Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis.

BACKGROUND: The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. METHODS: We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. RESULTS: We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. CONCLUSIONS: This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.

Impact of wearing a helmet on the risk of hospitalization and intracranial haemorrhage after a sports injury.

BACKGROUND: Despite their reported protective effect against the occurrence of head injuries, helmets are still used inconsistently in sports in which they are optional. We aimed to assess the impact of helmet use on the risk of hospitalization and intracranial haemorrhage for trauma occurring during sport activities. METHODS: Retrospective cohort of all patients who presented themselves, over an 18-month period, at the emergency department of a tertiary trauma centre for an injury sustained in a sport or leisure activity where the use of a helmet is optional. Impact of helmet use was assessed using multivariable regression analyses (relative risks, RR). RESULTS: Among the 1,022 patients included in the study, half were cyclists and 40% were skiers or snowboarders. A total of 40 % of patients wore a helmet at the time of injury, 18% had a head injury, 16% were hospitalized and 13% of patients with a head injury had an intracranial haemorrhage. Among all patients, no association was observed between hospital admission and helmet use. However, helmet use in patients with a head injury was associated with significant reductions in the risks of hospitalization (RR 0.41 [95% CI: 0.22-0.76]) and intracranial haemorrhage (RR 0.28 [95% CI: 0.11-0.71]). CONCLUSIONS: Results suggest that, in recreational athletes who sustain a head injury, helmet use is associated with a reduced risk of hospitalization (all sports) and intracranial haemorrhage (cyclists).

Frail older adults with minor fractures show lower health-related quality of life (SF-12) scores up to six months following emergency department discharge.

BACKGROUND: Minor fractures (e.g. wrist, ankle) are risk factors for lower physical health-related quality of life (HRQoL) in seniors. Recent studies found that measures of frailty were associated with decreased physical and mental HRQoL in older people. As most people with minor fractures go to emergency departments (EDs) for treatment, measuring their frailty status in EDs may help stratify their level of HRQoL post-injury and provide them with appropriate health care and services after discharge. This study thus examines the HRQoL of seniors visiting EDs for minor fractures at 3 and 6 months after discharge, according to their frailty status. METHODS: This prospective sub-study was conducted within the larger Canadian Emergency Team Initiative (CETI) cohort. Independent seniors (≥65 years) were recruited in 7 Canadian EDs after treatment for various minor fractures. Frailty status in the ED phase was assessed by the Canadian Study of Health and Aging--Clinical Frailty Scale (CSHA-CFS). The SF-12 questionnaire was completed at 3 and 6 months after ED discharge to ascertain HRQoL. Demographic and clinical data were collected. Linear mixed models were used to test for differences between frailty levels and HRQoL outcomes, controlling for confounding variables and repeated measures over time. RESULTS: The sample comprised 334 participants with minor fractures. Prevalence of frailty was as follows: 56.6 % very fit-well; 32.3 % well with treated comorbidities-apparently vulnerable; and 11.1 % mildly-moderately frail. After adjusting for confounding variables, the frailest group showed significantly lower mean HRQoL scores than the fittest group on the physical scale at 3 months (49.3 ± 3.7 vs 60.9 ± 2.0) and 6 months (48.7 ± 3.8 vs 61.1 ± 1.8), as well as on the mental scale at 3 months (59.5 ± 4.4 vs 69.6 ± 1.9). Analyses exploring differences in proportion of patients with HRQoL < 50/100 between the three groups produced similar results. CONCLUSIONS: Older adults with minor fractures who were frail had lower physical and mental HRQoL scores at 3 and 6 months after ED discharge than their fittest counterparts. Measuring the frailty status of older adults who suffered a minor fracture in ED might help clinical decision-making at the time of discharge by providing them with appropriate health care and services to improve their HRQoL in the following months.

Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study.

BACKGROUND: Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007-2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression. RESULTS: Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles. CONCLUSIONS: Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.

Potential benefits of incentive spirometry following a rib fracture: a propensity score analysis.

CLINICIAN'S CAPSULEWhat is known about the topic?Literature regarding the impact of incentive spirometry on patients with rib fractures is unclear; there are no recommendations for its use in the emergency department (ED).What did this study ask?The objective of this study was to assess the impact of incentive spirometry on delayed complications in patients with rib fractures in the ED.What did this study find?Unsupervised incentive spirometry use does not have a protective effect against delayed pulmonary complications after a rib fracture.Why does this study matter to clinicians?Clear guidelines for incentive spirometry use for patients with rib fractures and further research to assess its usefulness in other ED populations are needed.

OBJECTIFS: La spirométrie incitative est parfois prescrite en vue d'encourager le rétablissement de la fonction respiratoire. Toutefois, peut de littérature est disponible sur la spirométrie incitative et ses effets chez les patients avec fracture de côtes, et il n'existe pas de recommandation sur son utilisation au département des urgences (DU), tout particulièrement pour les fractures de côtes, qui sont reconnues pour accroître le risque de complications pulmonaires. Cette étude visait donc à évaluer l'utilisation de la spirométrie incitative et à mesurer son impact sur l'incidence de complications tardives chez les patients ayant été libéré de l'urgence après une confirmation de fracture de côtes. MÉTHODE: Il s'agit d'une sous-étude planifiée d'une étude observationnelle de cohorte prospective, qui a eu lieu dans 4 DU au Canada, entre novembre 2006 et mai 2012. Des patients âgés de 16 ans et plus, non hospitalisés, avec au moins une fracture de côte confirmée par radiographie ont été sélectionnés. La décision de prescrire la spirométrie incitative était laissée à la discrétion du médecin traitant. Les principaux résultats consistaient en l'apparition d'une pneumonie, d'atélectasie ou d'un hémothorax dans les 14 jours suivant le traumatisme. Des analyses d'appariement des coefficients de propension ont été réalisées. RÉSULTATS: Un total de 439 patients ont participé à l'étude, dont 182 (41,5%) ont été reçu la spirométrie incitative. 99 cas d'hémothorax (22,6%), 103 cas d'atélectasie (23,5%) et 4 cas de pneumonie (0,9%) ont été observés. Nos résultats indiquent que la spirométrie incitative ne semble pas un moyen de protection contre l'hémothorax (risque relatif [RR] = 1,03 [0,66­1,64]) ni contre l'atélectasie ou la pneumonie (RR = 1,07 [0,68­1,72]). CONCLUSION: Nos résultats suggèrent que la spirométrie incitative non supervisée n'offrirait pas d'effet protecteur contre l'apparition tardive de complications pulmonaires à la suite d'une fracture de côtes. D'autres recherches sont nécessaires afin de valider la pertinence de prescrire la spirométrie incitative au DU, chez certains groupes de blessés plus spécifiques.

Child labour and health: a systematic review.

OBJECTIVES: This study aimed to synthesise the available knowledge, identify unexplored areas and discuss general limits of the published evidence. We focused on outcomes commonly hypothesised to be affected by child labour: nutritional status, harmful exposures and injuries. METHODS: Four electronic databases (EMBASE, MEDLINE, Scopus, ISI Web of Science) were searched in November 2017. All articles published since 1996, without restrictions on language, were considered for inclusion. RESULTS: Out of the 1090 abstracts initially identified by the search, 78 articles were selected for inclusion and reviewed. Most of the studies were conducted in Asia and South America, and only a third of them compared working children to a control group of non-working children. Child labour appears to be associated with poor nutritional status, diseases due to harmful exposures, and a higher prevalence of injuries. CONCLUSIONS: Despite evidence for a negative relation between child work and health, the cross-sectional design of most studies limits the causal interpretation of existing findings. More rigorous observational studies are needed to confirm and better quantify these associations.

Prognostic Value of S-100ß Protein for Prediction of Post-Concussion Symptoms after a Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to determine the prognostic value of S-100ß protein to identify patients with post-concussion symptoms after a mild traumatic brain injury (mTBI). A search strategy was submitted to seven databases from their inception to October 2016. Individual patient data were requested. Cohort studies evaluating the association between S-100ß protein level and post-concussion symptoms assessed at least seven days after the mTBI were considered. Outcomes were dichotomized as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies including between seven and 223 patients (n = 2505) were included. Post-concussion syndrome (PCS) (16 studies) and neuropsychological symptoms (9 studies) were the most frequently assessed outcomes. The odds of having persistent PCS (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.34-1.12, p = 0.11, I2 0% [n = five studies]) in patients with an elevated S-100ß protein serum level were not significantly different from those of patients with normal values while the odds of having early PCS (OR 1.67, 95% CI: 0.98-2.85, p = 0.06, I2 38% [n = five studies]) were close to statistical significance. Similarly, having an elevated S-100ß protein serum level was not associated with the odds of returning to work at six months (OR 2.31, 95% CI: 0.50-10.64, p = 0.28, I2 22% [n = two studies]). Overall risk of bias was considered moderate. Results suggest that the prognostic biomarker S-100ß protein has a low clinical value to identify patients at risk of persistent post-concussion symptoms. Variability in injury to S-100ß protein sample time, mTBI populations, and outcomes assessed could potentially explain the lack of association and needs further evaluation.

Performance of International Classification of Diseases-based injury severity measures used to predict in-hospital mortality and intensive care admission among traumatic brain-injured patients.

BACKGROUND: The International Classification of Diseases (ICD) is the main classification system used for population-based traumatic brain injury (TBI) surveillance activities but does not contain direct information on injury severity. International Classification of Diseases-based injury severity measures can be empirically derived or mapped to the Abbreviated Injury Scale, but no single approach has been formally recommended for TBI. OBJECTIVE: The aim of this study was to compare the accuracy of different ICD-based injury severity measures for predicting in-hospital mortality and intensive care unit (ICU) admission in TBI patients. METHODS: We conducted a population-based retrospective cohort study. We identified all patients 16 years or older with a TBI diagnosis who received acute care between April 1, 2006, and March 31, 2013, from the Quebec Hospital Discharge Database. The accuracy of five ICD-based injury severity measures for predicting mortality and ICU admission was compared using measures of discrimination (area under the receiver operating characteristic curve [AUC]) and calibration (calibration plot and the Hosmer-Lemeshow goodness-of-fit statistic). RESULTS: Of 31,087 traumatic brain-injured patients in the study population, 9.0% died in hospital, and 34.4% were admitted to the ICU. Among ICD-based severity measures that were assessed, the multiplied derivative of ICD-based Injury Severity Score (ICISS-Multiplicative) demonstrated the best discriminative ability for predicting in-hospital mortality (AUC, 0.858; 95% confidence interval, 0.852-0.864) and ICU admissions (AUC, 0.813; 95% confidence interval, 0.808-0.818). Calibration assessments showed good agreement between observed and predicted in-hospital mortality for ICISS measures. All severity measures presented high agreement between observed and expected probabilities of ICU admission for all deciles of risk. CONCLUSIONS: The ICD-based injury severity measures can be used to accurately predict in-hospital mortality and ICU admission in TBI patients. The ICISS-Multiplicative generally outperformed other ICD-based injury severity measures and should be preferred to control for differences in baseline characteristics between TBI patients in surveillance activities or injury research when only ICD codes are available. LEVEL OF EVIDENCE: Prognostic study, level III.

Feasibility of emergency department point-of-care ultrasound for rib fracture diagnosis in minor thoracic injury.

OBJECTIVES: The main objective of this study was to evaluate the feasibility of emergency department (ED) point-of-care ultrasound (PoCUS) for rib fracture diagnosis in patients with minor thoracic injury (mTI). Secondary objectives were to 1) evaluate patients' pain during the PoCUS procedure, 2) identify the limitations of the use of PoCUS technique, and 3) compare the diagnosis obtained with PoCUS to radiography results. METHODS: Adult patients who presented with clinical suspicion of rib fractures after mTI were included. All patients underwent PoCUS performed by emergency physicians (EPs) prior to a rib view X-ray. A visual analogue scale (VAS) ranging from 0 to 100 was used to ascertain feasibility, patients' pain and clinicians' degree of certitude. Feasibility was defined as a score of more than 50 on the VAS. We documented the radiologists' interpretation of rib view X-ray. Radiologists were blinded to the PoCUS results. RESULTS: Ninety-six patients were included. A majority (65%) of EPs concluded that the PoCUS technique to diagnose rib fracture was feasible (VAS score > 50). Median score for feasibility was 63. Median score was 31 (Interquartile range [IQR] 5-57) for patients' pain related to the PoCUS. The main limiting factor of the PoCUS technique was pain during patient examination (15%). CONCLUSION: PoCUS examination appears to be a feasible technique for a rib fracture diagnosis in the ED.

Hospital length of stay following admission for traumatic brain injury in a Canadian integrated trauma system: A retrospective multicenter cohort study.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of disability in children and young adults and costs CAD$3 billion annually in Canada. Stakeholders have expressed the urgent need to obtain information on resource use for TBI to improve the quality and efficiency of acute care in this patient population. We aimed to assess the components and determinants of hospital and ICU LOS for TBI admissions. METHODS: We performed a retrospective multicenter cohort study on 11,199 adults admitted for TBI between 2007 and 2012 in an inclusive Canadian trauma system. Our primary outcome measure was index hospital LOS (admission to the hospital with the highest designation level). Index LOS was compared to total LOS (all consecutive admissions related to the injury). Expected LOS was calculated by matching TBI admissions to all-diagnosis hospital admissions by age, gender, and year of admission. LOS determinants were identified using multilevel linear regression. RESULTS: Geometric mean total LOS was 1day longer than geometric mean index LOS (12.6 versus 11.7 days). Observed index and ICU LOS were respectively 4.2days and 2.5days longer than that expected according to all-diagnosis admissions. The six most important determinants of LOS were discharge destination, severity of concomitant injuries, extracranial complications, GCS, TBI severity, and mechanical ventilation, accounting for 80% of explained variation. CONCLUSIONS: Results of this multicenter retrospective cohort study suggest that hospital and ICU LOS for TBI admissions are 56% and 119% longer than expected according to all-diagnosis admissions, respectively. In addition, hospital LOS is underestimated when only the index visit is considered and is largely influenced by discharge destination and extracranial complications, suggesting that improvements could be achieved with better discharge planning and interventions targeting prevention of in-hospital complications. This study highlights the importance of considering TBI patients as a distinct population when allocating resources or planning quality improvement interventions.

General Practitioners' Clinical Impression in the Screening for Frailty: Data From the FAP Study Pilot.

BACKGROUND: The progression of frailty is marked by an increased risk of adverse health outcomes in the elderly including falls, physical and/or cognitive disability, hospitalizations, and mortality. In primary care, the general practitioner's (GP's) clinical impression about their elderly patients' frailty state seems to be a key point in identifying frail individuals in their clinical practice. The aim of this article is to examine if GPs' clinical impressions regarding frailty concurs with objective measures of the gold standard frailty phenotype as described by Fried in community-dwelling older persons. DESIGN: Cross-sectional study in 14 primary care GP offices in the Toulouse area from May 1st to October 31st, 2015. PARTICIPANTS: Fourteen GPs screened their patients ≥70 years old. MEASUREMENTS: GPs' "frailty impression" was based on the Gérontopôle Frailty Screening Tool. "Objective measures of the five Fried frailty criteria" were obtained by a geriatric nurse through standardized testing. The capacity of the GPs' clinical impression to detect participants objectively measured as frail was examined with diagnostic values of observed sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). RESULTS: A total of 268 participants were screened by GPs and assessed by a nurse. Mean age was 81 years and 62.3% were female. According to the objective measures of Fried's criteria, frailty (three to five criteria) and pre-frailty (one to two criteria) states were identified in 31% and 45.2% of participants, respectively. The Se of the GPs' impression was good (80.39%; 95% confidence interval [CI], 74.27%-85.61%), and the Sp was moderate (64.06%; 95% CI, 5.10%-75.68%). The overall PPV of the GPs' impression was 87.70% (95% CI, 82.12%-92.04%), and the NPV was 50.51% (95% CI, 39.27%-61.91%). Although the PPV increased with age reaching 93.33% (95% CI, 85.12%-97.80%) among patients ≥ 85 years old, the NPV decreased accordingly to a minimal 21.43% (95% CI, 4.66%-50.80%) in that subgroup. CONCLUSION: The present study highlights the importance of the GPs' clinical impression on frailty as a fair means to identify this syndrome in community-dwelling older patients in primary care. This clinical impression may not be sufficient, however, and some objective tests could be added to improve the accuracy of frailty detection in older patients in primary care.

Impact of socio-economic status on unplanned readmission following injury: A multicenter cohort study.

BACKGROUND: Unplanned readmissions cost the US economy approximately $17 billion in 2009 with a 30-day incidence of 19.6%. Despite the recognised impact of socio-economic status (SES) on readmission in diagnostic populations such as cardiovascular patients, its impact in trauma patients is unclear. We examined the effect of SES on unplanned readmission following injury in a setting with universal health insurance. We also evaluated whether additional adjustment for SES influenced risk-adjusted readmission rates, used as a quality indicator (QI). STUDY DESIGN: We conducted a multicenter cohort study in an integrated Canadian trauma system involving 56 adult trauma centres using trauma registry and hospital discharge data collected between 2005 and 2010. The main outcome was unplanned 30-day readmission; all cause, due to complications of injury and due to subsequent injury. SES was determined using ecological indices of material and social deprivation. Odds ratios of readmission and 95% confidence intervals adjusted for covariates were generated using multivariable logistic regression with a correction for hospital clusters. We then compared a readmission QI validated previously (original QI) to a QI with additional adjustment for SES (SES-adjusted QI) using the mean absolute difference. RESULTS: The cohort consisted of 52,122 trauma admissions of which 6.5% were rehospitalised within 30 days of discharge. Compared to patients in the lowest quintile of social deprivation, those in the highest quintile had a 20% increase in the odds of all-cause unplanned readmission (95% CI=1.06-1.36) and a 27% increase in the odds of readmission due to complications of injury (95% CI=1.04-1.54). No association was observed for material deprivation or for readmissions due to subsequent injuries. We observed a strong agreement between the original and SES-adjusted readmission (mean absolute difference= 0.04%). CONCLUSIONS: Patients admitted for traumatic injury who suffer from social deprivation have an increased risk of unplanned rehospitalisation due to complications of injury in the 30 days following discharge. Better discharge planning or follow up for such patients may improve patient outcome and resource use for trauma admissions. Despite observed associations, results suggest that the trauma QI based on unplanned readmission does not require additional adjustment for SES.

Performance of International Classification of Diseases-based injury severity measures used to predict in-hospital mortality: A systematic review and meta-analysis.

BACKGROUND: The International Classification of Diseases (ICD) is the main classification system used for population-based injury surveillance activities but does not contain information on injury severity. ICD-based injury severity measures can be empirically derived or mapped, but no single approach has been formally recommended. This study aimed to compare the performance of ICD-based injury severity measures to predict in-hospital mortality among injury-related admissions. METHODS: A systematic review and a meta-analysis were conducted. MEDLINE, EMBASE, and Global Health databases were searched from their inception through September 2014. Observational studies that assessed the performance of ICD-based injury severity measures to predict in-hospital mortality and reported discriminative ability using the area under a receiver operating characteristic curve (AUC) were included. Metrics of model performance were extracted. Pooled AUC were estimated under random-effects models. RESULTS: Twenty-two eligible studies reported 72 assessments of discrimination on ICD-based injury severity measures. Reported AUC ranged from 0.681 to 0.958. Of the 72 assessments, 46 showed excellent (0.80 ≤ AUC < 0.90) and 6 outstanding (AUC ≥ 0.90) discriminative ability. Pooled AUC for ICD-based Injury Severity Score (ICISS) based on the product of traditional survival proportions was significantly higher than measures based on ICD mapped to Abbreviated Injury Scale (AIS) scores (0.863 vs. 0.825 for ICDMAP-ISS [p = 0.005] and ICDMAP-NISS [p = 0.016]). Similar results were observed when studies were stratified by the type of data used (trauma registry or hospital discharge) or the provenance of survival proportions (internally or externally derived). However, among studies published after 2003 the Trauma Mortality Prediction Model based on ICD-9 codes (TMPM-9) demonstrated superior discriminative ability than ICISS using the product of traditional survival proportions (0.850 vs. 0.802, p = 0.002). Models generally showed poor calibration. CONCLUSION: ICISS using the product of traditional survival proportions and TMPM-9 predict mortality more accurately than those mapped to AIS codes and should be preferred for describing injury severity when ICD is used to record injury diagnoses. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.