Trauma models to identify major trauma and mortality in the prehospital setting.

BACKGROUND: Patients with major trauma might benefit from treatment in a trauma centre, but early identification of major trauma (Injury Severity Score (ISS) over 15) remains difficult. The aim of this study was to undertake an external validation of existing prognostic models for injured patients to assess their ability to predict mortality and major trauma in the prehospital setting. METHODS: Prognostic models were identified through a systematic literature search up to October 2017. Injured patients transported by Emergency Medical Services to an English hospital from the Trauma Audit and Research Network between 2013 and 2016 were included. Outcome measures were major trauma (ISS over 15) and in-hospital mortality. The performance of the models was assessed in terms of discrimination (concordance index, C-statistic) and net benefit to assess the clinical usefulness. RESULTS: A total of 154 476 patients were included to validate six previously proposed prediction models. Discriminative ability ranged from a C-statistic value of 0·602 (95 per cent c.i. 0·596 to 0·608) for the Mechanism, Glasgow Coma Scale, Age and Arterial Pressure model to 0·793 (0·789 to 0·797) for the modified Rapid Emergency Medicine Score (mREMS) in predicting in-hospital mortality (11 882 patients). Major trauma was identified in 52 818 patients, with discrimination from a C-statistic value of 0·589 (0·586 to 0·592) for mREMS to 0·735 (0·733 to 0·737) for the Kampala Trauma Score in predicting major trauma. None of the prediction models met acceptable undertriage and overtriage rates. CONCLUSION: Currently available prehospital trauma models perform reasonably in predicting in-hospital mortality, but are inadequate in identifying patients with major trauma. Future research should focus on which patients would benefit from treatment in a major trauma centre.

ANTECEDENTES: Los pacientes con traumatismo mayor pueden beneficiarse del tratamiento en un centro de trauma, pero la identificación precoz del traumatismo mayor (Injury Severity Score, ISS > 15) sigue siendo difícil. El objetivo de este estudio fue validar externamente los modelos pronósticos existentes para los pacientes con traumatismos con el fin de evaluar su capacidad para predecir el traumatismo mayor y la mortalidad en el entorno pre-hospitalario. MÉTODOS: Los modelos pronóstico se identificaron mediante una búsqueda sistemática de la literatura hasta octubre de 2017. Los pacientes incluidos fueron pacientes con traumatismos que fueron trasladados mediante los servicios de emergencia médica (emergency medical services, EMS) a un hospital inglés perteneciente a Trauma Audit and Research Network (TARN) entre 2013 y 2016. Las variables evaluadas fueron los traumatismos graves (ISS > 15) y la mortalidad hospitalaria. El rendimiento de los modelos se analizó en términos de discriminación (índice de concordancia, c) y de beneficio neto para evaluar la utilidad clínica. RESULTADOS: Se incluyeron un total de 154.476 pacientes para validar los seis modelos de predicción propuestos previamente. La capacidad discriminatoria osciló entre c = 0,602 (i.c. del 95%: 0,596-0,608) para el modelo que incluye mecanismo, escala de coma de Glasgow, edad y presión arterial (MGAP) hasta c = 0,793 (0,789-0,797) para la puntuación de medicina de emergencia rápida modificada (mREMS) en la predicción de la mortalidad hospitalaria (n = 11.882). Se identificó un traumatismo mayor en 52.818 pacientes, con una discriminación de c = 0,589 (0,586-0,592) para mREMS a c = 0,735 (0,733-0,737) para la puntuación de trauma de Kampala en la predicción de traumatismo mayor. Ninguno de los modelos de predicción cumplió con las tasas aceptables de subtriaje (undertriage) y sobretriaje (overtriage). CONCLUSIÓN: Los modelos de trauma pre-hospitalarios actualmente disponibles tienen un rendimiento razonable para predecir la mortalidad hospitalaria, pero son inadecuados para identificar a los pacientes con traumatismo mayor. En el futuro, las investigaciones deberían centrarse en identificar a los pacientes que se podrían beneficiar del tratamiento en un centro de trauma especializado.

The efforts of direct support professionals to facilitate inclusion: the role of psychological determinants and work setting.

BACKGROUND: Various studies have found that direct support professionals (DSPs) play an important role in determining the degree to which people with intellectual disabilities (ID) are included in society. However, less research has been conducted on the psychological processes that may influence the behavioural intentions of DSPs to actually engage with and invest effort in supporting their clients' inclusion. Five possible psychological variables are identified in the literature: attitudes, social norms, experienced competencies, identity and meta-evaluation. In our research, we tested whether these processes influence the (intended) efforts DSPs make to facilitate their clients' inclusion. METHOD: A structured questionnaire was sent to 927 DSPs working in one of three different locations (an ordinary non-segregated setting, a reversed non-segregated setting and a residential facility). Of these, 336 DSPs completed the questionnaire. RESULTS: Several variables revealed differences between the three locations, specifically in efforts to facilitate inclusion, attitudes, social norms, experienced competencies and professional identity. Looking at the overall means, we found (relatively) high scores for the experienced competencies, role identity and meta-evaluation. In contrast, the means were relatively negative regarding the DSPs' attitudes to inclusion and their assumed social norms. CONCLUSIONS: Direct support professionals' efforts to facilitate inclusion depend on their attitude towards inclusion, the experienced competencies, their role identity, the DSPs' meta-evaluation and, indirectly through attitudes, also on the assumed social norms of the relevant stakeholders. Organizations responsible for supporting people with ID and which may want their DSPs to make greater efforts to facilitate inclusion should pay attention to these psychological variables.