The Future of Road Safety: Challenges and Opportunities.

Policy Points Traditional approaches to addressing motor vehicle crashes are yielding diminishing returns. A comprehensive strategy known as the Safe Systems approach shows promise in both advancing safety and equity and reducing motor vehicle crashes. In addition, a range of emerging technologies, enabled by artificial intelligence, such as automated vehicles, impairment detection and telematics hold promise to advance road safety. Ultimately, the transportation system will need to evolve to provide the safe, efficient, and equitable movement of people and goods without reliance on private vehicle ownership, towards encouraging walking, bicycling and the use of public transportation.

Activation and On-Scene Intervals for Severe Trauma EMS Interventions: An Analysis of the NEMSIS Database.

Objective: Time to care is a determinant of trauma patient outcomes, and timely delivery of trauma care to severely injured patients is critical in reducing mortality. Numerous studies have analyzed access to care using prehospital intervals from a Carr et al. meta-analysis of studies from 1975 to 2005. Carr et al.'s research sought to determine national mean activation and on-scene intervals for trauma patients using contemporary emergency medical services (EMS) records. Since the Carr et al. meta-analysis was published, the National Highway Traffic Safety Administration (NHTSA) created and refined the National Emergency Medical Services Information System (NEMSIS) database. We sought to perform a modern analysis of prehospital intervals to establish current standards and temporal patterns.Methods: We utilized NEMSIS to analyze EMS data of trauma patients from 2016 to 2019. The dataset comprises more than 94 million EMS records, which we filtered to select for severe trauma and stratified by type of transport and rurality to calculate mean activation and on-scene intervals. Furthermore, we explored the impact of basic life support (BLS) and advanced life support (ALS) of ground units on activation and on-scene time intervals.Results: Mean activation and on-scene intervals for ground transport were statistically different when stratified by rurality. Urban, suburban, and rural ground activation intervals were 2.60 ± 3.94, 2.88 ± 3.89, and 3.33 ± 4.58 minutes, respectively. On-scene intervals were 15.50 ± 10.46, 17.56 ± 11.27, and 18.07 ± 16.13 minutes, respectively. Mean helicopter transport activation time was 13.75 ± 7.44 minutes and on-scene time was 19.42 ± 16.09 minutes. This analysis provides an empirically defined mean for activation and on-scene times for trauma patients based on transport type and rurality. Results from this analysis proved to be significantly longer than the previous analysis, except for helicopter transport on-scene time. Shorter mean intervals were seen in ALS compared to BLS for activation intervals, however ALS on-scene intervals were marginally longer than BLS.Conclusions: With the increasing sophistication of geospatial technologies employed to analyze access to care, these intervals are the most accurate and up-to-date and should be included in access to care models.

Effect of Severe Distal Tibia, Ankle, and Mid- to Hindfoot Trauma on Meeting Physical Activity Guidelines 18 Months After Injury.

OBJECTIVE: To examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA. DESIGN: Secondary analysis of observational cohort study. SETTING: A total of 34 United States trauma centers PARTICIPANTS: A total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328). INTERVENTIONS: None. MAIN OUTCOME MEASURES: The Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week. RESULTS: Fewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31). CONCLUSIONS: Patients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.

Incremental Cost of Emergency Versus Elective Surgery.

OBJECTIVE: To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. BACKGROUND: Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. METHODS: Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses. RESULTS: A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures. CONCLUSIONS: Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.

Association between intentional injury and long-term survival after trauma.

OBJECTIVE: To determine the risk-adjusted mortality of intentionally injured patients within 7 to 9 years postinjury, compared with unintentionally injured patients. BACKGROUND: Violent injury contributes significantly to trauma mortality in the United States. Homicide is the second leading killer of American youth, aged 15 to 24 years. Long-term survival among intentionally injured patients has not been well studied. It is also unknown whether intentionally injured patients have worse long-term survival compared with unintentionally or accidentally injured patients with equivalent injuries. METHODS: Adult trauma patients admitted for 24 hours or more and discharged alive from the Johns Hopkins Hospital from January 1, 1998, to December 31, 2000, were included. The primary outcome was mortality within 7 to 9 years postinjury. Long-term patient survival was determined using the National Death Index. The association between injury intentionality and mortality was investigated using a Cox proportional hazard regression model, adjusted for confounders such as injury severity and patient race, socioeconomic status, and comorbid conditions. Overall differences in survival between those with intentional versus unintentional injury were also determined by comparing adjusted Kaplan-Meier survival curves. RESULTS: A total of 2062 patients met inclusion criteria. Of these, 56.4% were intentionally injured and 43.6% were unintentionally injured. Compared with unintentionally injured patients, intentionally injured patients were younger and more often male and from a zip code with low median household income. Approximately 15% of all patients had died within 7 to 9 years of follow-up. Older age and presence of comorbidities were associated with this outcome; however, intentional injury was not found to be significantly associated with long-term mortality rates. There was also no significant difference in survival curves between groups; intentionally injured patients were much more likely to die of a subsequent injury, whereas those with unintentional injury commonly died of noninjury causes. CONCLUSIONS: There was no significant difference in mortality between intentionally injured and unintentionally injured patients within 7 to 9 years postinjury. These results confirm the long-term effectiveness of lifesaving trauma care for those with intentional injury. However, given that patients with intentional injuries were more likely to suffer a subsequent violent death, interventions focused on breaking the cycle of violence are needed.

Rehabilitation following pediatric traumatic brain injury: variability in adherence to psychosocial quality-of-care indicators.

OBJECTIVE: To examine variations in processes of pediatric inpatient rehabilitation care related to family-centered care, management of neurobehavioral and psychosocial needs, and community reintegration after traumatic brain injury. SETTING: Nine acute rehabilitation facilities from geographically diverse areas of the United States. PARTICIPANTS: A total of 174 children with traumatic brain injury. DESIGN: Retrospective chart review. MAIN MEASURES: Adherence to care indicators (the number of times recommended care was delivered or attempted divided by the number of times care was indicated). RESULTS: Across facilities, adherence rates (adjusted for difficulty of delivery) ranged from 33.6% to 73.1% (95% confidence interval, 13.4-53.9, 58.7-87.4) for family-centered processes, 21.3% to 82.5% (95% confidence interval, 6.6-36.1, 67.6-97.4) for neurobehavioral and psychosocial processes, and 22.7% to 80.3% (95% confidence interval, 5.3-40.1, 68.1-92.5) for community integration processes. Within facilities, standard deviations for adherence rates were large (24.3-34.9, family-centered domain; 22.6-34.2, neurobehavioral and psychosocial domain; and 21.6-40.5, community reintegration domain). CONCLUSION: The current state of acute rehabilitation care for children with traumatic brain injury is variable across different quality-of-care indicators addressing neurobehavioral and psychosocial needs and facilitating community reintegration of the patient and the family. Individual rehabilitation facilities demonstrate inconsistent adherence to different indicators and inconsistent performance across different care domains.

Improving outcomes: understanding the psychosocial aspects of the orthopaedic trauma patient.

The care of orthopaedic trauma patients with multiple injuries has dramatically improved in the past 25 years. The understanding of the physiology of trauma has evolved, new surgical approaches have been developed, and technologic advances have created better implants. New methods of treating fractures include fluoroscopic and computer-assisted imaging. Surgical interventions have changed from extensive and prolonged dissections to more limited and effective percutaneous and minimally invasive techniques. The lives of patients are being saved, and radiographic outcomes are improving; however, medical and surgical advances that achieve better radiographic and anatomic outcomes do not always improve functional outcomes. Understanding and optimizing the management of the psychosocial factors that affect trauma patients can improve outcomes.

Proceedings from a National Summit on Workplace Mental Health and Well-Being: A Focus on the Graduate Academic Environment.

OBJECTIVE: To spotlight the challenges, gaps, and opportunities to improve workforce mental health and well-being in higher education institutions (HEIs). METHODS: We convened a full-day summit of subject matter experts from academia, business, government, and practice to share research and best practices on workplace mental health. RESULTS: Highlights from the summit are presented in this paper covering the importance of leadership and culture; the mental health costs associated with being a Black STEM scholar; the role of the environment; case studies of three university mental health and well-being programs; and the future of work. CONCLUSIONS: Establishing a culture of caring requires leadership commitment; strategic planning; accountability and shared responsibility; and measurement and evaluation. HEI leaders are called to lead by example; foster community partnerships; adopt a Total Worker Health framework; and regularly evaluate progress.

Do Transtibial Amputations Outperform Amputations of the Hind- and Midfoot Following Severe Limb Trauma?: A Secondary Analysis of the OUTLET Study.

BACKGROUND: The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications. METHODS: The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing. RESULTS: There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index [distal versus transtibial], 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury. CONCLUSIONS: Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials.

BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. METHODS: Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. RESULTS: A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. CONCLUSIONS: A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative effectiveness of inhospital trauma resuscitation at a French trauma center and matched patients treated in the United States.

OBJECTIVE: The objective of this paper is to compare mortality outcomes between patients treated at a trauma center in France and matched patients in the United States. BACKGROUND: Although trauma systems in France and the United States differ significantly in prehospital and inhospital management, previous comparisons have been challenged by the lack of comparable data. METHODS: Coarsened exact matching identified matching patients between a single center trauma database from Lyon, France, and the National Trauma Data Bank (NTDB) of the United States. Moderate to severely injured [injury severity score (ISS) > 8] adult patients (age ≥ 16) presenting alive to level 1 trauma centers from 2002 to 2005 with blunt or penetrating injuries were included. After matching patients, multivariate regression analyses were performed to determine difference in mortality between patients in Lyon and the NTDB. RESULTS: A total of 1043 significantly injured patients were presented to the Lyon center. Matching eligible patients with complete records were sought from 219,985 patients in the NTDB. The unadjusted odds of mortality at the Lyon center was 2.5 times higher than that of the NTDB [95% confidence interval (CI) = 2.18-2.98]. However, the Lyon center received patients with higher ISS, lower Glasgow Coma Score (GCS), and lower systolic blood pressure (SBP) (all P < 0.001). After 1:1 matching, 858 patient pairs were produced, and the odds of mortality became equivalent [odds ratio (OR) = 1.3, 95% CI = 0.91-1.73]. Similar results were found in multiple subset analyses. CONCLUSIONS: Trauma patients admitted to a single French trauma center had an equal chance of survival compared with similarly injured patients treated at US trauma centers.

Minority trauma patients tend to cluster at trauma centers with worse-than-expected mortality: can this phenomenon help explain racial disparities in trauma outcomes?

OBJECTIVES: To determine whether minority trauma patients are more commonly treated at trauma centers (TCs) with worse observed-to-expected (O/E) survival. BACKGROUND: Racial disparities in survival after traumatic injury have been described. However, the mechanisms that lead to these inequities are not well understood. METHODS: Analysis of level I/II TCs included in the National Trauma Data Bank 2007-2010. White, Black, and Hispanic patients 16 years or older sustaining blunt/penetrating injuries with an Injury Severity Score of 9 or more were included. TCs with 50% or more Hispanic or Black patients were classified as predominantly minority TCs. Multivariate logistic regression adjusting for several patient/injury characteristics was used to predict the expected number of deaths for each TC. O/E mortality ratios were then generated and used to rank individual TCs as low (O/E <1), intermediate, or high mortality (O/E >1). RESULTS: A total of 556,720 patients from 181 TCs were analyzed; 86 TCs (48%) were classified as low mortality, 6 (3%) intermediate, and 89 (49%) as high mortality. More of the predominantly minority TCs [(82% (22/27) vs 44% (67/154)] were classified as high mortality (P < 0.001). Approximately 64% of Black patients (55,673/87,575) were treated at high-mortality TCs compared with 54% Hispanics (32,677/60,761) and 41% Whites (165,494/408,384) (P < 0.001). CONCLUSIONS: Minority trauma patients are clustered at hospitals with significantly higher-than-expected mortality. Black and Hispanic patients treated at low-mortality hospitals have a significantly lower odds of death than similar patients treated at high-mortality hospitals. Differences in TC outcomes and quality of care may partially explain trauma outcomes disparities.

Developing, testing, and sustaining rehabilitation interventions via participatory action research.

Few published intervention studies in the rehabilitation literature have included consumers in the research process other than as study participants. This lack of consumer involvement in intervention research may contribute to the challenges encountered developing, translating, disseminating, and sustaining evidence-based rehabilitation interventions in clinical practice. The overall objective of this article is to promote the integration of participatory action research (PAR) into rehabilitation intervention research as a mechanism for addressing these gaps. First, we outline essential components of a PAR model across 5 key phases of intervention research, specifically: agenda setting, methods, implementation, diffusion/dissemination, and sustainability. Second, we describe the use of PAR in rehabilitation intervention research within each of these phases by reviewing relevant literature and by providing an illustrative research example from a randomized controlled trial that integrated PAR throughout the research process. Finally, we conclude with a discussion of 5 specific recommendations for promoting the integration of PAR into rehabilitation intervention research.

Variations in the quality of inpatient rehabilitation care to facilitate school re-entry and cognitive and communication function for children with TBI.

OBJECTIVE: To examine variations in processes of paediatric inpatient rehabilitation care related to school re-entry and management of cognitive and communication impairments after traumatic brain injury. DESIGN: Retrospective cohort study. METHODS: Adherence to care processes recommended for children (aged 0-17) with moderate-to-severe traumatic brain injury and admitted for inpatient rehabilitation was assessed. Quality-of-care indicators for processes supporting school re-entry and cognitive and communication rehabilitation were applied to measure variations in care delivered to 174 children across nine facilities using medical record review. MAIN OUTCOMES AND RESULTS: Adherence rates (the number of times recommended care was delivered or attempted divided by the number of times care was indicated) were calculated, revealing substantial variations in care within and between facilities. Overall, children received 51.3% (95% CI = 31.9-70.7) and 72.3% (95% CI = 61.1-83.5), of the care recommended for school re-entry and cognitive and communication rehabilitation, respectively. CONCLUSION: Substantial variations exist in the delivery of paediatric inpatient rehabilitation care processes for managing school re-entry and cognitive and communication impairments after traumatic brain injury. Measures of association of these care processes with patient outcomes are necessary. Reduction in this variation is essential to improving quality of care.

Development and pilot implementation of a locally developed Trauma Registry: lessons learnt in a low-income country.

BACKGROUND: Trauma registries (TRs) play an integral role in the assessment of trauma care quality. TRs are still uncommon in developing countries owing to awareness and cost. We present a case study of development and pilot implementation of "Karachi Trauma Registry" (KITR), using existing medical records at a tertiary-care hospital of Karachi, Pakistan to present results of initial data and describe its process of implementation. METHODS: KITR is a locally developed, customized, electronic trauma registry based on open source software designed by local software developers in Karachi. Data for KITR was collected from November 2010 to January 2011. All patients presenting to the Emergency Department (ED) of the Aga Khan University Hospital (AKUH) with a diagnosis of injury as defined in ICD-9 CM were included. There was no direct contact with patients or health care providers for data collection. Basic demographics, injury details, event detail, injury severity and outcome were recorded. Data was entered in the KITR and reports were generated. RESULTS: Complete data of 542 patients were entered and analysed. The mean age of patients was 27 years, and 72.5% were males. About 87% of patients had sustained blunt injury. Falls and motor vehicle crashes were the most common mechanisms of injury. Head and face, followed by the extremities, were the most frequently injured anatomical regions. The mean Injury Severity Score (ISS) was 4.99 and there were 8 deaths. The most common missing variables in the medical records were ethnicity, ED notification prior to transfer, and pre-hospital IV fluids. Average time to review each chart was 14.5 minutes and entry into the electronic registry required 15 minutes. CONCLUSION: Using existing medical records, we were able to enter data on most variables including mechanism of injuries, burden of severe injuries and quality indicators such as length of stay in ED, injury to arrival delay, as well as generate injury severity and survival probability but missed information such as ethnicity, ED notification. To make the data collection process more effective, we propose provider based data collection or making a standardized data collection tool a part of medical records.

Barriers to implementation of a hospital-based program for survivors of traumatic injury.

The Trauma Survivors Network is a multimodal program for trauma patients and their families. Despite training representatives of 30 trauma centers, only 3 have fully implemented the program. The purpose of this study was to identify barriers to program implementation among trainees through in-depth phone interviews and an electronic survey. Although interviewees were positive about the Trauma Survivors Network concept, they identified numerous barriers to implementation. Trainee confidence in their ability to implement program components was predictive of their success. We recommend that future trainings include program advocacy, implementation skills, and an assessment of trainees' roles in the hospital.

Quality of care indicators for the rehabilitation of children with traumatic brain injury.

OBJECTIVE: To develop measurement tools for assessing compliance with identifiable processes of inpatient care for children with traumatic brain injury (TBI) that are reliable, valid, and amenable to implementation. DESIGN: Literature review and expert panel using the RAND/UCLA Appropriateness Method and a Delphi technique. SETTING: Not applicable. PARTICIPANTS: Children with TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Quality of care indicators. RESULTS: A total of 119 indicators were developed across the domains of general management; family-centered care; cognitive-communication, speech, language, and swallowing impairments; gross and fine motor skill impairments; neuropsychologic, social, and behavioral impairments; school reentry; and community integration. There was a high degree of agreement on these indicators as valid and feasible quality measures for children with TBI. CONCLUSIONS: These indicators are an important step toward building a better base of evidence about the effectiveness and efficiency of the components of acute inpatient rehabilitation for pediatric patients with TBI.

Variation in adherence to new quality-of-care indicators for the acute rehabilitation of children with traumatic brain injury.

OBJECTIVE: To determine variations in care provided by 9 inpatient rehabilitation units for children with traumatic brain injury (TBI) using newly developed quality indicators. DESIGN: Retrospective cohort study. SETTING: Nine inpatient rehabilitation units. PARTICIPANTS: Children (N=174; age range, 0-17y) admitted for the inpatient rehabilitation of moderate to severe TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Adherence to 119 newly developed quality-of-care indicators in 7 different domains: general care, family-centered care, cognitive-communication, motor, neuropsychological, school, and community integration. RESULTS: There was substantial variation both within and between institutions in the percentage of patients receiving recommended care in the 7 domains. The lowest scores were found for the school domain. Only 5 institutions scored above 50% for all quality indicators, and only 1 institution scored above 70% overall. Greater adherence to quality indicators was found for facilities with a higher proportion of therapists with pediatric training and for facilities that only admitted children. Patient volume was not associated with adherence to quality indicators. CONCLUSIONS: The results indicate a tremendous variability and opportunity for improvement in the care of children with TBI.

Quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury.

OBJECTIVES: To develop evidence-based and expert-driven quality indicators for measuring variations in the structure and organization of acute inpatient rehabilitation for children after traumatic brain injury (TBI) and to survey centers across the United States to determine the degree of variation in care. DESIGN: Quality indicators were developed using the RAND/UCLA modified Delphi method. Adherence to these indicators was determined from a survey of rehabilitation facilities. SETTING: Inpatient rehabilitation units in the United States. PARTICIPANTS: A sample of rehabilitation programs identified using data from the National Association of Children's Hospitals and Related Institutions, Uniform Data System for Medical Rehabilitation, and the Commission on Accreditation of Rehabilitation Facilities yielded 74 inpatient units treating children with TBI. Survey respondents comprised 31 pediatric and 28 all age units. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Variations in structure and organization of care among institutions providing acute inpatient rehabilitation for children with TBI. RESULTS: Twelve indicators were developed. Pediatric inpatient rehabilitation units and units with higher volumes of children with TBI were more likely to have: a census of at least 1 child admitted with a TBI for at least 90% of the time; adequate specialized equipment; a classroom; a pediatric subspecialty trained medical director; and more than 75% of therapists with pediatric training. CONCLUSIONS: There were clinically and statistically significant variations in the structure and organization of acute pediatric rehabilitation based on the pediatric focus of the unit and volume of children with TBI.

Measurement of functional outcomes in the Major Extremity Trauma Research Consortium (METRC).

Measurement of functional outcome is a central tool in the assessment of the human and economic consequences of trauma. As such, functional outcome is the ideal basis against which to judge the efficacy of surgical approaches, drugs, and devices in the context of evidence-based medicine. A well-designed outcome measurement plan improves the validity of clinical research, facilitates the optimal use of limited research resources, and maximizes opportunities for future secondary data analyses. However, a key challenge in the development of a study measurement plan is the identification of appropriate, practical, well-validated measures. The Major Extremity Trauma Research Consortium (METRC) is a large 5-year research effort to develop and conduct multicenter clinical studies relevant to the treatment and outcomes of orthopaedic trauma. METRC is funded to conduct nine clinical studies. One of the main goals is to benefit from the consortium approach by standardizing data collection across these studies. METRC investigators have developed a standard set of measurement instruments designed to examine outcomes across a defined set of key domains: complications, depression, posttraumatic stress disorder, pain, activity and participation, health-related quality of life, patient satisfaction, and healthcare utilization. In addition, METRC investigators have developed a standard set of sociodemographic and clinical covariates to be collected across all studies.