Exploring community mental health service use following hospital-treated intentional self-harm among older Australians: a survival analysis.

OBJECTIVES: This study aimed to examine the impact of community mental health (CMH) care following index hospital-treated intentional self-harm (ISH) on all-cause mortality. A secondary aim was to describe patterns of CMH care surrounding index hospital-treated ISH. DESIGN: A longitudinal whole-of-population record linkage study was conducted (2014-2019), with index ISH hospitalization (Emergency Department and/or hospital admissions) linked to all available hospital, deaths/cause of death, and CMH data. SETTING: Australia's most populous state, New South Wales (NSW) comprised approximately 7.7 million people during the study period. CMH services are provided statewide, to assess and treat non-admitted patients, including post-discharge review. PARTICIPANTS: Individuals with an index hospital presentation in NSW of ISH during the study period, aged 45 years or older. INTERVENTION: CMH care within 14 days from index, versus not. MEASUREMENTS: Cox-proportionate hazards regression analysis evaluated all-cause mortality risk, adjusted for relevant covariates. RESULTS: Totally, 24,544 persons aged 45 years or older experienced a nonfatal hospital-treated ISH diagnosis between 2014 and 2019. CMH care was received by 56% within 14 days from index. Survival analysis demonstrated this was associated with 34% lower risk of death, adjusted for age, sex, marital status, index diagnosis, and 14-day hospital readmission (HR 0.66, 95% CI 0.58, 0.74, p < 0.001). Older males and chronic injury conveyed significantly greater risk of death overall. CONCLUSIONS: CMH care within 14 days of index presentation for self-harm may reduce the risk of all-cause mortality. Greater effort is needed to engage older males presenting for self-harm in ongoing community mental health care.

Playground injury prevention: the need for consistent and national implementation of Australian safety standards.

OBJECTIVES: Hospitalisation rates for injury, including at playgrounds, have not changed in the past decade. There are nine Australian Standards specific to playgrounds. The impact (if any) of these standards on playground injury resulting in hospitalisation is unknown. METHODS: Retrospective data for patients under 18 years presenting to emergency departments and/or admitted between October 2015 and December 2019 due to an injury documented as occurring at a playground were retrieved by the Illawarra Shoalhaven Local Health District Planning, Information and Performance Department. Maintenance and Australian Standard (AS) compliance data for the 401 local playgrounds were requested from the four Local Governments in Illawarra Shoalhaven Local Health District. Descriptive statistics were used. RESULTS: A total of 548 children were treated in emergency departments and/or admitted following playground injury. There was an overall increase of 39.3% in playground injury across the study period, and expenditure rose from $43,478 in 2011 to $367,259 in 2019 (a 744.7% increase). CONCLUSIONS: Playground injury has not decreased in the Illawarra Shoalhaven. Data regarding maintenance and AS compliance are lacking. This is not unique to our region. IMPLICATIONS FOR PUBLIC HEALTH: Without a national approach to adequately resource and monitor playground injury, it is not possible to assess the impact of Australian Standards or any injury prevention program.

A Public Health Review into Two Decades of Domestic Trampoline Injuries in Children within Queensland, Australia.

Trampolining as an activity brings enjoyment and many health benefits, but at the same time it carries an injury risk. Most domestic trampoline users are children who are developing in skill, cognition, risk perception, physical strength and resilience to injury. Several common patterns of child trampoline injuries have been identified and countermeasures outlined in standards have been taken to reduce higher risk injury mechanisms, such as entrapment and falls from the trampoline through design, product and point of sale labelling. In Australia, the first national trampoline standard was published in 2003 which introduced improvements in trampoline design and requirements for labelling and padding. This work investigated the potential impact of these and subsequent changes based on almost two decades of emergency department trampoline injury data collected in Queensland, Australia. These data describe the changing representative proportion and pattern of trampoline injuries in Queensland over time by age, mechanism, gender, severity and nature of injury of injured persons up to the age of 14 years. The interrelationships between different injury characteristics were also analysed to propose the main factors influencing injury occurrence and severity. These findings seem to indicate that safety evolution in the form of enclosure nets, frame impact attenuation and entrapment protection have likely improved domestic trampoline safety. Other factors, such as adult supervision, minimum age and avoidance of multiple users, could further reduce injury but are harder to influence in the domestic setting.

Exploring Sociodemographic Correlates of Suicide Stigma in Australia: Baseline Cross-Sectional Survey Findings from the Life-Span Suicide Prevention Trial Studies.

The risk of suicidal behaviour in Australia varies by age, sex, sexual preference and Indigenous status. Suicide stigma is known to affect suicide rates and help-seeking for suicidal crises. The aim of this study was to investigate the sociodemographic correlates of suicide stigma to assist in prevention efforts. We surveyed community members and individuals who had attended specific emergency departments for suicidal crisis. The respondents were part of a large-scale suicide prevention trial in New South Wales, Australia. The data collected included demographic characteristics, measures of help-seeking and suicide stigma. The linear regression analyses conducted sought to identify the factors associated with suicide stigma. The 5426 participants were predominantly female (71.4%) with a mean (SD) age of 41.7 (14.8) years, and 3.9% were Indigenous. Around one-third of participants reported a previous suicide attempt (n = 1690, 31.5%) with two-thirds (n = 3545, 65.3%) seeking help for suicidal crisis in the past year. Higher stigma scores were associated with Indigenous status (ß 0.123, 95%CI 0.074-0.172), male sex (ß 0.527, 95%CI 0.375-0.626) and regional residence (ß 0.079, 95%CI 0.015-0.143). Lower stigma scores were associated with younger age (ß -0.002, 95%CI -0.004--0.001), mental illness (ß -0.095, 95%CI -0.139 to -0.050), male bisexuality (ß -0.202, 95%CI -0.351 to -0.052) and males who glorified suicide (ß -0.075, 95%CI -0.119 to -0.031). These results suggested that suicide stigma differed across the community, varying significantly by sex, sexual orientation and Indigenous status. Targeted educational programs to address suicide stigma could assist in suicide prevention efforts.

Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review.

BACKGROUND: Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI. OBJECTIVE: To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS: A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis. RESULTS: After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review. CONCLUSIONS: Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

Intentions and willingness to engage in risky driving behaviour among high school adolescents: evaluating the bstreetsmart road safety programme.

OBJECTIVE: To investigate the impact of a road safety programme on adolescents' willingness to engage in risky behaviour as probationary drivers, adjusted for covariates of interest. METHOD: The bstreetsmart is a road safety programme delivered to around 25 000 adolescent students annually in New South Wales. Using a smartphone-based app, student and teacher participation incentives, students were surveyed before and after programme attendance. Mixed-methods linear regression analysed pre/post-modified Behaviour of Young Novice Driver (BYNDS_M) scores. RESULTS: 2360 and 1260 students completed pre-event and post-event surveys, respectively. Post-event BYNDS_M scores were around three points lower than pre-event scores (-2.99, 95% CI -3.418 to -2.466), indicating reduced intention to engage in risky driving behaviours. Covariates associated with higher stated intentions of risky driving were exposure to risky driving as a passenger (1.21, 95% CI 0.622 to 2.011) and identifying as non-binary gender (2.48, 95% CI 1.879 to 4.085), adjusting for other predictors. CONCLUSIONS: Trauma-informed, reality-based injury prevention programmes can be effective in changing short-term stated intentions to engage in risky driving, among a pre-independent driving student population. The adolescent novice driver age group is historically challenging to engage, and injury prevention action must be multipronged to address the many factors influencing their behaviour.

An international survey of the structure and process of care for traumatic spinal cord injury in acute and rehabilitation facilities: lessons learned from a pilot study.

BACKGROUND: To describe the key findings and lessons learned from an international pilot study that surveyed spinal cord injury programs in acute and rehabilitation facilities to understand the status of spinal cord injury care. METHODS: An online survey with two questionnaires, a 74-item for acute care and a 51-item for rehabilitation, was used. A subset of survey items relevant to the themes of specialized care, timeliness, patient-centeredness, and evidence-based care were operationalized as structure or process indicators. Percentages of facilities reporting the structure or process to be present, and percentages of indicators met by each facility were calculated and reported separately for facilities from high-income countries (HIC) and from low and middle-income countries (LMIC) to identify "hard to meet" indicators defined as those met by less than two-thirds of facilities and to describe performance level. RESULTS: A total of 26 acute and 26 rehabilitation facilities from 25 countries participated in the study. The comparison of the facilities based on the country income level revealed three general observations: 1) some indicators were met equally well by both HIC and LMIC, such as 24-hour access to CT scanners in acute care and out-patient services at rehabilitation facilities; 2) some indicators were hard to meet for LMIC but not for HIC, such as having a multidisciplinary team for both acute and rehabilitation settings; and 3) some indicators were hard to meet by both HIC and LMIC, including having peer counselling programs. Variability was also observed for the same indicator between acute and rehabilitation facilities, and a wide range in the total number of indicators met among HIC facilities (acute 59-100%; rehabilitation 36-100%) and among LMIC facilities (acute: 41-82%; rehabilitation: 36-93%) was reported. CONCLUSIONS: Results from this international pilot study found that the participating acute and rehabilitation facilities on average adhered to 74% of the selected indicators, suggesting that the structure and processes to provide ideal traumatic spinal cord injury care were broadly available. Recruiting a representative sample of SCI facilities and incorporating regional attributes in future surveys will be helpful to examine factors affecting adherence to indicators.

Protective Factors against Self-Harm and Suicidality among Australian Indigenous Adolescents: A Strengths-Based Analysis of the Longitudinal Study of Indigenous Children.

Background: Understanding and encouraging social and emotional well-being (SEWB) among Indigenous adolescents is vital in countering the impacts of colonisation and intergenerational trauma. As self-harm and suicidality are considered markers of poor SEWB among Indigenous communities, we aimed to identify the individual-level and community-level factors protecting Indigenous adolescents from self-harm and suicidality. Methods: Data came from Footprints in Time­The Longitudinal Study of Indigenous Children (waves 10 and 11), conducted among Indigenous families across Australia. A strengths-based analysis fitted multilevel logistic regression to explore associations with factors proposed as protective against self-reported self-harm and suicidality among Indigenous adolescents. Results: Our study cohort included 365 adolescents with complete data for the variables of interest. Adolescents had a mean (SD) age of 14.04 (0.45) years and a sex ratio of almost 1:1, and most were attending school (96.2%). Previous self-harm was reported by 8.2% (n = 30); previous suicidality was reported by 4.1% (n = 15). Individual-level factors protecting against self-harm and suicidality were being male, living in a cohesive family, and having low total Strengths and Difficulty Questionnaire scores (p < 0.05 for all). Residing in major cities compared with regional/remote areas was protective against self-harm (OR 5.94, 95% CI 1.31−26.81). Strong cultural identity was not found to be a protective factor against self-harm and/or suicidality in the sample. Conclusions: This study identified key individual- and community-level factors that can protect Australian Indigenous adolescents against self-harm and suicidality, particularly family cohesion. Identifying strengths for this at-risk population can inform prevention strategies, particularly for rural living adolescents with high distress.

Investigation into the Trampoline Dynamic Characteristics and Analysis of Double Bounce Vibrations.

Double bounce is an unusual and potentially very hazardous phenomenon that most trampoline users may have experienced, yet few would have really understood how and why it occurs. This paper provides an in-depth investigation into the double bounce. Firstly, the static and dynamic characteristics of a recreational trampoline are analysed theoretically and verified through experiments. Then, based on the developed trampoline dynamic model, double bounce simulation is conducted with two medicine balls released with different time delays. Through simulation, the process of double bounce is presented in detail, which comprehensively reveals how energy is transferred between users during double bounce. Furthermore, the effect of release time delay on double bounce is also presented. Finally, we conducted an experiment which produced similar results to the simulation and validated the reliability of the trampoline dynamic model and double bounce theoretical analysis.

A Measurement of 'Walking-the-Wall' Dynamics: An Observational Study Using Accelerometry and Sensors to Quantify Risk Associated with Vertical Wall Impact Attenuation in Trampoline Parks.

This study illustrates the application of a tri-axial accelerometer and gyroscope sensor device on a trampolinist performing the walking-the-wall manoeuvre on a high-performance trampoline to determine the performer dynamic conditions. This research found that rigid vertical walls would allow the trampolinist to obtain greater control and retain spatial awareness at greater levels than what is achievable on non-rigid vertical walls. With a non-rigid padded wall, the reaction force from the wall can be considered a variable force that is not constrained, and would not always provide the feedback that the trampolinist needs to maintain the balance with each climb up the wall and fall from height. This research postulates that unattenuated vertical walls are safer than attenuated vertical walls for walking-the-wall manoeuvres within trampoline park facilities. This is because non-rigid walls would provide higher g-force reaction feedback from the wall, which would reduce the trampolinist's control and stability. This was verified by measuring g-force on a horizontal rigid surface versus a non-rigid surface, where the g-force feedback was 27% higher for the non-rigid surface. Control and stability are both critical while performing the complex walking-the-wall manoeuvre. The trampolinist experienced a very high peak g-force, with a maximum g-force of approximately 11.5 g at the bottom of the jump cycle. It was concluded that applying impact attenuation padding to vertical walls used for walking-the-wall and similar activities would increase the likelihood of injury; therefore, padding of these vertical surfaces is not recommended.

Comparison of physical and psychological health outcomes for motorcyclists and other road users after land transport crashes: an inception cohort study.

BACKGROUND: Serious injuries and fatalities among vulnerable road users on two wheeled motorised vehicles have increased across Australia and internationally in the past decade yet fallen for motor vehicle occupants. Almost half of all reported motorcycle injury crashes cause serious injury or death, nearly double that of motor vehicle police-reported crashes. This study explores associations with sociodemographic and pre-injury health characteristics and health outcomes after a road traffic injury; aiming to compare motorcyclists with other road users and inform recovery care. METHODS: An inception cohort study recruited 1854 individuals aged > 17 years, injured following land-transport crashes in New South Wales, Australia (July 2013-November 2016). Interviews conducted at baseline, 6-and 12-months post-injury elicited demographic, socioeconomic, and self-reported health conditions. RESULTS: Primary analysis involved 1854 participants who were recruited at baseline as three distinct road user groups; 628 (33.9%) motorcyclists, 927 (50%) vehicle occupants and 299 (16.1%) bicyclists. At baseline, injury patterns differed significantly between road user groups; motorcyclists were more than twice as likely to sustain lower extremity injury (p < 0.001); to have more severe injury severity scores (p < 0.001) and longer hospital stays versus vs vehicle occupants and bicyclists (< 0.001) across these measures. Injured motorcyclists were predominantly male (88.1%, p < 0.001), were younger on average (38 years) than bicyclists (41.5 years), had lower income and education levels, and poorer pre-injury physical health than other road user groups. Despite these differences, at 12 months post-injury motorcyclists had better physical health (SF12-PCS 2.07 (0.77, 3.36), p = 0.002) and reported lower pain scores (- 0.51 (- 0.83, - 0.2), p < 0.001) than vehicle occupants. Motorcyclists displayed less evidence of psychological distress than vehicle occupants, but more than bicyclists across several measures used. CONCLUSIONS: Road user types differ in important characteristics, including pre-injury health status and recovery after injury. As vulnerable road users experiencing transport crash and considering their higher initial injury severity, the degree of recovery among motorcyclists compared with other user types is remarkable and unexplained. Health and recovery outcomes after land-transport crashes is least favourable among vehicle occupants despite their higher levels of protection in a crash. This information is valuable for targeting early intervention strategies by road user type during the post-crash care phase, to improve long-term recovery.

A Qualitative Analysis of Motivators to Participation in Suicide-Focused Research from a Community-Based Australian Sample.

Suicide prevention strategies internationally appear to be falling short of making a meaningful impact on global suicide deaths. Increasing the rates of general community participation in suicide research may improve knowledge generalisability as it relates to suicidal behaviour and leads to new suicide prevention approaches. This study aims to explore the motivations of a community-based sample to participate in suicide research. A subsample of the Australian general population took part in an online survey which is part of a multilevel suicide prevention trial. The survey concluded with an optional open-text question asking about peoples' motivations for participating in the study; 532 participants left a response to this question. These responses were qualitatively analysed using Thematic Network Analysis. Motivations to participate in suicide research were represented by four global themes: altruism, solve systemic problems, lived experience, and personal benefit. Of these themes, three were focused on the benefit of others, while only the final theme articulated motivation to participate that was self-focused. The impact of suicide is felt throughout the wider community. This new understanding of the motivations of community-based samples to participate in suicide research should be used to increase participation rates and reach people who would not normally contribute their voice to suicide research.

A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study.

BACKGROUND: Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. METHODS: This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. RESULTS: Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. CONCLUSIONS: Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.

Pre-existing mental disorder, clinical profile, inpatient services and costs in people hospitalised following traumatic spinal injury: a whole population record linkage study.

BACKGROUND: Risk of traumatic injury is increased in individuals with mental illness, substance use disorder and dual diagnosis (mental disorders); these conditions will pre-exist among individuals hospitalised with acute traumatic spinal injury (TSI). Although early intervention can improve outcomes for people who experience mental disorders or TSI, the incidence, management and cost of this often complex comorbid health profile is not sufficiently understood. In a whole population cohort of patients hospitalised with acute TSI, we aimed to describe the prevalence of pre-existing mental disorders and compare differences in injury epidemiology, costs and inpatient allied health service access. METHODS: Record linkage study of all hospitalised cases of TSI between June 2013 and June 2016 in New South Wales, Australia. TSI was defined by specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes. Mental disorder status was considered as pre-existing where specific ICD-10-AM codes were recorded in incident admissions. RESULTS: 13 489 individuals sustained acute TSI during this study. 13.11%, 6.06% and 1.82% had pre-existing mental illness, substance use disorder and dual diagnosis, respectively. Individuals with mental disorder were older (p<0.001), more likely to have had a fall or self-harmed (p<0.001), experienced almost twice the length of stay and inpatient complications, and increased injury severity compared with individuals without mental disorder (p<0.001). CONCLUSION: Individuals hospitalised for TSI with pre-existing mental disorder have greater likelihood of increased injury severity and more complex, costly acute care admissions compared with individuals without mental disorder. Care pathway optimisation including prevention of hospital-acquired complications for people with pre-existing mental disorders hospitalised for TSI is warranted.

Gap in funding for specialist hospitals treating patients with traumatic spinal cord injury under an activity-based funding model in New South Wales, Australia.

Objective The aim of this study was to estimate the difference between treatment costs in acute care settings and the level of funding public hospitals would receive under the activity-based funding model. Methods Patients aged ≥16 years who had sustained an incident traumatic spinal cord injury (TSCI) between June 2013 and June 2016 in New South Wales were included in the study. Patients were identified from record-linked health data. Costs were estimated using two approaches: (1) using District Network Return (DNR) data; and (2) based on national weighted activity units (NWAU) assigned to activity-based funding activity. The funding gap in acute care treatment costs for TSCI patients was determined as the difference in cost estimates between the two approaches. Results Over the study period, 534 patients sustained an acute incident TSCI, accounting for 811 acute care hospital separations within index episodes. The total acute care treatment cost was estimated at A$40.5 million and A$29.9 million using the DNR- and NWAU-based methods respectively. The funding gap in total costs was greatest for the specialist spinal cord injury unit (SCIU) colocated with a major trauma service (MTS), at A$4.4 million over the study period. Conclusions The findings of this study suggest a substantial gap in funding for resource-intensive patients with TSCI in specialist hospitals under current DRG-based funding methods. What is known about the topic? DRG-based funding methods underestimate the treatment costs at the hospital level for patients with complex resource-intensive needs. This underestimation of true direct costs can lead to under-resourcing of those hospitals providing specialist services. What does this paper add? This study provides evidence of a difference between true direct costs in acute care settings and the level of funding hospitals would receive if funded according to the National Efficient Price and NWAU for patients with TSCI. The findings provide evidence of a shortfall in the casemix funding to public hospitals under the activity-based funding for resource-intensive care, such as patients with TSCI. Specifically, depending on the classification system, the principal referral hospitals, the SCIU colocated with an MTS and stand-alone SCIU were underfunded, whereas other non-specialist hospitals were overfunded for the acute care treatment of patients with TSCI. What are the implications for practitioners? Although health care financing mechanisms may vary internationally, the results of this study are applicable to other hospital payment systems based on diagnosis-related groups that describe patients of similar clinical characteristics and resource use. Such evidence is believed to be useful in understanding the adequacy of hospital payments and informing payment reform efforts. These findings may have service redesign policy implications and provide evidence for additional loadings for specialist hospitals treating low-volume, resource-intensive patients.

The Nature and Cost of Readmissions after Work-Related Traumatic Spinal Injuries in New South Wales, Australia.

This study aimed to measure the subsequent health and health service cost burden of a cohort of workers hospitalised after sustaining work-related traumatic spinal injuries (TSI) across New South Wales, Australia. A record-linkage study (June 2013-June 2016) of hospitalised cases of work-related spinal injury (ICD10-AM code U73.0 or workers compensation) was conducted. Of the 824 individuals injured during this time, 740 had sufficient follow-up data to analyse readmissions ≤90 days post-acute hospital discharge. Individuals with TSI were predominantly male (86.2%), mean age 46.6 years. Around 8% (n = 61) experienced 119 unplanned readmission episodes within 28 days from discharge, over half with the primary diagnosis being for care involving rehabilitation. Other readmissions involved device complications/infections (7.5%), genitourinary or respiratory infections (10%) or mental health needs (4.3%). The mean ± SD readmission cost was $6946 ± $14,532 per patient. Unplanned readmissions shortly post-discharge for TSI indicate unresolved issues within acute-care, or poor support services organisation in discharge planning. This study offers evidence of unmet needs after acute TSI and can assist trauma care-coordinators' comprehensive assessments of these patients prior to discharge. Improved quantification of the ongoing personal and health service after work-related injury is a vital part of the information needed to improve recovery after major work-related trauma.

Heterogeneous emergency department management of published recommendation defined hypotension in patients with acute traumatic spinal cord injury: A multi-centre overview.

OBJECTIVE: Evidence-based management for patients with acute traumatic spinal cord injury (TSCI) in the ED has a critical impact on long-term outcomes. Acute hypotension post-injury may compromise spinal cord perfusion and extend neurological damage. Published guidelines recommend mean arterial blood pressure (BP) maintenance between 85 and 90 mmHg for 7 days post-injury; the extent to which this is followed in Australia is unknown. METHODS: Prospective observational study of patients ≥16 years with TSCI, treated at 48 hospitals across two Australian states. Mean arterial BPs were recorded in the Ambulance, and ED arrival and discharge. Patients' medical records documented treatment provided (intravenous fluids, vasopressors or both) for BP augmentation. Hypotension was defined as mean arterial BP <85 mmHg, per the American Association of Neurological Surgeons guidelines. RESULTS: The 208 patients with TSCI in the present study were more likely to receive BP augmentation if they experienced direct transport to a Spinal Cord Service hospital (OR 5.57, 95% CI 2.32-10.11), had a cervical level injury (OR 2.32, 95% CI 1.01-5.5) or were hypotensive on ED arrival (OR 2.42, 95% CI 1.34-4.39). Of the 112 patients who were hypotensive, 71 (63.4%) received treatment for this; however, the majority (76%) remained hypotensive on discharge. CONCLUSION: Hypotensive patients' post-TSCI experienced heterogeneous ED care discordant with published guidelines; varying by hospital type. Specialist care and more severe injury increased likelihood of guideline adherence. Lack of adherence may influence patient outcomes. Level 1 evidence is needed along with consistent guideline implementation and clinician training to likely improve TSCI management and outcomes.

Identifying Predictors of Higher Acute Care Costs for Patients With Traumatic Spinal Cord Injury and Modeling Acute Care Pathway Redesign: A Record Linkage Study.

STUDY DESIGN: Record linkage study using healthcare utilization and costs data. OBJECTIVE: To identify predictors of higher acute-care treatment costs and length of stay for patients with traumatic spinal cord injury (TSCI). SUMMARY OF BACKGROUND DATA: There are few current or population-based estimates of acute hospitalization costs, length of stay, and other outcomes for people with TSCI, on which to base future planning for specialist SCI health care services. METHODS: Record linkage study using healthcare utilization and costs data; all patients aged more than or equal to 16 years with incident TSCI in the Australian state of New South Wales (June 2013-June 2016). Generalized Linear Model regression to identify predictors of higher acute care treatment costs for patients with TSCI. Scenario analysis quantified the proportionate cost impacts of patient pathway modification. RESULTS: Five hundred thirty-four incident cases of TSCI (74% male). Total cost of all acute index episodes approximately AUD$40.5 (95% confidence interval [CI] ±4.5) million; median cost per patient was AUD$45,473 (Interquartile Range: $15,535-$94,612). Patient pathways varied; acute care was less costly for patients admitted directly to a specialist spinal cord injury unit (SCIU) compared with indirect transfer within 24 hours. Over half (53%) of all patients experienced at least one complication during acute admission; their care was less costly if they had been admitted directly to SCIU. Scenario analysis demonstrated that a reduction of indirect transfers to SCIU by 10% yielded overall cost savings of AUD$3.1 million; an average per patient saving of AUD$5,861. CONCLUSION: Direct transfer to SCIU for patients with acute TSCI resulted in lower treatment costs, shorter length of stay, and less costly complications. Modeling showed that optimizing patient-care pathways can result in significant acute-care cost savings. Reducing potentially preventable complications would further reduce costs and improve longer-term patient outcomes. LEVEL OF EVIDENCE: 3.