Impacting trauma care in resource-limited settings: Lessons learned from Tanzania's web-based trauma registry initiatives.

BACKGROUND: Trauma significantly impacts Tanzanian healthcare. Lacking standardized hospital-based minimal trauma data sets places further challenges for policymakers. In other resource-limited countries, implementing trauma systems and registries has reduced injury mortalities. In 2013, we introduced an electronic trauma registry, iTRAUMATM at the Tanzanian Muhimbili Orthopedic Institute (MOI) but noted several drawbacks. In 2023, we introduced a robust web-based trauma registry platform. This study assesses the feasibility and utility of implementing the platform at MOI and summarizes challenges, lessons, and results compared to existing systems. METHODS: This prospective observational study involved clinicians collecting data directly on the platform at the point-of-care, following specific training. Semi-structured interviews with local stakeholders identified challenges and areas for improvement. Data were reported from July to December 2023. RESULTS: Data from 2930 patients showed 59% of injuries were from road traffic collisions (RTCs), with 43% of patients arriving at MOI by non-ambulances. Our findings show that non-ambulance arrivals were associated with higher injury severity (p < 0.026), mortalities (p < 0.017), and delayed hospital arrival (p < 0.004), underscoring the critical role of prompt transport in trauma management. The new platform identified trauma care gaps, with a mean arrival-to-care time of 29.89 min, prompting trauma training at MOI to enhance clinician capacities. It also demonstrated superiority over existing systems by improving data completeness, timeliness, and usability. Challenges included gaining support for the platform's functionality, technology integration, and navigating administrative changes. With continued communication, stakeholder acceptance and support were achieved. CONCLUSION: The web-based platform has become MOI's standard trauma database, demonstrating its feasibility and utility. It overcame the existing challenges of data completeness, timeliness, and usability for policymaking. Positive feedback has prompted plans to expand the platform to other hospitals, benefiting clinical benchmarking and trauma preventive efforts. Ensuring sustainability requires involvement from the Ministry of Health, ongoing training, functionality enhancements, and strengthened global partnerships.

Digitizing operating theater data in resource-limited settings: Understanding surgical care delivery post-implementation at Tanzanian referral hospital.

BACKGROUND: Digitizing surgical data infrastructure is critical for policymakers to make informed decisions. The implementation of the first web-based operating theater (OT) recordings at Muhimbili Orthopedic Institute (MOI) represents significant advancements in data management for Tanzania. This study aims to share post-platform implementation outcomes, challenges, and insights gained offering guidance to settings facing similar data repository challenges. METHODS: In July 2023, after training clinicians, the platform was deployed at MOI operating theaters (OTs) to facilitate prospective data entry following procedures, ensuring timely updates of perioperative outcomes. Semi-structured interviews were conducted with key stakeholders to gather insights into the platform's functionality and efficient data management systems. We presented data from August 2023 to February 2024 along with platform insights. RESULTS: Over 4449 procedures were conducted, comprising 1321 emergencies and 3128 electives, with orthopedics/trauma accounting for the majority (3606). Trauma-related emergencies (921) predominate among interventions. General anesthesia was prevalent; 60.56% in emergencies and 44.51% in electives. Orthopedics/trauma utilized 90.91% of assigned operating days in electives, while neurosurgery utilized 93.39% (p < 0.011). The cancellation rate was 7.5%, primarily due to emergency interferences (32%). Of procedures, 96.76% were discharged, while 2.81% died. Challenges encountered during platform implementation included securing local support, integrating technology, and navigating administrative adjustments. Lessons learned emphasized continuous communication for stakeholder buy-in and training for platform familiarity. CONCLUSION: The web-based OT recordings at MOI succeeded with local support and showed promise for wider scalability. To ensure sustainability, ongoing follow-up, monitoring of platform functionality, local funding establishment, and strengthening global partnerships are recommended.

Enhancing trauma care through innovative trauma and disaster team response training: A blended learning approach in Tanzania.

BACKGROUND: In Tanzania, inadequate infrastructures and shortages of trauma-response training exacerbate trauma-related fatalities. McGill University's Centre for Global Surgery introduced the Trauma and Disaster Team Response course (TDTR) to address these challenges. This study assesses the impact of simulation-based TDTR training on care providers' knowledge/skills and healthcare processes to enhance patient outcomes. METHODS: The study used a pre-post-interventional design. TDTR, led by Tanzanian instructors at Muhimbili Orthopedic Institute from August 16-18, 2023, involved 22 participants in blended online and in-person approaches with simulated skills sessions. Validated tools assessed participants' knowledge/skills and teamwork pre/post-interventions, alongside feedback surveys. Outcome measures included evaluating 24-h emergency department patient arrival-to-care time pre-/post-TDTR interventions, analyzed using parametric and non-parametric tests based on data distributions. RESULTS: Participants' self-assessment skills significantly improved (median increase from 34 to 58, p < 0.001), along with teamwork (median increase from 44.5 to 87.5, p < 0.003). While 99% of participants expressed satisfaction with TDTR meeting their expectations, 97% were interested in teaching future sessions. The six-month post-intervention arrival-to-care time significantly decreased from 29 to 13 min, indicating a 55.17% improvement (p < 0.004). The intervention led to fewer ward admissions (35.26% from 51.67%) and more directed to operating theaters (29.83% from 16.85%), suggesting improved patient management (p < 0.018). CONCLUSION: The study confirmed surgical skills training effectiveness in Tanzanian settings, highlighting TDTR's role in improving teamwork and healthcare processes that enhanced patient outcomes. To sustain progress and empower independent trauma educators, ongoing refresher sessions and expanding TDTR across low- and middle-income countries are recommended to align with global surgery goals.

Assessing Ethiopia's surgical capacity in light of global surgery 2030 initiatives: Is there progress in the past decade?

Background: Surgical, anesthetic, and obstetric (SAO) care plays a crucial role in global health, recognized by the World Health Organization (WHO) and The Lancet Commission on Global Surgery (LCoGS). LCoGS outlines six indicators for integrating SAO services into a country's healthcare system through National Surgical Obstetrics and Anesthesia Plans (NSOAPs). In Ethiopia, surgical services progress lacks evaluation. This study assesses current Ethiopian surgical capacity using the LCoGS NSOAPs framework. Methods: We conducted a narrative review of published literature on critical LCoGS NSAOPs metrics to extract information on key domains; service delivery, workforce, infrastructure, finance, and information management. Results: Ethiopia's surgical services face challenges, including a low surgical volume (43) and a scarcity of specialist SOA physicians (0.5) per 100,000 population. Over half of Ethiopians reside outside the 2-hour radius of surgery-ready hospitals, and 98 % face surgery-related impoverished expenditures. Lacking the LCoGS-recommended SOA reporting systems, approximately 44 % of facilities exist for handling bellwether procedures. Despite the prevalence of essential surgeries, primary district hospitals have limited operative infrastructures, resulting in disparities in the surgical landscape. Most surgery-ready facilities are concentrated in cities, leaving Ethiopia's 80 % rural population with inadequate access to surgical care. Conclusion: Ethiopia's surgical capacity falls below LCoGS NSOAPs recommendations, with challenges in infrastructure, personnel, and data retrieval. Critical measures include scaling up access, workforce, public insurance, and information management to enhance SAO services. Ethiopia pioneered in Sub-Saharan Africa by establishing Saving Lives Through Safe Surgery (SaLTS) in response to NSOAPs, but progress lags behind LCoGS recommendations.

Advancing access to care: An assessment of the prehospital system in Senegal.

BACKGROUND: Most low- and middle-income countries do not have a mature prehospital system limiting access to definitive care. This study sought to describe the current state of the prehospital system in Senegal and offer recommendations aimed at improving system capacity and population access to definitive care. METHODS: Structured interviews were conducted with key informants in various regions throughout the country using qualitative and quantitative techniques. A standardized questionnaire was generated using needs assessment forms and system frameworks. Descriptive statistics were performed for quantitative data analysis, and qualitative data was consolidated and presented using ATLAS.ti. RESULTS: Two (20%) of the studied regions, Dakar and Saint-Louis, had a mature prehospital system in place, including dispatch centers and teams of trained personnel utilizing equipped ambulances. 80% of the studied regions lacked an established prehospital system. The vast majority of the population relied on the fire department for transport to a healthcare facility. The ambulances in rural regions were not part of a formal prehospital system, were not equipped with life-support supplies, and were limited to inter-facility transfers. CONCLUSIONS: While Dakar and Saint-Louis have mature prehospital systems, the rest of the country is served by the fire department. There are significant opportunities to further strengthen the prehospital system in rural Senegal by training the fire department in basic life support and first aid, maintaining cost efficiency, and building on existing national resources. This has the potential to significantly improve access to definitive care and outcomes of emergent illness in the Senegalese community.

Repeat imaging increases detection of delayed pseudoaneurysms in patients with high-grade solid organ injury following abdominal trauma.

BACKGROUND: Nonoperative management of abdominal trauma can be complicated by the development of delayed pseudoaneurysms. Early intervention reduces the risk of rupture and decreases mortality. The objective of this study is to determine the utility of repeat computed tomography (CT) imaging in detecting delayed pseudoaneurysms in patients with abdominal solid organ injury. METHODS: A retrospective cohort study reviewing Montreal General Hospital registry between 2013 and 2019. Patients with The American Association for the Surgery of Trauma (AAST) grade 3 or higher solid organ injury following abdominal trauma were identified. A chart review was completed, and demographics, mechanism of injury, Injury Severity Score (ISS) score, AAST injury grade, CT imaging reports, and interventions were collected. Descriptive analysis and logistic regression model were completed. RESULTS: We identified 195 patients with 214 solid organ injuries. The average age was 38.6 years; 28.2% were female, 90.3% had blunt trauma, and 9.7% had penetrating trauma. The average ISS score was 25.4 (SD 12.8) in patients without pseudoaneurysms and 19.5 (SD 8.6) in those who subsequently developed pseudoaneurysms. The initial management was nonoperative in 57.0% of the patients; 30.4% had initial angioembolization, and 12.6% went to the operating room. Of the cohort, 11.7% had pseudoaneurysms detected on repeat CT imaging within 72 h. Grade 3 represents the majority of the injuries at 68.0%. The majority of these patients underwent angioembolization. CONCLUSIONS: In patients with high-grade solid organ injury following abdominal trauma, repeat CT imaging within 72 h enabled the detection of delayed development of pseudoaneurysms in 11.7% of injuries. The majority of the patients were asymptomatic.

Predictors of clinical deterioration and intensive care unit admission in trauma patients transferred from northern Quebec to a level 1 trauma centre: a retrospective cohort study.

BACKGROUND: Trauma care in Nunavik, Quebec, is highly challenging. Geographic distances and delays in transport can translate into precarious patient transfers to tertiary trauma care centres. The objective of this study was to identify predictors of clinical deterioration during transport and eventual intensive care unit (ICU) admission for trauma patients transferred from Nunavik to a tertiary trauma care centre. METHODS: This is a retrospective cohort study using the Montreal General Hospital (MGH) trauma registry. All adult trauma patients transferred from Nunavik and admitted to the MGH from 2010 to 2019 were included. Main outcomes of interest were hemodynamic and neurologic deterioration during transport and ICU admission. RESULTS: In total, 704 patients were transferred from Nunavik and admitted to the MGH during the study period. The median age was 33 (interquartile range [IQR] 23-47) years and the median Injury Severity Score was 10 (IQR 5-17). On multiple regression analysis, transport time from site of injury to the MGH (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.06), thoracic injuries (OR 1.75, 95% CI 1.03-2.99), and head and neck injuries (OR 3.76, 95% CI 2.10-6.76) predicted clinical deterioration during transfer. Injury Severity Score (OR 1.04, 95% CI 1.01-1.08), abnormal local Glasgow Coma Scale score (OR 2.57, 95% CI 1.34-4.95), clinical deterioration during transfer (OR 4.22, 95% CI 1.99-8.93), traumatic brain injury (OR 2.44, 95% CI 1.05-5.68), and transfusion requirement at the MGH (OR 4.63, 95% CI 2.35-9.09) were independent predictors of ICU admission. CONCLUSION: Our study identified several predictors of clinical deterioration during transfer and eventual ICU admission for trauma patients transferred from Nunavik. These factors could be used to refine triage criteria in Nunavik for more timely evacuation and higher level care during transport.

Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients. METHODS: We searched Medline, EMBASE, Scopus, and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to October 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients 15 years and younger, nontrauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Meta-analysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year. RESULTS: Twenty-four articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% confidence interval, 5%-13%). In post hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (odds ratio, 0.87; 95% confidence interval, 0.75-0.99; p = 0.046; R 2 = 35%; I 2 = 48%). CONCLUSION: This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level III.

Surgical, trauma and telehealth capacity in Indigenous communities in Northern Quebec: a cross-sectional survey.

BACKGROUND: Delivering trauma and surgical care to Northern Quebec presents unique challenges owing to the region's remoteness, extreme weather and limited transport; the expansion of telehealth could help address these difficulties. We aimed to evaluate current surgical, trauma and telemedicine capacity in Nunavik, Quebec. METHODS: We used validated assessment tools, including the Personnel, Infrastructure, Procedures, Equipment and Supplies survey, the International Assessment of Capacity for Trauma index and the Maryland Health Care Commission Telemedicine Readiness tool to evaluate surgical, trauma and telemedicine capacity, respectively. We adapted these tools to the Northern Quebec context through discussions with local leadership. Data were collected in 2 regional hospitals - the Ungava Tulattavik Health Centre (UTHC) and the Inuulitsivik Health Centre (IHC) - and 12 Centres locaux de services communautaires (CLSCs; local community services centres) in 6 villages along the Hudson Bay coast and 6 villages along the Ungava Bay coast through iterative discussions with 4 chief nurses from each regional hospital and set of CLSCs; resources were confirmed through on-site evaluation by the respondents. We performed a descriptive analysis of the data. RESULTS: Surgical capacity was highest in the IHC (6.76) and lowest in the Ungava Bay CLSCs (5.52). Personnel (0%-0%) and procedures (13%-33%) were the least available resources. Trauma capacity was highest in the IHC (7.25) and lowest in the Hudson Bay CLSCs (5.58). Although equipment (90%-100%) and supplies (100%-100%) were readily available, personnel (0%-0%) and procedures (25%-56%) were lacking. The UTHC was most prepared for telehealth (67.80%), and the Ungava Bay CLSCs achieved a lower score (51.13%). Underdeveloped telehealth criteria included funding, administrative support, quality improvement and physical spaces (all 33%-67%). CONCLUSION: Acute care capacity in Nunavik appears heterogeneous, with readily available equipment and supplies, but a lack of personnel capable of performing lifesaving procedures. To address the need for telemedicine, future initiatives should focus on improving funding, administrative support, physical spaces and quality-improvement initiatives.

Who are the trauma team leaders across Canada? A national survey evaluating the profession in adult and pediatric level one trauma centres.

OBJECTIVES: Trauma Team Leaders (TTLs) are critical for coordinating and leading trauma resuscitations. This survey sought to characterize the demographics and professional practices of Canadian TTLs at level one trauma centres. As a secondary objective, this information will be utilized to inform the operational goals of the Trauma Association of Canada (TAC) TTL Committee. METHODS: A detailed survey, developed by the TAC board of directors and TTL committee leads, was sent to 225 TTLs across Canada's level one trauma centres. TTLs were identified via contacting trauma directors at each level one centre, in addition to public registry searches. This survey captured demographics, professional background, resuscitation practices, trauma team composition, and TTL involvement in trauma responses. RESULTS: The response rate was 41.7%. Mean respondent age was 42 (SD 7.4) and 71.0% were male. Most TTLs trained in emergency medicine (53.1%) or general surgery (25.5%); 63.8% underwent TTL training: either via a trauma surgery fellowship or TTL fellowship. All centres have a massive hemorrhage protocol implemented, and there is no large variation between the rates of use of cryoprecipitate and fibrinogen, nor the ratio of blood products transfused (2:1 vs 1:1). Most TTL respondents intend to participate in a TTL group associated with TAC (85.1%). CONCLUSION: The results of this survey will contribute to the recognition of TTLs as a crucial role in the initial phase of care of severely injured trauma patients and serves as the first publication to document professional backgrounds and practices of Canadian TTLs at level one trauma centres. All the information gathered via this survey will be used by the TAC TTL Committee, which will focus on several initiatives such as the dissemination of best practice guidelines and creation of a TTL stream at the TAC Annual Conference.

RéSUMé: OBJECTIFS: Les chefs d'équipe de traumatologie (TTL) sont essentiels pour coordonner et diriger les réanimations traumatiques. Cette enquête visait à caractériser la démographie et les pratiques professionnelles des TTL canadiens dans les centres de traumatologie de niveau 1. À titre d'objectif secondaire, cette information sera utilisée pour éclairer les objectifs opérationnels du Comité TTL de l'Association canadienne de traumatologie (ATC). MéTHODES: Un sondage détaillé, élaboré par le conseil d'administration de l'ATC et les responsables des comités de TTL, a été envoyé à 225 TTL dans les centres de traumatologie de niveau 1 du Canada. Les TTL ont été identifiés en contactant les directeurs de traumatologie de chaque centre de niveau 1, en plus des recherches dans le registre public. Cette enquête a porté sur la démographie, les antécédents professionnels, les pratiques de réanimation, la composition de l'équipe de traumatologie et la participation de la TTL aux réponses traumatologiques. RéSULTATS: Le taux de réponse était de 41,7 %. L'âge moyen des répondants était de 42 ans (ET 7,4) et 71,0 % étaient des hommes. La plupart des TTL ont suivi une formation en médecine d'urgence (53,1%) ou en chirurgie générale (25,5%); 63,8% ont suivi une formation TTL : soit via une bourse en chirurgie traumatologique ou une bourse TTL. Tous les centres ont mis en œuvre un protocole d'hémorragie massive, et il n'y a pas de grande variation entre les taux d'utilisation du cryoprécipité et du fibrinogène, ni entre le rapport des produits sanguins transfusés (2:1 vs 1:1). La plupart des répondants TTL ont l'intention de participer à un groupe TTL associé au TAC ( 85,1 %). CONCLUSION: Les résultats de ce sondage contribueront à la reconnaissance des TTL comme un rôle crucial dans la phase initiale des soins aux patients ayant subi un traumatisme grave et serviront de première publication pour documenter les antécédents et les pratiques professionnelles des TTL canadiens au niveau un centres de traumatologie. Toutes les informations recueillies dans le cadre de cette enquête seront utilisées par le Comité TAC TTL, qui se concentrera sur plusieurs initiatives telles que la diffusion de lignes directrices sur les meilleures pratiques et la création d'un flux TTL à la conférence annuelle TAC.

Virtual trauma patient simulation design using the McGill Simulation Complexity Score (MSCS): a breakthrough in trauma education.

BACKGROUND: Virtual patient simulations are interactive, computer-based cases. We designed scenarios based on the McGill Simulation Complexity Score (MSCS), a previously described objective complexity score. We aimed to establish validity of the MSCS and introduce a novel learning tool in trauma education at our institution. METHODS: After design of an easy and difficult patient scenario, we randomized medical students and residents to each perform 1 of the 2 scenarios. We conducted a 2-way analysis of variance of training level (medical student, resident) and scenario complexity (easy, difficult) to assess their effects on virtual time, the number of steps taken in the scenario, beneficial and harmful actions, and the ratio of beneficial over harmful actions. RESULTS: Virtual patient scenarios were successfully designed using the MSCS. Twenty-four medical students and 12 residents participated in the easy scenario (MSCS = 3), and 27 medical students and 12 residents did the difficult scenario (MSCS = 18). Though beneficial actions were similar between students and residents, sudents performed more harmful actions, particularly when the scenario was difficult. One virtual patient died in the easy scenario and 3 died in the difficult one (all medical students). Performance varied with level of complexity and there was significant interaction between level of training and number of steps, as well as with number of harmful actions. Decreasing performance with increasing level of complexity, as defined by the MSCS, suggests this score can accurately quantify difficulty. CONCLUSION: We established validity of the MSCS and showed its successful application on virtual patient scenario design.

The McGill Simulation Complexity Score (MSCS): a novel complexity scoring system for simulations in trauma.

BACKGROUND: In medical education, simulation can be defined as an activity in which an individual demonstrates skills, procedures and critical thinking using interactive mannequins in a setting closely resembling the clinical environment. To our knowledge, the complexity of trauma simulations has not previously been assessed. We aimed to develop an objective trauma simulation complexity score and assess its interrater reliability. METHODS: The McGill Simulation Complexity Score (MSCS) was designed to address the need for objective evaluation of the complexity of trauma scenarios. Components of the score reflected the Advanced Trauma Life Support approach to trauma. The score was developed to take into account the severity of trauma injuries and the complexity of their management. We assessed interrater reliability at 5 high-fidelity simulation events. Interrater reliability was calculated using the Pearson correlation coefficient (PCC) and the intraclass correlation coefficient (ICC). RESULTS: The MSCS has 5 categories: airway, breathing, circulation, disability, and extremities or exposure. The scale has 5 levels for each category, from 0 to 4; level increases with complexity, with 0 corresponding to normal or absent. Cases designed to lead to cardiac arrest, regardless of whether or not the trainee has the ability to resuscitate the simulated patient and regardless of the level of each category, are automatically assigned the maximum score. Between 3 and 9 raters used the MSCS to grade the level of complexity of 26 scenarios at the 5 events. The mean MSCS was 10.2 (range 3.0-20.0). Mean PCC and ICC values were both above 0.7 and therefore statistically significant. CONCLUSION: The MSCS for trauma is an innovative scoring system with high interrater reliability.

Organizing a virtual scientific conference: experiences from the Bethune Round Table 2021.

In response to the COVID-19 pandemic, organizations used virtual platforms to host academic meetings. This includes the Canadian Network for International Surgery and the Centre for Global Surgery at the McGill University Health Centre, who were tasked with organizing the Bethune Round Table (BRT), held May 28-31, 2021. With 496 registrants and 300 attendees representing 50 countries, the BRT 2021 was the most trafficked BRT conference in its 20-year history. One month after the conference's conclusion, attendees were continuing to view the recorded sessions. Here we describe the successes of the virtual BRT 2021 conference and the plan to continue offering a digital mode of delivery for future BRT conferences.

Validation of Quality Indicators Targeting Low-Value Trauma Care.

Importance: Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences. Objective: To assess the validity of quality indicators on low-value trauma care using trauma registry data. Design, Setting, and Participants: Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts. Main Outcomes and Measures: Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time). Results: The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs. Conclusions and Relevance: This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.

Penn State equation versus indirect calorimetry for nutritional assessment in patients with traumatic brain injury.

BACKGROUND: Nutritional assessment can be challenging in patients with traumatic brain injury (TBI), and indirect calorimetry may be a more suitable method than predictive equations. We compared the Penn State equation versus the gold standard of indirect calorimetry for the nutritional assessment of patients with TBI, and quantified the difference between nutritional requirements and actual patient intake. METHODS: This single-centre, prospective cohort study included patients with moderate (Glasgow Coma Scale score 9-12) and severe (Glasgow Coma Scale score 3-8) TBI admitted to the Montreal General Hospital intensive care unit (ICU) between June 2018 and March 2019. Penn State equation estimates and indirect calorimetry measurements were collected, and actual intake was drawn from medical records. We compared the 2 assessment methods using a Spearman correlation coefficient. RESULTS: Twenty-three patients with TBI (moderate in 7 and severe in 16) were included in the study. Overall, there was a moderate positive correlation between the Penn State equation estimate and indirect calorimetry readings (correlation coefficient 0.457, p = 0.03); however, the correlation was weaker in severe TBI (correlation coefficient 0.174, p = 0.5) than in moderate TBI (correlation coefficient 0.929, p = 0.003). When compared to indirect calorimetry assessment, patients received 5.4% (p = 0.5) of required intake on the first day and 43.9% (p = 0.8) of required daily intake throughout their ICU stay. CONCLUSION: Patients with moderate or severe TBI in the ICU received less than 50% of their nutritional requirements. The difference between the Penn State equation and indirect calorimetry assessments was most noticeable for patients with severe TBI, which indicates that indirect calorimetry may be a more suitable tool for assessment of nutritional needs in this population.

Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care.

Importance: The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective: To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, Setting, and Participants: This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main Outcomes and Measures: Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results: Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and Relevance: In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

Feasibility of intraoperative angioembolization for trauma patients using C-arm digital subtraction angiography.

PURPOSE: Hemodynamically unstable trauma patients who would benefit from angioembolization (AE) typically also require emergent surgery for their injuries. The critical decision of transferring a patient to the operating room versus the interventional radiology (IR) suite can be bypassed with the advent of intra-operative AE (IOAE). Previously limited by the availability of costly rooms termed RAPTOR (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using C-arm digital subtraction angiography (DSA) is a comparable alternative. This case series aims to establish the feasibility and safety of IOAE. METHODS: We conducted a retrospective analysis of all trauma patients at our level 1 trauma center who underwent IOAE with a concomitant surgical intervention from January 2011 to May 2019. Descriptive analyses were conducted. RESULTS: A total of 49 patients (80% male, 44 ± 17 years, 92% blunt) underwent IOAE using the C-arm DSA during the study period. All but one patient underwent exploratory laparotomy, 56% of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopedic). Either Gelfoam® (Pfizer, New York, USA) (90%), coils (2.0%), or a combination (8.2%) were used for embolization. Internal iliac embolization was performed in 88% of cases (59% bilateral). IOAE was successful in all but four cases (8.2%) and thirty-day mortality was 31%. CONCLUSION: IOAE appears to be a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control.

A pilot trauma registry in Peshawar, Pakistan - A roadmap to decreasing the burden of injury - Quality improvement study.

BACKGROUND/LOCAL PROBLEM: In Pakistan, trauma is a significant public health issue accounting for the second leading cause of disability and fifth for healthy years of life lost. Well-developed trauma systems, utilizing trauma registries, have been proven to decrease morbidity and mortality from injuries, and helped to reduce the number of injured patients. In Pakistan, most data on injury are acquired through methods that are retrospective, incomplete, and open to recall bias. To that end, a trauma registry was piloted at the Lady Reading Hospital (LRH) in Peshawar, Pakistan to elucidate the importance of trauma registries in designing healthcare targeted quality improvement initiatives. INTERVENTION: Upon receiving ethics approval, a twenty-five-point registry was piloted at the Lady Reading Hospital. METHODS: The pilot implementation was carried out from May 9th to May 13th, 2018. RESULTS: A total of 267 patients were included in the pilot registry. Motor vehicle collisions were the most prevalent cause of injury (46%). The other causes of injury included falls (24%), blunt assaults (9%), stabs/cuts (8%), gunshots (6%), crush injuries (3%), burns (2%), and blasts/landmines (2%). Most patients were treated in the trauma bay and required no further acute intervention (51%). CONCLUSION: This 5-day pilot trauma registry was the first of its kind in Peshawar, Pakistan, and despite its short course, an immense amount of data was garnered on the epidemiology of injury in the region. Significantly, the data collected can already be used to develop evidence-based changes, which will effectively minimize the impact of trauma.

Trauma in northern Quebec, 2005-2014: epidemiologic features, transfers and patient outcomes.

BACKGROUND: The Inuit people residing in Nunavik, Quebec, are vulnerable to major trauma owing to environmental and social factors; however, there is no systematic data collection for trauma in Nunavik, and, apart from data regarding patients who are transferred to tertiary care centres, no data enter the Quebec trauma registry directly from Nunavik. We performed a study to characterize the epidemiologic features of trauma in Nunavik, and describe indications for transfer and outcomes of patients referred to the tertiary trauma centre. METHODS: We collected data retrospectively for all patients with trauma admitted to the Centre de santé Tulattavik de l'Ungava in Kuujjuaq from 2005 to 2014. Sociodemographic, injury and health services data were extracted. The data were analyzed in conjunction with coroners' reports on death from trauma in Nunavik. RESULTS: A total of 797 trauma cases were identified. The most common causes of injury were motor vehicle collisions (258 cases [32.4%]), falls (137 [17.2%]) and blunt assault (95 [11.9%]). One-third of patients (262 [32.9%]) were transferred to the tertiary care centre in Montréal. The incidence rate of major trauma (Injury Severity Score > 12) was 18.1 and 21.7 per 10 000 person-years in the Kuujjuaq region and the Puvirnituq region, respectively, which translates to a relative risk (RR) of 4 compared to the Quebec population. The disparity observed in trauma mortality rate was even greater, with an RR of 47.6 compared to the Quebec population. CONCLUSION: The study showed major disparity in trauma incidence and mortality rate between Nunavik and the province of Quebec. Our findings allow for a better understanding of the burden of injury and regional trauma mortality in Nunavik, and recommendations for optimization of the trauma system in this unique setting.

Calibration and validation of the pediatric resuscitation and trauma outcome model among injured children in Rwanda.

BACKGROUND: Trauma is a leading cause of mortality in low- and middle-income countries. The Pediatric Resuscitation and Trauma Outcomes (PRESTO) model uses six low-tech variables available at point of care in resource-limited environments to predict in-hospital mortality of injured children. This model was never calibrated and validated in a low-income country. We aimed to calibrate the model's coefficients and compare its performance against the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS) using data from a low-income country. STUDY DESIGN: Data from 2011 to 2015 in the prospectively-maintained Rwanda Injury Registry were reviewed after ethical approval was obtained. Patients were included for analysis if they were referred or admitted for traumatic injury, were younger than 15 years and if hospital outcomes were recorded. The variables in the PRESTO model include age, hypotension, heart rate, neurological status, oxygen saturation and airway intervention. The outcome of interest was in-hospital death. After calibration, Receiver-Operating-Characteristic curves were constructed to compare the area-under-curve (AUC) of PRESTO, RTS, and KTS with imputation of missing data. Comparisons of the relative AUC's were performed using Delong's test after bootstrapping in the full cohort and in a subset of patients <5 years-old. RESULTS: There were 113 in-hospital deaths out of 1695 included patients (6.7%). The AUC for the PRESTO model was 0.90 (95% CI [0.82-0.91]), higher than for RTS (0.77, 95% CI [0.80-0.97], p < 0.01) but not statistically different from KTS (0.89, 95% CI [0.72-0.82], p = 0.856). In the under-five cohort, the PRESTO model AUC was 0.84 (95% CI [0.75-0.92]), significantly higher than RTS (0.73 95% CI [0.64-0.81], p < 0.01) and KTS (0.58, 95% CI [0.50-0.66], p < 0.01). CONCLUSION: PRESTO appears to be the superior benchmarking tool for pediatric patients in a low- and middle-income country context. The PRESTO score outperforms the KTS in children <5 years of age. Further validation of the PRESTO model is needed from other low- and middle-income settings. LEVEL OF EVIDENCE: Level III: case-control (prognostic) study.