Development of a Quality Indicator Set for the Optimal Acute Management of Moderate to Severe Traumatic Brain Injury in the Australian Context.

BACKGROUND: The aim of this study was to develop a consensus-based set of indicators of high-quality acute moderate to severe traumatic brain injury (msTBI) clinical management that can be used to measure structure, process, and outcome factors that are likely to influence patient outcomes. This is the first stage of the PRECISION-TBI program, which is a prospective cohort study that aims to identify and promote optimal clinical management of msTBI in Australia. METHODS: A preliminary set of 45 quality indicators was developed based on available evidence. An advisory committee of established experts in the field refined the initial indicator set in terms of content coverage, proportional representation, contamination, and supporting evidence. The refined indicator set was then distributed to a wider Delphi panel for assessment of each indicator in terms of validity, measurement feasibility, variability, and action feasibility. Inclusion in the final indicator set was contingent on prespecified inclusion scoring. RESULTS: The indicator set was structured according to the care pathway of msTBI and included prehospital, emergency department, neurosurgical, intensive care, and rehabilitation indicators. Measurement domains included structure indicators, logistic indicators, and clinical management indicators. The Delphi panel consisted of 44 participants (84% physician, 12% nursing, and 4% primary research) with a median of 15 years of practice. Of the 47 indicators included in the second round of the Delphi, 32 indicators were approved by the Delphi group. CONCLUSIONS: This study identified a set of 32 quality indicators that can be used to structure data collection to drive quality improvement in the clinical management of msTBI. They will also be used to guide feedback to PRECISION-TBI's participating sites.

Epidemiology of postinjury multiple organ failure: a prospective multicenter observational study.

PURPOSE: Postinjury multiple organ failure (MOF) is the sequela to the disease of polytrauma. We aimed to describe the contemporary population-based epidemiology of MOF within a mature trauma system, to analyse the time taken for MOF to develop, and to evaluate the temporal patterns and contributions of the individual constituent organ failures. METHODS: Prospective observational study conducted across five Level-1 trauma centers in New South Wales, Australia. Trauma patients at-risk of MOF (Denver > 3 from 48 h post-admission), aged > 16 years, ISS > 15, and who stayed in ICU for ≥ 48 h were eligible for inclusion. RESULTS: From May 2018-February 2021, 600 at-risk polytrauma patients were prospectively enrolled (mean(SD)age = 49(21)years, males = 453/600(76%),median(IQR)ISS = 26(20,34)). MOF incidence was 136/600(23%) among at-risk patients, 142/6248(2%) among major trauma patients (ISS > 12 per Australian definition), and 0.8/100,000 in the general population. The mortality rate was 55/600(11%) in the overall study population, and 34/136(25%) in MOF patients. 82/136(60%) of MOF patients developed MOF on day-3. No patients developed MOF after day-13. Among MOF patients, 60/136(44%) had cardiac failures (mortality = 37%), 39/136(29%) had respiratory failures (mortality = 23%), 24/136(18%) had renal failures (mortality = 63%), and 12/136(9%) had hepatic failures (mortality = 50%). CONCLUSION: Although a rare syndrome in the general population, MOF occurred in 23% of the most severely injured polytrauma patients. When compared to previous risk-matched cohorts, MOF become more common, but not more lethal, despite a decade older cohort. The heart has superseded the lungs as the most common organ to fail. Cardiac and respiratory failures occurred earlier and were associated with lower mortality than renal and hepatic failures.

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review.

BACKGROUND: The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. METHODS: This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. RESULTS: A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). CONCLUSION: A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. LEVEL OF EVIDENCE: Delphi-Consensus/Systematic Review; Level IV.

Rehabilitation systems: trauma centers Asia-Pacific (Australia and Japan).

Rehabilitation systems in Australia and Japan represent a multidisciplinary team approach that have similarities and differences. Treatment is based on a goal-driven, holistic, patient-centered approach. This article provides an overview of the structure of the rehabilitation systems in Australia and Japan, including written guidelines, in-hospital programs, and postdischarge options.

Rehabilitation after surgery for hip fracture - the impact of prompt, frequent and mobilisation-focused physiotherapy on discharge outcomes: an observational cohort study.

PURPOSE: To determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture. METHODS: A cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders. RESULTS: Of 437 patients, 62% were female, 56% were aged ≥ 85 years, 23% were previously living in a residential aged care facility, 48% usually walked with a gait aid, and 38% were cognitively impaired prior to their injury. The median acute and total LOS were 8 (IQR 5-13) and 20 (IQR 8-38) days. Approximately 71% (n = 179/251) of patients originally living in private residence returned home and 29% (n = 72/251) were discharged to a residential aged care facility. Previously mobile patients had a higher total LOS if they walked day 2-3 (10.3 days; 95% CI 3.2, 17.4) or transferred with a mechanical lifter or did not get out of bed day 1 (7.6 days; 95% CI 0.6, 14.6) compared to those who walked day 1 postoperatively. Previously mobile patients from private residence had a reduced odds of return to private residence if they walked day 2-3 (OR 0.38; 95% CI 0.17, 0.87), day 4 + (OR 0.38; 95% CI 0.15, 0.96), or if they only sat, stood or stepped on the spot day 1 (OR 0.29; 95% CI 0.13, 0.62) when compared to those who walked day 1 postoperatively. Among patients from private residence, each additional physiotherapy session per day was associated with a -2.2 (95% CI -3.3, -1.0) day shorter acute LOS, and an increased log odds of return to private residence (OR 1.76; 95% CI 1.02, 3.02). CONCLUSION: Hip fracture patients who walked earlier, were more active day 1 postoperatively, and/or received a higher number of physiotherapy sessions were more likely to return home after a shorter LOS.

Time from injury to operative intervention in traumatic intracranial hematoma: A systematic literature review and meta-analysis.

BACKGROUND: The outcomes in traumatic intracranial hematoma (TICH) have not improved significantly despite advances in trauma care. A modifiable factor in TICH management is time to operation room (TOR). TOR has become a key marker in Traumatic brain injury care despite a lack of contemporary evidence. This study aimed to determine the timing of TICH evacuation and its association with mortality and neurological outcomes. METHODS: A systematic review of PubMed, OVID MEDLINE, CINAHL, and Web of Science. Included studies reported data on adult patients with acute TICH who underwent surgical evacuation. The primary outcome was TOR and its association with mortality or functional neurological recovery. RESULTS: From 1838 articles screened, 17 were included. Eight studies reported TOR as a continuous variable, ranging between 3 and 7.1 h. Three studies found better outcomes with shorter TOR, five found no difference, and one found worse outcomes with shorter TOR. Five articles were included in meta-analysis of mortality in patients undergoing operative decompression less than or greater than 4 h from injury which found lower mortality in the >4-h group, OR = 1.53. Longitudinal regression analysis showed no difference in TOR over the 33-year span of articles included. CONCLUSION: There is limited data available on TOR in TICH, with equivocal results on the effect of timing on outcomes. TOR has not decreased over the last 4 decades. The unvalidated 4-h cut-off seems to be associated with better survival. Contemporary assessment of this potentially important performance indicator is required.

Time to traumatic intracranial hematoma evacuation: contemporary standard and room for improvement.

PURPOSE: Traumatic intracranial hematoma (TICH) is a neurosurgical emergency with high mortality and morbidity. The time to operative decompression is a modifiable but inconsistently reported risk factor for TICH patients? OUTCOMES: We aimed to provide contemporary time to evacuation data and long-term trends in timing of TICH evacuation in a trauma system. METHODS: A 13-year retrospective cohort study ending in 2021 at a trauma system with one level-1 trauma center included all patients undergoing urgent craniotomy or craniectomy for evacuation of TICH. Demographics, injury severity and key timeframes of care were collected. Subgroups analyzed were polytrauma versus isolated head injury, direct admissions versus transfers and those who survived versus those who died. Linear regression of times from injury to operating room was performed. RESULTS: Seventy-eight TICH patients (Age: 35 (22-56); 58 (74%) males; ISS: 25(25-41); AIS head: 5 (4-5); mortality: 21 (27%) patients) were identified. Initial GCS was 8 (3.25-14) which decreased to 3 (3-7) by arrival in the trauma center. There were 46 (59%) patients intubated prior to arrival. Median time from injury to operation was 4.88 (3.63-6.80) hours. Linear regression of injury to OR showed increasing times to operative intervention for direct admissions to the trauma center over the study period (p=0.04). There was no associated change in mortality or Glasgow outcome score over the same time. CONCLUSION: This contemporary data shows timing from injury to evacuation is approaching 5 hours. Over the 13-year study period the time to operative intervention significantly increased for direct admissions. This study will guide our institutions response to TICH presentations in the future. Other trauma systems should critically appraise their results with the same reporting standard.

Open fractures: evidence-based best practices.

Open fracture management is a common challenge to orthopaedic trauma surgeons and a burdensome condition to the patient, health care, and entire society. Fracture-related infection (FRI) is the leading morbid complication to avoid during open fracture management because it leads to sepsis, nonunion, limb loss, and overall very poor region-specific and general functional outcomes. This review, based on a symposium presented at the 2022 OTA International Trauma Care Forum, provides a practical and evidence-based summary on key strategies to prevent FRI in open fractures, which can be grouped as optimizing host factors, antimicrobial prophylaxis, surgical site management (skin preparation, debridement, and wound irrigation), provision of skeletal stability, and soft-tissue coverage. When it is applicable, strategies are differentiated between optimal resource and resource-limited settings.

Modifiability of surgical timing in postinjury multiple organ failure patients.

BACKGROUND: Postinjury multiple organ failure (MOF) is the leading cause of late trauma deaths, with primarily non-modifiable risk factors. Timing of surgery as a potentially modifiable risk factor is frequently proposed, but has not been quantified. We aimed to compare mortality, hospital length of stay (LOS), and ICU LOS between MOF patients who had surgery that preceded MOF with modifiable timings versus those with non-modifiable timings. METHODS: Retrospective analysis of an ongoing 17-year prospective cohort study of ICU polytrauma patients at-risk of MOF. Among MOF patients (Denver score>3), we identified patients who had surgery that preceded MOF, determined whether the timing of these operation(s) were modifiable(M) or non-modifiable (non-M), and evaluated the change in physiological parameters as a result of surgery. RESULTS: Of 716 polytrauma patients at-risk of MOF, 205/716 (29%) developed MOF, and 161/205 (79%) had surgery during their ICU admission. Of the surgical MOF patients, 147/161 (91%) had one or more operation(s) that preceded MOF, and 65/161 (40%) of them had operation(s) with modifiable timings. There were no differences in age (mean (SD) 52 (19) vs 53 (21)years), injury severity score (median (IQR) 34 (26-41)vs34 (25-44)), admission physiological and resuscitation parameters, between M and non-M-patients. M patients had longer ICU LOS (median (IQR) 18 (12-28)versus 11 (8-16)days, p < 0.0001) than non-M-patients, without difference in mortality (14%vs16%, p = 0.7347), or hospital LOS (median (IQR) 32 (18-52)vs27 (17-47)days, p = 0.3418). M-patients had less fluids and transfusions intraoperatively. Surgery did not compromise patient physiology. CONCLUSION: Operations preceding MOF are common in polytrauma and seem to be safe in maintaining physiology. The margin for improvement from optimizing surgical timing is modest, contrary to historical assumptions.

Comparison of iterative reconstruction implementations for multislice helical CT.

The most mature image reconstruction algorithms in multislice helical computed tomography are based on analytical and iterative methods. Over the past decades, several methods have been developed for iterative reconstructions that improve image quality by reducing noise and artifacts. In the regularization step of iterative reconstruction, noise can be significantly reduced, thereby making low-dose CT. The quality of the reconstructed image can be further improved by using model-based reconstructions. In these reconstructions, the main focus is on modeling the data acquisition process, including the behavior of the photon beams, the geometry of the system, etc. In this article, we propose two model-based reconstruction algorithms using a virtual detector for multislice helical CT. The aim of this study is to compare the effect of using a virtual detector on image quality for the two proposed algorithms with a model-based iterative reconstruction using the original detector model. Since the algorithms are implemented using multiple GPUs, the merging of separately reconstructed volumes can significantly affect image quality. This issue is often referred to as the "long object" problem, for which we also present a solution that plays an important role in the proposed reconstruction processes. The algorithms were evaluated using mathematical and physical phantoms, as well as patient cases. The SSIM, MS-SSIM and L1 metrics were utilized to evaluate the image quality of the mathematical phantom case. To demonstrate the effectiveness of the algorithms, we used the CatPhan 600 phantom. Additionally, anonymized patient scans were used to showcase the improvements in image quality on real scan data.

Traumatic rhabdomyolysis: rare but morbid, potentially lethal, and inconsistently monitored.

PURPOSE: Although traumatic rhabdomyolysis (TR) is shown to be associated with acute kidney injury (AKI), there are no large prospective epidemiological studies, interventional trials, official guidelines outlining the appropriate investigation, monitoring, and treatment on this poorly understood condition. We aimed to establish the contemporary epidemiology and describe current practices for TR to power future higher quality studies. We hypothesised that investigation and monitoring occur in an ad hoc fashion. MATERIAL AND METHODS: We conducted a 1-year retrospective cohort study of all patients > 16 years of age, with an ISS > 12 and, admitted to a level 1 trauma centre. Demographics, initial vital signs, admission laboratory values, and daily creatinine kinase (CK) values were collected. The primary outcome was TR (defined by CK > 5000 IU), secondary outcomes included AKI (KDIGO criteria), mortality, multiple organ failure, length of stay, and need for renal replacement therapy (RRT). RESULTS: 586 patients met inclusion criteria and 15 patients (2.56%) developed TR. CK testing occurred in 78 (13.1%) patients with 29 (37.7%) of these having values followed until downtrending. AKI occurred in 63 (10.8%) patients within the entire study population. Among those with TR, nine (60%) patients developed AKI. Patients with TR had higher ISS (median 29 vs 18) and mortality (26.7% vs 8.9%). DISCUSSION: Whilst TR appears rare without liberal screening, it is strongly associated with AKI. Given the poor outcomes, standardised monitoring, and liberal testing of CK could be justified in trauma patients with higher injury severity. This epidemiological data can help to define study populations and power future multicentre prospective studies on this infrequent yet morbid condition.

Long-term functional outcomes in polytrauma: a fundamentally new approach is needed in prediction.

PURPOSE: Modern trauma care has reduced mortality but poor long-term outcomes with low follow-up rates are common with limited recommendations for improvements. The aim of this study was to describe the impact of severe injury on the health-related quality of life, specifically characterise the non-responder population and to identify modifiable predictors of poorer outcomes. METHODS: Five-year (2012-2016) prospective cohort study was performed at a level 1 trauma centre. Baseline Short-Form Health Survey (SF36) was collected at admission, and at 6 and 12 months postinjury together with demographics, injury mechanism and severity, psychosocial wellbeing, and return to work capacity. RESULTS: Of the 306 consecutive patients [age 52 ± 17 years, male 72%, ISS 21 (17, 29), mortality 5%], 195 (64%) completed questionnaires at baseline, and at 12 months. Preinjury physical health scores were above the general population (53.1 vs. 50.3, p < 0.001) and mental health component was consistent with the population norms (51.7 vs. 52.9, p = 0.065). One year following injury, both physical health (13.2, 95% CI 14.8, 11.6) and mental health scores (6.0, 95% CI 8.1, 3.8) were significantly below age- and sex-adjusted preinjury baselines. Non-responders had similar ISS but with a lower admission GCS, and were more likely to be younger, and without comorbidities, employment, or university education. CONCLUSION: Contrary to their better than population norm preinjury health status, polytrauma patients remain functionally impaired at least 1 year after injury. The identified high risk for non-responding group needs more focused efforts for follow-up. A fundamentally different approach is required in polytrauma research which identify modifiable predictors of poor long-term outcomes.

The Operating Room management for emergency Surgical Activity (ORSA) study: a WSES international survey.

BACKGROUND: Despite advances and improvements in the management of surgical patients, emergency and trauma surgery is associated with high morbidity and mortality. This may be due in part to delays in definitive surgical management in the operating room (OR). There is a lack of studies focused on OR prioritization and resource allocation in emergency surgery. The Operating Room management for emergency Surgical Activity (ORSA) study was conceived to assess the management of operating theatres and resources from a global perspective among expert international acute care surgeons. METHOD: The ORSA study was conceived as an international web survey. The questionnaire was composed of 23 multiple-choice and open questions. Data were collected over 3 months. Participation in the survey was voluntary and anonymous. RESULTS: One hundred forty-seven emergency and acute care surgeons answered the questionnaire; the response rate was 58.8%. The majority of the participants come from Europe. One hundred nineteen surgeons (81%; 119/147) declared to have at least one emergency OR in their hospital; for the other 20/147 surgeons (13.6%), there is not a dedicated emergency operating room. Forty-six (68/147)% of the surgeons use the elective OR to perform emergency procedures during the day. The planning of an emergency surgical procedure is done by phone by 70% (104/147) of the surgeons. CONCLUSIONS: There is no dedicated emergency OR in the majority of hospitals internationally. Elective surgical procedures are usually postponed or even cancelled to perform emergency surgery. It is a priority to validate an effective universal triaging and scheduling system to allocate emergency surgical procedures. The new Timing in Acute Care Surgery (TACS) was recently proposed and validated by a Delphi consensus as a clear and reproducible triage tool to timely perform an emergency surgical procedure according to the clinical severity of the surgical disease. The new TACS needs to be prospectively validated in clinical practice. Logistics have to be assessed using a multi-disciplinary approach to improve patients' safety, optimise the use of resources, and decrease costs.

Clinical validation of the "Straight-Leg-Evaluation-Trauma-Test" (SILENT) as a rapid assessment tool for injuries of the lower extremity in trauma bay patients.

PURPOSE: Clinical assessment of the major trauma patient follows international validated guidelines without standardized trauma-specific assessment of the lower extremities for injuries. This study aimed to validate a novel clinical test for lower extremity evaluation during trauma resuscitation phase. METHODS: This diagnostic, prognostic observational cohort study was performed on trauma patient treated at one level I trauma center between Mar 2022 and Mar 2023. The Straight-Leg-Evaluation-Trauma (SILENT) test follows three steps during the primary survey: inspection for obvious fractures (e.g., open fracture), active elevation of the leg, and cautious elevation of the lower extremity from the heel. SILENT was considered positive when obvious fracture was present and painful or pathological mobility was observed. The SILENT test was compared with standardized radiographs (CT scan or X-ray) as the reference test for fractures. Statistical analysis included sensitivity, specificity, and receiver operating characteristic testing. RESULTS: 403 trauma bay patients were included, mean age 51.6 (SD 21.2) years with 83 fractures of the lower extremity and 27 pelvic/acetabular fractures. Overall sensitivity was 75% (95%CI 64 to 84%), and overall specificity was 99% (95%CI 97 to 100%). Highest sensitivity was for detection of tibia fractures (93%, 95%CI 77 to 99%). Sensitivity of SILENT was higher in the unconscious patient (96%, 95%CI 78 to 100%) with a near 100% specificity. AUC was highest for tibia fractures (0.96, 95%CI 0.92 to 1.0) followed by femur fractures (0.92, 95%CI 0.84 to 0.99). CONCLUSION: The SILENT test is a clinical applicable and feasible rule-out test for relevant injuries of the lower extremity. A negative SILENT test of the femur or the tibia might reduce the requirement of additional radiological imaging. Further large-scale prospective studies might be required to corroborate the beneficial effects of the SILENT test.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS).

BACKGROUND: The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. METHODS: A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. RESULTS: A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). CONCLUSIONS: This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

Postinjury multiple organ failure in polytrauma: more frequent and potentially less deadly with less crystalloid.

BACKGROUND: Recently, retrospective registry-based studies have reported the decreasing incidence and increasing mortality of postinjury multiple organ failure (MOF). We aimed to describe the current epidemiology of MOF following the introduction of haemostatic resuscitation. METHODS: A 10-year prospective cohort study was undertaken at a Level-1 Trauma Centre-based ending in December 2015. Inclusion criteria age ≥ 16 years, Injury Severity Score (ISS) > 15, Abbreviated Injury Scale (AIS) Head < 3 and survived > 48 h. Demographics, physiological and shock resuscitation parameters were collected. The primary outcome was MOF defined by a Denver Score > 3. SECONDARY OUTCOMES: intensive care unit length of stay (ICU LOS), ventilation days and mortality. RESULTS: Three hundred and forty-seven patients met inclusion criteria (age 48 ± 20; ISS 30 ± 11, 248 (71%) were males and 23 (6.6%) patients died. The 74 (21%) MOF patients (maximum Denver Score: 5.5 ± 1.8; Duration; 5.6 ± 5.8 days) had higher ISS (32 ± 11 versus 29 ± 11) and were older (54 ± 19 versus 46 ± 20 years) than non-MOF patients. Mean daily Denver scores adjusted for age, sex, MOF and ISS did not change over time. Crystalloid usage decreased over the 10-year period (p value < 0.01) and PRBC increased (p value < 0.01). Baseline cumulative incidence of MOF at 28 days was 9% and competing risk analyses showed that incidence of MOF increased over time (subdistribution hazard ratio 1.14, 95% CI 1.04 to 1.23, p value < 0.01). Mortality risk showed no temporal change. ICU LOS increased over time (subdistribution hazard ratio 0.95, 95% CI 0.92 to 0.98, p value < 0.01). Ventilator days increased over time (subdistribution hazard ratio 0.94, 95% CI 0.9 to 0.97, p value < 0.01). CONCLUSION: The epidemiology of MOF continues to evolve. Our prospective cohort suggests an ageing population with increasing incidence of MOF, particularly in males, with little changes in injury or shock parameters, who are being resuscitated with less crystalloids, stay longer on ICU without improvement in survival.