Intensity of hospital resource use following traumatic brain injury: a multicentre cohort study, 2013-2016.

BACKGROUND: The knowledge gap regarding acute care resource use for patients with traumatic brain injury (TBI) impedes efforts to improve the efficiency and quality of the care of these patients. Our objective was to evaluate interhospital variation in resource use for patients with TBI, identify determinants of high resource use and assess the association between hospital resource use and clinical outcomes. METHODS: We conducted a multicentre retrospective cohort study including patients aged 16 years and older admitted to the inclusive trauma system of Quebec following TBI, between 2013 and 2016. We estimated resource use using activity-based costs. Clinical outcomes included mortality, complications and unplanned hospital readmission. Interhospital variation was evaluated using intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs). Correlations between hospital resource use and clinical outcomes were evaluated using correlation coefficients on weighted, risk-adjusted estimates with 95% CIs. RESULTS: We included 6319 patients. We observed significant interhospital variation in resource use for patients discharged alive, which was not explained by patient case mix (ICC 0.052, 95% CI 0.043 to 0.061). Adjusted mean resource use for patients discharged to long-term care was more than twice that of patients discharged home. Hospitals with higher resource use tended to have a lower incidence of mortality (r -0.347, 95% CI -0.559 to -0.087) and unplanned readmission (r -0.249, 95% CI -0.481 to 0.020) but a higher incidence of complications (r 0.491, 95% CI 0.255 to 0.666). CONCLUSION: Resource use for TBI varies significantly among hospitals and may be associated with differences in mortality and morbidity. Negative associations with mortality and positive associations with complications should be interpreted with caution but suggest there may be a trade-off between adverse events and survival that should be evaluated further.

Interhospital Variations in Resource Use Intensity for In-hospital Injury Deaths: A Retrospective Multicenter Cohort Study.

OBJECTIVE: Evaluate interhospital variation in resource use for in-hospital injury deaths. BACKGROUND: Significant variation in resource use for end-of-life care has been observed in the US for chronic diseases. However, there is an important knowledge gap on end-of-life resource use for trauma patients. METHODS: We conducted a multicenter, retrospective cohort study of injury deaths following hospitalization in any of the 57 trauma centers in a Canadian trauma system (2013-2016). Resource use intensity was measured using activity-based costing (2016 $CAN) according to time of death (72 h, 3-14 d, ≥14 d). We used multilevel log-linear regression to model resource use and estimated interhospital variation using intraclass correlation coefficients (ICC). RESULTS: Our study population comprised 2044 injury deaths. Variation in resource use between hospitals was observed for all 3 time frames (ICC = 6.5%, 6.6%, and 5.9% for < 72 h, 3-14 d, and ≥14 d, respectively). Interhospital variation was stronger for allied health services (ICC = 18 to 26%), medical imaging (ICC = 4 to 10%), and the ICU (ICC = 5 to 6%) than other activity centers. We observed stronger interhospital variation for patients < 65 years of age (ICC = 11 to 34%) than those ≥65 (ICC = 5 to 6%) and for traumatic brain injury (ICC = 5 to 13%) than other injuries (ICC = 1 to 8%). CONCLUSIONS: We observed variation in resource use intensity for injury deaths across trauma centers. Strongest variation was observed for younger patients and those with traumatic brain injury. Results may reflect variation in level of care decisions and the incidence of withdrawal of life-sustaining therapies.

Derivation and validation of actionable quality indicators targeting reductions in complications for injury admissions.

PURPOSE: Approximately, one out of five patients hospitalized following injury will develop at least one hospital complication, more than three times that observed for general admissions. We currently lack actionable Quality Indicators (QI) targeting specific complications in this population. We aimed to derive and validate QI targeting hospital complications for injury admissions and develop algorithms to identify patient charts to review. METHODS: We conducted a retrospective cohort study including patients with major trauma admitted to any level I or II adult trauma center an integrated Canadian trauma system (2014-2019). We used the trauma registry to develop five QI targeting deep vein thrombosis/pulmonary embolism (DVT/PE), decubitus ulcers, delirium, pneumonia and urinary tract infection (UTI). We developed algorithms to identify patient charts to revise on consultation with a group of clinical experts. RESULTS: The study population included 14,592 patients of whom 5.3% developed DVT or PE, 2.7% developed a decubitus ulcer, 8.6% developed delirium, 14.7% developed pneumonia and 7.3% developed UTI. The indicators demonstrated excellent predictive performance (Area Under the Curve 0.81-0.87). We identified 4 hospitals with a higher than average incidence of at least one of the targeted complications. The algorithms identified on average 50 and 20 charts to be reviewed per year for level I and II centers, respectively. CONCLUSION: In line with initiatives to improve the quality of trauma care, we propose QI targeting reductions in hospital complications for injury admissions and algorithms to generate case lists to facilitate the review of patient charts.

A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults.

Background: Older patients (age ≥ 65 yr) with trauma have increased morbidity and mortality compared to younger patients; this is partly explained by undertriage of older patients with trauma, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. The objective of this study was to identify modifiers to the prehospital and emergency department phases of major trauma care for older adults based on expert consensus. Methods: We conducted a modified Delphi study between May and September 2019 to identify major trauma care modifiers for older adults based on national expert consensus. The panel consisted of 24 trauma care professionals from across Canada from the prehospital and emergency department phases of care. The survey consisted of 16 trauma care modifiers. Three online survey rounds were distributed. Consensus was defined a priori as a disagreement index score less than 1. Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panellists. The panel achieved consensus agreement for 17 of the 19 trauma care modifiers. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate less than 10 or greater than 20 breaths/min or need for ventilatory support. The emergency department modifier with the strongest level of agreement was obtaining 12-lead electrocardiography following the primary and secondary survey. Conclusion: Using a modified Delphi process, an expert panel agreed on 17 trauma care modifiers for older adults in the prehospital and emergency department settings. These modifiers may improve the delivery of trauma care for older adults and should be considered when developing local and national trauma guidelines.

Contexte: Les polytraumatisés âgés (≥ 65 ans) sont exposés à un risque plus grand de morbidité et de mortalité comparativement aux jeunes polytraumatisés; cela s'explique en partie par un triage inadéquat des patients âgés victimes de traumatismes, qui fait en sorte qu'on ne les oriente pas vers un centre de traumatologie ou qu'on ne fait pas intervenir l'équipe de traumatologie. L'objectif de la présente étude était d'identifier les éléments de soins à modifier au stade préhospitalier et en médecine d'urgence lors de la prise en charge des cas de traumatismes graves chez les adultes âgés, sur la base d'un consensus d'experts. Méthodes: Nous avons procédé à une analyse Delphi modifiée entre mai et septembre 2019 pour recenser les éléments de soins à modifier chez les polytraumatisés âgés à partir d'un consensus national d'experts. Le panel d'experts se composait de 24 professionnels en traumatologie du Canada entier chargés des soins au stade préhospitalier et en médecine d'urgence. Le questionnaire portait sur 16 éléments à modifier en traumatologie. Trois questionnaires successifs ont été distribués en ligne. Le consensus était défini a priori par un indice de désaccord inférieur à 1. Résultats: Le taux de réponse a été de 100 % pour les 3 questionnaires. Les membres du comité ont suggéré 3 nouveaux éléments à modifier. Le comité est arrivé à un consensus pour 17 des éléments à modifier sur 19. L'élément préhospitalier ayant fait l'objet du plus solide consensus concernant le transfert vers un centre de traumatologie était une fréquence respiratoire inférieure à 10 ou supérieure à 20 respirations/minute ou la nécessité d'une assistance respiratoire. L'élément à modifier parmi les soins prodigués à l'urgence ayant fait l'objet du plus solide consensus après les 2 premiers questionnaires était l'obtention d'un électrocardiogramme à 12 dérivations. Conclusion: À l'aide d'une analyse Delphi modifiée, un comité d'expert s'est entendu sur 17 éléments de soins à modifier chez les polytraumatisés âgés au stade préhospitalier et en médecine d'urgence. Ces éléments pourraient améliorer les soins aux adultes âgés et méritent d'être pris en compte lors de la création de lignes directrices locales et nationales en traumatologie.

Value of repeat CT for nonoperative management of patients with blunt liver and spleen injury: a systematic review.

PURPOSE: To evaluate the effectiveness of routine repeat computed tomography (CT) for nonoperative management (NOM) of adults with blunt liver and/or spleen injury. METHODS: We conducted a systematic review of randomized and non-randomized controlled trials (RCTs), quasi-experimental and observational studies of repeat CT in adult patients with blunt abdominal injury. We searched Medline, Embase, Web of Science, and Cochrane Central from their inception to October 2020 using Cochrane guidelines. Primary outcomes were change in clinical management (e.g., emergency surgery, embolization, blood transfusion, clinical surveillance), mortality, and complications. Secondary outcomes were hospital readmission and length of stay. RESULTS: Search results yielded 1611 studies of which 28 studies including 2646 patients met our inclusion criteria. The majority reported on liver (n = 9) or spleen injury (n = 16) or both (n = 3). No RCTs were identified. Meta-analyses were not possible because no study performed direct comparisons of study outcomes across intervention groups. Only seven of the twenty-eight studies reported whether repeat CT was routine or prompted by clinical indication. In these 7 studies, among the 254 repeat CT performed, 188 (74%) were routine and 8 (4%) of these led to a change in clinical management. Of the 66 (26%) repeated CT prompted by clinical indication, 31 (47%) led to a change in management. We found no data allowing comparison of any other outcomes across intervention groups. CONCLUSION: Routine repeat CT without clinical indication is not useful in the management of patients with liver and/or spleen injury. However, effect estimates were imprecise and included studies were of low methodological quality. Given the risks of unnecessary radiation and costs associated with repeat CT, future research should aim to estimate the frequency of such practices and assess practice variation. LEVEL OF EVIDENCE: Systematic reviews and meta-analyses, Level II.

Inter-hospital variation in surgical intensity for trauma admissions: A multicentre cohort study.

BACKGROUND: Guidelines for injury care are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. We aimed to assess inter-hospital variation in surgical intensity for injury admissions and evaluate the correlation between hospital surgical intensity and mortality/complications. METHODS: We included adults admitted for major trauma between 2006 and 2016 in a Canadian provincial trauma system. Analyses were stratified for orthopaedic (n = 16 887), neurological (n = 12 888) and torso injuries (n = 9816). Surgical intensity was quantified with the number of surgical procedures <72 hours. Inter-hospital variation was assessed with the intra-class correlation coefficient (ICC). We assessed the correlation between the risk-adjusted mean number of surgical procedures and risk-adjusted incidence of mortality and complications using Pearson correlation coefficients (r). RESULTS: Moderate inter-hospital variation was observed for orthopaedic surgery (ICC = 14.0%) whereas variation was low for torso surgery (ICC = 2.7%) and neurosurgery (ICC = 0.8%). Surgical intensity was negatively correlated with hospital mortality for torso injury (r = -.32, P = .02) and neurotrauma (r = -.65, P = .08). A strong positive correlation was observed with hospital complications for orthopaedic injuries (r = .36, P = .006) whereas the opposite was observed for neurotrauma (r = -.71, P = .05). CONCLUSIONS: Results should be interpreted with caution as they may be a result of residual confounding. However, they may suggest that there are opportunities for quality improvement in surgical care for injury admissions, particularly for orthopaedic injuries. Moving forward, we should aim to prospectively evaluate adherence to guidelines on non-operative management and their impact on mortality and morbidity.

Kinematic alignment in total knee arthroplasty better reproduces normal gait than mechanical alignment.

PURPOSE: Kinematic alignment technique for TKA aims to restore the individual knee anatomy and ligament tension, to restore native knee kinematics. The aim of this study was to compare parameters of kinematics during gait (knee flexion-extension, adduction-abduction, internal-external tibial rotation and walking speed) of TKA patients operated by either kinematic alignment or mechanical alignment technique with a group of healthy controls. The hypothesis was that the kinematic parameters of kinematically aligned TKAs would more closely resemble that of healthy controls than mechanically aligned TKAs. METHODS: This was a retrospective case-control study. Eighteen kinematically aligned TKAs were matched by gender, age, operating surgeon and prosthesis to 18 mechanically aligned TKAs. Post-operative 3D knee kinematics analysis, performed with an optoelectronic knee assessment device (KneeKG®), was compared between mechanical alignment TKA patients, kinematic alignment TKA patients and healthy controls. Radiographic measures and clinical scores were also compared between the two TKA groups. RESULTS: The kinematic alignment group showed no significant knee kinematic differences compared to healthy knees in sagittal plane range of motion, maximum flexion, abduction-adduction curves or knee external tibial rotation. Conversely, the mechanical alignment group displayed several significant knee kinematic differences to the healthy group: less sagittal plane range of motion (49.1° vs. 54.0°, p = 0.020), decreased maximum flexion (52.3° vs. 57.5°, p = 0.002), increased adduction angle (2.0-7.5° vs. - 2.8-3.0°, p < 0.05), and increased external tibial rotation (by a mean of 2.3 ± 0.7°, p < 0.001). The post-operative KOOS score was significantly higher in the kinematic alignment group compared to the mechanical alignment group (74.2 vs. 60.7, p = 0.034). CONCLUSIONS: The knee kinematics of patients with kinematically aligned TKAs more closely resembled that of normal healthy controls than that of patients with mechanically aligned TKAs. This may be the result of a better restoration of the individual's knee anatomy and ligament tension. A return to normal gait parameters post-TKA will lead to improved clinical outcomes and greater patient satisfaction. LEVEL OF EVIDENCE: III.

Hospital and Intensive Care Unit Length of Stay for Injury Admissions: A Pan-Canadian Cohort Study.

OBJECTIVE: To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations. BACKGROUND: Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care. METHODS: We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces. RESULTS: Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%. CONCLUSIONS: We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.

Canadian benchmarks for acute injury care.

BACKGROUND: Acute care injury outcomes vary substantially across Canadian provinces and trauma centres. Our aim was to develop Canadian benchmarks to monitor mortality and hospital length of stay (LOS) for injury admissions. METHODS: Benchmarks were derived using data from the Canadian National Trauma Registry on patients with major trauma admitted to any level I or II trauma centre in Canada and from the following patient subgroups: isolated traumatic brain injury (TBI), isolated thoracoabdominal injury, multisystem blunt injury, age 65 years or older. We assessed predictive validity using measures of discrimination and calibration, and performed sensitivity analyses to assess the impact of replacing analytically complex methods (multiple imputation, shrinkage estimates and flexible modelling) with simple models that can be implemented locally. RESULTS: The mortality risk adjustment model had excellent discrimination and calibration (area under the receiver operating characteristic curve 0.886, Hosmer-Lemeshow 36). The LOS risk-adjustment model predicted 29% of the variation in LOS. Overall, observed:expected ratios of mortality and mean LOS generated by an analytically simple model correlated strongly with those generated by analytically complex models (r > 0.95, κ on outliers > 0.90). CONCLUSION: We propose Canadian benchmarks that can be used to monitor quality of care in Canadian trauma centres using Excel (see the appendices, available at canjsurg.ca). The program can be implemented using local trauma registries, providing that at least 100 patients are available for analysis.

CONTEXTE: L'issue des traitements dispensés dans les services de traumatologie d'urgence varie substantiellement d'une province canadienne et d'un centre de traumatologie à l'autre. Notre but était d'établir des valeurs de référence pour suivre la mortalité et la durée des séjours hospitaliers en traumatologie au Canada. MÉTHODES: Les paramètres ont été sélectionnés à partir des données du Registre national des traumatismes concernant les grands polytraumatisés admis dans tout centre de traumatologie de niveau I ou II au Canada et selon les catégories de patients suivantes : traumatisme crânien isolé (TCI), traumatisme thoraco-abdominal isolé, traumatisme plurisystémique fermé, âge de 65 ans ou plus. Nous avons évalué la validité prédictive à l'aide de critères discriminants et de paramètres d'étalonnage et nous avons procédé à des analyses de sensibilité pour évaluer l'impact du remplacement de méthodes analytiques complexes (imputation multiple, estimations par contraction des coefficients et modélisation flexible) par des modèles simples applicables à l'échelle locale. RÉSULTATS: Le modèle d'ajustement du risque de mortalité s'est révélé doté d'un pouvoir discriminant et d'un étalonnage excellents (aire sous la courbe de la fonction d'efficacité du récepteur [ROC] 0,886, test de Hosmer-Lemeshow 36). Le modèle d'ajustement du risque pour la durée du séjour hospitalier a permis de prédire 29 % de sa variation. De plus, les rapports observés:attendus pour la mortalité et la durée moyenne des séjours hospitaliers générés par un modèle analytique simple ont été en étroite corrélation avec les rapports générés par les modèles analytiques complexes (r > 0,95, κ pour valeurs aberrantes > 0,90). CONCLUSION: Nous proposons des valeurs de référence canadiennes qui peuvent être utilisées pour faire le suivi de la qualité des soins dans les centres de traumatologie canadiens à l'aide d'un simple programme Excel (voir les annexes, accessible à l'adresse canjsurg.ca). Le programme peut être appliqué à l'aide des données des registres de traumatologie locaux à la condition qu'au moins 100 patients y soient accessibles pour analyse.

Impact of trauma centre designation level on outcomes following hemorrhagic shock: a multicentre cohort study.

BACKGROUND: Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS). METHODS: We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999-2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS. RESULTS: Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [CI]) of mortality for level III and IV centres were 1.71 (1.03-2.85) and 2.25 (1.08-4.73), respectively. Surgical delays did not vary across designation levels, but mean LOS and complications were lower in level II-IV centres than level I centres. CONCLUSION: Level I/II centres may offer a survival advantage over level III/IV centres for patients requiring emergency intervention for hemorrhagic shock. Further research with larger sample sizes is required to confirm these results and to identify optimal transport time thresholds for bypassing level III/IV centres in favour of level I/II centres.

CONTEXTE: Le choc hémorragique est responsable de 45 % des décès chez les polytraumatisés en Amérique du Nord, et 50 % de ces décès surviennent dans les 2 h suivant le traumatisme. On ne dispose pas actuellement de données concernant la trajectoire des patients en état de choc hémorragique et les bénéfices potentiels de soins de niveaux I/II pour ces patients. Nous avons voulu comparer la mortalité selon les niveaux de désignation des centres de traumatologie pour les patients en état de choc hémorragique. Les objectifs secondaires étaient de comparer les délais d'accès à la chirurgie, les complications et la durée des séjours hospitaliers. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective basée sur un système de traumatologie inclusif au Canada (1999-2012), incluant des adultes dont la tension artérielle systolique (TAS) était < 90 mm Hg à l'arrivée et qui nécessitaient un traitement chirurgical urgent (< 6 h). La régression logistique a été utilisée pour analyser l'influence du niveau de désignation du centre de traumatologie sur le délai d'accès à la chirurgie, la mortalité et les complications ajustés selon le risque. La régression linéaire a été utilisée pour analyser la durée du séjour hospitalier. RÉSTULATS: Comparativement aux centres de niveau I, les rapports des cotes ajustés (et les intervalles de confiance [IC] de 95 %) de mortalité pour les centres de niveaux III et IV ont été 1,71 (1,03-2,85) et 2,25 (1,08-4,73), respectivement. Les délais d'accès à la chirurgie n'ont pas varié en fonction des niveaux de désignation, mais la durée moyenne du séjour hospitalier et les complications étaient moindres dans les centres de niveaux II et IV comparativement aux centres de niveau I. CONCLUSION: Les centres de niveaux I/II peuvent offrir des avantages au plan de la survie comparativement aux centres de niveaux III/IV pour les patients en état de choc hémorragique qui ont besoin d'une intervention d'urgence. Il faudra approfondir la recherche auprès d'échantillons de plus grande taille pour confirmer ces résultats et établir les seuils optimaux en termes de temps de transport permettant de passer outre les centres de niveaux III/IV en faveur des centres de niveaux I/II.

Mortality in Canadian Trauma Systems: A Multicenter Cohort Study.

OBJECTIVE: To measure the variation in trauma center mortality across Canadian trauma systems, assess the contribution of traumatic brain injury and thoracoabdominal injury to observed variations, and evaluate whether the presence of recommended trauma system components is associated with mortality. SUMMARY BACKGROUND DATA: Injuries represent one of the leading causes of mortality, disability, and health care costs worldwide. Trauma systems have improved injury outcomes, but the impact of trauma system configuration on mortality is unknown. METHODS: We conducted a retrospective cohort study of adults admitted for major injury to trauma centers across Canada (2006-2012). Multilevel logistic regression was used to estimate risk-adjusted hospital mortality and assess the impact of 13 recommended trauma system components. RESULTS: Of 78,807 patients, 8382 (10.6%) died in hospital including 6516 (78%) after severe traumatic brain injury and 749 (9%) after severe thoracoabdominal injury. Risk-adjusted mortality varied from 7.0% to 14.2% across provinces (P < 0.0001); 11.1% to 26.0% for severe traumatic brain injury (P < 0.0001), and 4.7% to 5.9% for thoracoabdominal injury (P = 0.2). Mortality decreased with increasing number of recommended trauma system elements; adjusted odds ratio = 0.93 (0.87-0.99). CONCLUSIONS: We observed significant variation in trauma center mortality across Canadian provinces, specifically for severe traumatic brain injury. Provinces with more recommended trauma system components had better patient survival. Results suggest that trauma system configuration may be an important determinant of injury mortality. A better understanding of which system processes drive optimal outcomes is required to reduce the burden of injury worldwide.

Trends in Injury Outcomes Across Canadian Trauma Systems.

Importance: In response to the burden of injury, the structure of injury care has changed considerably across Canada in the past decade. However, little is known about how patient outcomes have evolved. Objective: To evaluate trends in mortality, hospital length of stay, and unplanned readmission in Canadian trauma systems between 2006 and 2012. Design, Setting, and Participants: A pan-Canadian retrospective cohort study was conducted among adults admitted for major injury to a Canadian level I or II trauma center between April 1, 2006, and March 31, 2012. Data analysis was conducted from April 15 to December 3, 2015. Exposures: Trauma centers and systems. Main Outcomes and Measures: Multilevel generalized linear models were used to evaluate trends in the risk-adjusted incidence of mortality and readmission and risk-adjusted mean length of stay. Trend analyses were conducted globally and by province. Results: Among 78 807 patients (mean [SD] age, 50.7 [22.0] years; 22 540 women and 56 267 men) admitted for major injury during the study period, risk-adjusted mortality decreased from 12.1% (95% CI, 9%-16.1%) to 9.9% (95% CI, 7.4%-13.3%; P < .001) and mean length of hospital stay decreased from 11.6 (95% CI, 9.9-13.6) to 10.6 (95% CI, 9.1-12.5) days (P < .001). Statistically significant reductions in mortality were observed for Ontario (12% [95% CI, 10.7%-13.6%] to 8% [95% CI, 6.9%-9.2%]; P < .001), Alberta (12% [95% CI, 10%-14.3%] to 9.1% [95% CI, 7.7%-10.8%]; P = .02), and Manitoba (13% [95% CI, 9.1%-18.4%] to 11.1% [95% CI, 8.3%-14.7%]; P = .04). Risk-adjusted hospital stay decreased significantly in Québec (11.6 [95% CI, 11.1-12] to 9.1 [95% CI, 8.9-9.5] days; P < .001), British Columbia (12.5 [95% CI, 12-13.1] to 11.4 [10.9-11.9] days; P < .001), and Ontario (10.1 [95% CI, 9.8-10.4] to 9.8 [95% CI, 9.5-10.1] days; P < .001). No change in the incidence of readmission was observed. Conclusions and Relevance: We observed an 18.2% relative decrease in risk-adjusted mortality in Canadian trauma centers during the study period, representing 248 additional lives saved in 2012 vs 2006. Risk-adjusted mean hospital stay decreased by 8.6%, representing nearly 10 000 hospital days saved. A better understanding of the structures and processes behind observed improvements is needed to further reduce the burden of injury in Canada.

Three-dimensional analysis of the locked position in patients with recurrent shoulder instability.

BACKGROUND: Although recurrent anterior shoulder instability (RASI) is a common condition in young patients, no studies to date have measured the 3-dimensional (3D) locked position of the glenohumeral joint during an anterior dislocation. Therefore, our goal was to estimate it with 3D computed tomography (CT) scans. METHODS: Patients in this prospective observational study were separated in 3 groups: normal laxity, hyperlaxity, and epilepsy. They were characterized by questionnaires (Western Ontario Shoulder Instability Index, 11-item version of the Disabilities of the Arm, Shoulder and Hand, and Beighton Laxity Score), and a CT scan revealing bipolar bone defects. 3D models of the humeral head and the glenoid were reconstructed from the CT scan, and the rotations and displacements of the humerus relative to the glenoid, from initial to locked position, were calculated. Intraobserver and interobserver reliability by intraclass correlation coefficient (ICC), analysis of variance test, and the Pearson correlation were used to evaluate data. RESULTS: This study involved 44 patients (46 shoulders): 18 with "normal" laxity, 18 with hyperlaxity and 8 (2 bilateral) with epilepsy. The mean locked position was of 12° of abduction, 90° of external rotation, and 21° of extension. The intraobserver and interobserver reliability was excellent for all the rotations and displacements (ICCs, 0.751-0.977) except the proximal-distal displacement (ICCs, 0.409-0.688). Significant differences were found for external rotation, anterior displacement, and medial displacement among the 3 groups of patients. Correlation was found between locked position and function. CONCLUSIONS: This study produced highly reliable measurements, with abduction angles proving to be lower than expected. Future work should focus on the effect of this low abduction angle on Hill-Sachs lesion management.

Derivation and Validation of a Quality Indicator to Benchmark In-Hospital Complications Among Injury Admissions.

IMPORTANCE: The rate of complications among injury admissions has been estimated to be more than 3 times that observed for general admissions, and complications have been targeted as an important quality-of-care metric. Despite the negative effect of complications on resource use and patient mortality and morbidity, there is no standardized method to benchmark trauma centers in terms of in-hospital complications, to our knowledge. OBJECTIVES: To develop a quality indicator (QI) for in-hospital complications that can be used to evaluate the quality of acute injury care and to assess its validity. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study. The setting was a well-established inclusive trauma system in Canada. Participants included all 66 048 moderate or major injury admissions to an adult trauma center between April 1, 2006, and March 31, 2012. The dates of the analysis were January to April 2015. MAIN OUTCOMES AND MEASURES: The primary outcome was the occurrence of at least 1 in-hospital complication. We selected risk-adjustment variables by expert consultation and bootstrap resampling. We evaluated internal validity using measures of discrimination, construct validity, and forecasting. RESULTS: The study cohort comprised 66 048 patients. Their mean (SD) age was 59 (22) years, and 48.0% were female. Fifteen percent of patients had at least 1 in-hospital complication. The risk-adjustment model has excellent discrimination (area under the curve, 0.81) and calibration. The QI was correlated with the risk-adjusted incidence of mortality (r = 0.71), unplanned readmission (r = 0.43), and mean length of stay (r = 0.68). Hospital performance on the QI from 2007 to 2009 was predictive of performance from 2010 to 2012 (r = 0.82). CONCLUSIONS AND RELEVANCE: We developed a QI to benchmark trauma centers on in-hospital complications among injury admissions. The QI is based on data that are routinely collected in most trauma systems and demonstrates good internal validity. The integration of this QI in trauma quality improvement programs will facilitate the identification of quality problems, the implementation of solutions, and the evaluation of their effectiveness. Therefore, the QI has the potential to lead to reductions in mortality, morbidity, and resource use after injury.

Trauma simulation in bilingual Canada: Insurmountable barrier or unexpected strength? Insights from the first bilingual S.T.A.R.T.T. course.

SUMMARY: The Standardized Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course focuses on training multidisciplinary trauma teams: surgeons/physicians, registered nurses (RNs), respiratory therapists (RTs) and, most recently, prehospital personnel. The S.T.A.R.T.T. curriculum highlights crisis management (CRM) skills: communication, teamwork, leadership, situational awareness and resource utilization. This commentary outlines the modifications made to the course curriculum in order to satisfy the learning needs of a bilingual audience. The results suggest that bilingual multidisciplinary CRM courses are feasible, are associated with high participant satisfaction and have no clear detriments.

Evolution of patient outcomes over 14 years in a mature, inclusive Canadian trauma system.

BACKGROUND: The introduction of trauma systems in many countries worldwide has been shown to improve injury survival. However, few data are available on the long-term evolution of outcomes other than mortality. The objective of this study was to describe trends in mortality, unplanned readmission, complications, and length of stay in a mature inclusive trauma system from 1999 to 2012. METHODS: This retrospective cohort study was based on the inclusive trauma system of Quebec, Canada. Data were drawn from the trauma registry linked to the hospital discharge database. Time trends were evaluated using generalized linear mixed models with a correction for hospital clusters and cohort effects. RESULTS: Between 1999 and 2012, risk-adjusted mortality decreased from 5.8 to 4.2% for all patients and from 14.9 to 13.1% for major trauma (p < 0.0001). Mean LOS decreased from 9.5 days to 8.0 days for all patients and from 15.5 days to 11.5 days for major trauma (p < 0.0001). Unplanned readmission and complication rates remained stable over the observation period at around 6.6 and 11.6% for all patients and 7.6 and 25.6% for major trauma, respectively. CONCLUSION: The results of this study suggest that there have been significant decreases in patient mortality and hospital length of stay in the inclusive trauma system of Québec over the last decade. Results also suggest that efforts should be made to reduce in-hospital complications and unplanned readmissions. Future research should attempt to identify determinants of observed decreases in mortality and LOS and assess whether similar improvements have occurred in functional outcomes.

Validation of Complications Selected by Consensus to Evaluate the Acute Phase of Adult Trauma Care: A Multicenter Cohort Study.

OBJECTIVE: Evaluate the predictive validity of complications derived using expert consensus methodology to monitor the quality of trauma care. Secondary objectives were to assess the predictive validity of complications not selected by consensus and identify determinants of complications. BACKGROUND: A list of complications to monitor the quality of trauma care has recently been derived using Delphi consensus methodology. However, the predictive validity of consensus complications has not yet been demonstrated. METHODS: We conducted a multicenter cohort study of adults admitted to the 57 adult trauma centers of a Canadian integrated trauma system (2007-2012; n = 84,216). Multiple generalized linear models were used to assess the influence of complications on mortality and acute care length of stay (LOS) and to identify determinants of consensus complications. RESULTS: The presence of at least 1 consensus complication was associated with a 2.7-fold [95% confidence interval (CI): 2.45-2.90] and 2.2-fold (95% CI: 2.11-2.19) increase in the odds of mortality and mean LOS, respectively. Nonselected complications were associated with no increase in mortality (odds ratio = 0.90, 95% CI: 0.80-1.01) and a 60% increase in LOS (geometric mean ratio = 1.60, 95% CI: 1.57-1.62). Patient-related factors and factors related to treatment explained 66% and 34% of the variation in complication rates, respectively. CONCLUSIONS: In addition to the face and content validity ensured by consensus methodology, this study suggests that consensus complications have good predictive validity. Monitoring these complications as part of quality improvement activities would provide an opportunity to improve outcome and resource use for injury admissions.

Complications to evaluate adult trauma care: An expert consensus study.

BACKGROUND: Complications affect up to 37% of patients hospitalized for injury and increase mortality, morbidity, and costs. One of the keys to controlling complications for injury admissions is to monitor in-hospital complication rates. However, there is no consensus on which complications should be used to evaluate the quality of trauma care. The objective of this study was to develop a consensus-based list of complications that can be used to assess the acute phase of adult trauma care. METHODS: We used a three-round Web-based Delphi survey among experts in the field of trauma care quality with a broad range of clinical expertise and geographic diversity. The main outcome measure was median importance rating on a 5-point Likert scale (very low to very high); complications with a median of 4 or greater and no disagreement were retained. A secondary measure was the perceived quality of information on each complication available in patient files. RESULTS: Of 19 experts invited to participate, 17 completed the first (brainstorming) round and 16 (84%) completed all rounds. Of 73 complications generated in Round 1, a total of 25 were retained including adult respiratory distress syndrome, hospital-acquired pneumonia, sepsis, acute renal failure, deep vein thrombosis, pulmonary embolism, wound infection, decubitus ulcers, and delirium. Of these, 19 (76%) were perceived to have high-quality or very high-quality information in patient files by more than 50% of the panel members. CONCLUSION: This study proposes a consensus-based list of 25 complications that can be used to evaluate the quality of acute adult trauma care. These complications can be used to develop an informative and actionable quality indicator to evaluate trauma care with the goal of decreasing rates of hospital complications and thus improving patient outcomes and resource use. DRG International Classification of Diseases codes are provided.

Validation of an experimental testing apparatus simulating the stance phase of a canine pelvic limb at trot in the normal and the cranial cruciate-deficient stifle: an in vitro kinematic study.

OBJECTIVE: To design an experimental testing apparatus simulating a quasi-static model of the stance phase at a trot for a normal and a cranial cruciate ligament (CCL)-deficient stifle under near physiologic conditions. STUDY DESIGN: In vitro biomechanical study. ANIMALS: Paired pelvic limbs (n=6) from 3 dogs, weighing 29.5-31 kg. METHODS: With the limbs mounted in a testing apparatus, the stance phase of gait was simulated with a computerized sequence. Two conditions were evaluated: intact stifle and CCL-deficient stifle. Three-dimensional (3D) kinematics was measured with an optoelectronic system. Vertical reaction forces were also measured. Validation consisted of evaluating intra- and interspecimen variability of the 3D kinematic values of the stifle. Amplitude of motion and peak vertical force (PVF) as well as of kinematic values were also compared with in vivo curves reported in the literature. RESULTS: Mean intra- and interspecimen variability were low for all variables measured in both conditions (normal intact CCL, CCL deficient), and comparable to that reported in the literature. Amplitude of motion and PVF as well as kinematic values were also similar to those reported in vivo although 3D kinematics' values were lower for CCL-deficient stifles in our model. CONCLUSION: Results show that the testing apparatus generates reproducible motion on a loaded limb in a quasi-static way. Values are representative of the in vivo 3D values reported in the literature. CLINICAL RELEVANCE: This model could be used to evaluate and compare different surgical techniques, and determine which surgical procedures have the potential to reestablish normal stifle kinematics.