported using an ambulance trauma transport protocol: A data linkage analysis from New South Wales Australia.

INTRODUCTION: Prehospital trauma systems are designed to ensure optimal survival from critical injuries by triaging and transporting such patients to the most appropriate hospital in a timely manner. OBJECTIVES: We sought to evaluate whether prehospital time and location (metropolitan versus non-metropolitan) were associated with 30-day mortality in a cohort of patients transported by road ambulance using a trauma transport protocol. METHODS: Data linkage analysis of routinely collected ambulance and hospital data across all public hospitals in New South Wales (NSW). The data linkage cohort included adult patients (age ≥ 16years) transported by NSW Ambulance, where a T1 Major Trauma Transport Protocol was documented by paramedic crews and transported by road to a public hospital emergency department in NSW for two years between January 2019 and December 2020. The outcomes of interest were prehospital times (response time, scene time and transport time) and 30-day mortality due to injury. RESULTS: 9012 cases were identified who were transported to an emergency department with T1 protocol indication. Median prehospital transport times were longer in non-metropolitan road transports [n = 3,071, 98 min (71-126)] compared to metropolitan transports [n = 5,941, 65 min (53-80), p < 0.001]. There was no significant difference in 30-day mortality between the two groups (1.24% vs 1.65%, p = 0.13). In the subgroup of patients with abnormal vital signs, the only predictors of mortality were increasing age, presence of severe injury (OR 24.87, 95%CI 11.02, 56.15, p < 0.001), and arrival at a non-trauma facility (OR 3.01, 95%CI 1.26, 7.20, p < 0.05). Increasing transport times were not found to increase the odds of 30-day mortality. DISCUSSION: In the context of an inclusive trauma system and an established prehospital major trauma protocol, increasing prehospital transport times and scene location were not associated with increased mortality.

Evaluation of the New South Wales ambulance T1 major trauma transport protocol: A state-wide data linkage study.

INTRODUCTION: Prehospital triage and transport protocols are critical components of the trauma systems. Still, there have been limited studies evaluating the performance of trauma protocols in New South Wales, such as the NSW ambulance major Trauma transport protocol (T1). OBJECTIVES: Determine the performance of a major trauma transport protocol in a cohort of ambulance road transports METHODS: A data-linkage study using routine ambulance and hospital datasets across New South Wales Australia. Adult patients (age > 16 years) where any trauma protocol was indicated by paramedic crews and transported to any emergency department in the state were included. Major injury outcome was defined as an Injury Severity Score >8 based on coded in-patient diagnoses, or admission to intensive care unit or death within 30 days due to injury. Multivariable logistic regression was used to determine ambulance predictors of major injury outcome. RESULTS: There were 168,452 linked ambulance transports analysed. Of the 9,012 T1 protocol activations, 2,443 cases had major injury [positive predictive value (PPV) = 27.1%]. There were 16,823 major injuries in total giving a sensitivity of the T1 protocol of 2,443/16,823 (14.5%), specificity of 145,060/151,629 (95.7%) and a negative predictive value (NPV) of 145,060/159,440 (91%). Overtriage rate associated with T1 protocol was 5,697/9,012 (63.2%) and undertriage rate was 5,509/159,440 (3.5%). The most important predictor of major injury was the activation of more than one trauma protocol by ambulance paramedics. DISCUSSION: Overall, the T1 was associated with low undertriage and high specificity. The protocol may be improved by considering age and the number of trauma protocols activated by paramedics for any given patient.