Trauma care in England was re-organised in 2012 with ambulance bypass of local hospitals to newly designated Major Trauma Centres (MTCs). There is still controversy about the optimal way to organise ...health series for patients suffering severe injury.
A longitudinal series of annual cross-sectional studies of care process and outcomes from April 2008 to March 2017. Data was collected through the national clinical audit of major trauma care. The primary analysis was carried out on the 110,863 patients admitted to 35 hospitals that were 'consistent submitters' throughout the study period. The main outcome was longitudinal analysis of risk adjusted survival.
Major Trauma networks were associated with significant changes in (1) patient flow (with increased numbers treated in Major Trauma Centres), (2) treatment systems (more consultant led care and more rapid imaging), (3) patient factors (an increase in older trauma), and (4) clinical care (new massive transfusion policies and use of tranexamic acid). There were 10,247 (9.2%) deaths in the 110,863 patients with an ISS of 9 or more. There were no changes in unadjusted mortality. The analysis of trends in risk adjusted survival for study hospitals shows a 19% (95% CI 3%-36%) increase in the case mix adjusted odds of survival from severe injury over the 9-year study period. Interrupted time series analysis showed a significant positive change in the slope after the intervention time point of April 2012 (+ 0.08% excess survivors per quarter, p = 0.023), in other words an increase of 0.08 more survivors per 100 patients every quarter.
A whole system national change was associated with significant improvements in both the care process and outcomes of patients after severe injury.
This analysis was carried out independently and did not receive funding. The data collection for the national clinical audit was funded by subscriptions from participating hospitals.
Intracranial bleeding (IB) is a common and serious consequence of traumatic brain injury (TBI). IB can be classified according to the location into: epidural haemorrhage (EDH) subdural haemorrhage ...(SDH) intraparenchymal haemorrhage (IPH) and subarachnoid haemorrhage (SAH). Studies involving repeated CT scanning of TBI patients have found that IB can develop or expand in the 48 hours after injury. If IB enlarges after hospital admission and larger bleeds have a worse prognosis, this would provide a therapeutic rationale for treatments to prevent increase in the extent of bleeding. We analysed data from the Trauma Audit & Research Network (TARN), a large European trauma registry, to evaluate the association between the size of IB and mortality in patients with TBI.
We analysed 13,962 patients presenting to TARN participating hospitals between 2001 and 2008 with a Glasgow Coma Score (GCS) less than 15 at presentation or any head injury with Abbreviated Injury Scale (AIS) severity code 3 and above. The extent of intracranial bleeding was determined by the AIS code. Potential confounders were age, presenting Glasgow Coma Score, mechanism of injury, presence and nature of other brain injuries, and presence of extra-cranial injuries. The outcomes were in-hospital mortality and haematoma evacuation. We conducted a multivariable logistic regression analysis to evaluate the independent effect of large and small size of IB, in comparison with no bleeding, on patient outcomes. We also conducted a multivariable logistic regression analysis to assess the independent effect on mortality of large IB in comparison with small IB.
Almost 46% of patients had at some type of IB. Subdural haemorrhages were present in 30% of the patients, with epidural and intraparenchymal present in approximately 22% each. After adjusting for potential confounders, we found that large IB, wherever located, was associated with increased mortality in comparison with no bleeding. We also found that large IB was associated with an increased risk of mortality in comparison with small IB. The odds ratio for mortality for large SDH, IPH and EDH, in comparison with small bleeds, were: 3.41 (95% CI: 2.684.33), 3.47 (95% CI: 2.265.33) and 2.86 (95% CI: 1.864.38) respectively.
Large EDH, SDH and IPH are associated with a substantially higher probability of hospital mortality in comparison with small IB. However, the limitations of our data, such as the large proportion of missing data and lack of data on other confounding factors, such as localization of the bleeding, make the results of this report only explanatory. Future studies should also evaluate the effect of IB size on functional outcomes.
The purpose of Abbreviated Injury Scale (AIS) is to code various types of Traumatic Brain Injuries (TBI) based on their anatomical location and severity. The Marshall CT Classification is used to ...identify those subgroups of brain injured patients at higher risk of deterioration or mortality. The purpose of this study is to determine whether and how AIS coding can be translated to the Marshall Classification
Initially, a Marshall Class was allocated to each AIS code through cross-tabulation. This was agreed upon through several discussion meetings with experts from both fields (clinicians and AIS coders). Furthermore, in order to make this translation possible, some necessary assumptions with regards to coding and classification of mass lesions and brain swelling were essential which were all approved and made explicit.
The proposed method involves two stages: firstly to determine all possible Marshall Classes which a given patient can attract based on allocated AIS codes; via cross-tabulation and secondly to assign one Marshall Class to each patient through an algorithm.
This method can be easily programmed in computer softwares and it would enable future important TBI research programs using trauma registry data.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Background There is strong evidence that severely injured patients are optimally treated within inclusive trauma networks. One feature of such networks is prehospital triage of the most ...injured patients to designated trauma hospitals. In April, 2012, major trauma services across England were reconfigured into regional trauma networks based around designated major trauma centres (MTCs). This study explored the early effects of the regionalisation of major trauma services in England. Methods The Trauma & Audit Research Network (TARN) identified severely injured patients treated in the 9 months before and after each MTC became fully operational. Outcomes included quality indicators (eg, time to CT scanning for head injured patients) and clinical outcomes (eg, in-hospital mortality). Completeness of the TARN dataset was quantified with Hospital Episode Statistics. Death registrations were used to identify any change in the overall number of traumatic deaths in England. Findings The number of severely injured patients treated in MTCs increased from 7705 to 12 476. All care quality indicators improved: treatment by a consultant (30·4% before MTC vs 54·3 after MTC, p<0·0001), administration of tranexamic acid to bleeding patients (17·0% vs 58·5, p=0·006), and time to CT scanning for head injured patients (49·2 min vs 31·2, p<0·0001). Fewer patients required secondary transfer between hospitals (31·3% vs 25·9, p<0·0001) and a greater proportion were discharged with a Glasgow Outcome Scale of good recovery (52·4% vs 64·5, p<0·0001). There were no differences in either crude or adjusted mortality between the periods for all patients or for those with an Injury Severity Score of more than 15. The overall number of traumatic deaths in England did not change. Interpretation There is early evidence of improved care associated with trauma service regionalisation, including some process measures, enhanced case reporting for national audit, and reduced need for secondary transfer of patients between hospitals. However, in this early post-implementation analysis, significant reductions in patient mortality were not observed. Funding Royal College of Surgeons of England Fulbright Scholarship.
Traumatic brain injury (TBI) remains a leading cause of death and disability. The National Institute for Health and Clinical Excellence (NICE) guidelines recommend transfer of severe TBI cases to ...neurosurgical centres, irrespective of the need for neurosurgery. This observational study investigated the risk-adjusted mortality of isolated TBI admissions in England/Wales, and Victoria, Australia, and the impact of neurosurgical centre management on outcomes.
Isolated TBI admissions (>15 years, July 2005-June 2006) were extracted from the hospital discharge datasets for both jurisdictions. Severe isolated TBI (AIS severity >3) admissions were provided by the Trauma Audit and Research Network (TARN) and Victorian State Trauma Registry (VSTR) for England/Wales, and Victoria, respectively. Multivariable logistic regression was used to compare risk-adjusted mortality between jurisdictions.
Mortality was 12% (749/6256) in England/Wales and 9% (91/1048) in Victoria for isolated TBI admissions. Adjusted odds of death in England/Wales were higher compared to Victoria overall (OR 2.0, 95% CI: 1.6, 2.5), and for cases <65 years (OR 2.36, 95% CI: 1.51, 3.69). For severe TBI, mortality was 23% (133/575) for TARN and 20% (68/346) for VSTR, with 72% of TARN and 86% of VSTR cases managed at a neurosurgical centre. The adjusted mortality odds for severe TBI cases in TARN were higher compared to the VSTR (OR 1.45, 95% CI: 0.96, 2.19), but particularly for cases <65 years (OR 2.04, 95% CI: 1.07, 3.90). Neurosurgical centre management modified the effect overall (OR 1.12, 95% CI: 0.73, 1.74) and for cases <65 years (OR 1.53, 95% CI: 0.77, 3.03).
The risk-adjusted odds of mortality for all isolated TBI admissions, and severe TBI cases, were higher in England/Wales when compared to Victoria. The lower percentage of cases managed at neurosurgical centres in England and Wales was an explanatory factor, supporting the changes made to the NICE guidelines.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Management of patients with head injury Mendelow, A David, Prof; Timothy, Jake, FRCS; Steers, James W, FRCS ...
The Lancet (British edition),
08/2008, Letnik:
372, Številka:
9639
Journal Article
Recenzirano
Revised UK guidelines from the National Institute for Health and Clinical Excellence (NICE) for the management of acute head injury address the initial management and triage/ Evidence has also shown ...that even patients who have sustained a minor head injury have difficulty reintegrating into society.5 Thus, management of head injury is an important topic. The principles for the triage of patients with head injuries were set out in the Royal College of Surgeons' report in 2005.11 This report and the Scottish Intercollegiate Guidelines Network6 were largely based on clinical risk factors and the presence of a skull fracture radiograph.15 This approach resulted in about 5% of patients (about 50000 patients per year in the UK) with head injury proceeding to a CT scan.
Abstract Introduction Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. ...Although a SBP of <90 mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints. Methods We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care. Results 5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120 mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120 mmHg, doubled at <100 mmHg, tripled at <90 mmHg, and six times greater at SBP < 70 mmHg, p < 0.01. Conclusions These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP < 90 mmHg, should be reconsidered.
Prediction models for trauma outcome routinely control for age but there is uncertainty about the need to control for comorbidity and whether the two interact. This paper describes recent revisions ...to the Trauma Audit and Research Network (TARN) risk adjustment model designed to take account of age and comorbidities. In addition linkage between TARN and the Office of National Statistics (ONS) database allows patient's outcome to be accurately identified up to 30 days after injury. Outcome at discharge within 30 days was previously used.
Prospectively collected data between 2010 and 2013 from the TARN database were analysed. The data for modelling consisted of 129 786 hospital trauma admissions. Three models were compared using the area under the receiver operating curve (AuROC) for assessing the ability of the models to predict outcome, the Akaike information criteria to measure the quality between models and test for goodness-of-fit and calibration. Model 1 is the current TARN model, Model 2 is Model 1 augmented by a modified Charlson comorbidity index and Model 3 is Model 2 with ONS data on 30 day outcome.
The values of the AuROC curve for Model 1 were 0.896 (95% CI 0.893 to 0.899), for Model 2 were 0.904 (0.900 to 0.907) and for Model 3 0.897 (0.896 to 0.902). No significant interaction was found between age and comorbidity in Model 2 or in Model 3.
The new model includes comorbidity and this has improved outcome prediction. There was no interaction between age and comorbidity, suggesting that both independently increase vulnerability to mortality after injury.
Many previous studies have shown that patients admitted to hospital at weekends have worse outcomes than those on other days. It has been proposed that parity of clinical services throughout the week ...could mitigate the 'weekend effect'. This study aimed to determine whether or not a weekend effect is observed within an all-hours consultant-led major trauma service.
We undertook an observational cohort study using data submitted by all 22 major trauma centres (MTCs) in England to the Trauma Audit & Research Network. The inclusion criteria were all major trauma patients admitted for at least 3 days, admitted to a high-dependency area, or deceased following arrival at hospital. Patients with Injury Severity Score (ISS) >15 were also analysed separately. The outcome measures were length of stay, in-hospital mortality and Glasgow Outcome Score (GOS). Secondary transfer of patients between hospitals was also included as a process outcome.
There were 49 070 patients, 22 248 (45.3%) of which had an ISS >15. Within multivariable logistic regression models, odds of secondary transfer into an MTC were higher at night (adjusted OR 2.05, 95% CI 1.93 to 2.19) but not during the day at weekends (1.09, 0.99 to 1.19). Neither admission at night nor at the weekend was associated with increased length of stay, worse GOS or higher odds of in-hospital death. These findings remained stable when confining analyses to the most severely injured patients (ISS >15), excluding transferred patients, and using a single mid-week (Wednesday) baseline.
After adjustment for known confounders the weekend effect is not detectable within a regionalised major trauma service.
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