Development of a standardized minimum dataset for including low-severity trauma patients in trauma registry collections in Australia and Aotearoa New Zealand.

BACKGROUND: Trauma continues to place a burden on individuals, communities and health care systems around the world. To help reduce this burden and improve care, trauma registries in Australia and Aotearoa New Zealand collect standardized data on patients admitted with Injury Severity Scores greater than 12. There is currently no agreed minimum data set for trauma patients with Injury Severity Score less than 13, representing an opportunity to provide more data for quality improvement and injury prevention. METHODS: A binational, expert, advisory group assessed the value of potential fields for a minimum dataset for low severity trauma. Existing trauma registries in Australia and Aotearoa New Zealand were assessed to ensure compatibility. RESULTS: Thirty-five data fields met criteria for inclusion in the low-severity minimum dataset. The fields comprised a subset of the Australia New Zealand Major Trauma Registry and were included in existing low-severity registries. CONCLUSION: A minimum data set for low severity has been defined for use in Australia and Aotearoa New Zealand. In addition to high severity trauma data this will provide a standard for data collection that will contribute to quality improvement and injury prevention.

Development and validation of a risk-adjustment model for mortality and hospital length of stay for trauma patients: a prospective registry-based study in Australia.

OBJECTIVES: Adequate risk adjustment for factors beyond the control of the healthcare system contributes to the process of transparent and equitable benchmarking of trauma outcomes. Current risk adjustment models are not optimal in terms of the number and nature of predictor variables included in the model and the treatment of missing data. We propose a statistically robust and parsimonious risk adjustment model for the purpose of benchmarking. SETTING: This study analysed data from the multicentre Australia New Zealand Trauma Registry from 1 July 2016 to 30 June 2018 consisting of 31 trauma centres. OUTCOME MEASURES: The primary endpoints were inpatient mortality and length of hospital stay. Firth logistic regression and robust linear regression models were used to study the endpoints, respectively. Restricted cubic splines were used to model non-linear relationships with age. Model validation was performed on a subset of the dataset. RESULTS: Of the 9509 patients in the model development cohort, 72% were male and approximately half (51%) aged over 50 years . For mortality, cubic splines in age, injury cause, arrival Glasgow Coma Scale motor score, highest and second-highest Abbreviated Injury Scale scores and shock index were significant predictors. The model performed well in the validation sample with an area under the curve of 0.93. For length of stay, the identified predictor variables were similar. Compared with low falls, motor vehicle occupants stayed on average 2.6 days longer (95% CI: 2.0 to 3.1), p<0.001. Sensitivity analyses did not demonstrate any marked differences in the performance of the models. CONCLUSION: Our risk adjustment model of six variables is efficient and can be reliably collected from registries to enhance the process of benchmarking.

Validation of the geriatric trauma outcome scores in predicting outcomes of elderly trauma patients.

BACKGROUND: Using three patient characteristics, including age, Injury Severity Score (ISS) and transfusion within 24 h of admission (yes vs. no), the Geriatric Trauma Outcome Score (GTOS) and Geriatric Trauma Outcome Score II (GTOS II) have been developed to predict mortality and unfavourable discharge (to a nursing home or hospice facility), of those who were ≥65 years old, respectively. OBJECTIVES: This study aimed to validate the GTOS and GTOS II models. For the nested-cohort requiring intensive care, we compared the GTOS scores with two ICU prognostic scores - the Acute Physiology and Chronic Health Evaluation (APACHE) III and Australian and New Zealand Risk of Death (ANZROD). METHODS: All elderly trauma patients admitted to the State Trauma Unit between 2009 and 2019 were included. The discrimination ability and calibration of the GTOS and GTOS II scores were assessed by the area under the receiver-operating-characteristic (AUROC) curve and a calibration plot, respectively. RESULTS: Of the 57,473 trauma admissions during the study period, 15,034 (26.2%) were ≥65 years-old. The median age and ISS of the cohort were 80 (interquartile range [IQR] 72-87) and 6 (IQR 2-9), respectively; and the average observed mortality was 4.3%. The ability of the GTOS to predict mortality was good (AUROC 0.838, 95% confidence interval [CI] 0.821-0.855), and better than either age (AUROC 0.603, 95%CI 0.581-0.624) or ISS (AUROC 0.799, 95%CI 0.779-0.819) alone. The GTOS II's ability to predict unfavourable discharge was satisfactory (AUROC 0.707, 95%CI 0.696-0.719) but no better than age alone. Both GTOS and GTOS II scores over-estimated risks of the adverse outcome when the predicted risks were high. The GTOS score (AUROC 0.683, 95%CI 0.591-0.775) was also inferior to the APACHE III (AUROC 0.783, 95%CI 0.699-0.867) or ANZROD (AUROC 0.788, 95%CI 0.705-0.870) in predicting mortality for those requiring intensive care. CONCLUSIONS: The GTOS scores had a good ability to discriminate between survivors and non-survivors in the elderly trauma patients, but GTOS II scores were no better than age alone in predicting unfavourable discharge. Both GTOS and GTOS II scores were not well-calibrated when the predicted risks of adverse outcome were high.

The journey from traffic offender to severe road trauma victim: destiny or preventive opportunity?

BACKGROUND: Road trauma is a leading cause of death and injury in young people. Traffic offences are common, but their importance as a risk indicator for subsequent road trauma is unknown. This cohort study assessed whether severe road trauma could be predicted by a history of prior traffic offences. METHODOLOGY AND PRINCIPAL FINDINGS: Clinical data of all adult road trauma patients admitted to the Western Australia (WA) State Trauma Centre between 1998 and 2013 were linked to traffic offences records at the WA Department of Transport. The primary outcomes were alcohol exposure prior to road trauma, severe trauma (defined by Injury Severity Score >15), and intensive care admission (ICU) or death, analyzed by logistic regression. Traffic offences directly leading to the road trauma admissions were excluded. Of the 10,330 patients included (median age 34 years-old, 78% male), 1955 (18.9%) had alcohol-exposure before road trauma, 2415 (23.4%) had severe trauma, 1360 (13.2%) required ICU admission, and 267 (2.6%) died. Prior traffic offences were recorded in 6269 (60.7%) patients. The number of prior traffic offences was significantly associated with alcohol-related road trauma (odds ratio [OR] per offence 1.03, 95% confidence interval [CI] 1.02-1.05), severe trauma (OR 1.13, 95%CI 1.14-1.15), and ICU admission or death (OR 1.10, 95%CI 1.08-1.11). Drink-drinking, seat-belt, and use of handheld electronic device offences were specific offences strongly associated with road trauma leading to ICU admission or death--all in a 'dose-related' fashion. For those who recovered from road trauma after an ICU admission, there was a significant reduction in subsequent traffic offences (mean difference 1.8, 95%CI 1.5 to 2.0) and demerit points (mean difference 7.0, 95%CI 6.5 to 7.6) compared to before the trauma event. SIGNIFICANCE: Previous traffic offences were a significant risk factor for alcohol-related road trauma and severe road trauma leading to ICU admission or death.

An injury awareness education program on outcomes of juvenile justice offenders in Western Australia: an economic analysis.

BACKGROUND: Injury is a major cause of mortality and morbidity of young people and the cost-effectiveness of many injury prevention programs remains uncertain. This study aimed to analyze the costs and benefits of an injury awareness education program, the P.A.R.T.Y. (Prevent Alcohol and Risk-related Trauma in Youth) program, for juvenile justice offenders in Western Australia. METHODS: Costs and benefits analysis based on effectiveness data from a linked-data cohort study on 225 juvenile justice offenders who were referred to the education program and 3434 who were not referred to the program between 2006 and 2011. RESULTS: During the study period, there were 8869 hospitalizations and 113 deaths due to violence or traffic-related injuries among those aged between 14 and 21 in Western Australia. The mean length of hospital stay was 4.6 days, a total of 320 patients (3.6%) needed an intensive care admission with an average length of stay of 6 days. The annual cost saved due to serious injury was $3,765 and the annual net cost of running this program was $33,735. The estimated cost per offence prevented, cost per serious injury avoided, and cost per undiscounted and discounted life year gained were $3,124, $42,169, $8,268 and $17,910, respectively. Increasing the frequency of the program from once per month to once per week would increase its cost-effectiveness substantially. CONCLUSIONS: The P.A.R.T.Y. injury education program involving real-life trauma scenarios was cost-effective in reducing subsequent risk of committing violence or traffic-related offences, injuries, and death for juvenile justice offenders in Western Australia.

Effect of an injury awareness education program on risk-taking behaviors and injuries in juvenile justice offenders: a retrospective cohort study.

BACKGROUND: Risk-taking behavior is a leading cause of injury and death amongst young people. METHODOLOGY AND PRINCIPAL FINDINGS: This was a retrospective cohort study on the effectiveness of a 1-day youth injury awareness education program (Prevent Alcohol and Risk-related Trauma in Youth, P.A.R.T.Y.) program in reducing risk taking behaviors and injuries of juvenille justice offenders in Western Australia. Of the 3659 juvenile justice offenders convicted by the court magistrates between 2006 and 2010, 225 were referred to the P.A.R.T.Y. education program. In a before and after survey of these 225 participants, a significant proportion of them stated that they were more receptive to modifying their risk-taking behavior (21% before vs. 57% after). Using data from the Western Australia Police and Department of Health, the incidence of subsequent offences and injuries of all juvenile justice offenders was assessed. The incidence of subsequent traffic or violence-related offences was significantly lower for those who had attended the program compared to those who did not (3.6% vs. 26.8%; absolute risk reduction [ARR] = 23.2%, 95% confidence interval [CI] 19.9%-25.8%; number needed to benefit = 4.3, 95%CI 3.9-5.1; p = 0.001), as were injuries leading to hospitalization (0% vs. 1.6% including 0.2% fatality; ARR = 1.6%, 95%CI 1.2%-2.1%) and alcohol or drug-related offences (0% vs. 2.4%; ARR 2.4%, 95%CI 1.9%-2.9%). In the multivariate analysis, only P.A.R.T.Y. education program attendance (odds ratio [OR] 0.10, 95%CI 0.05-0.21) and a higher socioeconomic background (OR 0.97 per decile increment in Index of Relative Socioeconomic Advantage and Disadvantage, 95%CI 0.93-0.99) were associated with a lower risk of subsequent traffic or violence-related offences. SIGNIFICANCE: Participation in an injury education program involving real-life trauma scenarios was associated with a reduced subsequent risk of committing violence- or traffic-related offences, injuries, and death for juvenille justice offenders.

Major trauma deaths at Perth secondary hospitals.

OBJECTIVE: Some major trauma (Injury Severity Score [ISS] >15) patients transported to a secondary hospital in Perth do not survive. We sought to describe this cohort and assess preventability. METHODS: A cohort study from a previously developed cohort of trauma deaths in Western Australia from 1 July 1997 to 30 June 2006. A preformatted data sheet was used to collect a range of descriptive, time, physiological, and autopsy data. Trauma scores were calculated. Preventability was assessed using three approaches, based on ISS, Trauma Revised Injury Severity Score (TRISS) and individual case review. RESULTS: There were 74 major trauma deaths, mean age 55.6 ± 26.3 years (range 3-95). Thirty-seven (50%) were motor vehicle crashes. The mean Revised Trauma Score was 3.84 ± 3.09 (0-7.84), median ISS 31 (interquartile range [IQR] 25-51), median TRISS 0.127 (IQR 0.031-0.772) and median time to death was 80 min (IQR 20 min-10 h 8 min). Severe head and chest injuries were the most common. Almost half (36, 48.6%) were receiving CPR on arrival to the hospital. The crude proportion of potentially preventable deaths, based on ISS, TRISS and case review, were 16.2%, 32.4% and 6.7%, respectively. However, these were predominantly elderly patients and a decision against resuscitation was recorded in 54%. CONCLUSIONS: The proportion of potentially preventable major trauma deaths at Perth secondary hospitals is low. The most notable group were the elderly after falls, and trauma system efforts should be focused on this group. Primary prevention of major trauma represents the biggest opportunity for improvements in trauma survival.

Extracranial injuries are important in determining mortality of neurotrauma.

OBJECTIVE: This study aimed to assess the significance of extracranial injuries, as measured by Injury Severity Score, on 6-mo and 9-yr mortality of neurotrauma. DESIGN: Retrospective linked data cohort study. SETTING: A major neurotrauma center in Western Australia. PATIENTS: Six hundred eighty-three adult neurotrauma patients. MEASUREMENTS AND MAIN RESULTS: Data were first used to validate the largest published international neurotrauma "extended" mortality prognostic model, in which extracranial injuries are considered significant if the patient has hypoxemia or hypotension on admission. Logistic and Cox regression, incorporating bootstrap techniques to adjust for overfitting, were used to assess the significance of Injury Severity Score in determining 6-mo and 9-yr mortality, respectively. Among a total of 683 patients admitted between 1994 and 2002, 636 (93.1%) had extracranial injuries. The international neurotrauma "extended" mortality prognostic model was poorly calibrated and underestimated the observed mortality (slope and intercept of the calibration curve were 2.14 and 0.35, respectively) when applied to our patients. Incorporating Injury Severity Score into the model improved its calibration. Injury Severity Score accounted for 11% of the variability and was the third most important factor after Marshall computed tomographic grading (17.8%) and pupil reactivity (14.5%) in determining 6-mo mortality. There was a notable increase in mortality between 6-mo (19.2%) and 24-mo follow-up (25.8%). Injury Severity Score remained important and accounted for 9.2% of the variability in determining 9-yr mortality after the injury. CONCLUSIONS: Hypotension and hypoxemia on admission were inadequate markers of extracranial injuries; incorporating more comprehensive extracranial injury assessment by the Injury Severity Score to the standard neurologic prognostic factors improved the accuracy of predictions on mortality after neurotrauma.