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(RSS) Karim's Weblog

Random snippets and thoughts - hopefully mostly trauma related!

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(RSS) Trauma Research Blog

Selected new & juicy research papers, with editorial comment.

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NAO CoverThe National Audit Office has just released a report on the provision of major trauma services in the UK.  The report contains no new surprises - similar reports from independent bodies have been released regularly since the Ormond-Clarke report in 1961.  The NAO report does mandate a hearing in the parliament Public Accounts Committee however and it is expected that some action must follow.

Some snippets from the report:

"We estimate that there are at least 20,000 cases of major trauma each year in England resulting in 5,400 deaths and many others resulting in permanent disabilities requiring long-term care. There are around a further 28,000 cases which, although not meeting the precise definition of major trauma, would be cared for in the same way. [...]   We estimate that major trauma costs the NHS between £0.3 and £0.4 billion a year in immediate treatment. The cost of any subsequent hospital treatments, rehabilitation, home care support, or informal carer costs are unknown. We estimate that the annual lost economic output as a result of major trauma is between £3.3 billion and £3.7 billion."

"Despite repeated reports identifying poor practice, the Department and NHS trusts have taken very little action to improve major trauma care. Deficiencies in major trauma care were identified by the Royal College of Surgeons in 1988, but there has been little progress since. In 2007, a report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) concluded that 60 per cent of major trauma patients received a standard of care that was ‘less than good practice’.

"As major trauma is a relatively small part of the work of an emergency department, optimal care cannot be delivered cost-effectively by all hospitals. People who have suffered major trauma often have multiple injuries which need to be treated by different surgical specialties. [...] The delivery of major trauma care lacks coordination and can lead to 11 unnecessary delays in diagnosis, treatment and surgery. There are currently no formal protocols for determining where people should be taken for treatment, nor a formal system for transferring patients between hospitals."

"The availability of rehabilitation varies widely across the country, and 14 services have not developed on the basis of geographical need. Although rehabilitation may help to reduce length of stay, minimise hospital readmissions, and reduce the use of NHS resources following the initial period of hospitalisation, it has not been considered to any great degree by strategic health authorities in their reviews of major trauma services. There is a widely perceived lack of capacity for the specialist rehabilitation of major trauma patients, but with little hard evidence about what services are currently available and how well they are arranged to meet patient needs, it is difficult to reach a conclusion on this."

The London Trauma System goes live on 1st April 2010.  There is a national process in place at the moment, although there are no deadlines or deliverables for this yet.  While the London system is probably secure politically, the national process is at the mercy of a change in government and policy.  Both systems are at risk if some key elements of the system are not addressed, especially the financial structure for trauma and the woeful state of rehabilitation services.  

The full report and executive summary are available from the National Audit Office website.  The BBC has radio and TV coverage of the release, including some footage filmed with us at the Royal London Hospital.

 

 

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PubMed ID: 20068485
J Trauma. 2010 Jan 9. [Epub ahead of print]
Authors: Glance LG, Osler TM, Dick AW, Mukamel DB, Meredith W.

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BACKGROUND:: This report describes a project funded by the Agency for Healthcare Research and Quality to evaluate the impact of providing hospitals with nonpublic report cards on trauma outcomes. The Survival Measurement and Reporting Trial for Trauma explores the feasibility of using the National Trauma Data Bank as a platform for measuring and improving trauma outcomes. METHODS:: We identified a cohort of 125 hospitals in the National Trauma Data Bank with annual hospital volumes of 250 or more trauma cases meeting specific minimum criteria for data quality. The performance of hospitals in this cohort was evaluated using hierarchical logistic regression model. The effect of each hospital on trauma mortality was captured by a shrinkage coefficient, which is exponentiated to yield an adjusted odds ratio. This adjusted odds ratio represents the likelihood that a trauma patient treated at a specific hospital is more or less likely to die compared with a patient treated at an "average" hospital. RESULTS:: The initial hospital cohort includes 125 hospitals and 157,045 patients admitted in 2006. Most hospitals are either level I (36%) or level II (34%) trauma centers. Patients admitted to the worst-performing hospitals were at least 50% more likely to die than patients admitted to the average hospital, after adjusting for injury severity. CONCLUSION: The initial findings of this trial suggest that there is significant variability in trauma mortality across centers caring for injured patients after adjusting for differences in patient casemix. This variation in risk-adjusted mortality presents an opportunity for improvement. The Survival Measurement and Reporting Trial for Trauma study is designed to test the hypothesis that nonpublic report cards can lead to improved population mortality for injured patients. The results of this study may have substantial implications in the future design and implementation of a national effort to report and improve trauma outcomes in the United States.

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This wide variability in outcomes at different hospitals is mirrored by other studies of injury care at individual institutions.   The Trauma Audit & Research Network iregularly collates this data for hospitals in England & Wales:

TARN trauma outcomes
(Source)

What is more concerning is that, unlike the UK figures, the hospitals in this study are mainly trauma centres and therefore should be meeting designated performance standards in order to maintain their trauma centre status.  It'd be interesting to see if there is similar variability between hospitals accredited under American College of Surgeons criteria for designation, rather than state or local criteria.

There are problems with this form of modelling.  Hospital's whose case mix varies from the national average may have skewed results (positively or negatively).  Additionally the relationship between statistical modelling of unexpected deaths or survivors has not yet been validated against assessment of the quality of clinical care.

Interesting also is that these are non-reported data.  TARN data is available to the general public, so you can see how your local hospital performs compared to the national average.  Here's part of our page from the Royal London Hospital.

Royal London Hospital TARN outcomes

There's nothing like public opinion to make hospitals up their game.

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Trauma Massive Transfusion - Epidemiology & Outcomes

 

So, just in time for this year's London Trauma Conference, we've uploaded the presentations from the 'Trauma Massive Transfusion & Coagulopathy State of the Art Symposium' held at the London Trauma Conference in 2008.  This set of lectures presents an overview of the current state of knowledge in the exploding field of Trauma Induced Coagulopathy (TIC) and transfusion practice.  At this year's conference we'll be holding a complementary Scientific Symposium on Trauma Haemostasis & Transfusion.  The programme is just being finalized and will be available in the next few days.  Meanwhile, enjoy the presentations from last year - and TRAUMA.ORG's new video channel on Vimeo.

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PubMed ID: 19680160
J Trauma. 2009 Aug 12.
Authors: Teixeira PG, Inaba K, Oncel D, Dubose J, Chan L, Rhee P, Salim A, Browder T, Brown C, Demetriades D.

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OBJECTIVE:: Because of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR. METHODS:: After approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Student's t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality. RESULTS:: Of 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >/=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality. CONCLUSION:: BCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.

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Coming shortly after our description of the patient with cardiac herniation following blunt trauma is this review of the National Trauma DataBank from the LA County group. Of course this is the tip of the iceberg as most patients will die at scene, but there's a surprisingly low (42%) mortality in the emergency department, suggesting that a significant proportion of these patients should be salvageable if identified early and managed appropriately.

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