A population-based assessment of major trauma in a large Canadian region

doi:10.1016/j.amjsurg.2005.01.036

The American Journal of Surgery

Volume 189, Issue 5, May 2005, Pages 571-576

Presented at the 91st Annual Meeting of the North Pacific Surgical Association, Tacoma, Washington, November 12–13, 2004

https://doi.org/10.1016/j.amjsurg.2005.01.036 Get rights and content

Abstract

Background

The cause of major trauma has not been well defined using population-based methodologies.

Methods

We performed a population-based surveillance of major traumatic injuries in adult residents of the Calgary Health Region over a period of 3 years.

Results

A total of 1,475 victims of major trauma were identified (69.5 per 100,000/y). Males were at significantly higher risk as compared with females (104.5 vs. 35.2 per 100,000; relative risk = 3.0, 95% confidence interval = 2.64–3.35), as were urban as compared with rural residents (70.7 vs. 49.0 per 100,000; relative risk = 1.4; 95% confidence interval = 1.11–1.91). A strikingly high incidence rate of major trauma was observed among those aged 85 years or more at 242.3 per 100,000 per year; elderly men were at 16.8-fold (95% confidence interval = 11.04–24.79) higher risk than young females. The majority were unintentional (53.9 per 100,000/y). Suicide, assault, and homicide occurred at annualized rates of 8.5, 4.8, and 1.6 per 100,000, respectively. Motor vehicle-related injuries (39%), falls or jumps (33%), and being struck by an object or animal (10%) were responsible for the majority of traumas. Firearm injuries were relatively uncommon (2.0 per 100,000/y). The annual mortality rate was 20.0 per 100,000.

Conclusions

This study provides rigorous, population-based data on the cause of severe injury in the Calgary Health Region. It is hoped that ongoing work in this area will be useful in the development of effective injury prevention and health resource allocation strategies.

Section snippets

Patient population

The Calgary Health Region (CHR) is a fully integrated, publicly funded health system that provides virtually all medical and surgical care to the residents of the cities of Calgary and Airdrie and approximately 20 nearby small towns, villages, and hamlets [21]. In the CHR, adult trauma services are regionalized to the Foothills Medical Centre, which is the only adult tertiary care trauma center servicing southern Alberta, Canada. All adult (≥18 years) victims of major traumatic injury as

General features of the study population

A total of 1,475 patients were victims of a major trauma during the study period for an overall annual adult incidence rate of 69.5 per 100,000 population (total population at risk over 3 years = 2,123,049). Three individuals had second discrete episodes of major trauma during the study period but the second episodes were excluded from analyses. Significant quarterly variations in trauma incidence were observed, with the highest incidence occurring between July and September (29%) and the

Comments

This study provides important information on the burden of illness associated with major trauma in a nonselected Canadian population and identifies demographic groups at the highest risk for acquiring major injury. We used an active, prospective, population-based surveillance methodology that is regarded widely as optimal for defining the cause of a health condition [9], [24], [27]. An important threat to the validity of this design is the comprehensive identification of all patients fulfilling

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The registries will create case series of traumatic events and will profile population-based cohorts of injured patients for research and health policy analyses. As in previous studies, data can be mapped to identify vulnerable populations, evolving patterns of injury, and risk factors associated with traumatic injuries,38-40 however, eTHR will allow this to occur in real time. Future research in this area should describe processes for successful adaptation of mHealth tools into diverse trauma environments through iterative testing and perpetual redesign of the apps.
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The study was conducted in 3 phases: 1. Design of an electronic application capable of supporting clinical care and injury surveillance; 2. Preliminary feasibility testing of eTHR in a low-resource, high-volume trauma center; and 3. Qualitative usability testing with 22 trauma clinicians from a spectrum of high- and low-resource and urban and remote settings including Vancouver General Hospital, Whitehorse General Hospital, British Columbia Mobile Medical Unit, and Groote Schuur Hospital in Cape Town, South Africa.
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The eTHR has potential to be used as an electronic medical record, guiding clinical care while providing data for injury surveillance, without significantly hindering hospital workflow in various health-care settings.
Evaluating potential spatial access to trauma center care by severely injured patients
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Injuries are a major public health problem around the world. Previous research has suggested that providing prompt access to specialized trauma center care may greatly improve the health outcomes of trauma patients. In this paper, a geographic information system (GIS) method is used to examine potential spatial access to trauma centers by individuals who were either hospitalized or died as a result of a major trauma. Overall, it was determined that 68.5% of individuals who suffered from a major trauma lived within one hour travel time of a Level I or II trauma center. In addition, major traumas resulting in death were found to have poorer potential spatial access to trauma center care than those that were admitted to hospital.
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Few studies have assessed the impact of pre-existing medical comorbidities on long-term survival after major trauma. This study investigated the influence of comorbidities as measured by the Charlson Comorbidity Index (CCI) on the 1-year mortality after major traumatic injury.
Adult patients who survived their initial trauma admission in Calgary, Alberta, Canada, between April 1, 2002, and March 31, 2006, defined the study population. Clinical and outcome information was obtained from regional electronic databases.
The study population consisted of 3,080 patients. The median age was 43.3 years (interquartile range, 26.9–59.3 y), and the median Injury Severity Score was 20 (interquartile range, 16–25). A total of 478 patients (15.5%) had at least one pre-existing comorbidity. The 1-year mortality rate was 2.7% (83 of 3,080). After adjusting for the confounding effects of age, the CCI was independently associated with 1-year mortality with an odds ratio of 1.24 (95% confidence interval, 1.02–1.51; P = .03) per point on the CCI. A model that included the CCI and age accurately predicted 1-year mortality (C-statistic, .83; 95% confidence interval, .78–.87; P < .0001).
Comorbid illnesses have an important influence on long-term outcomes after major trauma. Whether this represents an inherent risk for adverse outcome or an opportunity for enhanced medical co-management remains to be defined.
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There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines (‘potential major trauma’) with trauma patients who are identified as ‘confirmed major trauma patients’ at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.
For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as ‘confirmed major trauma patients’ and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the ‘potential major trauma’ group. Non-major trauma patients (N = 27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.
The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.
While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.
A comparison of metropolitan vs rural major trauma in Western Australia
2011, Resuscitation
Citation Excerpt :
There have been few population based studies of major trauma.14–17 They are often limited by failures to account for interhospital transfers, prehospital deaths, or referrals from outside the base population.17 Comparisons can be difficult because of variability of definitions of severe trauma and methodologic inconsistencies.17
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Major trauma (Injury Severity Score, ISS > 15) data from the Royal Flying Doctor Service (RFDS) and Trauma Registries, 1 July 1997–30 June 2006. Two groups were studied: Metro (metropolitan major trauma transported directly to a tertiary hospital), and Rural (rural major trauma transferred by the RFDS to a tertiary hospital in Perth). The primary endpoint was death. We used logistic regression and multiple imputation.
3333 major trauma patients were identified (mean age 40.1 ± 22.6 yrs; Metro = 2005, Rural = 1328). The rural patients were younger, had a larger proportion of motor vehicle crashes, and higher median ISS (25 vs 24, p < 0.001). Mean times to definitive care were 59 min versus 11.6 h, respectively (p < 0.0001). After adjusting for age, injury severity and the effect of time with the initial rural deaths, there was a significantly increased risk of death (OR 2.60, 95% CI 1.05–6.53, p = 0.039) in the Rural group. For those rural patients who reached Perth, the adjusted OR for death was 1.10 (95% CI 0.66–1.84, p = 0.708).
There is more than double the risk of major trauma death in rural and remote WA. However, if a major trauma patient survives to be retrieved to Perth by the RFDS, then mortality outcomes are equivalent to the metropolitan area.
Cost and outcomes of nosocomial bloodstream infections complicating major traumatic injury
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The objective of this study was to assess the incidence, outcomes, and costs of trauma-related nosocomial bloodstream infection (BSI). This was a 3:1 matched cohort study in patients with severe trauma [defined by an injury severity score (ISS) ≥ 12] admitted to adult or paediatric regional trauma centres over a four-year period. Case patients with nosocomial BSI were matched to controls without a BSI based on predetermined criteria. Outcomes of interest included mortality, length of stay (LOS), and cost attributable to nosocomial BSI. Fifty-seven cases were identified, among whom 51 were successfully matched to three controls. The mean ISS among cases was 30.3, and Staphylococcus aureus was the most commonly isolated pathogen (27%). Being a case was accompanied by a 27% relative increase in the hospital LOS (P = 0.02). The odds ratio for 30 day mortality associated with being a case was 5.8 (95% confidence interval (CI): 1.1–30.8; P = 0.04). Among survivor-matched groups, being a case was associated with 53% relative increase in the geometric mean total hospital cost [$97,993 (95% CI: $70,143–136,899) for cases and $62,297 (95% CI: $52,155–74,411) for controls, P < 0.0001]. This is the first study to show that nosocomial BSI complicating severe trauma is associated with a substantial increase in hospital LOS and in total hospital cost. Our data provide justification to support efforts to reduce the adverse impact of BSI in trauma victims.

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Scientific paperA population-based assessment of major trauma in a large Canadian region

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patient population

General features of the study population

Comments

J Clin Epidemiol

J Am Coll Surg

Am J Prev Med

Arch Phys Med Rehabil

Am J Ophthalmol

Am J Ophthalmol

The epidemiology of disability and occupation handicap resulting from major traumatic injury

Disabil Rehabil

A population-based study of hospitalized injuries in Kingston, Ontario, identified via the Canadian Hospitals Injury Reporting and Prevention Program

Chronic Dis Can

The epidemiology of major trauma in Northern Ireland

Ulster Med J

Incidence rates of firearm injuries in Galveston, Texas, 1979–1981

Am J Epidemiol