Early predictors of health-related quality of life outcomes at 12 months post-burn: ABLE study.

There remains a paucity of evidence on the early predictors of long-term Health-Related Quality of Life (HRQoL) outcomes post-burn in hospitalised adults. The overall aim of this study was to identify the factors (personal, environmental, burn injury and burn treatment factors) that may predict long-term HRQoL outcomes among adult survivors of hospitalised burn injuries at 12 months post-burn. A total of 274 participants, aged 18 years or over, admitted to a single state-wide burn centre with a burn injury were recruited. Injury and burn treatment information were collected from medical records or the hospital database and surveys collected demographic and social data. HRQoL outcome data were collected at 3-, 6- and 12-months using the 12-Item Short Form Survey (SF-12 v1) and Burns Specific Health Scale-Brief (BSHS-B). Personal, environmental, burn injury and burn treatment factors were also recorded at baseline. Analyses were performed using linear and logistic regression. Among 274 participants, 71.5 % (N=196) remained enrolled in the study at 12 months post-burn. The majority of participants reported HRQoL outcomes comparable with population norms and statistically significant improvements in generic (SF-12 v1) and condition-specific (BSHS-B) outcomes over time. However, for participants with poor HRQoL outcomes at 12-months post-burn, Univariable predictors included longer hospital length of stay, unemployment at the time of injury, a diagnosed pre-injury mental health condition, inadequate pre-burn social support, intentional injury, recreational drug use pre-injury and female gender. The early multivariable predictors of insufficient HRQoL outcomes were female gender, a previously diagnosed mental health condition, unemployment, inadequate social support, intentional injury, and prolonged hospital length of stay. These results suggest potential factors that could be used to screen and burns patients for psychosocial intervention and long-term follow up.

Reinforcing informed medication prescription for low back pain in the emergency department (RIME): a controlled interrupted time series implementation study protocol.

INTRODUCTION: Management guidelines for low back pain (LBP) recommend exclusion of serious pathology, followed by simple analgesics, superficial heat therapy, early mobilisation and patient education. An audit in a large metropolitan hospital emergency department (ED) revealed high rates of non-recommended medication prescription for LBP (65% of patients prescribed opioids, 17% prescribed benzodiazepines), high inpatient admission rates (20% of ED LBP patients), delayed patient mobilisation (on average 6 hours) and inadequate patient education (48% of patients). This study aims to improve medication prescription for LBP in this ED by implementing an intervention shown previously to improve guideline-based management of LBP in other Australian EDs. METHODS AND ANALYSIS: A controlled interrupted time series study will evaluate the intervention in the ED before (24 weeks; 20 March 2023-3 September 2023) and after (24 weeks; 27 November 2024-12 May 2024) implementation (12 weeks; 4 September 2023-26 November 2023), additionally comparing findings with another ED in the same health service. The multicomponent implementation strategy uses a formalised clinical flow chart to support clinical decision-making and aims to change clinician behaviour, through clinician education, provision of alternative treatments, educational resources, audit and feedback, supported by implementation champions. The primary outcome is the percentage of LBP patients prescribed non-recommended medications (opioids, benzodiazepines and/or gabapentinoids), assessed via routinely collected ED data. Anticipated sample size is 2000 patients (n=1000 intervention, n=1000 control) based on average monthly admissions of LBP presentations in the EDs. Secondary outcomes include inpatient admission rate, time to mobilisation, provision of patient education, imaging requests, representation to the ED within 6 months and healthcare costs. In nested qualitative research, we will study ED clinicians' perceptions of the implementation and identify how benefits can be sustained over time. ETHICS AND DISSEMINATION: This study received ethical approval from the Metro North Human Research Ethics Committee (HREC/2022/MNHA/87995). Study findings will be published in peer-reviewed journals and presented at international conferences and educational workshops. TRIAL REGISTRATION NUMBER: ACTRN12622001536752.

A population-based epidemiological and health economic analysis of fracture-related infection.

Aims: The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods: This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results: There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion: The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies.

Factors associated with higher alcohol concentrations in emergency department presentations: PACE study.

INTRODUCTION: The health impact from alcohol is of recognised concern, from acute intoxication as well as increased risk of chronic health issues over time. Identifying factors associated with higher alcohol consumption when presenting to the emergency department (ED) will inform public health policy and enable more targeted health care and appropriate referrals. METHODS: Secondary testing of blood samples collected during routine clinical care of 1160 ED patients presenting to the Royal Brisbane and Women's Hospital in Queensland, Australia, for 10 days between 22 January and 1 February 2021. Alcohol was measured by blood ethanol (intake in recent hours) and phosphatidylethanol (PEth; intake over 2-4 weeks). Zero-inflated negative binomial regression was used to identify demographic and clinical factors associated with higher alcohol concentrations. RESULTS: Males were found to have 83% higher blood ethanol and 32% higher PEth concentrations than females (adjusted rate ratio [ARR] 1.83, 95% confidence interval [CI] 1.37-2.45 and ARR 1.32, 95% CI 1.04-1.68, respectively). Blood ethanol concentrations were 3.4 times higher for those 18-44 years, compared to those aged 65+ (ARR 3.40, 95% CI 2.40-4.82) whereas PEth concentrations were found to be the highest in those aged 45-64 years, being 70% higher than those aged 65+ (ARR 1.70, 95% CI 1.19-2.44). Patients brought in involuntarily had eight-times higher blood ethanol concentrations than those who self-attended. DISCUSSION AND CONCLUSIONS: This study used two alcohol markers to identify factors associated with higher alcohol concentrations in emergency presentations. The findings demonstrate how these biomarkers can provide informative data for public health responses and monitoring of alcohol use trends.

The epidemiology of sports and leisure-related injury hospitalisations in Queensland: A five-year review.

OBJECTIVE: To describe the epidemiology of sports and leisure-related injury hospitalisations in Queensland DESIGN, SETTING, AND PATIENTS: Retrospective analysis of routinely collected hospital admissions data from all Queensland hospitals (public and private) between 2012 and 2016 for injury-related admissions where the activity engaged in when injured was coded as sports or leisure activity. MAIN OUTCOME MEASURES: Number of hospitalisations; rate of hospitalisation per 100,000 population and demographic, injury, treatment, and outcome details of hospitalised injury patients. RESULTS: Between 01 January 2012 and 31 December 2016, 76,982 people were hospitalised for a sports or leisure-related injury in Queensland. More people were hospitalised in public hospitals than private. Rates were highest for those under 14 years (601.5/100,000 population) and were higher in males (130.6/100,000 population) than females (28.9/100,000 population). A total of 18,734 injuries (24.3%; 79.5/100,000 population) were sustained while playing team ball sports, with rugby codes (rugby union, rugby league and rugby unspecified) representing the single largest source of injuries with 6,592. The extremities were the most likely body location of injury (46,644; 198/100,000 population), and the most common injury type was a fracture (35,018; 148.6/100,000 population). CONCLUSIONS: The findings highlight the significant burden of sport and leisure-related injury hospitalisations in Queensland. This information is important for injury prevention and trauma system planning.

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.

Understanding compensable and non-compensable patient profiles, pathways and physical outcomes for transport and work-related injuries in Queensland, Australia through data linkage.

INTRODUCTION: In many jurisdictions, people experiencing an injury often pursue compensation to support their treatment and recovery expenses. Healthcare costs form a significant portion of payments made by compensation schemes. Compensation scheme regulators need accurate and comprehensive data on injury severity, treatment pathways and outcomes to enable scheme modelling, monitoring and forecasting. Regulators routinely rely on data provided by insurers which have limited healthcare information. Health data provide richer information and linking health data with compensation data enables the comparison of profiles, patterns, trends and outcomes of injured patients who claim and injured parties who are eligible but do not claim. METHODS AND ANALYSIS: This is a retrospective population-level epidemiological data linkage study of people who have sought ambulatory, emergency or hospital treatment and/or made a compensation claim in Queensland after suffering a transport or work-related injury, over the period 1 January 2011 to 31 December 2021. It will use person-linked data from nine statewide data sources: (1) Queensland Ambulance Service, (2) Emergency Department, (3) Queensland Hospital Admitted Patients, (4) Retrieval Services, (5) Hospital Costs, (6) Workers' Compensation, (7) Compulsory Third Party Compensation, (8) National Injury Insurance Scheme and (9) Queensland Deaths Registry. Descriptive, parametric and non-parametric statistical methods and geospatial analysis techniques will be used to answer the core research questions regarding the patient's health service use profile, costs, treatment pathways and outcomes within 2 years postincident as well as to examine the concordance and accuracy of information across health and compensation databases. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Royal Brisbane and Women's Hospital Human Research Ethics Committee, and governance approval was obtained via the Public Health Act 2005, Queensland. The findings of this study will be used to inform key stakeholders across the clinical, research and compensation regulation area, and results will be disseminated through peer-reviewed journals, conference presentations and reports/seminars with key stakeholders.

Iron status in patients with burn anaemia.

PURPOSE: The iron status of burn patients is poorly understood, limited by difficulty interpreting conventional iron studies in the context of the acute phase response triggered by critical illness. The aim of this study was to evaluate the iron status of patients with burn anaemia using recent post-operative guidelines. METHODOLOGY: This retrospective cohort study utilised data collected from records for adult patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% TBSA. Rates of iron deficiency, defined as ferritin< 100 µg/L or ferritin 100-300 µg/L with transferrin saturation< 20%, and low iron availability, defined as transferrin saturation< 20%, were calculated. RESULTS: Of 60 included patients (90% male), 16 (27%) underwent iron studies. 11 (18%) were treated with intravenous iron. Iron studies showed that five (31%) patients had evidence of iron deficiency, and ten out of 12 (83%) had evidence of reduced iron availability. Two patients (40%) with evidence of iron deficiency were not treated with intravenous iron. CONCLUSION: Application of recent guidelines for interpretation of conventional iron studies in patients with inflammatory states may improve the identification of iron deficiency in burn patients. Iron deficiency may be an under-recognised and under-treated contributor to burn anaemia.

Intravenous iron therapy to treat burn anaemia: A retrospective cohort study.

PURPOSE: Intravenous iron is an effective treatment for anaemia in many populations but has not been evaluated in those with burn anaemia. This study aimed to evaluate the efficacy and safety of intravenous iron to manage burn anaemia. METHODOLOGY: This was a retrospective cohort study of patients admitted to the Royal Brisbane and Women's Hospital with burns to at least 15% total body surface area (TBSA). Data collected from patient records included demographics, treatment details, and outcomes including length of stay, blood transfusions, and serum haemoglobin concentrations. Linear mixed effects regression models were used to assess the effect of treatment with intravenous iron on haemoglobin over time. RESULTS: Sixty patients met inclusion criteria, with 11 (18%) treated using intravenous iron. Those treated with intravenous iron had higher TBSA burns (median 39% vs 18%, P = 0.0005), more operations (3 vs 1, P = 0.0012), and more blood transfusions (median 8 units vs 0 units, P = 0.0002). One patient (9%) experienced a minor adverse drug reaction from intravenous iron. When examining the change in modelled haemoglobin levels over the first 14 days following the last major operation, the change in the intravenous iron group (11.22 g/L) was 14.56 g/L greater than the change in the group not receiving intravenous iron (-3.34 g/L, P = 0.0282). CONCLUSION: This exploratory study provides preliminary evidence of benefit and safety of intravenous iron treatment on burn anaemia recovery.

Cardiovascular mortality post burn injury.

BACKGROUND: Burn injury is responsible for both acute and ongoing inflammation, resulting in systematic changes impacting the cardiovascular, hepatobiliary, endocrine, and metabolic systems, but there is minimal investigation into long-term clinical outcomes. This study aimed to investigate mortality due to cardiovascular related long-term postburn injury. METHODS: This was a retrospective cohort study linking a burns unit database with mortality outcomes from a Registry of Births, Deaths and Marriages. Data were extracted from the Australian Institute of Health and Welfare and stratified into three age groups: 15 to 44 years, 45 to 64 years, and 65+ years. Mortality rate ratios (MRRs) and 95% confidence interval (CI) were calculated to compare the burns cohort mortality incidence rates with the national mortality incidence rates for each of the three age groups. Logistic regression was used to identify demographic and clinical factors associated with cardiovascular mortality. RESULTS: A total of 4,134 individuals in the database were analyzed according to demographic and clinical variables. The 20-year age-standardized cardiovascular mortality rate for the burns cohort was significantly higher compared with the Australian population (250.6 per 100,000 person-years vs. 207.9 per 100,000 person-years) (MRR, 1.21; 95% CI, 1.001-1.45). Cardiovascular mortality was significantly higher in males aged 15-44 and 45-64 years had a cardiovascular mortality rate significantly higher than the Australian population (MRR = 10.06, 95% CI 3.49-16.63), and (MRR = 2.40, 95% CI 1.42-3.38) respectively. Those who died of cardiovascular disease were more frequently intubated postburn injury ( p = 0.01), admitted to intensive care ( p < 0.0001), and had preexisting comorbid physical conditions (60.9% vs. 15.0%, p < 0.0001). CONCLUSION: Survivors from burn injury, especially young males, are at increased long-term risk of death from cardiovascular disease. Increased screening and counseling pertaining to lifestyle factors should be standard management postburn injury. Longitudinal observation of physiological changes, investigation of mechanistic factors, and investigation of interventional strategies should be instituted. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Prevalence of alcohol consumption in emergency presentations: Novel approach using two biomarkers, ethanol and phosphatidylethanol.

INTRODUCTION: The aim was to determine the prevalence of alcohol-related presentations to an emergency department (ED) in a major Australian hospital, through a novel surveillance approach using two biomarkers, blood ethanol and phosphatidylethanol (PEth). METHODS: Observational study using secondary testing of blood samples collected during routine clinical care of ED patients presenting to the Royal Brisbane and Women's Hospital in Queensland, Australia, between 22 January and 2 February 2021. Data were collected from 1160 patients during the 10-day study period. The main outcomes were the prevalence of acute alcohol intake, as determined by blood ethanol, and recent use over 2-4 weeks, as determined by PEth concentrations, for all ED presentations and different diagnostic groups. RESULTS: The overall prevalence for blood ethanol was 9.3% (95% confidence interval [CI] 7.8%, 11.1%), 5.3% for general medical presentations, increasing four-fold to 22.2% for injury presentations. The overall prevalence of PEth positive samples was 32.5% (95% CI 29.9%, 35.3%) and 41.4% for injury presentations. There were 263 (25.3%) cases that tested negative for acute blood ethanol but positive for PEth concentrations indicative of significant to heavy medium-term alcohol consumption. DISCUSSION AND CONCLUSIONS: This novel surveillance approach demonstrates that using blood ethanol tests in isolation significantly underestimates the prevalence of medium-term alcohol consumption in ED presentations. Prevalence of alcohol use was higher for key diagnostic groups such as injury presentations. Performing periodic measurement of both acute and medium-term alcohol consumption accurately and objectively in ED presentations, would be valuable for informing targeted public health prevention and control strategies.

Costs and 30-day readmission after lower limb fractures from motorcycle crashes in Queensland, Australia: A linked data analysis.

BACKGROUND: Lower limb trauma is the most common injury sustained in motorcycle crashes. There are limited data describing this cohort in Australia and limited international data establishing costs due to lower limb trauma following motorcycle crashes. METHODS: This retrospective cohort study utilised administrative hospitalisation data from Queensland, Australia from 2011-2017. Eligible participants included those admitted with a principal diagnosis coded as lower extremity or pelvic fracture following a motorcycle crash (defined as the index admission). Multiply injured motorcyclists where the lower limb injury was not coded as the primary diagnosis (i.e. principal diagnosis was rather coded as head injury, internal organ injures etc.) were not included in the study. Hospitalisation data were also linked to clinical costing data. Logistic regression was used to determine risk factors for 30-day readmission. Costing data were compared between those readmitted and those who weren't, using bootstrapped t-tests and ANVOA. RESULTS: A total of 3342 patients met eligibility, with the most common lower limb fracture being tibia/fibula fractures (40.8%). 212 participants (6.3%) were readmitted within 30-days of discharge. The following were found to predict readmission: male sex (OR 1.84, 95% CI 1.01-1.94); chronic anaemia (OR 2.19, 95% CI 1.41-3.39); current/ex-smoker (OR 1.60, 95% CI 1.21-2.12); emergency admission (OR 2.77, 95% CI 1.35-5.70) and tibia/fibula fracture type (OR 1.46, 95% CI 1.10-1.94). The most common reasons for readmission were related to ongoing fracture care, infection or post-operative complications. The average hospitalisation cost for the index admission was AU$29,044 (95% CI $27,235-$30,853) with significant differences seen between fracture types. The total hospitalisation cost of readmissions was almost AU$2 million over the study period, with an average cost of $10,977 (95% CI $9,131- $13,059). CONCLUSIONS: Unplanned readmissions occur in 6.3% of lower limb fractures sustained in motorcycle crashes. Independent predictors of readmission within 30 days of discharge included male sex, chronic anaemia, smoking status, fracture type and emergency admission. Index admission and readmission hospitalisation costs are substantial and should prompt health services to invest in ways to reduce readmission.

Community Opioid Dispensing After Injury (CODI): Protocol for a Population-Based Data Linkage Study.

BACKGROUND: There is an urgent need to reduce preventable deaths and hospitalizations from prescription opioid harms and minimize the negative effect opioid misuse can have on injured individuals, families, and the wider community. Data linkage between administrative hospitalization records for injured patients and community opioid dispensing can improve our understanding of the health and surgical trajectories of injured persons and generate insights into corresponding opioid dispensing patterns. OBJECTIVE: The Community Opioid Dispensing after Injury (CODI) study aims to link inpatient hospitalization data with opioid dispensing data to examine the distribution and predictive factors associated with high or prolonged community opioid dispensing among adults, for 2 years following an injury-related hospital admission. METHODS: This is a retrospective population-based cohort study of adults aged 18 years or older hospitalized with an injury in Queensland, Australia. The study involves the linkage of statewide hospital admissions, opioid prescription dispensing, and mortality data collections. All adults hospitalized for an injury between January 1, 2014, and December 31, 2015, will be included in the cohort. Demographics and injury factors are recorded at the time of the injury admission. Opioid dispensing data will be linked and extracted for 3 months prior to the injury admission date to 2 years after the injury separation date (last date December 31, 2017). Deaths data will be extracted for the 2-year follow-up period. The primary outcome measure will be opioid dispensing (frequency and quantity) in the 2 years following the injury admission. Patterns and factors associated with community opioid dispensing will be examined for different injury types, mechanisms, and population subgroups. Appropriate descriptive statistics will be used to describe the cohort. Regression models will be used to examine factors predictive of levels and duration of opioid use. Nonparametric methods will be applied when the data are not normally distributed. RESULTS: The project is funded by the Royal Brisbane and Women's Hospital Foundation. As of November 2021, all ethics and data custodian approvals have been granted. Data extraction and linkage has been completed. Data management and analysis is underway with results relating to an analysis for blunt chest trauma patients expected to be published in 2022. CONCLUSIONS: Little is currently known of the true prevalence or patterns of opioid dispensing following injury across Queensland. This study will provide new insights about factors associated with high and long-term opioid dispensing at a population level. This information is essential to inform targeted public policy and interventions to reduce the risk of prolonged opioid use and dependence for those injured. The novel work undertaken for this project will be vital to planning, delivering, monitoring, and evaluating health care services for those injured. The findings of this study will be used to inform key stakeholders as well as clinicians and pain management services. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/36357.

Rural and urban patterns of severe injuries and hospital mortality in Australia: An analysis of the Australia New Zealand Trauma Registry: 2015-2019.

INTRODUCTION: In Australia, people living in rural areas, compared to major cities are at greater risk of poor health. There is much evidence of preventable disparities in trauma outcomes, however research quantifying geographic variations in injuries, pathways to specialised care and patient outcomes is scarce. AIMS: (i) To analyse the Australia New Zealand Trauma Registry (ATR) data and report patterns of serious injuries according to rurality of the injury location ii) to examine the relationship between rurality and hospital mortality and iii) to compare ATR death rates with all deaths from similar causes, Australia-wide. METHOD: A retrospective cohort study of patients in the ATR from 1st July 2015 to 30th June 2019 was conducted. Descriptive analyses of trauma variables according to rurality was performed. Logistic regression quantified the moderating effect of rurality on trauma variables and hospital mortality. Australian death data on similar injuries were sourced to quantify the additional mortality attributable to severe injury occurring outside Major Trauma Centres (MTCs). RESULTS: Compared to major cities, rural patients were younger, more likely to have spinal cord injuries, and sustain traffic-related injuries that are 'off road'. Injuries occurring outside people's homes are more likely. Mortality risk was greater for patients sustaining severe traumatic brain injury (TBI) spinal cord injury (SCI) and head trauma in addition to intentional injuries. Compared to the ATR data, Australian population-wide trauma mortality rates showed diverging trends according to rurality. The ATR only captures 14.1% of all injury deaths occurring in major cities and, respectively, 6.3% and 3.2% of deaths in regional and remote areas. CONCLUSION: Compared to major cities, injuries occurring in rural areas of Australia often involve different mechanisms and result in different types of severe injuries. Patients with neurotrauma and intentional injuries who survived to receive definitive care at a MTC were at higher risk of hospital death. To inform prevention strategies and reduce morbidity and mortality associated with rural trauma, improvements to data systems are required that involve data linkage and include information about patient care from pre-hospital providers, regional hospitals and major trauma centres.

Paediatric trauma imaging in a regional Queensland hospital: Do we need clearer guidance?

OBJECTIVE: Paediatric trauma is a major cause of morbidity and mortality in those aged 0-14. Anatomical and physiological differences require a specialised approach to paediatric trauma care. Medical imaging, particularly computed tomography (CT) scans, requires specific consideration because of the consequences of radiation exposure in the paediatric population. The present study compares current practice of CT scan ordering in paediatric trauma patients at a regional Australian hospital against consensus guidelines published in the UK. METHODS: A retrospective audit of paediatric trauma CT scans referred from the ED from May 2017 to May 2018 was completed. Details relating to CT scan ordering were reviewed and compliance with the Royal College of Radiologists Paediatric trauma protocols, was determined. Descriptive statistics and χ2 tests comparing those that met and did not meet guidelines were performed. RESULTS: A total of 71 CT scans were included with an overall compliance rate of 56.3%. Specific regional compliance was lowest with CT neck at 14%. Patients where a trauma call was initiated were more likely to receive a full body (pan) scan rather than region specific imaging. Compliance improved when paediatric team involvement was documented. CONCLUSIONS: Evidence-based guidelines for CT imaging in paediatric trauma are essential to reduce unnecessary radiation exposure for children. The present study has demonstrated that current practice has the potential to be improved and that decisions should involve a multidisciplinary team.

Rib fractures in blunt chest trauma: factors that influence daily patient controlled opiate use during acute care.

BACKGROUND: Opiates are frequently used in the inpatient management of chest wall injury following blunt trauma. However, the daily sum of opiates used during acute care, and the impact that additional injuries or rib fracture displacement may have on daily opiate requirement is unknown. METHODS: A retrospective sample of 85 adult patients admitted to a tertiary trauma centre between April 2018 and October 2019 after a major chest wall injury (Abbreviated Injury Scale >2) and referral to Acute Pain Management Service was used in this study. Daily opiate usage was calculated each day for the first seven days following initial admission and converted to morphine milliequivalents (MME). Additional adjunct analgesia therapy was also recorded each day. The presence of rib fracture displacement and concurrent clavicle/scapular fractures was also noted. A comparison of the average daily MME for the various subgroups of interest was performed. RESULTS: The maximum average MME in patients with rib fractures typically occurs at day 2 post injury and admission, with the highest day 2 average MME being in the Patient Controlled Analgesia (PCA) and ketamine subgroup. Presence of rib displacement delayed the onset of maximal MME to day 3 and resulted in higher average MME over the total seven days. Patients with concurrent clavicle or scapular fractures also had higher average MME each day, regardless of the addition of a regional block. CONCLUSIONS: This study has demonstrated the daily opioid requirement is maximal on day 2 post-admission following isolated major chest wall injury. The addition of a regional block resulted in a reduction of the average MME used each day over the first seven days post-admission, compared to ketamine when added to PCA. The presence of displaced rib fractures or clavicle/scapular fractures increased the MME used each day, changed the day of peak consumption and increased the average daily opioid requirement during acute hospitalisation.

Prevalence of Alcohol Consumption in Emergency department presentations (PACE) in Queensland, Australia, using alcohol biomarkers ethanol and phosphatidylethanol: an observational study protocol.

INTRODUCTION: Alcohol use in patients presenting to the emergency department (ED) is a significant problem in many countries. There is a need for valid and reliable surveillance of the prevalence of alcohol use in patients presenting to the ED, to provide a more complete picture of the risk factors and inform targeted public health interventions. This PACE study will use two biomarkers, blood ethanol and phosphatidylethanol (PEth), to determine the patterns, presence and level of alcohol use in patients presenting to an Australian ED. METHODS AND ANALYSIS: This is an observational prevalence study involving the secondary use of routinely collected blood samples from patients presenting to the Royal Brisbane and Women's Hospital (RBWH) Emergency and Trauma Centre (ETC). Samples will be tested for acute and medium-term alcohol intake using the two biomarkers blood ethanol and PEth respectively, over one collection period of 10-12 days. Descriptive statistics such as frequencies, percentages, means, SD, medians and IQRs, will be used to describe the prevalence, pattern and distribution of acute and medium-term alcohol intake in the study sample. The correlation between acute and medium-term alcohol intake levels will also be examined. ETHICS AND DISSEMINATION: This study has been approved by the RBWH Human Research Ethics Committee (reference, LNR/2019/QRBW/56859). Findings will be disseminated to key stakeholders such as RBWH ETC, Australasian College for Emergency Medicine, Royal Australasian College of Surgeons, Statewide Clinical Networks, and used to inform clinicians and hospital services. Findings will be submitted for publication in peer-reviewed journals and presentation at appropriate conferences.

Trauma Tertiary Survey: Trauma Service Medical Officers and Trauma Nurses Detect Similar Rates of Missed Injuries.

BACKGROUND: Trauma tertiary surveys (TTSs) can improve patient outcomes by identifying missed injuries following initial trauma reception and resuscitation. Most TTSs are conducted by medical officers despite the multidisciplinary team approach of modern trauma care. OBJECTIVE: The study aim was to assess the accuracy of detecting missed injuries when the TTS was performed by specialist trauma nursing staff, rather than trauma service medical officers (TSMOs). METHODS: A prospective, convenience sample of adult trauma patients admitted to a tertiary trauma center and attended by the trauma service between October 2015 and August 2018 was obtained. For this sample, a TTS was completed by both the TSMO and the trauma nurse (TN). The number of radiological investigations ordered and missed injuries identified were compared between the two clinicians. Additional injuries were graded using the Clavien-Dindo system. RESULTS: The study sample consisted of 165 patients with a dual TTS, for which at least one team member requested 35 additional radiological investigations. There was fair agreement (κ = 0.36) between the TN and the TSMO in requesting additional radiological investigations. Ten missed injuries were identified by TN-initiated review (n = 24), and 4 missed injuries were identified by TSMO-initiated review (n = 21). Injuries identified following TTSs ranged in severity grading from 0 to 3. CONCLUSIONS: Performance of the TN on the TTS in the identification of missed injuries is similar to that of the TSMO. Trauma nurses use an appropriate and rationalized approach to ordering additional radiological investigations and contribute a valuable addition to trauma patient care.

Comparing the accuracy of ICD-based severity estimates to trauma registry-based injury severity estimates for predicting mortality outcomes.

INTRODUCTION: Trauma registries have been used internationally for several decades to measure the quality of trauma care between hospitals. Given the significant costs involved in establishing and maintaining trauma registries, and increasing availability of routinely collected, linked health data describing a patient's journey (and inherent cost savings in data re-use), there is significant interest in development of integrated, comprehensive trauma data repositories. However, approaches to estimating injury severity using routinely collected data would need to be developed if routinely collected hospital data were to be used as an alternative/supplement to registries. OBJECTIVES: This study aimed to compare the accuracy of registry-based injury severity estimates with ICD-based injury severity estimates in predicting mortality outcomes in a cohort of minor and major trauma patients in Queensland, using retrospectively linked trauma registry and hospital admissions data. METHODS: Queensland Trauma Registry (QTR) data with an admission date between 1 January 2005 and 31 December 2011 was linked with all acute care patients included in the Queensland Hospital Admitted Patient Data Collection (QHAPDC) with a Principal Diagnosis coded with an ICD-10-AM code within Chapter 19 (S00-T98). Abbreviated Injury Scale coding was undertaken manually by QTR trauma data nurses for the registry data. ICD-based injury severity scores (ICISS) were calculated automatically using all injury-related diagnoses captured in the QHAPDC data using the ICISS multiplicative and worst injury method. RESULTS: There were 92,140 QTR patients admitted between January 2005 and December 2011 with a valid ISS with a matching QHAPDC record (98.4% survived, 1.6% died). ICISS (multiplicative and worst injury approach) showed marginally better predictive accuracy than ISS when predicting mortality across minor and major injury and ICISS showed marginally better predictive accuracy to ISS when restricted to major trauma/high threat to life cases. Both ICISS and ISS restricted to major trauma/high threat to life showed poorer accuracy compared to the predictive performance when both minor and major cases were included. CONCLUSION: ICD-based predictions were as accurate as ISS-based predictions for this cohort and this study provides evidence to support the potential for using routinely coded hospital data for risk adjustment within State-based trauma data repositories.

Three Es of linked injury data: Episodes, Encounters and Events.

BACKGROUND: Treatment and recovery times following injury can be lengthy, comprising multiple interactions with the hospital system for initial acute care, subsequent rehabilitation and possible re-presentation due to complications. AIMS: This article aims to promote the use of consistent terminology in injury data linkage studies, suggest important factors to consider when managing linked injury data, and encourage thorough documentation and a robust discourse around different approaches to data management to ensure reproducibility, consistency and comparability of analyses arising from linked injury data. APPROACH: This paper is presented in sections describing: (1) considerations for identifying injury cohorts, (2) considerations for grouping Episodes into Encounters and (3) considerations for grouping Encounters into Events. Summary tools are provided to aid researchers in the management of linked injury data. DISCUSSION: Careful consideration of decisions made when identifying injury cohorts and grouping data into units of analysis (Episodes/Encounters/Events) is essential when using linked injury data. Choices made have the potential to significantly impact the epidemiological and clinical findings derived from linked injury data studies, which ultimately affect the quality of injury prevention initiatives and injury management policy and practice. It is intended that this paper will act as a call to action for injury linkage methodologists, and those using linked data, to critique approaches, share tools and engage in a robust discourse to further advance the use of linked injury data, and ultimately enhance the value of linked injury data for clinicians and health and social policymakers.