Time to definitive care within major trauma networks in England.

BACKGROUND: Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016. METHODS: An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death. RESULTS: Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001). CONCLUSION: Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.

ANTECEDENTES: Se han demostrado mejoras significativas en la mortalidad tras la implementación de las redes de trauma en Inglaterra. El traslado a tiempo de pacientes con lesiones graves para el tratamiento definitivo es un indicador clave del rendimiento de la red de traumatismos. Este estudio evaluó los plazos de tiempo desde la activación del servicio de emergencia (emergency service,EMS) hasta el tratamiento definitivo entre 2013 y 2016. MÉTODOS: Se realizó un estudio observacional en base a los datos obtenidos de la auditoría clínica nacional del Reino Unido de la atención de traumatismos graves en pacientes con puntuación de gravedad de lesiones superior a 15. Los resultados incluyeron los intervalos de tiempo entre la activación del EMS hasta la llegada a una Unidad de Trauma (Trauma Unit, TU) o a un centro de traumatismos graves (Major Trauma Center, MTC), la práctica de una tomografía computarizada (computerised tomography, CT), la práctica de cirugía de urgencia, y la mortalidad. RESULTADOS: El traslado secundario se asoció con un aumento en el tiempo hasta la cirugía urgente (7,23 h (rango intercuartílico, RIQ 5,48-9,28 versus 4,37 (3,00-6,57), P < 0,001)) y un aumento de la mortalidad cruda (19,6% (i.c. del 95% 16,9-22,3) versus 15,7% (14,7-16,7)). La CT y la cirugía urgente se efectuaron con mayor rapidez en los centros MTC que TU (2,00 h (RIQ 1,55-2,73) versus 3,15 h (RIQ 2,17-4,63) y 4,37 h (RIQ 3,00-6,57) versus 5,37 h (RIQ 3,50-7,65), respectivamente (P < 0,001)). El tiempo de traslado y el tiempo hasta la práctica de la CT aumentaron entre 2013 y 2016 (P < 0,001). El tiempo de traslado, el tiempo hasta la práctica de la CT y el tiempo hasta la práctica de cirugía urgente variaron significativamente entre las redes regionales (P < 0,001). CONCLUSIÓN: El traslado secundario se asoció de forma significativa con el retraso en las imágenes radiológicas, retraso en la cirugía y aumento de la mortalidad. Las intervenciones clave se realizaron más rápidamente en centro MTC que en centros TU.

Variations in the management of adolescents with blunt splenic trauma in England and Wales: are we preserving enough?

INTRODUCTION: Management of blunt splenic injury has changed drastically with non-operative management increasingly used in paediatric and adult patients. Studies from America and Australia demonstrate disparities in care of patients treated at paediatric and adult centres. This study assessed management of splenic injuries in UK adolescents. MATERIALS AND METHODS: Data were acquired from the Trauma Audit and Research Network on isolated blunt splenic injuries reported 2006-2015. Adolescents were divided into age groups of 11-15 years and 16-20 years, and injuries classified as minor (grades 1/2) or major (3+). Primary outcomes were needed for splenectomy and blood transfusion. RESULTS: A total of 445 adolescents suffered isolated blunt splenic injuries. Road traffic collisions were the most common mechanism. There were no deaths as a result of isolated blunt splenic injuries, but 49 (11%) adolescents needed transfusions and 105 (23.6%) underwent splenectomies. There was no significant difference observed in the management of adolescents with minor trauma. In major trauma, 11-15-year-olds were more likely to have splenectomies when managed at local trauma units compared with major trauma centres (31% vs 4%, odds ratio 11.5; 95% confidence interval 3.82-34.38, p < 0.0001). Within major trauma centres, older adolescents were more likely to have splenectomies than younger adolescents (35.5% vs 3.8%, odds ratio 14; 95% confidence interval 4.55-43.26, p < 0.0001). There were no significant differences in haemodynamic status, transfusion requirement or embolisation rates. CONCLUSIONS: There appears to be a large variation in the management of isolated blunt splenic injuries in the UK. The reasons for this remain unclear however non-operative management is safe and should be first line management in the haemodynamically stable adolescent, even with major splenic injuries.

Impact of a physician-led pre-hospital critical care team on outcomes after major trauma.

The deployment of physician-led pre-hospital enhanced care teams capable of critical care interventions at the scene of injury may confer a survival benefit to victims of major trauma. However, the evidence base for this widely adopted model is disputed. Failure to identify a clear survival benefit has been attributed to several factors, including an inherently more severely injured patient group who are attended by these teams. We undertook a novel retrospective analysis of the impact of a regional enhanced care team on observed vs. predicted patient survival based on outcomes recorded by the UK Trauma Audit and Research Network (TARN). The null hypothesis of this study was that attendance of an enhanced care team would make no difference to the number of 'unexpected survivors'. Patients attended by an enhanced care team were more seriously injured. Analysis of Trauma Audit and Research Network patient outcomes did not demonstrate an improved adjusted survival rate for trauma patients who were treated by a physician-led enhanced care team, but confirmed differences in patient characteristics and severity of injury for those who were attended by the team. We conclude that a further prospective multicentre analysis is warranted. An essential prerequisite for this would be to address the current blind spot in the Trauma Audit and Research Network database - patients who die from trauma before ever reaching hospital. We speculate that early on-scene critical care may convert this cohort of invisible trauma deaths into patients who might survive to reach hospital. Routine collection of data from these patients is warranted to include them in future studies.

Comparison of two prognostic models in trauma outcome.

BACKGROUND: The Trauma Audit and Research Network (TARN) in the UK publicly reports hospital performance in the management of trauma. The TARN risk adjustment model uses a fractional polynomial transformation of the Injury Severity Score (ISS) as the measure of anatomical injury severity. The Trauma Mortality Prediction Model (TMPM) is an alternative to ISS; this study compared the anatomical injury components of the TARN model with the TMPM. METHODS: Data from the National Trauma Data Bank for 2011-2015 were analysed. Probability of death was estimated for the TARN fractional polynomial transformation of ISS and compared with the TMPM. The coefficients for each model were estimated using 80 per cent of the data set, selected randomly. The remaining 20 per cent of the data were used for model validation. TMPM and TARN were compared using calibration curves, measures of discrimination (area under receiver operating characteristic curves; AUROC), proximity to the true model (Akaike information criterion; AIC) and goodness of model fit (Hosmer-Lemeshow test). RESULTS: Some 438 058 patient records were analysed. TMPM demonstrated preferable AUROC (0·882 for TMPM versus 0·845 for TARN), AIC (18 204 versus 21 163) and better fit to the data (32·4 versus 153·0) compared with TARN. CONCLUSION: TMPM had greater discrimination, proximity to the true model and goodness-of-fit than the anatomical injury component of TARN. TMPM should be considered for the injury severity measure for the comparative assessment of trauma centres.

Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks.

AIMS: The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS: National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS: A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION: This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.

Improved outcomes for hepatic trauma in England and Wales over a decade of trauma and hepatobiliary surgery centralisation.

BACKGROUND: Over the last decade trauma services have undergone a reconfiguration in England and Wales. The objective is to describe the epidemiology, management and outcomes for liver trauma over this period and examine factors predicting survival. METHODS: Patients sustaining hepatic trauma were identified using the Trauma Audit and Research Network database. Demographics, management and outcomes were assessed between January 2005 and December 2014 and analysed over five, 2-year study periods. Independent predictor variables for the outcome of liver trauma were analysed using multiple logistic regression. RESULTS: 4368 Patients sustained hepatic trauma (with known outcome) between January 2005 and December 2014. Median age was 34 years (interquartile range 23-49). 81% were due to blunt and 19% to penetrating trauma. Road traffic collisions were the main mechanism of injury (58.2%). 241 patients (5.5%) underwent liver-specific surgery. The overall 30-day mortality rate was 16.4%. Improvements were seen in early consultant input, frequency and timing of computed tomography (CT) scanning, use of tranexamic acid and 30-day mortality over the five time periods. Being treated in a unit with an on-site HPB service increased the odds of survival (odds ratio 3.5, 95% confidence intervals 2.7-4.5). CONCLUSIONS: Our study has shown that being treated in a unit with an on-site HPB service increased the odds of survival. Further evaluation of the benefits of trauma and HPB surgery centralisation is warranted.

The impact of age on major orthopaedic trauma: an analysis of the United Kingdom Trauma Audit Research Network database.

AIMS: To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries. PATIENTS AND METHODS: The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients. RESULTS: Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures. CONCLUSION: Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. Cite this article: Bone Joint J 2017;99-B:1677-80.

A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes?

INTRODUCTION The spleen remains one of the most frequently injured organs following blunt abdominal trauma. In 2012, regional trauma networks were launched across England and Wales with the aim of improving outcomes following trauma. This retrospective cohort study investigated the management and outcomes of blunt splenic injuries before and after the establishment of regional trauma networks. METHODS A dataset was drawn from the Trauma Audit Research Network database of all splenic injuries admitted to English and Welsh hospitals from 1 April 2010 to 31 March 2014. Demographic data, injury severity, treatment modalities and outcomes were collected. Management and outcomes were compared before and after the launch of regional trauma networks. RESULTS There were 1457 blunt splenic injuries: 575 between 2010 and 2012 and 882 in 2012-14. Following the introduction of the regional trauma networks, use of splenic artery embolotherapy increased from 3.5% to 7.6% (P = 0.001) and splenectomy rates decreased from 20% to 14.85% (P = 0.012). Significantly more patients with polytrauma and blunt splenic injury were treated with splenic embolotherapy following 2012 (61.2% vs. 30%, P < 0.0001). Increasing age, injury severity score, polytrauma and Charlson Comorbidity Index above 10 were predictors of increased mortality (P < 0.001). Increasing systolic blood pressure (odds ratio, OR, 0.757, 95% confidence interval, CI, 0.716-0.8) and Glasgow Coma Scale (OR 0.988, 95% CI 0.982-0.995) were protective. CONCLUSIONS This study demonstrates a reduction in splenectomy rate and an increased use of splenic artery embolotherapy since the introduction of the regional trauma networks. This may have resulted from improved access to specialist services and reduced practice variation since the establishment of these networks.

Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality.

OBJECTIVES: To provide a comprehensive assessment of the management of traumatic brain injury (TBI) relating to epidemiology, complications and standardised mortality across specialist units. DESIGN: The Trauma Audit and Research Network collects data prospectively on patients suffering trauma across England and Wales. We analysed all data collected on patients with TBI between April 2014 and June 2015. SETTING: Data were collected on patients presenting to emergency departments across 187 hospitals including 26 with specialist neurosurgical services, incorporating factors previously identified in the Ps14 multivariate logistic regression (Ps14n) model multivariate TBI outcome prediction model. The frequency and timing of secondary transfer to neurosurgical centres was assessed. RESULTS: We identified 15 820 patients with TBI presenting to neurosurgical centres directly (6258), transferred from a district hospital to a neurosurgical centre (3682) and remaining in a district general hospital (5880). The commonest mechanisms of injury were falls in the elderly and road traffic collisions in the young, which were more likely to present in coma. In severe TBI (Glasgow Coma Score (GCS) ≤8), the median time from admission to imaging with CT scan is 0.5 hours. Median time to craniotomy from admission is 2.6 hours and median time to intracranial pressure monitoring is 3 hours. The most frequently documented complication of severe TBI is bronchopneumonia in 5% of patients. Risk-adjusted W scores derived from the Ps14n model indicate that no neurosurgical unit fell outside the 3 SD limits on a funnel plot. CONCLUSIONS: We provide the first comprehensive report of the management of TBI in England and Wales, including data from all neurosurgical units. These data provide transparency and suggests equity of access to high-quality TBI management provided in England and Wales.

Regionalisation of trauma care in England.

AIMS: We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England. PATIENTS AND METHODS: An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital. RESULTS AND CONCLUSION: A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

Older patients with traumatic brain injury present with a higher GCS score than younger patients for a given severity of injury.

INTRODUCTION: Recent evidence suggests that presenting GCS may be higher in older rather than younger patients for an equivalent anatomical severity of traumatic brain injury (TBI). The aim of this study was to confirm these observations using a national trauma database and to test explanatory hypotheses. METHODS: The Trauma Audit Research Network database was interrogated to identify all adult cases of severe isolated TBI from 1988 to 2013. Cases were categorised by age into those under 65 years and those 65 years and older. Median presenting GCS was compared between the groups at abbreviated injury score (AIS) level (3, 4 and 5). Comparisons were repeated for subgroups defined by mechanism of injury and type of isolated intracranial injury. RESULTS: 25 082 patients with isolated TBI met the inclusion criteria, 10 936 in the older group and 14 146 in the younger group. Median or distribution of presenting GCS differed between groups at each AIS level. AIS 3: 14 (11-15) vs 15 (13-15), AIS 4: 14 (9-15) vs 14 (13-15), AIS 5: 9 (4-14) vs 14 (5-15) all p<0.001. Similar differences between the groups were observed across all mechanisms of injury and types of isolated intracranial injury. We detected no influence of gender on results. CONCLUSIONS: For an equivalent severity of intracranial injury, presenting GCS is higher in older patients than in the young. This observation is unlikely to be explained by differences in mechanism of injury or types of intracranial injury between the two groups.

The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989-2013.

INTRODUCTION: Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989-2013. METHODS: The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both. RESULTS: Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14-35) for blunt trauma and 14 (IQR: 9-18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation. CONCLUSIONS: Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.

Trauma scoring systems and databases.

This review considers current trauma scoring systems and databases and their relevance to improving patient care. Single physiological measures such as systolic arterial pressure have limited ability to diagnose severe trauma by reflecting raised intracranial pressure, or significant haemorrhage. The Glasgow coma score has the greatest prognostic value in head-injured and other trauma patients. Trauma triage tools and imaging decision rules-using combinations of physiological cut-off measures with mechanism of injury and other categorical variables-bring both increased sophistication and increased complexity. It is important for clinicians and managers to be aware of the diagnostic properties (over- and under-triage rates) of any triage tool or decision rule used in their trauma system. Trauma registries are able to collate definitive injury descriptors and use survival prediction models to guide trauma system governance, through individual patient review and case-mix-adjusted benchmarking of hospital and network performance with robust outlier identification. Interrupted time series allow observation in the changes in care processes and outcomes at national level, which can feed back into clinical quality-based commissioning of healthcare. Registry data are also a valuable resource for trauma epidemiological and comparative effectiveness research studies.

Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres.

BACKGROUND: Centralization of complex healthcare services into specialist high-volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients. METHODS: A retrospective before-after study was undertaken of severely injured patients attending four hospitals that became major trauma centres (MTCs) in March 2012. Consecutive patients with major trauma were identified from a national registry and divided into two groups according to injury before or after the launch of a new trauma network. The two cohorts were compared for differences in case mix, demand on hospital resources, and outcomes. RESULTS: Patient volume increased from 442 to 1326 (200 per cent), operations from 349 to 1231 (253 per cent), critical care bed-days from 1100 to 3704 (237 per cent), and total hospital bed-days from 7910 to 22,772 (188 per cent). Patient age increased on MTC designation from 45.0 years before March 2012 to 48.2 years afterwards (P = 0.021), as did the proportion of penetrating injuries (1.8 versus 4.1 per cent; P = 0.025). Injury severity fell as measured by median Injury Severity Score (16 versus 14) and Revised Trauma Score (4.1 versus 7.8). Fewer patients required secondary transfer to a MTC from peripheral hospitals (19.9 versus 16.1 per cent; P = 0.100). There were no significant differences in total duration of hospital stay, critical care requirements or mortality. However, there was a significant increase, from 55.5 to 62.3 per cent (P < 0.001), in the proportion of patients coded as having a 'good recovery' at discharge after institution of the trauma network. CONCLUSION: MTC designation leads to an increased case volume with considerable implications for operating theatre capacity and bed occupancy. Although no mortality benefit was demonstrated within 6 months of establishing this trauma network, early detectable advantages included improved functional outcome at discharge.

Epidemiology of in-hospital trauma deaths.

PURPOSE: About half of all trauma-related deaths occur after hospital admission. The present study tries to characterize trauma deaths according to the time of death, and, thereby, contributes to the discussion about factors considered as the cause of death. METHODS: Data from two large European trauma registries (Trauma Registry of the German Society of Trauma Surgery, TR-DGU, and the Trauma Audit and Research Network, TARN) were analyzed in parallel. All hospital deaths with Injury Severity Score (ISS) > 9 documented between 2000 and 2010 were considered. Patients were categorized into five subgroups according to the time to death (0-6 h; 7-24 h; day 1-6; day 7-30; beyond day 30). Surviving patients from the same time period served as a control group. RESULTS: In total, 6,685 and 6,867 non-survivors were included from the TR-DGU and TARN, respectively. The hospital mortality rate was between 15 and 17%. About half of all deaths occurred within the first 24 h after admission (TR-DGU: 54%; TARN: 45%). The earliest subgroup of trauma deaths showed the highest mean ISS and the highest rate of mass transfusions. Severe head injury was most frequently observed in the subgroup of day 1-6. Late deaths are associated with higher age and more complications (sepsis, multiple organ failure). CONCLUSIONS: The time to death after severe trauma does not follow a trimodal distribution but shows a constantly decreasing incidence.

Prognostic value of various intracranial pathologies in traumatic brain injury.

OBJECTIVE: Various intracranial pathologies in traumatic brain injury (TBI) can help to predict patient outcomes. These pathologies can be categorised using the Marshall Classification or the Abbreviated Injury Scale (AIS) dictionary or can be described through traditional descriptive terms such as subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural haemorrhage (EDH) etc. The purpose of this study is to assess the prognostic value of AIS scores, the Marshall Classification and various intracranial pathologies in TBI. METHODS: A dataset of 802 TBI patients in the Trauma Audit and Research Network (TARN) database was analysed using logistic regression. First, a baseline model was constructed with age, Glasgow Coma Scale (GCS), pupillary reactivity, cause of injury and presence/absence of extracranial injury as predictors and survival at discharge as the outcome. Subsequently, AIS score, the Marshall Classification and various intracranial pathologies such as haemorrhage, SAH or brain swelling were added in order to assess the relative predictive strength of each variable and also to assess the improvement in the performance of the model. RESULTS: Various AIS scores or Marshal classes did not appear to significantly affect the outcome. Among traditional descriptive terms, only brain stem injury and brain swelling significantly influenced outcome [odds ratios for survival: 0.17 (95% confidence interval [CI]; 0.08-0.40) and 0.48 (95% CI; 0.29-0.80), respectively]. Neither haemorrhage nor its subtypes, such as SAH, SDH and EDH, were significantly associated with outcome. Adding AIS scores, the Marshall Classification and various intracranial pathologies to the prognostic models resulted in an almost equal increase in the predictive performance of the baseline model. CONCLUSIONS: In this relatively recent dataset, each of the brain injury classification systems enhanced equally the performance of an early mortality prediction model in traumatic brain injury patients. The significant effect of brain swelling and brain stem injury on the outcome in comparison to injuries such as SAH suggests the need to improve therapeutic approaches to patients who have sustained these injuries.

Temporal trends in head injury outcomes from 2003 to 2009 in England and Wales.

BACKGROUND: Case fatality rates after blunt head injury (HI) did not improve in England and Wales between 1994 and 2003. The United Kingdom National Institute of Clinical Excellence subsequently published HI management guidelines, including the recommendation that patients with severe head injuries (SHIs) should be treated in specialist neuroscience units (NSU). The aim of this study was to investigate trends in case fatality and location of care since the introduction of national HI clinical guidelines. METHODS: We conducted a retrospective cohort study using prospectively recorded data from the Trauma and Audit Research Network (TARN) database for patients presenting with blunt trauma between 2003 and 2009. Temporal trends in log odds of death adjusted for case mix were examined for patients with and without HI. Location of care for patients with SHI was also studied by examining trends in the proportion of patients treated in non-NSUs. RESULTS: Since 2003, there was an average 12% reduction in adjusted log odds of death per annum in patients with HI (n=15,173), with a similar but smaller trend in non-HI trauma mortality (n=48,681). During the study period, the proportion of patients with HI treated entirely in non-NSUs decreased from 31% to 19%, (p <0.01). INTERPRETATION: The reduction in odds of death following HI since 2003 is consistent with improved management following the introduction of national HI guidelines and increased treatment of SHI in NSUs.

Vital signs and estimated blood loss in patients with major trauma: testing the validity of the ATLS classification of hypovolaemic shock.

AIM: The Advanced Trauma Life Support (ATLS) system classifies the severity of shock. The aim of this study is to test the validity of this classification. METHODS: Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. For each patient, the blood loss was estimated and patients were divided into four groups based on the estimated blood loss corresponding to the ATLS classes of shock. The median and interquartile ranges (IQR) of the heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS) were calculated for each group. RESULTS: The median HR rose from 82 beats per minute (BPM) in estimated class 1 shock to 95 BPM in estimated class 4 shock. The median SBP fell from 135 mm Hg to 120 mm Hg. There was no significant change in RR or GCS. CONCLUSION: With increasing estimated blood loss there is a trend to increasing heart rate and a reduction in SBP but not to the degree suggested by the ATLS classification of shock.

Testing the validity of the ATLS classification of hypovolaemic shock.

AIM: The Advanced Trauma Life Support system classifies the severity of shock. The aim of this study is to test the validity of this classification. METHODS: Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. Patients were divided into groups representing the four ATLS classes of shock, based on heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS). The relationships between variables were examined by classifying the cohort by each recorded variable in turn and deriving the median and interquartile range (IQR) of the remaining three variables. Patients with penetrating trauma and major injuries were examined in sub-group analyses. RESULTS: In blunt trauma patients grouped by HR, the median SBP decreased from 128 mmHg in patients with HR<100 BPM to 114 mmHg in those with HR>140 BPM. The median RR increased from 18 to 22 bpm and the GCS reduced from 15 to 14. The median HR in hypotensive patients was 88 BPM compared to 83 BPM in normotensive patients and the RR was the same. When grouped by RR, the HR increased with increasing RR but there were no changes in SBP. CONCLUSION: In trauma patients there is an inter-relationship between derangements of HR, SBP, RR and GCS but not to the same degree as that suggested by the ATLS classification of shock.

A major trauma centre is a specialty hospital not a hospital of specialties.

BACKGROUND: High estimates of preventable death rates have renewed the impetus for national regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance improvement programme was hypothesized to have resulted in improved outcomes for severely injured patients. METHODS: This was a comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma Audit and Research Network (England and Wales), 2000-2005. Preventable mortality was evaluated by prospective analysis of the RLH performance improvement programme. RESULTS: Mortality from critical injury at the RLH was 48 per cent lower in 2005 than 2000 (17.9 versus 34.2 per cent; P = 0.001). Overall mortality rates were unchanged for acute hospitals (4.3 versus 4.4 per cent) and other multispecialty hospitals (8.7 versus 7.3 per cent). Secondary transfer mortality in critically injured patients was 53 per cent lower in the regional network than the national average (5.2 versus 11.0 per cent; P = 0.001). Preventable death rates fell from 9 to 2 per cent (P = 0.040) and significant gains were made in critical care and ward bed utilization. CONCLUSION: Institution of a specialist trauma service and performance improvement programme was associated with significant improvements in outcomes that exceeded national variations.