To compare mortality in elderly trauma patients sustaining fall or motor vehicle collision (MVC) related injuries and who are subsequently treated at regional Level I (tertiary) trauma centers.
An increase in the mean age of the Canadian population is leading to a higher proportion of older patients injured in falls who are subsequently treated at Level 1 trauma centers in Quebec. The Level 1 centers were designed to treat younger patients injured in MVCs and violent acts. As a result, discordance may exist between the type of care supplied at these centers and the increased demand for care tailored to older trauma patients.
A retrospective cohort study comprised of 4,717 patients over the age of 65; 606 (12.8%) injured in MVCs and 4,111 (87.2%) in falls. The mean (SD) age was 79.6 (8.0) years and 67.9% were female. The mean (SD) Injury Severity Score (ISS) was 10.8 (7.4). Data were obtained from the Quebec Trauma Registry (QTR) for patients treated at 3 Level I trauma centers in the province of Quebec, Canada. The primary outcome measure in this study was mortality.
Being injured in a fall was a strong predictor for mortality, with an odds ratio of 5.11 (95% C.I. = 1.84-14.17, P = 0.002). Additionally, the adjusted mortality rate was 25.3% among fall victims, versus 7.8% for MVC patients. Female gender, older age, higher ISS and an increasing number of injuries were all associated with heightened mortality. In contrast, the number of body regions injured, experiencing complications, sustaining a hip fracture, the Revised Trauma Score, the Prehospital Index and the Charlson (comorbidity) Index had no association with mortality in the Level I centers.
Elderly patients sustaining fall-related injuries and treated at Level I trauma centers are at risk for excess mortality when compared with those injured in MVCs. Effective and efficient methods for treating this population must be determined.
Regionalized trauma systems have been shown repeatedly to improve the outcome of seriously injured patients. However, we do not have data regarding which components of these systems have the most impact on outcome and to what degree. The objective of this study was to understand the association between various components that make up a trauma system and outcome.
Surveys were administered to trauma directors at 59 hospitals in the province of Quebec, Canada. Data from the surveys were then linked with specific outcome variables obtained from a regionalized trauma database. Specific outcomes were assigned to trauma system- and in-hospital-based components after controlling for injury severity.
Over 4.8 years, 72,073 patients met inclusion criteria. Components found to affect survival after risk adjustment were prehospital notification (OR, 0.61; 95% CI, 0.39-0.94) and the presence of a performance improvement program in that hospital (OR, 0.44; 95% CI, 0.20-0.94). Increased patient volume was associated with a reduction in risk-adjusted mortality (OR, 0.98; 95% CI, 0.97-0.99). Tertiary trauma centers were also associated with a reduction in risk-adjusted mortality compared with both secondary and primary centers (OR, 0.68; 95% CI, 0.48-0.99).
Improvements in outcome in a regionalized trauma system are secondary to a combination of elements, as well as to the interplay of these elements on each other. Prehospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.
The most important benefit of a socialized health care system is the elimination of the threat of personal financial ruin to pay for medical care. Serious disadvantages of a socialized health care system, particularly in a university hospital setting, include restricted financial resources for education and patient care, limited working facilities, and loss of physician-directed decision making in planning and prioritizing. This article describes how a group practice model has supported clinical and academic activities within the faculty of medicine of our university and offers this model as a possible template for other surgical and medical disciplines working in an academic socialized environment.
We sought to evaluate the performance of the Prehospital Index (PHI), the high velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients.
The study population included all prehospital trauma patients transported by an emergency medical service to 2 level I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage.
Of 16,805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score > or = 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the low est rate of overtriage.
Although the combination of PHI score, HVI presence and EMT judgment offers the highest sensitivity for the identification of patients that could benefit from direct transport to a level I trauma centre, overall sensitivity remains low and over triage is high. More research is required to improve prehospital triage.
The purpose of this study was to describe the functional status and quality of life (QOL) of patients at 12 months after injury.
Retrospective study consisting of patients treated at three tertiary trauma centers for injuries. Functional capacity (FC) was measured using the Sickness Impact Profile and QOL was measured using the Medical Outcomes Study Short Form (MOS SF-36) at approximately 12 months after the date of injury.
There were 144 patients that fulfilled the study inclusion and exclusion criteria. The mean duration of follow-up was 1.3 years, with a range of 0.8 to 1.5 years. Age and gender were not associated with the FC or QOL. The mean(standard deviation) Injury Severity Score (ISS) was 18.9(9.4), whereas ISS category distribution was 1 to 11 (22.9%), 12 to 24 (50.0%), and 25 to 49 (27.1%). Patients with an ISS of 25 to 49 had significantly worse physical (p = 0.008) and total (p = 0.023) Sickness Impact Profile scores and had more physical functioning (p = 0.096), emotional role functioning (p = 0.080), and energy (p = 0.017) impairments when compared with those with an ISS less than 24. Patients injured in motor vehicle collisions had significantly impaired psychosocial function (p = 0.031), whereas those injured in falls had reduced quality of life scores for physical function (p = 0.089), physical role (p = 0.066), and mental health (p = 0.081).
Patients who survive injuries experience residual impairments in FC and QOL for as long as 1 year after injury. Changes to the long-term management of these patients should be considered.
Didactic lectures have been the mainstay of core teaching in the surgical residency program at our school. Our concerns about the educational impact of these passive activities led us to consider more interactive teaching approaches.
We developed an interactive games-based approach to learning. One set of games was labeled "Who wants to be a Surgeon" (WS) and the other was called "Senior Face-off" (SF). We evaluated the impact of this innovation using an end-of-year questionnaire.
Enjoyment, teaching quality and preference over lectures were high for both games. However, the WS sparked interest significantly more in junior residents (4.3 +/- 0.21 vs 3.3 +/- 0.31, p = 0.015) and senior residents found both games more stressful than did junior residents (WS: 2.88 +/- 0.32 vs 2.00 +/- 0.21, p = 0.038, and SF: 3.54 +/- 0.29 vs 1.80 +/- 0.33, p = 0.001).
This innovative teaching technique promoted learner interest and was regarded as a worthwhile educational activity. Games with a competitive emphasis may unduly stress senior residents.
The treatment of obesity and related comorbidities are significant financial burdens and sources of resource expenditure. This study was conducted in order to assess the impact of weight-reduction surgery on health-related costs.
This was an observational two-cohort study. The treatment cohort included patients having undergone weight-reduction (bariatric) surgery at the McGill University Health Centre (MUHC) between 1986 and 2002. The control group included age and gender matched obese patients who had not undergone weight-reduction surgery from the Quebec provincial health insurance database (RAMQ). The cohorts were followed for a maximum of 5 years from inception. The primary outcome measure was overall direct healthcare costs. Secondary outcomes included cost analysis by diagnostic category for the treatment of new medical conditions following cohort inception.
The cohorts were well-matched for age, gender and duration of follow-up. Patients having undergone bariatric surgery had significant reductions in mean percent initial excess weight loss (67.1%, P
The regionalization of trauma services has been implemented in many health care systems and communities over the past 10 to 20 years. As these trauma systems mature and evolve, changes are made to improve the care and efficiency of the system. Trauma care regionalization was introduced in Quebec in 1993. This study looked at the evolution of trauma care in Quebec over the past 13 years, from the preregionalization era to the present.
A retrospective review scientifically evaluated a trauma system, the implementation of evidence-based changes, and the efficacy of these changes.
Various changes have been made in the Quebec trauma system since the introduction of regionalization. These changes have led to an incremental decrease in mortality caused by severe trauma from 51.8% in 1992 to 8.6% in 2002.
A trauma system is fluid and constantly evolving. Research and constant reevaluation are necessary for continuous evaluation of the system and improvement of its outcomes and efficiency.
: Despite serious documented limitations, the Trauma Injury Severity Score (TRISS) is still used for risk adjustment in trauma system evaluation and clinical research. Several modifications have been proposed to address TRISS limitations. We aimed to assess the impact of proposed TRISS modifications on the accuracy of mortality prediction for blunt trauma.
: The Quebec Trauma Registry (QTR), based on a mature, regionalized trauma system with mandatory participation of all trauma centers as well as standardized inclusion criteria and coding practices, was used to evaluate TRISS modifications. The National Trauma Data Bank was then used to validate our findings. Gains in predictive accuracy were evaluated in logistic regression models of hospital mortality with the area under the receiving operator curve and the Hosmer-Lemeshow statistic.
: When population-based weights, expanding age, modeling the Glasgow Coma Scale score as a quantitative variable, adding an indicator of comorbid status, and modeling quantitative variables with nonparametric functions to allow the expression of nonlinear relations to mortality were used, all were associated with a significant improvement in model discrimination.
: Several modifications that have been proposed to address limitations of the TRISS lead to significant improvements in the accuracy of mortality prediction. This study provides valuable information in the quest to improve trauma mortality modeling.
Since the introduction of a regionalized trauma system in Quebec in 1993, patient loads at level I trauma centres have been increasing gradually. We aimed to investigate the type of patient presenting to 4 tertiary trauma centres in Quebec, the nature of their injuries and whether there was a need to modify triage protocols.
The study consisted of a review of major trauma patients entered into a regional trauma registry between Apr. 7, 1993, and Mar. 31, 2000. A total of 29 669 patients fulfilled the eligibility criteria. We compared patient demographics, injury type and severity and mechanism of injury.
During the 7 years of the study, there was an increase in the volume and presentation of patients injured in falls (p
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