The Australian Traumatic Brain Injury Initiative: Systematic Review of the Effect of Acute Interventions on Outcome for People With Moderate-Severe Traumatic Brain Injury.

The Australian Traumatic Brain Injury Initiative (AUS-TBI) is developing a data resource to enable improved outcome prediction for people with moderate-severe TBI (msTBI) across Australia. Fundamental to this resource is the collaboratively designed data dictionary. This systematic review and consultation aimed to identify acute interventions with potential to modify clinical outcomes for people after msTBI, for inclusion in a data dictionary. Standardized searches were implemented across bibliographic databases from inception through April 2022. English-language reports of randomized controlled trials (RCTs) evaluating any association between any acute intervention and clinical outcome in at least 100 patients with msTBI, were included. A predefined algorithm was used to assign a value to each observed association. Consultation with AUS-TBI clinicians and researchers formed the consensus process for interventions to be included in a single data dictionary. Searches retrieved 14,455 records, of which 124 full-length RCTs were screened, with 35 studies included. These studies evaluated 26 unique acute interventions across 21 unique clinical outcomes. Only 4 interventions were considered to have medium modifying value for any outcome from the review, with an additional 8 interventions agreed upon through the consensus process. The interventions with medium value were tranexamic acid and phenytoin, which had a positive effect on an outcome; and decompressive craniectomy surgery and hypothermia, which negatively affected outcomes. From the systematic review and consensus process, 12 interventions were identified as potential modifiers to be included in the AUS-TBI national data resource.

HIP fracture Supplemental Therapy to Enhance Recovery (HIPSTER): a protocol for a randomised controlled trial.

INTRODUCTION: Hip fractures result in substantial health impacts for patients and costs to health systems. Many patients require prolonged hospital stays and up to 60% do not regain their prefracture level of mobility within 1 year. Physical rehabilitation plays a key role in regaining physical function and independence; however, there are no recommendations regarding the optimal intensity. This study aims to compare the clinical efficacy and cost-effectiveness of early intensive in-hospital physiotherapy compared with usual care in patients who have had surgery following a hip fracture. METHODS AND ANALYSIS: This two-arm randomised, controlled, assessor-blinded trial will recruit 620 participants who have had surgery following a hip fracture from eight hospitals. Participants will be randomised 1:1 to receive usual care (physiotherapy according to usual practice at the site) or intensive physiotherapy in the hospital over the first 7 days following surgery (two additional sessions per day, one delivered by a physiotherapist and the other by an allied health assistant). The primary outcome is the total hospital length of stay, measured from the date of hospital admission to the date of hospital discharge, including both acute and subacute hospital days. Secondary outcomes are functional mobility, health-related quality of life, concerns about falling, discharge destination, proportion of patients remaining in hospital at 30 days, return to preadmission mobility and residence at 120 days and adverse events. Twelve months of follow-up will capture data on healthcare utilisation. A cost-effectiveness evaluation will be undertaken, and a process evaluation will document barriers and facilitators to implementation. ETHICS AND DISSEMINATION: The Alfred Hospital Ethics Committee has approved this protocol. The trial findings will be published in peer-reviewed journals, submitted for presentation at conferences and disseminated to patients and carers. TRIAL REGISTRATION NUMBER: ACTRN12622001442796.

Comparison of short-term outcomes between people with and without a pre-morbid mental health diagnosis following surgery for traumatic hand injury: a prospective longitudinal study of a multicultural cohort.

BACKGROUND: Following traumatic hand injury, few studies have compared outcomes between people with and without a pre-morbid mental health diagnosis. This study aimed to compare sub-acute outcomes in a multicultural patient cohort with surgically managed traumatic hand injury with and without a pre-morbid mental health diagnosis. METHODS: A prospective, observational cohort study of people with traumatic hand injury presenting pre- surgically to a high-volume hand injury centre in a region of cultural and language diversity was conducted. Participants were assessed face-to-face (baseline) then via telephone (3-months post-surgery) and categorized according to a pre-morbid medically diagnosed mental health diagnosis. Baseline and follow-up assessments included global mental health, and the EuroQol (EQ) 'Health Today' analogue scale (0-100) and health domains. Return-to-work status, complications/symptomatic complaints, and hand function (QuickDASH) were also collected at follow-up. Adjusted analyses-accounting for covariates including cultural identity-were conducted to determine whether 3-month outcomes were associated with a pre-morbid mental health diagnosis. RESULTS: From 405 eligible patients, 386 were enrolled (76% male, mean age 38.9 (standard deviation 15.6)); 57% self-identified as Australian and 22% had a pre-morbid mental health diagnosis. Common injuries regardless of pre-morbid mental health diagnosis were skin (40%), tendon (17%) and bone (17%) injuries. None were complex mutilating injuries. Seventy-eight per cent of the cohort was followed-up. In adjusted analyses, a pre-morbid mental health diagnosis was associated with lower odds for reporting 'good or better' global mental health (Odds Ratio (OR) 0.23 (95% Confidence Interval (CI) 0.18, 0.47), p < 0.001), 'no' anxiety or depression (OR 0.21 (0.11, 0.40), p < 0.001) and no pain (OR 0.56 (0.31, 0.98), p = 0.04)(EQ domains), and worse EQ 'Health Today' (10 points on average (95%CI -14.9, -5.1, p < 0.001). QuickDASH scores, rates of complications/symptomatic complaints and return-to-work profiles were similar. CONCLUSIONS: Despite reporting worse mental and health-related quality-of-life outcomes post-surgery, people with a pre-morbid mental health diagnosis regardless of cultural identity experienced similar clinical and return-to-work outcomes. Future research assessing the value of screening for pre-morbid mental health conditions on post-surgical outcomes is required and should include people with more complex hand injuries.

Cost-effectiveness of a purpose-built ward environment and new allied health model of care for major trauma.

BACKGROUND: Targeted rehabilitation within the acute inpatient setting could have a substantial impact on improving outcomes for major trauma patients. The aim of this study was to investigate the cost-effectiveness of the introduction of a purpose-built ward environment, and a new allied health model of care (AHMOC) delivered in the acute inpatient setting, in a major trauma population. METHODS: The statewide trauma registry, the trauma center's data warehouse, and electronic medical record data were used for this observational study. There were three phases: baseline, new ward, and new AHMOC. Cost-effectiveness was measured as cost per quality-adjusted life year using preinjury, hospital discharge, 1-month and 6-month 5-level, EQ-5D utility scores. Total costs included initial acute and inpatient rehabilitation care, as well as outpatient, readmission and ED presentations to 6-months. RESULTS: Four hundred eleven patients were included. Case-mix was stable between phases. The median (IQR) number of allied health services received by patients was 8 (5-17) at baseline, 10 (5-19) in the new ward phase, and 17 (9-23) in the AHMOC phase. The proportion discharged to rehabilitation was 37% at baseline, 45% with the new ward and 28% with the new AHMOC. Mean (SD) total Australian dollar costs were $69,335 ($141,175) at baseline, $55,943 ($82,706) with the new ward and $37,833 ($49,004) with the AHMOC. The probability of the AHMOC being cost-effective at a willingness-to-pay threshold of $50,000 per quality-adjusted life year was 99.4% compared with baseline and 98% compared with the new ward. CONCLUSION: The new allied health model of care was found to be a cost-effective intervention. Uptake of this model of allied health care at other trauma centers has the potential to reduce the cost and burden of major trauma. LEVEL OF EVIDENCE: Economic and Value-based Evaluations; Level III.

Examining the patient profile and variance of management and in-hospital outcomes for Australian adult burns patients.

BACKGROUND: Burn injuries are a common subtype of trauma. Variation in models of care impacts clinical measures of interest, but a nation-wide examination of these measures has not been undertaken. Using data from the Burns Registry of Australia and New Zealand (BRANZ), we explored variation between Australian adult burn services with respect to treatment and clinical measures of interest. METHODS: Data for admissions July 2016 to June 2020 were extracted. Clinical measures of interest included intensive care admission, skin grafting, in-hospital death, unplanned readmissions, and length of stay (LOS). Estimated probabilities, means, and corresponding 95% confidence intervals (CI) were calculated for each service. RESULTS: The BRANZ recorded 8365 admissions during the study period. Variation between specialist burn services in admissions, demographics, management, and clinical measures of interest were observed. This variation remained after accounting for covariates. Specifically, the adjusted proportion (95% CI) of in-hospital mortality ranged from 0.15% (0.10-0.21%) to 1.22% (0.9-1.5%). The adjusted mean LOS ranged from 3.8 (3.3-4.3) to 8.2 (6.7-9.7) days. CONCLUSIONS: A decade after its launch, BRANZ data displays variation between Australian specialist burn services. We suspect differences in models of care between services contributes to this variation. Ongoing research has begun to explore reasons underlying how this variation influences clinical measures of interest. Further engagement with services about models of care will enhance understanding of this variation and develop evidence-based guidelines for burn care in Australia.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review.

INTRODUCTION: Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix. ETHICS AND DISSEMINATION: Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers. PROSPERO REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (CRD42021226934).

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.

Does patient preference for online or telephone follow-up impact on response rates and data completeness following injury?

BACKGROUND: Routine collection of patient-reported outcomes is needed to better understand recovery, benchmark between trauma centers and systems, and monitor outcomes over time. A key component of follow-up methodology is the mode of administration of outcome measures with multiple options available. We aimed to quantify patient preference and compare the response rates and data completeness for telephone and online completion in trauma patients. METHODS: A registry-based cohort study of adult (16 years and older) patients registered to the Victorian State Trauma Registry and Victorian Orthopedic Trauma Outcomes Registry from April 2020 to December 2020 was undertaken. Survivors to discharge were contacted by telephone and offered the option of telephone or online completion of 6-month follow-up using the five-level EuroQol five-dimension (EQ-5D-5L) questionnaire and the 12-item World Health Organization Disability Assessment Schedule (WHODAS). The online and telephone groups were compared for differences in characteristics, follow-up rates, and data completeness. Multivariable logistic regression was used to identify predictors of choosing online completion. RESULTS: Of the 3,886 patients, 51% (n = 1,994) chose online follow-up, and the follow-up rates were lower for online (77%), compared with telephone (89%), follow-up. Younger age, higher socioeconomic status, and preferred language other than English were associated with higher adjusted odds of choosing online completion. Admission to intensive care was associated with lower adjusted odds of choosing online completion. Completion rate for the EQ-5D-5L utility score was 97% for both groups. A valid total 12-WHODAS score could be calculated for 63% of online respondents compared with 86% for the telephone group. CONCLUSION: More than half of trauma patients opted for online completion. Completion rates did differ depending on the questionnaire and telephone follow-up rates were higher. Nevertheless, given the wide diversity of the trauma population, the high rate of online uptake, and potential resource constraints, the study findings largely support the use of dual methods for follow-up. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level III.

Chronic physical health conditions up to five years after serious orthopaedic injury.

BACKGROUND: Information about the prevalence of chronic physical health conditions following serious orthopaedic injury is currently lacking in the general population and is essential for quantifying the burden of injury and improving outcomes. OBJECTIVES: To determine the prevalence of chronic physical health conditions recorded within hospitalisations and emergency department presentations and associated factors five years following serious orthopaedic injury. METHODS: We conducted a registry-based cohort study using data from the Victorian State Trauma Registry (2007-2016) linked with hospital admissions and ED presentations for 16,249 adults with serious orthopaedic injuries. We considered that people who were admitted to hospital or presented to an emergency department with a chronic physical health condition one to five years post-injury had "new-onset" conditions. We applied Kaplan-Meier failure curves and Cox proportional hazard regression models to determine factors associated with new-onset conditions. RESULTS: There were 1420 people (11.0%) with at least one new-onset condition. Cancer (6.1%), cardiovascular disease (5.1%) and hypertension (6.2%) were the three most common "new-onset" chronic physical health conditions. Older adults, women, smokers, and people with mental health and alcohol and drug-related conditions had a higher risk of hospitalisation or emergency department presentation with new-onset conditions post-injury. CONCLUSION: People with serious orthopaedic injuries experienced a significant additional burden of chronic physical health conditions up to five years after serious orthopaedic injury, posing a new challenge to post-trauma care. Early preventive interventions may be required in people with serious orthopaedic injuries to minimise modifiable risk factors such as smoking, excessive consumption of alcohol or drug use.

Chronic Physical Health Conditions After Injury: A Comparison of Prevalence and Risk in People With Orthopedic Major Trauma and Other Types of Injury.

OBJECTIVES: To determine (1) the prevalence of chronic physical health conditions reported preinjury, at the time of injury, up to 1 year postinjury, and 1 to 5 years postinjury; and (2) the risk of chronic physical health conditions reported 1 to 5 years postinjury in people with orthopedic and other types of major trauma. DESIGN: Cohort study using linked trauma registry and health administrative datasets. SETTING: This study used linked data from the Victorian State Trauma Registry (VSTR), the Victorian Registry of Births, Deaths and Marriages (BDM), the Victorian Admitted Episodes Dataset (VAED), and the Victorian Emergency Minimum Dataset (VEMD). PARTICIPANTS: Major trauma patients (N=28,522) aged 18 years and older who were registered by the VSTR, with dates of injury from 2007 to 2016, and who survived to at least 1 year after injury, were included in this study. Major trauma cases were classified into 4 groups: (1) orthopedic injury, (2) severe traumatic brain injury (s-TBI), (3) spinal cord injury, and (4) other major trauma. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Prevalence of chronic physical health conditions. RESULTS: The cumulative prevalence of any chronic physical health condition for all participants was 69.3%. The s-TBI group had the highest cumulative prevalence of conditions. The most common conditions were arthritis and arthropathies, cancer, and cardiovascular diseases. Preinjury chronic conditions were most common in people with s-TBI (19.3%) and were least common in people with other types of major trauma (6.6%). The highest prevalence of new-onset conditions after injury was found in people with s-TBI (21.7%) and orthopedic major trauma (21.4%), whereas the lowest prevalence was found in people with other types of major trauma (9.2%). For the orthopedic injury group, there were no significant differences in the adjusted risk of conditions reported 1 to 5 years postinjury compared with other major trauma groups. CONCLUSIONS: Chronic physical health conditions were common among all injury groups. There was no significant difference in the risk of chronic conditions among injury groups. Rehabilitation practitioners should be aware of the risk of chronic conditions in people with orthopedic and other types of major trauma. Long-term follow-up care after injury should include prevention and treatment of chronic conditions.

Towards a national perioperative outcomes registry: A survey of perioperative electronic medical record utilisation to support quality assurance and research at Australian and New Zealand College of Anaesthetists Clinical Trials Network hospitals in Australia.

In Australia, 2.7 million surgical procedures are performed annually. Historically, a lack of perioperative data standardisation and infrastructure has limited pooling of routinely collected data across institutions. We surveyed Australian and New Zealand College of Anaesthetists (ANZCA) Clinical Trials Network hospitals to investigate current and potential uses of perioperative electronic medical record data for research and quality assurance.A targeted survey was sent to 131 ANZCA Clinical Trials Network-affiliated hospitals in Australia. The primary aim was to map current electronic data collection methods and data utilisation in six domains of the perioperative pathway.The survey response rate was 32%. Electronic data recording in the six domains ranged from 19% to 85%. Where electronic data exist, the ability of anaesthesiology departments to export them for analysis ranged from 27% to 100%. The proportion of departments with access to data exports that are regularly exporting the data for quality assurance or research ranged from 13% to 58%.The existence of a perioperative electronic medical record does not automatically lead to the data being used to measure and improve clinical outcomes. The first barrier is clinician access to data exports. Even when this barrier is overcome, a large gap remains between the proportion of departments able to access data exports and those using the data regularly to inform and improve clinical practice. We believe this gap can be addressed by establishing a national perioperative outcomes registry to lead high-quality multicentre registry research and quality assurance in Australia.

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.

Association between type 2 diabetes and long-term outcomes in middle-aged and older trauma patients.

BACKGROUND: Diabetes is associated with increased hospital complications and mortality following trauma. However, there is limited research on the longer-term recovery of trauma patients with diabetes. The aim of this study was to explore the association between type 2 diabetes (T2D) and in-hospital and 24-month outcomes in major trauma patients. METHODS: In this cohort study using the Victorian State Trauma Registry, middle-aged and older adults (≥45 years) with major trauma were followed up at 24 months postinjury. Logistic regression (univariable and multivariable) analyses were used to determine the association between diabetes status and 24-month patient-reported outcomes. In-hospital outcomes were compared between groups using χ2 tests. RESULTS: Of the 11,490 participants who survived to hospital discharge, 8,493 survived to 24 months postinjury and were followed up at that time point: 953 people (11%) with and 7540 (89%) without T2D. People with T2D had a higher in-hospital death rate (19%) compared with people without T2D (16%; p < 0.001). After adjusting for confounders, people with T2D had poorer outcomes 24 months postinjury than people without T2D, with respect to functional recovery (Glasgow Outcome Scale Extended) (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.48-0.69) and return to work/study (AOR, 0.51; 95% CI, 0.37-0.71]). People with T2D experienced higher odds of problems with mobility (AOR, 1.92; 95% CI, 1.60-2.30), self-care (AOR, 1.94; 95% CI, 1.64, 2.29), usual activities (AOR, 1.50; 95% CI, 1.26-1.79), pain and discomfort (AOR, 1.75; 95% CI, 1.49-2.07), anxiety and depression (AOR, 1.45; 95% CI, 1.24, 1.70), and self-reported disability (AOR, 1.51; 95% CI, 1.28-1.79) than people without T2D. CONCLUSION: Major trauma patients with T2D have a poorer prognosis than patients without T2D, both during their hospital admission and 24 months postinjury. Patients with T2D may need additional health care and support following trauma to reach their recovery potential. LEVEL OF EVIDENCE: Prognostic, level III.

Learning From England's Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes.

OBJECTIVE: The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan. SUMMARY BACKGROUND DATA: Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative. METHODS: Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000 to 2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65 years) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved. RESULTS: A total of 806,036 English and 3,221,109 US hospitalizations were included. After BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7-3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000 to 2016, US outcomes were stagnant (P > 0.05), resulting in an inversion of the countries' mortality and >38,000 potential annual US lives saved. CONCLUSIONS: Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.

Residential aged care homes: Why do they call '000'? A study of the emergency prehospital care of older people living in residential aged care homes.

OBJECTIVE: To describe the clinical characteristics, medical interventions and patterns of ambulance service use related to the emergency, prehospital care of older people living in residential aged care (RAC) homes. METHODS: Retrospective cohort study using secondary analyses of routinely collected clinical and administrative data from Ambulance Victoria and population data from the Australian Bureau of Statistics for the state of Victoria, Australia. Participants included people aged 65 years and over, attended by emergency ambulances from 2008 to 2013, with data captured in the Ambulance Victoria electronic record. RESULTS: The mean (standard deviation) age of RAC residents attended by emergency ambulance was 85 (7.3) years and 63% were women. Common comorbidities included dementia (32.7%), ischaemic heart disease (27.7%) and osteoarthritis (24.6%). Polypharmacy was prevalent with 70% currently prescribed antibiotics, over 20% prescribed sedatives and a further 14.9% antipsychotics. Fifteen percent of attendances were for falls, which were more frequent among women than men. Other common reasons for ambulance call-out included uncontrolled pain, respiratory tract infection, non-specific febrile illness and altered conscious state. Almost 90% of people were transported to hospital from the RAC, with just over half of call-outs occurring out-of-hours. CONCLUSION: This is the first study to describe emergency prehospital care, case-mix and intervention of frail, older people living in RAC. These results demonstrate a clinically complex group of people with high rates of comorbidity, cognitive impairment and polypharmacy. These valuable data will inform education and training of prehospital clinicians, assist in targeting preventative medicine and primary care programmes and further development of alternate, acute and emergency care pathways for this unique patient group.

Systematic review of perioperative mortality risk prediction models for adults undergoing inpatient non-cardiac surgery.

BACKGROUND: Risk prediction tools can be used in the perioperative setting to identify high-risk patients who may benefit from increased surveillance and monitoring in the postoperative period, to aid shared decision-making, and to benchmark risk-adjusted hospital performance. We evaluated perioperative risk prediction tools relevant to an Australian context. METHODS: A systematic review of perioperative mortality risk prediction tools used for adults undergoing inpatient noncardiac surgery, published between 2011 and 2019 (following an earlier systematic review). We searched Medline via OVID using medical subject headings consistent with the three main areas of risk, surgery and mortality/morbidity. A similar search was conducted in Embase. Tools predicting morbidity but not mortality were excluded, as were those predicting a composite outcome that did not report predictive performance for mortality separately. Tools were also excluded if they were specifically designed for use in cardiac or other highly specialized surgery, emergency surgery, paediatrics or elderly patients. RESULTS: Literature search identified 2568 studies for screening, of which 19 studies identified 21 risk prediction tools for inclusion. CONCLUSION: Four tools are candidates for adapting in the Australian context, including the Surgical Mortality Probability Model (SMPM), Preoperative Score to Predict Postoperative Mortality (POSPOM), Surgical Outcome Risk Tool (SORT) and NZRISK. SORT has similar predictive performance to POSPOM, using only six variables instead of 17, contains all variables of the SMPM, and the original model developed in the UK has already been successfully adapted in New Zealand as NZRISK. Collecting the SORT and NZRISK variables in a national surgical outcomes study in Australia would present an opportunity to simultaneously investigate three of our four shortlisted models and to develop a locally valid perioperative mortality risk prediction model with high predictive performance.

Association between gender and outcomes of acute burns patients.

BACKGROUND: Burn injuries are a complex and serious public health concern. Where the total body surface area of the burn exceeds 50%, mortality rates as high as 48% have been reported. While the association between gender and burn injury outcomes has been explored, findings are inconsistent. METHODS: Adult patients (>15 years) admitted between 1 July 2009 and 30 June 2018 to intensive care units of burn centres that provide specialist burn care in Australia and New Zealand were included. Raw mortality rates were examined and a multivariable Cox proportional hazards regression was used to investigate the association between gender and time to in-hospital death. RESULTS: There were 2227 eligible burn injury admissions. Men comprised the majority (77.6%). The proportion of women who died in hospital was greater than men and the adjusted odds of in-hospital mortality were 34% lower in men (odds ratio 0.66; 95% confidence interval (CI) 0.45-0.98). The unadjusted rate of in-hospital mortality for men was 44% lower than women (hazard ratio 0.56; 95% CI 0.41-0.76). After adjusting for confounders, there was no association between gender and survival time (hazard ratio 0.76; 95% CI 0.54-1.06). CONCLUSION: After adjustment for key differences in case-mix between men and women, there was an association between gender and in-hospital mortality and no association between gender and time to death. Our findings indicate that the worse outcomes observed for women are associated with different age and patterns of injury, and provide further information to direct and inform targeted prevention measures for vulnerable populations.

The current status of disaster preparedness in Canadian trauma centers.

Mass casualty incidents (MCIs) put substantial stress on loco-regional resources, and trauma centers are critical to responding to these events. Our previous evaluation of Canadian centers helped to identify several weaknesses in disaster responsiveness. In this analysis, we determined the current state of MCI readiness across Canada and how this has changed over time. A multinational cross-sectional survey-based study on MCI preparedness was performed, including 24 Canadian trauma centers. Surveys were completed anonymously online by representatives of each facility. Responses from Canadian centers were examined and compared to previous findings to assess temporal changes in institutional capacity. Fifteen (63%) trauma centers responded, 100% of which had a disaster committee. Sixty percent had a single all-hazards emergency plan, and 71% performed a practice drill in the last two years. Sixty-two percent had communications systems designed to function during an MCI. Ninety-two percent had a triage system in place, and 54% of centers could monitor surge capacity. Half (54%) reported back-up systems for survival essentials, but the capability for prolonged operation during a disaster was limited. A minority (15%) had a database denoting staff with emergency training, although half (54%) had disaster training programs. Comparison to past data showed an increased prevalence of committees dedicated to disaster preparedness and disaster drills but worsened external stakeholder representation and poor ability to provide a prolonged response to crises. Our results demonstrate that MCI preparedness is a growing focus of Canadian trauma centers, but that there are deficiencies that remain unaddressed. Future efforts should focus on these vulnerabilities to ensure the provision of a robust disaster response. LEVEL OF EVIDENCE: Level 3b (prevalence study, limited population).

Discharge destination and patient-reported outcomes after inpatient treatment for isolated lower limb fractures.

OBJECTIVES: To examine the association between discharge destination (home or inpatient rehabilitation) for adult patients treated in hospital for isolated lower limb fractures and patient-reported outcomes. DESIGN: Review of prospectively collected Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) data. SETTING, PARTICIPANTS: Adults (18-64 years old) treated for isolated lower limb fractures at four Melbourne trauma hospitals that contribute data to the VOTOR, 1 March 2007 - 31 March 2016. MAIN OUTCOME MEASURES: Return to work and functional recovery (assessed with the extended Glasgow Outcomes Scale, GOS-E); propensity score analysis of association between discharge destination and outcome. RESULTS: Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries. After propensity score adjustment, the odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home (odds ratio, 0.44; 95% CI, 0.37-0.51); for the 5057 people working before their accident, the odds of return to work were reduced by 66% (odds ratio, 0.34; 95% CI, 0.26-0.46). Propensity score analysis improved matching of the discharge destination groups, but imbalances in funding source remained for both outcome analyses, and for also for site and cause of injury in the GOS-E analysis (standardised differences, 10-16%). CONCLUSIONS: Discharge to inpatient rehabilitation after treatment for isolated lower limb fractures was associated with poorer outcomes than discharge home. Factors that remained unbalanced after propensity score analysis could be assessed in controlled trials.

Twelve month mortality rates and independent living in people aged 65 years or older after isolated hip fracture: A prospective registry-based study.

INTRODUCTION: This study investigated which patient and injury characteristics are associated with 12-month mortality rates and living independently after isolated hip fracture. METHODS: Older adults aged ≥65 years were included if they had an isolated hip fracture, were admitted to hospital between July 2009 and June 2016, inclusive, and were registered to the Victorian Orthopaedic Trauma Outcomes Registry. Mortality up to 12 months (365 days) post-injury, and functional outcomes (Glasgow Outcome Scale-Extended; GOS-E) at 12 months post-injury were examined. Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs), and multivariable logistic regression was used to identify predictors of living independently compared with severe disability or death on the GOS-E. RESULTS: 4,912 patients were included, of whom 28% died, 46% had moderate-severe disability, and 26% were living independently 12 months post-injury. Mortality rates were lower in women (aHR=0.56, 95%CI: 0.50, 0.63), and in people injured in a high fall vs low fall (aHR=0.47, 95%CI: 0.31, 0.72). Mortality rates were higher in people in the older age groups (75-84 years: aHR=1.53, 95%CI: 1.21, 1.93; 95+ years: aHR=3.58, 95%CI: 2.68, 4.77), living in areas with the highest level of socioeconomic disadvantage (aHR=1.25, 95%CI: 1.01, 1.55), with a Charlson Comorbidity Index weighting of one (aHR=1.60, 95%CI: 1.36, 1.88) or more than one (aHR=2.21, 95%CI: 1.94, 2.53), whose injury occurred in a residential institution versus at home (aHR=2.63, 95%CI: 1.97, 3.52), that resulted in intensive care unit admission (aHR=1.68, 95%CI: 1.21, 2.32), and in people who did not have surgery versus people who had internal fixation (aHR=1.65, 95%CI: 1.33, 2.04). Independent living was inversely associated with most of the same characteristics; however, people also had lower odds of living independently if they were from metropolitan residential areas versus rural areas (aOR=0.77, 95%CI: 0.62, 0.96), or had mild to moderate (aOR=0.33, 95%CI: 0.27, 0.39) or marked to severe (aOR=0.13, 95%CI: 0.09, 0.20) preinjury disability vs no preinjury disability. CONCLUSIONS: Characteristics that are associated with social disadvantage, frailty, poor health and reduced independence before injury were associated with increased rates of death and reduced odds of living independently 12 months after isolated hip fracture.