Major trauma presentations and patient outcomes in English hospitals during the COVID-19 pandemic: An observational cohort study.

BACKGROUND: Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related "lockdown" restrictions in England may have led to significant changes in the characteristics of major trauma patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England. METHODS AND FINDINGS: We completed an observational cohort study and interrupted time series analysis including all patients eligible for inclusion in England in the national clinical audit for major trauma presenting between 1 January 2017 and 31 of August 2021 (354,202 patients). Demographic characteristics (age, sex, physiology, and injury severity) and clinical pathways of major trauma patients in the first lockdown (17,510 patients) and second lockdown (38,262 patients) were compared to pre-COVID-19 periods in 2018 to 2019 (comparator period 1: 22,243 patients; comparator period 2: 18,099 patients). Discontinuities in trends for weekly estimated excess survival rate were estimated when lockdown measures were introduced using segmented linear regression. The first lockdown had a larger associated reduction in numbers of major trauma patients (-4,733 (21%)) compared to the pre-COVID period than the second lockdown (-2,754 (6.7%)). The largest reductions observed were in numbers of people injured in road traffic collisions excepting cyclists where numbers increased. During the second lockdown, there were increases in the numbers of people injured aged 65 and over (665 (3%)) and 85 and over (828 (9.3%)). In the second week of March 2020, there was a reduction in level of major trauma excess survival rate (-1.71%; 95% CI: -2.76% to -0.66%) associated with the first lockdown. This was followed by a weekly trend of improving survival until the lifting of restrictions in July 2020 (0.25; 95% CI: 0.14 to 0.35). Limitations include eligibility criteria for inclusion to the audit and COVID status of patients not being recorded. CONCLUSIONS: This national evaluation of the impact of COVID on major trauma presentations to English hospitals has observed important public health findings: The large reduction in overall numbers injured has been primarily driven by reductions in road traffic collisions, while numbers of older people injured at home increased over the second lockdown. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown.

Association between major trauma centre care and outcomes of adult patients injured by low falls in England and Wales.

BACKGROUND: Disability and death due to low falls is increasing worldwide and disproportionately affects older adults. Current trauma systems were not designed to suit the needs of these patients. This study assessed the association between major trauma centre (MTC) care and outcomes in adult patients injured by low falls. METHODS: Data were obtained from the Trauma Audit and Research Network on adult patients injured by falls from <2 m between 2017 and 2019 in England and Wales. 30-day survival, length of hospital stay and discharge destination were compared between MTCs and trauma units or local emergency hospitals (TU/LEHs) using an adjusted multiple logistic regression model. RESULTS: 127 334 patients were included, of whom 27.6% attended an MTC. The median age was 79.4 years (IQR 64.5-87.2 years), and 74.2% of patients were aged >65 years. MTC care was not associated with improved 30-day survival (adjusted OR (AOR) 0.91, 95% CI 0.87 to 0.96, p<0.001). Transferred patients had a significant impact on the results. After excluding transferred patients, MTC care was associated with greater odds of 30-day survival (AOR 1.056, 95% CI 1.001 to 1.113, p=0.044). MTC care was also associated with greater odds of 30-day survival in the most severely injured patients (AOR 1.126, 95% CI 1.04 to 1.22, p=0.002), but not in patients aged >65 years (AOR 1.038, 95% CI 0.982 to 1.097, p=0.184). CONCLUSION: MTC care was not associated with improved survival compared with TU/LEH care in the whole cohort. Patients who were transferred had a significant impact on the results. In patients who are not transferred, MTC care is associated with greater odds of 30-day survival in the whole cohort and in the most severely injured patients. Future research must determine the optimum means of identifying patients in need of higher-level care, the components of care which improve patient outcomes, develop patient-focused outcomes which reflect the characteristics and priorities of contemporary trauma patients, and investigate the need for transfer in specific subgroups of patients.

Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada.

BACKGROUND: Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada. METHODS: We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury. RESULTS: The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. "scoop and run" in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09-1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52-0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries. CONCLUSION: We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement.

Mortality in adolescent trauma: a comparison of children's, mixed and adult major trauma centres.

OBJECTIVE: We aimed to compare adolescent mortality rates between different types of major trauma centre (MTC or level 1; adult, children's and mixed). METHODS: Data were obtained from TARN (Trauma Audit Research Network) from English sites over a 6-year period (2012-2018), with adolescence defined as 10-24.99 years. Results are presented using descriptive statistics. Patient characteristics were compared using the Kruskal-Wallis test with Dunn's post-hoc analysis for pairwise comparison and χ2 test for categorical variables. RESULTS: 21 033 cases met inclusion criteria. Trauma-related 30-day crude mortality rates by MTC type were 2.5% (children's), 4.4% (mixed) and 4.9% (adult). Logistic regression accounting for injury severity, mechanism of injury, physiological parameters and 'hospital ID', resulted in adjusted odds of mortality of 2.41 (95% CI 1.31 to 4.43; p=0.005) and 1.85 (95% CI 1.03 to 3.35; p=0.041) in adult and mixed MTCs, respectively when compared with children's MTCs. In three subgroup analyses the same trend was noted. In adolescents aged 14-17.99 years old, those managed in a children's MTC had the lowest mortality rate at 2.5%, compared with 4.9% in adult MTCs and 4.4% in mixed MTCs (no statistical difference between children's and mixed). In cases of major trauma (Injury Severity Score >15) the adjusted odds of mortality were also greater in the mixed and adult MTC groups when compared with the children's MTC. Median length of stay (LoS) and intensive care unit LoS were comparable for all MTC types. Patients managed in children's MTCs were less likely to have a CT scan (46.2% vs 62.8% mixed vs 64% adult). CONCLUSIONS: Children's MTC have lower crude and adjusted 30-day mortality rates for adolescent trauma. Further research is required in this field to identify the factors that may have influenced these findings.

Age and the distribution of major injury across a national trauma system.

BACKGROUND: Trauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution. OBJECTIVES: There is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between. METHODS: The TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England. RESULTS: About 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs. CONCLUSIONS: Within adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.

Epidemiology of adolescent trauma in England: a review of TARN data 2008-2017.

OBJECTIVES: Trauma contributes significantly to adolescent morbidity and mortality. We aimed to ascertain the epidemiology of adolescent trauma to inform prevention strategies. METHODS: Data were abstracted from TARN (Trauma Audit Research Network) from English sites over a 10-year period (2008-2017). Adolescents were defined as 10-24 completed years. Descriptive statistical analysis was used in this study. RESULTS: There were 40 680 recorded cases of adolescent trauma. The majority were male (77.3%) and aged 16-24 years old (80.5%). There was a 2.6-fold increase during the study time frame (p<0.0001) in the total annual number of cases reported to TARN. To account for increasing hospital participation, the unit trauma cases per hospital per year was used, noting an increasing trend (p=0.048). Road traffic collision (RTC) was the leading cause of adolescent trauma (50.3%). Pedestrians (41.2%) and cyclists (32.6%) were more prevalent in the 10-15 year group, while drivers (22.9%) and passengers (17.8%) predominated in the 16-24 year group. Intentional injury was reported in 20.7% (alleged assault in 17.2% and suspected self-harm in 3.5%). This was more prevalent in the 16-24 year group. The proportion of trauma reported due to violence has increased with stabbings increasing from 6.9% in 2008 to 10.2% in 2017 (p<0.0001). Evidence of alcohol or drug use was recorded in 20.1% of cases. There was an increase in the number treated in major trauma centres (45.7% 2008 vs 63.5% 2017, p<0.0001). Trauma was more likely to occur between 08:00 and 00:00, at weekends and between April and October. Overall mortality rate was 4.1%. Those with a known psychiatric diagnosis had a higher mortality (6.3% vs 4.4%, p<0.001). CONCLUSIONS: RTCs and intentional injuries are leading aetiologies. Healthcare professionals and policy-makers need to prioritise national preventative public health measures and early interventions to reduce the incidence of trauma in this vulnerable age group.

Survival Trends After Surgery for Acute Subdural Hematoma in Adults Over a 20-year Period.

OBJECTIVE: We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period. SUMMARY OF BACKGROUND DATA: ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time. METHODS: Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data. RESULTS: The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors. CONCLUSIONS: A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.

The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to primary major incident triage.

INTRODUCTION: Triage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a military cohort, the Modified Physiological Triage Tool (MPTT) has demonstrated improved performance. Using a civilian trauma registry, this study aimed to validate the MPTT in a civilian environment. METHODS: Retrospective database review of the Trauma Audit and Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014. Patients were defined as Priority One if they received one or more LSIs from a previously defined list. Only patients with complete physiological data were included. Patients were categorised by the MPTT and existing triage tools using first recorded hospital physiology. Performance characteristics were evaluated using sensitivity, specificity and area under receiver operating characteristic (AUROC). RESULTS: During the study period, 218 985 adult patients were included in the TARN database. 127 233 (58.1%) had complete data: 55.6% male, aged 61.4 (IQR 43.1-80.0) years, Injury Severity Score 9 (IQR 9-16), 96.5% suffered blunt trauma and 24 791 (19.5%) were Priority One. The MPTT (sensitivity 57.6%, specificity 71.5%) outperformed all existing triage methods with a 44.7% absolute reduction in undertriage compared with existing UK civilian methods. AUROC comparison supported the use of the MPTT over other tools (P<0.001.) CONCLUSION: Within a civilian trauma registry population, the MPTT demonstrates improved performance at predicting need for LSI, with the lowest rates of undertriage and an appropriate level of overtriage. We suggest the MPTT be considered as an alternative to existing triage tools.

The use of whole-body computed tomography in major trauma: variations in practice in UK trauma hospitals.

INTRODUCTION: Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. METHODS: We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. RESULTS: Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there was no consistent relation with age. High falls and motor vehicle collisions also increased WBCT usage. Adjusting for casemix, there was a 13-fold intrahospital variation in the use of WBCT between MTCs and a 30-fold variation between TUs/NDHs. The amount of variability between individual hospitals that could not be accounted for by the factors shown to impact on WBCT use was 26% (95% CI 17% to 39%) for MTCs and 17% (95% CI 13% to 21%) for TUs/NDHs. CONCLUSION: There are significant variations in WBCT use between different hospitals in England and Wales, which require further investigation.

Are first rib fractures a marker for other life-threatening injuries in patients with major trauma? A cohort study of patients on the UK Trauma Audit and Research Network database.

BACKGROUND: First rib fractures are considered indicators of increased morbidity and mortality in major trauma. However, this has not been definitively proven. With an increased use of CT and the potential increase in detection of first rib fractures, re-evaluation of these injuries as a marker for life-threatening injuries is warranted. METHODS: Patients sustaining rib fractures between January 2012 and December 2013 were investigated using data from the UK Trauma Audit and Research Network. The prevalence of life-threatening injuries was compared in patients with first rib fractures and those with other rib fractures. Multivariate logistic regression was performed to determine the association between first rib fractures, injury severity, polytrauma and mortality. RESULTS: There were 1683 patients with first rib fractures and 8369 with fractures of other ribs. Life-threatening intrathoracic and extrathoracic injuries were more likely in patients with first rib fractures. The presence of first rib fractures was a significant predictor of injury severity (Injury Severity Score >15) and polytrauma, independent of mechanism of injury, age and gender with an adjusted OR of 2.64 (95% CI 2.33 to 3.00) and 2.01 (95% CI 1.80 to 2.25), respectively. Risk-adjusted mortality was the same in patients with first rib fractures and those with other rib fractures (adjusted OR 0.97, 95% CI 0.79 to 1.19). CONCLUSION: First rib fractures are a marker of life-threatening injuries in major trauma, though they do not independently increase mortality. Management of patients with first rib fractures should focus on identification and treatment of associated life-threatening injuries.

Is there a 'weekend effect' in major trauma?

BACKGROUND: Many previous studies have shown that patients admitted to hospital at weekends have worse outcomes than those on other days. It has been proposed that parity of clinical services throughout the week could mitigate the 'weekend effect'. This study aimed to determine whether or not a weekend effect is observed within an all-hours consultant-led major trauma service. METHODS: We undertook an observational cohort study using data submitted by all 22 major trauma centres (MTCs) in England to the Trauma Audit & Research Network. The inclusion criteria were all major trauma patients admitted for at least 3 days, admitted to a high-dependency area, or deceased following arrival at hospital. Patients with Injury Severity Score (ISS) >15 were also analysed separately. The outcome measures were length of stay, in-hospital mortality and Glasgow Outcome Score (GOS). Secondary transfer of patients between hospitals was also included as a process outcome. RESULTS: There were 49 070 patients, 22 248 (45.3%) of which had an ISS >15. Within multivariable logistic regression models, odds of secondary transfer into an MTC were higher at night (adjusted OR 2.05, 95% CI 1.93 to 2.19) but not during the day at weekends (1.09, 0.99 to 1.19). Neither admission at night nor at the weekend was associated with increased length of stay, worse GOS or higher odds of in-hospital death. These findings remained stable when confining analyses to the most severely injured patients (ISS >15), excluding transferred patients, and using a single mid-week (Wednesday) baseline. CONCLUSIONS: After adjustment for known confounders the weekend effect is not detectable within a regionalised major trauma service.

Prediction modelling for trauma using comorbidity and 'true' 30-day outcome.

BACKGROUND: Prediction models for trauma outcome routinely control for age but there is uncertainty about the need to control for comorbidity and whether the two interact. This paper describes recent revisions to the Trauma Audit and Research Network (TARN) risk adjustment model designed to take account of age and comorbidities. In addition linkage between TARN and the Office of National Statistics (ONS) database allows patient's outcome to be accurately identified up to 30 days after injury. Outcome at discharge within 30 days was previously used. METHODS: Prospectively collected data between 2010 and 2013 from the TARN database were analysed. The data for modelling consisted of 129 786 hospital trauma admissions. Three models were compared using the area under the receiver operating curve (AuROC) for assessing the ability of the models to predict outcome, the Akaike information criteria to measure the quality between models and test for goodness-of-fit and calibration. Model 1 is the current TARN model, Model 2 is Model 1 augmented by a modified Charlson comorbidity index and Model 3 is Model 2 with ONS data on 30 day outcome. RESULTS: The values of the AuROC curve for Model 1 were 0.896 (95% CI 0.893 to 0.899), for Model 2 were 0.904 (0.900 to 0.907) and for Model 3 0.897 (0.896 to 0.902). No significant interaction was found between age and comorbidity in Model 2 or in Model 3. CONCLUSIONS: The new model includes comorbidity and this has improved outcome prediction. There was no interaction between age and comorbidity, suggesting that both independently increase vulnerability to mortality after injury.

The effect of preinjury warfarin use on mortality rates in trauma patients: a European multicentre study.

OBJECTIVE: To define the relationship between preinjury warfarin use and mortality in a large European sample of trauma patients. METHODS: A multicentred study was conducted using data collated from European (predominately English and Welsh) trauma receiving hospitals. Patient data from the Trauma Audit and Research Network database from 2009 to 2013 were analysed. Univariate and multivariate logistic regression was used to estimate OR for mortality associated with preinjury warfarin use in the whole adult trauma cohort and a matched sample of patients comparable in terms of age, gender, GCS, pre-existing medical conditions and injury severity. RESULTS: A total of 136 617 adult trauma patients (2009-2013) were included, with 499 patients reported to be using warfarin therapy at the time of trauma. Preinjury warfarin use was associated with a significantly higher mortality rate at 30 days postinjury compared with the non-users. Following adjustment of age, injury severity and GCS, preinjury warfarin use was associated with increased mortality in trauma patients (adjusted OR 2.14; 95% CI 1.66 to 2.76; p<0.001). In the matched subset, 22% of warfarinised trauma patients died compared with 16.3% of non-warfarinised trauma patients with comparable age, injury severity and GCS (adjusted OR 1.94; 95% CI 1.25 to 3.01; p=0.003). CONCLUSIONS: Preinjury warfarin use has been demonstrated to be an independent predictor of mortality in trauma patients. Clinicians managing major trauma patients on warfarin need to be aware of the vulnerability of this group.

Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales.

INTRODUCTION: Non-compressible torso haemorrhage (NCTH) carries a high mortality in trauma as many patients exsanguinate prior to definitive haemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct that has the potential to bridge patients to definitive haemostasis. However, the proportion of trauma patients in whom REBOA may be utilised is unknown. METHODS: We conducted a population based analysis of 2012-2013 Trauma Audit and Research Network (TARN) data. We identified the number of patients in whom REBOA may have been utilised, defined by an Abbreviated Injury Scale score ≥3 to abdominal solid organs, abdominal or pelvic vasculature, pelvic fracture with ring disruption or proximal traumatic lower limb amputation, together with a systolic blood pressure <90 mm Hg. Patients with non-compressible haemorrhage in the mediastinum, axilla, face or neck were excluded. RESULTS: During 2012-2013, 72 677 adult trauma patients admitted to hospitals in England and Wales were identified. 397 patients had an indication(s) and no contraindications for REBOA with evidence of haemorrhagic shock: 69% men, median age 43 years and median Injury Severity Score 32. Overall mortality was 32%. Major trauma centres (MTCs) received the highest concentration of potential REBOA patients, and would be anticipated to receive a patient in whom REBOA may be utilised every 95 days, increasing to every 46 days in the 10 MTCs with the highest attendance of this injury type. CONCLUSIONS: This TARN database analysis has identified a small group of severely injured, resource intensive patients with a highly lethal injury that is theoretically amenable to REBOA. The highest density of these patients is seen at MTCs, and as such a planned evaluation of REBOA should be further considered in these hospitals.

The accuracy of existing prehospital triage tools for injured children in England: an analysis using emergency department data.

OBJECTIVE: To investigate the performance characteristics in children with moderate and minor injuries of prehospital paediatric triage tools currently in use in England for identifying seriously injured children. METHODS: Eight prehospital paediatric triage tools were identified from literature review and a survey of the lead trauma clinicians across the 10 English strategic health authorities. Retrospective clinical data from 2934 patient records collected by four emergency departments were used to analyse each tool. A target sensitivity of >95% and specificity of 50-75% was set based on the literature. RESULTS: Three tools (East Midlands, North West and Northern) demonstrated acceptable sensitivity (all 100%). The other five tools fell below the target sensitivity of >95%. All eight tools had acceptable specificity (with results between 79% and 99%). CONCLUSIONS: Three tools (East Midlands, North West and Northern) demonstrated acceptable over- and under-triage rates in this population of minor and moderately injured children. All tools reached recommended standards for over-triage, but the majority favoured under-triage.

Outcomes of polytrauma patients with diabetes mellitus.

BACKGROUND: The impact of diabetes mellitus in patients with multiple system injuries remains obscure. This study was designed to increase knowledge of outcomes of polytrauma in patients who have diabetes mellitus. METHODS: Data from the Trauma Audit and Research Network was used to identify patients who had suffered polytrauma during 2003 to 2011. These patients were filtered to those with known outcomes, then separated into those with diabetes, those known to have other co-morbidities but not diabetes and those known not to have any co-morbidities or diabetes. The data were analyzed to establish if patients with diabetes had differing outcomes associated with their diabetes versus the other groups. RESULTS: In total, 222 patients had diabetes, 2,558 had no past medical co-morbidities (PMC), 2,709 had PMC but no diabetes. The diabetic group of patients was found to be older than the other groups (P <0.05). A higher mortality rate was found in the diabetic group compared to the non-PMC group (32.4% versus 12.9%), P <0.05). Rates of many complications including renal failure, myocardial infarction, acute respiratory distress syndrome, pulmonary embolism and deep vein thrombosis were all found to be higher in the diabetic group. CONCLUSIONS: Close monitoring of diabetic patients may result in improved outcomes. Tighter glycemic control and earlier intervention for complications may reduce mortality and morbidity.

Outcome prediction modelling for trauma patients: a German perspective.

Prognostic models may have some clinical advantages when predicting the outcome of individual trauma patients is relevant. The variables that are predicted to have a negative effect on outcome in a model can also guide clinicians in their resuscitation attempt of trauma victims.

Predicting outcomes after blunt chest wall trauma: development and external validation of a new prognostic model.

INTRODUCTION: Blunt chest wall trauma accounts for over 15% of all trauma admissions to Emergency Departments worldwide. Reported mortality rates vary between 4 and 60%. Management of this patient group is challenging as a result of the delayed on-set of complications. The aim of this study was to develop and validate a prognostic model that can be used to assist in the management of blunt chest wall trauma. METHODS: There were two distinct phases to the overall study; the development and the validation phases. In the first study phase, the prognostic model was developed through the retrospective analysis of all blunt chest wall trauma patients (n = 274) presenting to the Emergency Department of a regional trauma centre in Wales (2009 to 2011). Multivariable logistic regression was used to develop the model and identify the significant predictors for the development of complications. The model's accuracy and predictive capabilities were assessed. In the second study phase, external validation of the model was completed in a multi-centre prospective study (n = 237) in 2012. The model's accuracy and predictive capabilities were re-assessed for the validation sample. A risk score was developed for use in the clinical setting. RESULTS: Significant predictors of the development of complications were age, number of rib fractures, chronic lung disease, use of pre-injury anticoagulants and oxygen saturation levels. The final model demonstrated an excellent c-index of 0.96 (95% confidence intervals: 0.93 to 0.98). CONCLUSIONS: In our two phase study, we have developed and validated a prognostic model that can be used to assist in the management of blunt chest wall trauma patients. The final risk score provides the clinician with the probability of the development of complications for each individual patient.

Comparison of several prognostic tools in traumatic brain injury including S100B.

PRIMARY OBJECTIVE: To identify which tool (a model, a biomarker or a combination of these) has better prognostic strength in traumatic brain injury (TBI). DESIGN AND METHODS: Data of 100 patients were analysed. TBI prognostic model B, constructed in Trauma Audit and Research Network (TARN), was run on the dataset and then S100B was added to this model. Another model was developed containing only S100B and, subsequently, other important predictors were added to assess the enhancement of the predictive power. The outcome measures were survival and favourable outcome. RESULTS: No difference between performance of the prognostic model or S100B in isolation is observed. Addition of S100B to the prognostic model improves the performance (e.g. AUC, R(2) Nagelkerke and classification accuracy of TARN model B to predict survival increase respectively from 0.66, 0.11 and 70% to 0.77, 0.25 and 75%). Similarly, the predictive power of S100B increases by adding other predictors (e.g. AUC (0.69 vs. 0.79), R(2) Nagelkerke (0.15 vs. 0.30) and classification accuracy (73% vs. 77%) for survival prediction). CONCLUSION: A better prognostic tool than those currently available may be a combination of clinical predictors with a biomarker.

The value of the difference between ED and prehospital vital signs in predicting outcome in trauma.

INTRODUCTION: Traditional vital signs are seen as an important part of trauma assessment, despite their poor predictive value in this regard. OBJECTIVE: This study evaluated whether the difference between systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and shock index (SI) taken in the emergency department (ED) and prehospital can predict 48 h mortality postadmission following trauma. METHODS: Retrospective cohort was obtained from the Trauma Audit and Research Network. Subjects were excluded if head or spinal injuries, prehospital intubation or CPR were present. Main outcome was 48 h mortality. The difference (delta, Δ) between ED and prehospital values were used as study variables (ie, ΔSI=SI-ED minus SI-prehospital). Accuracy was assessed using area under receiver operator characteristic curve (AUROC). AUROC coordinates were used to identify 95% specificity cut points and described further using sensitivity and likelihood ratios (LRs). RESULTS: Significant AUROC statistics were revealed for ΔSBP (0.57) and ΔRR (0.56) for the full sample, ΔSBP (0.62) and ΔSI (0.65) for moderate, and ΔRR (0.6) for severe injury. Best LRs were 3.4 and 2.4 for ΔRR and ΔSI, respectively, but sensitivities were low (<=26%). Cut point values for ΔSBP, ΔRR and ΔSI were 37 mm Hg, 8 breaths/min and 0.2, respectively. DISCUSSION: ΔSBP and ΔRR performed best overall, but ΔSI performed best in the moderate injury group, suggesting earlier identification with ΔSI. Use of Δ values result in good rule-in of 48 h mortality and may supplement trauma treatment decisions.