Early vocational rehabilitation and psychological support for trauma patients to improve return to work (the ROWTATE trial): study protocol for an individually randomised controlled multicentre pragmatic trial.

BACKGROUND: Moderately severe or major trauma (injury severity score (ISS) > 8) is common, often resulting in physical and psychological problems and leading to difficulties in returning to work. Vocational rehabilitation (VR) can improve return to work/education in some injuries (e.g. traumatic brain and spinal cord injury), but evidence is lacking for other moderately severe or major trauma. METHODS: ROWTATE is an individually randomised controlled multicentre pragmatic trial of early VR and psychological support in trauma patients. It includes an internal pilot, economic evaluation, a process evaluation and an implementation study. Participants will be screened for eligibility and recruited within 12 weeks of admission to eight major trauma centres in England. A total of 722 participants with ISS > 8 will be randomised 1:1 to VR and psychological support (where needed, following psychological screening) plus usual care or to usual care alone. The ROWTATE VR intervention will be provided within 2 weeks of study recruitment by occupational therapists and where needed, by clinical psychologists. It will be individually tailored and provided for ≤ 12 months, dependent on participant need. Baseline assessment will collect data on demographics, injury details, work/education status, cognitive impairment, anxiety, depression, post-traumatic distress, disability, recovery expectations, financial stress and health-related quality of life. Participants will be followed up by postal/telephone/online questionnaires at 3, 6 and 12 months post-randomisation. The primary objective is to establish whether the ROWTATE VR intervention plus usual care is more effective than usual care alone for improving participants' self-reported return to work/education for at least 80% of pre-injury hours at 12 months post-randomisation. Secondary outcomes include other work outcomes (e.g. hours of work/education, time to return to work/education, sickness absence), depression, anxiety, post-traumatic distress, work self-efficacy, financial stress, purpose in life, health-related quality of life and healthcare/personal resource use. The process evaluation and implementation study will be described elsewhere. DISCUSSION: This trial will provide robust evidence regarding a VR intervention for a major trauma population. Evidence of a clinically and cost-effective VR intervention will be important for commissioners and providers to enable adoption of VR services for this large and important group of patients within the NHS. TRIAL REGISTRATION: ISRCTN: 43115471. Registered 27/07/2021.

Injuries among children attributed to violence and social funding: a 10-year observational study.

BACKGROUND: Mechanisms and patterns of injury in children are changing, with violent mechanisms becoming more prevalent over time. Government funding of services for children and young people has reduced nationally over the last decade. We aimed to investigate the trends in admissions of injured children to a Major Trauma Centre (MTC) and examine the relationship between injuries sustained by violent mechanisms and local authority funding of children and youth services within the same catchment area. METHODS: A 10-year observational study included all patients aged<18 years treated at a regional MTC between April 2012 and April 2022. Number of admissions with violent trauma, mechanism of injury, requirement for operative intervention and mortality were compared with published annual local authority expenditure reports. RESULTS: 1126 children were included; 71.3% were boys, with median age 11 years (IQR 3-16). There were 154/1126 (14%) children who were victims of violent trauma; they were more likely to be boys than children injured by non-violent mechanisms (84% vs 69%). The proportion of injuries attributed to violence increased over the study period at the same time as reductions in local authority funding of services for the early years, families and youth services. However, there were insufficient data to formally assess the interdependency between these factors. CONCLUSIONS: The proportion of injuries attributed to violence has increased over time, and government spending on specific children and young people's services has decreased over the same time period. Further work is needed to examine the interdependency between spending and violent injuries in children, and public health interventions to target violence-related injuries should take into account youth service funding.

Injury by knife crime amongst children is associated with socioeconomic deprivation: an observational study.

PURPOSE: Children who live in areas of socioeconomic deprivation may be at higher risk of being victims of violent crime such as knife wounds. The current study investigated whether socioeconomic disparity was associated with higher risk of knife crime. METHODS: An observational study included patients aged ≤ 17 years at a UK Major Trauma Centre injured by knife trauma from 2016 to 2022. Indices of deprivation were recorded according to the zip code of residence and compared with those of all of England. These included Index of Multiple Deprivation (IMD); income; employment; education and skills; health and disability; crime; barriers to housing and services; living environment; and Income Deprivation Affecting Children Index (IDACI). RESULTS: There were 139 patients (96% male) with median age of 16 years. When compared with the whole of England, patients had worse indices of IMD (p = 0.021); income (p < 0.001); employment (p < 0.001); education and skills (p < 0.001); health and disability; and IDACI (p < 0.001). There were no significant differences in indices of crime, barriers to housing and services or living environment. CONCLUSIONS: Paediatric knife injury was associated with poor socioeconomic status in multiple domains. Focussed efforts to address socioeconomic disparities should be a priority as a public health measure for vulnerable children.

Site-Of-Care Viscoelastic Assay in Major Trauma Improves Outcomes and Is Cost Neutral Compared with Standard Coagulation Tests.

Major hemorrhage is often associated with trauma-induced coagulopathy. Targeted blood product replacement could achieve faster hemostasis and reduce mortality. This study aimed to investigate whether thromboelastography (TEG®) goal-directed transfusion improved blood utilization, reduced mortality, and was cost effective. Data were prospectively collected in a U.K. level 1 trauma center, in patients with major hemorrhage one year pre- and post-implementation of TEG® 6s Hemostasis Analyzers. Mortality, units of blood products transfused, and costs were compared between groups. Patient demographics in pre-TEG (n = 126) and post-TEG (n = 175) groups were similar. Mortality was significantly lower in the post-TEG group at 24 h (13% vs. 5%; p = 0.006) and at 30 days (25% vs. 11%; p = 0.002), with no difference in the number or ratio of blood products transfused. Cost of blood products transfused was comparable, with the exception of platelets (average £38 higher post-TEG). Blood product wastage was significantly lower in the post-TEG group (1.8 ± 2.1 vs. 1.1 ± 2.0; p = 0.002). No statistically significant difference in cost was observed between the two groups (£753 ± 651 pre-TEG; £830 ± 847 post-TEG; p = 0.41). These results demonstrate TEG 6s-driven resuscitation algorithms are associated with reduced mortality, reduced blood product wastage, and are cost neutral compared to standard coagulation tests.

Assessment of sensitivity of whole body CT for major trauma.

INTRODUCTION: Whole body computed tomography has become standard practice in many centres in the management of severely injured trauma patients, however, the evidence for it's diagnostic accuracy is limited. AIM: To assess the sensitivity of whole body CT in major trauma. METHOD: Retrospective review of all patients with injury severity score (ISS) > 15 presenting with blunt trauma to a UK Major Trauma Centre between May 2012 and April 2014. Injuries were classified as per ISS score-1 = head and neck 2 = face 3 = chest 4 = abdomen. The authors reviewed patient's electronic charts, radiological results; interventional procedure records, discharge letters and outpatient follow up documentation and referenced this with Trauma Audit and Research Network data. RESULTS: 407 patients with ISS > 15 presented to the Trauma centre during May 2012 and April 2014. Of these, 337 (82.8%) had a whole body CT scan. 246 pts were male, 91 were female. 74 (21.9%) were due to a fall from > 2 m, 41 (12.2%) due to a fall from < 2 m, 208 (61.7%) were due to motor vehicle crashes, 1 (0.3%) due to a blast injury, 5 (1.5%) due to blows, and 8 (2.4%) due to crush injuries. Sensitivity for Region 1 was 0.98, Region 2 = 0.98, Region 3 = 0.98 and Region 4 was 0.95. Overall sensitivity was 0.98. 15 injuries (2.4%) were not identified on initial CT (false -ve). These injuries were: colonic perforation = 1, splenic contusion = 1, pneumothorax = 1, liver laceration = 1, intracranial haemorrhage = 1, cerebral contusions = 1, spinal injuries = 7, canal haemorrhage = 1, maxilla fracture = 1. CONCLUSION: These results show that whole body CT in trauma has a high sensitivity and a low rate of missed injuries (2.4%). However, our study only evaluated a subgroup of patients with ISS > 15 and further work is required to assess the use of this investigation for all major trauma patients.

Examining multi-session brief intervention for substance use in primary care: research methods of a randomized controlled trial.

BACKGROUND: Brief interventions such as Screening, a single session of Brief Intervention, and Referral to Treatment (SBIRT) have shown mixed effectiveness in primary care. However, there are indications that multi-session brief interventions may demonstrate more consistently positive outcomes, and perhaps a more intensive approach would be of benefit in addressing substance use in primary care. This study compared the effectiveness of SBIRT with a single BI session (BI/RT) to a multi-session brief-treatment intervention (BI/RT+) in primary care. We also developed easy-to-use, evidence-based materials to assist clinicians in delivering these interventions. METHODS/DESIGN: This study was conducted in three Federally Qualified Healthcare Centers (FQHCs). A total of 10,935 patients were screened, and 600 individuals were recruited. The sample was primarily Black/African American (82 %) with a mean age of 40. Patients who attended a healthcare appointment were screened for substance use via the AUDIT and DAST. Patients were eligible for the study if they scored 8 or higher on the AUDIT, were using only marijuana and scored 2 or higher on the DAST, or were using other illicit drugs and scored 1 or higher on the DAST. Participants were randomly assigned to receive one-session BI/RT, or two to six sessions of brief intervention that incorporated elements of motivational enhancement therapy and cognitive-behavioral therapy (BI/RT+). Both interventions were delivered by behavioral health consultants at the FQHCs. Participants completed follow-up assessments every 3 months for 1 year. Primary outcome variables included substance use treatment sessions attended and days of substance use. Secondary outcomes included measures of health, employment, legal, and psychiatric functioning and HIV risk behaviors. Additionally, we will conduct an economic evaluation examining cost-effectiveness and will analyze outcomes from a process evaluation examining patient and provider experiences. DISCUSSION: The ability of brief interventions to impact substance use has great potential, but research findings have been mixed. By conducting a large-scale randomized controlled trial in real-world health centers, this study will answer important questions about the effectiveness of expanded BIs for patients who screen positive for risky substance use in primary care. Trial registration NCT01751672.

Development of a surgical skills curriculum for the training and assessment of manual skills in orthopedic surgical residents.

OBJECTIVE: To develop and conduct a pilot study of a curriculum of 4 surrogate bone training modules to assess and track progress in basic orthopedic manual skills outside the operating room. DESIGN: Four training modules were developed with faculty and resident input. The modules include (1) cortical drilling, (2) drill trajectory, (3) oscillating saw, and (4) pedicle probing. Orthopedic resident's performance was evaluated. Validity and reliability results were calculated using standard analysis of variance and multivariate regression analysis accounting for postgraduate year (PGY) level, number of attempts, and specific outcome target results specific to the simulation module. SETTING: St. Mary's Medical Center in San Francisco, CA. PARTICIPANTS: These modules were tested on 15 orthopedic surgery residents ranging from PGY 1 to PGY 5 experience. RESULTS: The cortical drilling module had a mean success rate of 56% ± 5%. There was a statistically significant difference in performance according to the diameter of the drill used from 33% ± 7% with large diameter to 70% ± 6% with small diameter. The drill trajectory module had a success rate of 85% ± 3% with a trend toward improvement across PGY level. The oscillating saw module had a mean success rate of 25% ± 5% (trajectory) and 84% ± 6% (depth). We observed a significant improvement in trajectory performance during the second attempt. The pedicle probing module had a success rate of 46% ± 10%. CONCLUSION: The results of this pilot study on a small number of residents are promising. The modules were inexpensive and easy to administer. Conclusions of statistical significance include (1) residents who could easily detect changes in surrogate bone thickness with a smaller diameter drill than with a larger diameter drill and (2) residents who significantly improved saw trajectory with an additional attempt at the module.

Developing an evidence-based, multimedia group counseling curriculum toolkit.

Training community-based addiction counselors in empirically supported treatments (ESTs) far exceeds the ever-decreasing resources of publicly funded treatment agencies. This feasibility study describes the development and pilot testing of a group counseling toolkit (an approach adapted from the education field) focused on relapse prevention (RP). When counselors (N = 17) used the RP toolkit after 3 hours of training, their content adherence scores on "coping with craving" and "drug refusal skills" showed significant improvement, as indicated by very large effect sizes (Cohen's d = 1.49 and 1.34, respectively). Counselor skillfulness, in the "adequate-to-average" range at baseline, did not change. Although this feasibility study indicates some benefit to counselor EST acquisition, it is important to note that the impact of the curriculum on client outcomes is unknown. Because a majority of addiction treatment is delivered in group format, a multimedia curriculum approach may assist counselors in applying ESTs in the context of actual service delivery.

Improving public addiction treatment through performance contracting: the Delaware experiment.

In fiscal 2002, Delaware replaced traditional cost-reimbursement contracts with performance-based contracts for all outpatient addiction treatment programs. Incentives included 90% capacity utilization and active patient participation in treatment. One of the programs failed to meet requirements. Strategies adopted by successful programs included extended hours of operation, facility enhancements, salary incentives for counselors, and two evidence-based therapies (MI and CBT). Average capacity utilization from 2001 to 2006 went from 54% to 95%; and the average proportion of patients' meeting participation requirements went from 53% to 70%--with no notable changes in the patient population. We conclude that properly designed, program-based contract incentives are feasible to apply, welcomed by programs and may help set the financial conditions necessary to implement other evidence-based clinical efforts; toward the overall goal of improving addiction treatment.