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Importance: Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking., Objective: To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation., Design, Setting, and Participants: A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included., Main Outcomes and Measures: Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%)., Results: A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%)., Conclusions and Relevance: In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data.

Mass casualty incidents (MCIs) are diverse, unpredictable, and increasing in frequency, but preparation is possible and necessary. The nature of MCIs requires a trauma response but also requires effective and tested disaster preparedness planning. From an international perspective, the aims of this narrative review are to describe the key components necessary for optimisation of trauma system preparedness for MCIs, whether trauma systems and centres meet these components and areas for improvement of trauma system response. Many of the principles necessary for response to MCIs are embedded in trauma system design and trauma centre function. These include robust communication networks, established triage systems, and capacity to secure centres from threats to safety and quality of care. However, evidence from the current literature indicates the need to strengthen trauma system preparedness for MCIs through greater trauma leader representation at all levels of disaster preparedness planning, enhanced training of staff and simulated disaster training, expanded surge capacity planning, improved staff management and support during the MCI and in the post-disaster recovery phase, clear provision for the treatment of paediatric patients in disaster plans, and diversified and pre-agreed systems for essential supplies and services continuity. Mass casualty preparedness is a complex, iterative process that requires an integrated, multidisciplinary, and tiered approach. Through effective preparedness planning, trauma systems should be well-placed to deliver an optimal response when faced with MCIs., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: Evaluate interhospital variation in resource use for in-hospital injury deaths., Background: Significant variation in resource use for end-of-life care has been observed in the US for chronic diseases. However, there is an important knowledge gap on end-of-life resource use for trauma patients., Methods: We conducted a multicenter, retrospective cohort study of injury deaths following hospitalization in any of the 57 trauma centers in a Canadian trauma system (2013-2016). Resource use intensity was measured using activity-based costing (2016 $CAN) according to time of death (72 h, 3-14 d, ≥14 d). We used multilevel log-linear regression to model resource use and estimated interhospital variation using intraclass correlation coefficients (ICC)., Results: Our study population comprised 2044 injury deaths. Variation in resource use between hospitals was observed for all 3 time frames (ICC = 6.5%, 6.6%, and 5.9% for < 72 h, 3-14 d, and ≥14 d, respectively). Interhospital variation was stronger for allied health services (ICC = 18 to 26%), medical imaging (ICC = 4 to 10%), and the ICU (ICC = 5 to 6%) than other activity centers. We observed stronger interhospital variation for patients < 65 years of age (ICC = 11 to 34%) than those ≥65 (ICC = 5 to 6%) and for traumatic brain injury (ICC = 5 to 13%) than other injuries (ICC = 1 to 8%)., Conclusions: We observed variation in resource use intensity for injury deaths across trauma centers. Strongest variation was observed for younger patients and those with traumatic brain injury. Results may reflect variation in level of care decisions and the incidence of withdrawal of life-sustaining therapies., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Mass casualty incidents (MCIs) put substantial stress on loco-regional resources, and trauma centers are critical to responding to these events. Our previous evaluation of Canadian centers helped to identify several weaknesses in disaster responsiveness. In this analysis, we determined the current state of MCI readiness across Canada and how this has changed over time. A multinational cross-sectional survey-based study on MCI preparedness was performed, including 24 Canadian trauma centers. Surveys were completed anonymously online by representatives of each facility. Responses from Canadian centers were examined and compared to previous findings to assess temporal changes in institutional capacity. Fifteen (63%) trauma centers responded, 100% of which had a disaster committee. Sixty percent had a single all-hazards emergency plan, and 71% performed a practice drill in the last two years. Sixty-two percent had communications systems designed to function during an MCI. Ninety-two percent had a triage system in place, and 54% of centers could monitor surge capacity. Half (54%) reported back-up systems for survival essentials, but the capability for prolonged operation during a disaster was limited. A minority (15%) had a database denoting staff with emergency training, although half (54%) had disaster training programs. Comparison to past data showed an increased prevalence of committees dedicated to disaster preparedness and disaster drills but worsened external stakeholder representation and poor ability to provide a prolonged response to crises. Our results demonstrate that MCI preparedness is a growing focus of Canadian trauma centers, but that there are deficiencies that remain unaddressed. Future efforts should focus on these vulnerabilities to ensure the provision of a robust disaster response. LEVEL OF EVIDENCE: Level 3b (prevalence study, limited population).

Background: The incidence of older adult traumatic brain injury (TBI) is increasing in both high and middle to low-income countries. It is unknown whether older adults with isolated, serious TBI can be safely managed outside of major trauma centres. This registry based cohort study aimed to compare mortality and functional outcomes of older adults with isolated, serious TBI who were managed at specialised Major Trauma Services (MTS) and Metropolitan Neurosurgical Services (MNS)., Method: Older adults (65 years and over) who sustained an isolated, serious TBI following a low fall (from standing or ≤ 1 m) were extracted from the Victorian State Trauma Registry from 2007 to 2016. Multivariable models were fitted to assess the association between hospital designation (MTS vs. MNS) and the two outcomes of interest: in-hospital mortality and functional outcome, adjusting for potential confounders. Functional outcomes were measured using the Glasgow Outcome Scale Extended at six months post-injury., Results: From 2007-2016, there were 1904 older adults who sustained an isolated, serious TBI from a low fall who received definitive care at an MTS (n = 1124) or an MNS (n = 780). After adjusting for confounders, there was no mortality benefit for patients managed at an MTS over an MNS (OR = 0.84; 95% CI: 0.65, 1.08; P = 0.17) or improvement in functional outcome six months post-injury (OR = 1.13; 95% CI: 0.94, 1.36; P = 0.21)., Conclusion: For older adults with isolated, serious TBI following a low fall, there was no difference in mortality or functional outcome based on definitive management at an MTS or an MNS. This confirms that MNS without the added designation of a major trauma centre are a suitable destination for the management of isolated, serious TBI in older adults., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Variations in adjusted costs have been observed among trauma centres in the United States but patient outcomes were not better in centres with higher costs. Attempts to improve injury care efficiency are hampered by insufficient patient-level information on resource use and on the drivers of resource use intensity., Objectives: To estimate patient-level resource use for injury admissions, identify determinants of resource use intensity, and evaluate inter-hospital variations in resource use., Methods: We conducted a retrospective cohort study including ≥16-year-olds admitted to adult trauma centres in a mature, inclusive Canadian trauma system between 2014 and 2016. We extracted data from the trauma registry and hospital financial reports. We estimated resource use with activity-based costs, identified determinants of resource use intensity using a multilevel linear model and assessed the relative importance of each determinant with Cohen's f 2 . We evaluated inter-provider variations with intraclass correlation coefficients (ICC) and 95% confidence intervals., Results: We included 32,411 patients. Median costs per admission were $4857 (Quartiles 1 and 3 2961-8448). The most important contributors to total resource use were the medical ward (57%), followed by the operating room (OR; 23%) and the intensive care unit (13%). The strongest determinant of resource use intensity was discharge destination (Cohen's f 2  = 7%). The most resource intense patient group was spinal cord injuries with $11,193 (7115-17,606) per admission. While resource use increased with increasing age for the medical ward, it decreased with increasing age for the OR. Resource use was 18% higher in level I centres compared to level IV centres and we observed significant variations in resource use across centres (ICC = 5% [4-6]), particularly for the OR (28% [20-40])., Conclusions: Resource use for acute injury care in Quebec is not solely due to the clinical status of patients. We identified determinants of resource use that can be used to establish evidence-based resource allocations and improve injury care efficiency. The method we developed for estimating patient-level, in-hospital resource use for injury admissions and identifying related determinants could be reproduced using local trauma registry data and our unit costs or unit costs specific to each setting., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Incidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient's health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon., Methods: Two hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers., Results: At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period., Conclusions: Overall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: The aim of this study was to describe post-discharge outcomes, and determine predictors of 3 and 6 months health status outcomes in a population of trauma patients at an inner city major trauma centre., Methods: This was a prospective cohort study of adult trauma patients admitted to this hospital with 3 and 6 months post-discharge outcomes assessment. Outcome measures were the Physical Component Scores (PCS) and Mental Component Scores (MCS) of the Short Form 12, EQ-5D, and return to work (in any capacity) if working prior to injury. Repeated measures mixed models and generalised estimating equation models were used to determine predictors of outcomes at 3 and 6 months., Results: One hundred and seventy-nine patients were followed up. Patients with lower limb injuries reported lower mean PCS scores between 3 and 6 months (coefficient -4.21, 95 % CI -7.58, -0.85) than those without lower limb injuries. Patients involved in pedestrian incidents or assaults and those with pre-existing mental health diagnoses reported lower mean MCS scores. In adjusted models upper limb injuries were associated with reduced odds of return to work at 3 and 6 months (OR 0.20, 95 % CI 0.07, 0.57) compared to those without upper limb injuries., Discussion: Predictors of poorer physical health status were lower limb injuries and predictors of mental health were related to the mechanism of injury and past mental health. Increasing injury severity score and upper limb injuries were the only predictors of reduced return to work. The results provide insights into the feasibility of routine post-discharge follow-up at a trauma service level.

Aims: In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip., Patients and Methods: All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days., Results: There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals., Conclusion: These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip., Take Home Message: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Introduction: Trampoline-related injuries in adults are uncommon. Participation in trampolining is increasing following its admission as a sport in the Olympics and the opening of local recreational trampoline centres. The aim of this study was to assess the number and outcomes of adult trampoline-related orthopaedic injuries presenting to four trauma hospitals in Victoria., Methods: A cohort study was performed for the period 2007-2013. Adult patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who had sustained a trampolining related injury were included in this study. Descriptive analyses were used to describe the patient population, the injuries sustained and their in-hospital and 6-month outcomes., Results: There was an increase in trampolining injuries from 2007 (n=3) to 2012 (n=14) and 2013 (n=18). Overall, fifty patients with a median age of 25 (range 16-66) were identified. Thirty-five patients (70%) had lower limb injuries, 20 patients (40%) had spinal injuries and one patient had an upper limb injury. Thirty-nine patients (78%) required surgery. Fractures of the tibia (n=13), ankle fractures (n=12) and cervical spine injuries (n=7) were the most common injuries; all of which required surgery. Complications included death, spinal cord injuries, compartment syndrome and open fractures. At 6 months post injury, more than half (52%) of the patients had not achieved a good recovery, 32% had some form of persistent disability, 14% did not get back to work and overall physical health for the cohort was well below population norms for the SF-12., Conclusion: Adult trampoline-related injuries have increased in the last few years in this cohort identified through VOTOR. Lower limb and spinal injuries are most prevalent. Public awareness and education are important to reduce the risk for people participating in this activity., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The Injury Severity Score (ISS) is the most ubiquitous summary score derived from Abbreviated Injury Scale (AIS) data. It is frequently used to classify patients as 'major trauma' using a threshold of ISS >15. However, it is not known whether this is still appropriate, given the changes which have been made to the AIS codeset since this threshold was first used. This study aimed to identify appropriate ISS and New Injury Severity Score (NISS) thresholds for use with the 2008 AIS (AIS08) which predict mortality and in-hospital resource use comparably to ISS >15 using AIS98., Methods: Data from 37,760 patients in a state trauma registry were retrieved and reviewed. AIS data coded using the 1998 AIS (AIS98) were mapped to AIS08. ISS and NISS were calculated, and their effects on patient classification compared. The ability of selected ISS and NISS thresholds to predict mortality or high-level in-hospital resource use (the need for ICU or urgent surgery) was assessed., Results: An ISS >12 using AIS08 was similar to an ISS >15 using AIS98 in terms of both the number of patients classified major trauma, and overall major trauma mortality. A 10% mortality level was only seen for ISS 25 or greater. A NISS >15 performed similarly to both of these ISS thresholds. However, the AIS08-based ISS >12 threshold correctly classified significantly more patients than a NISS >15 threshold for all three severity measures assessed., Conclusions: When coding injuries using AIS08, an ISS >12 appears to function similarly to an ISS >15 in AIS98 for the purposes of identifying a population with an elevated risk of death after injury. Where mortality is a primary outcome of trauma monitoring, an ISS >12 threshold could be adopted to identify major trauma patients., Level of Evidence: Level II evidence--diagnostic tests and criteria., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objectives: The primary aim of this study was to examine the impact of the introduction of an integrated adult critical care patient retrieval system in Victoria, Australia, on early clinical outcomes for major trauma patients who undergo interhospital transfer. The secondary aims were to examine the impact on quality and process measures for interhospital transfers in this population, and on longer-term patient-reported outcomes., Methods: This is a cohort study using data contained in the Victorian State Trauma Registry (VSTR) for major trauma patients >18 years of age between 2009 and 2013 who had undergone interhospital transfer. For eligible patients, data items were extracted from the VSTR for analysis: demographics, injury details, hospital details, transfer details, Adult Retrieval Victoria (ARV) coordination indicator and transfer indicator, key clinical observations and outcomes., Results: There were 3009 major trauma interhospital transfers in the state with a transfer time less than 24 h. ARV was contacted for 1174 (39.0%) transfers. ARV-coordinated metropolitan transfers demonstrated lower adjusted odds of inhospital mortality compared with metropolitan transfers occurring without ARV coordination (OR 0.39, 0.15 to 0.97). Adjusting for destination hospital type demonstrates that this impact was principally due to ARV facilitation of a Major Trauma Service as the destination for transferred patients (OR 0.41, 0.16 to 1.02). The median time spent at the referral hospital was lower for ARV-coordinated transfers (5.4 h (3.8 to 7.5) vs 6.1 (4.2 to 9.2), p<0.0001)., Conclusions: In a mature trauma system, an effective retrieval service can further reduce mortality and improve long-term outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To describe the burden of road transport-related serious injury in Victoria, Australia, over a 10-year period, after the introduction of an integrated trauma system., Background: Road traffic injury is a leading cause of death and disability worldwide. Efforts to improve care of the injured are important for reducing burden, but the impact of trauma care systems on burden and cost of road traffic injury has not been evaluated., Methods: All road transport-related deaths and major trauma (injury severity score >12) cases were extracted from population-based coroner and trauma registry data sets for July 2001 to June 2011. Modeling was used to assess changes in population incidence rates and odds of in-hospital mortality. Disability-adjusted life years, combining years of life lost and years lived with disability, were calculated. Cost of health loss was calculated from estimates of the value of a disability-adjusted life year., Results: Incidence of road transport-related deaths decreased (incidence rate ratio 0.95, 95% confidence interval: 0.94-0.96), whereas the incidence of hospitalized major trauma increased (incidence rate ratio 1.03, 95% confidence interval: 1.02-1.04). Years of life lost decreased by 43%, and years lived with disability increased by 32%, with an overall 28% reduction in disability-adjusted life years over the decade. There was a cost saving per case of A$633,446 in 2010-2011 compared with the 2001-2002 financial year., Conclusions: Since introduction of the trauma system in Victoria, Australia, the burden of road transport-related serious injury has decreased. Hospitalized major trauma cases increased, whereas disability burden per case declined. Increased survival does not necessarily result in an overall increase in nonfatal injury burden.

Introduction: Quality improvement programmes are an important part of care delivery in trauma centres. The objective was to describe the effect of a comprehensive quality improvement programme on long term patient outcome trends at a low volume major trauma centre in Australia., Methods: All patients aged 15 years and over with major trauma (Injury Severity Score>15) admitted to a single inner city major trauma centre between 1992 and 2012 were studied. The outcomes of interest were in-hospital mortality and transfer to rehabilitation. Time series analysis using integer valued autoregressive Poisson models was used to determine the reduction in adjusted monthly count data associated with the intervention period (2007-2012). Risk adjusted odds ratios for mortality over three yearly intervals was also obtained using multivariable logistic regression. Crude and risk adjusted mortality was compared before and after the implementation period., Results: 3856 patients were analysed. Crude in-hospital mortality fell from 16% to 10% after implementation (p<0.001). The intervention period was associated with a 25% decrease in monthly mortality counts. Risk adjusted mortality remained stable from 1992 to 2006 and did not fall until the intervention period. Crude and risk adjusted transfer to in-patient rehabilitation after major trauma also declined during the intervention period., Conclusion: In this low volume major trauma centre, the implementation of a comprehensive quality improvement programme was associated with a reduction in crude and risk adjusted mortality and risk adjusted discharge to rehabilitation in severely injured patients., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Head injury is the leading cause of death and long term disability from bicycle injuries and may be prevented by helmet wearing. We compared the pattern of injury in major trauma victims resulting from bicyclist injury admitted to hospitals in the State of Victoria, Australia and South-West Netherlands, with respective high and low prevalence of helmet use among bicyclists., Methods: A cohort of bicycle injured patients with serious injury (defined as Injury Severity Score>15) in South-West Netherlands, was compared to a cohort of serious injured bicyclists in the State of Victoria, Australia. Additionally, the cohorts of patients with serious injury admitted to a Dutch level 1 trauma centre in Rotterdam, the Netherlands and an Australian level 1 trauma centre in Melbourne, Australia were compared. Both cohorts included patients admitted between July 2001 and June 2009. Primary outcome was in-hospital mortality and secondary outcome was prevalence of severe injury per body region. Outcome was compared using univariate analysis and mortality outcomes were also calculated using multivariable logistic regression models., Results: A total of 219 cases in South-West Netherlands and 500 cases in Victoria were analyzed. Further analyses comparing the major trauma centres in each region, showed the percentage of bicycle-related death was higher in the Dutch population than in the Australian (n=45 (24%) vs n=13(7%); P<0.001). After adjusting for age, mechanism of injury, GCS and head injury severity in both hospitals, there was no significant difference in mortality (adjusted odds ratio 1.4; 95% confidence interval=0.6, 3.5). Patients in Netherlands trauma centre suffered from more serious head injuries (Abbreviated Injury Scale≥3) than patients in the Australian trauma centre (n=165 (88.2%) vs n=121 (62.4%); P<0.001). The other body regions demonstrated significant differences in the AIS scores with significantly more serious injuries (AIS≥3) of the chest, abdominal and extremities regions in the Australian group., Conclusion: Bicycle related major trauma admissions in the Netherlands trauma centre, and in South-West Netherlands had a higher mortality rate associated with a higher percentage of serious head injuries compared with that in the Australian trauma centre and the State of Victoria., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To describe outcomes of major trauma survivors managed in an organized trauma system, including the association between levels of care and outcomes over time., Background: Trauma care systems aim to reduce deaths and disability. Studies have found that regionalization of trauma care reduces mortality but the impact on quality of survival is unknown. Evaluation of a trauma system should include mortality and morbidity., Methods: Predictors of 12-month functional (Glasgow Outcome Scale-Extended) outcomes after blunt major trauma (Injury Severity Score >15) in an organized trauma system were explored using ordered logistic regression for the period October 2006 to June 2009. Data from the population-based Victorian State Trauma Registry were used., Results: There were 4986 patients older than 18 years. In-hospital mortality decreased from 11.9% in 2006-2007 to 9.9% in 2008-2009. The follow-up rate at 12 months was 86% (n = 3824). Eighty percent reported functional limitations. Odds of better functional outcome increased in the 2007-2008 [adjusted odds ratio (AOR): 1.22; 95% CI: 1.05, 1.41] and 2008-2009 (AOR: 1.16; 95% CI: 1.01, 1.34) years compared with 2006-2007. Cases managed at major trauma services (MTS) achieved better functional outcome (AOR: 1.22; 95% CI: 1.03, 1.45). Female gender, older age, and lower levels of education demonstrated lower adjusted odds of better outcome., Conclusions: Despite an annual decline in mortality, risk-adjusted functional outcomes improved over time, and cases managed at MTS (level-1 trauma centers) demonstrated better functional outcomes. The findings provide early evidence that this inclusive, regionalized trauma system is achieving its aims.

Background: Measuring long-term disability and functional outcomes after major trauma is not standardized across trauma registries. An ideal measure would be responsive to change but not have significant ceiling effects. The aim of this study was to compare the responsiveness of the Glasgow Outcome Scale (GOS), GOS-Extended (GOSE), Functional Independence Measure (FIM), and modified FIM in major trauma patients, with and without significant head injuries., Methods: Patients admitted to two adult Level I trauma centers in Victoria, Australia, who survived to discharge from hospital, were aged 15 years to 80 years with a blunt mechanism of injury, and had an estimated Injury Severity Score >15 on admission, were recruited for this prospective study. The instruments were administered at baseline (hospital discharge) and by telephone interview 6 months after injury. Measures of responsiveness, including effect sizes, were calculated. Bootstrapping techniques, and floor and ceiling effects, were used to compare the measures., Results: Two hundred forty-three patients participated, of which 234 patients (96%) completed the study. The GOSE and GOS were the most responsive instruments in this major trauma population with effect sizes of 5.3 and 4.4, respectively. The GOSE had the lowest ceiling effect (17%)., Conclusions: The GOSE was the instrument with greatest responsiveness and the lowest ceiling effect in a major trauma population with and without significant head injuries and is recommended for use by trauma registries for monitoring functional outcomes and benchmarking care. The results of this study do not support the use of the modified FIM for this purpose.

Objective: To describe and identify predictors of 12-month outcomes of serious orthopaedic injuries due to sport and active recreation., Design: Prospective cohort study with 12-month follow-up., Setting: Two Level 1 adult trauma centers in Victoria, Australia., Participants: A total of 366 adults admitted to two Level 1 trauma centers for an orthopaedic sport and active recreation injury between August 2003 and March 2006. Patients were captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), followed up at 12 months, and were free of moderate to severe disability prior to injury., Assessment of Risk Factors: Independent variables assessed for predictors of outcome were sporting group, age, sex, marital status, education level, Injury Severity Score, injury patterns, and head injury status., Main Outcome Measurements: The 12-item Short Form Health Survey and maximum pain scores., Results: At 12 months postinjury, 22.8% of patients reported moderate to severe physical disability, 12.1% reported moderate to severe mental health disability, and 11.1% reported moderate to severe pain. There were significant differences in physical outcomes between sporting groups, with motor and equestrian sports reporting the worst physical outcomes. Multivariate analysis indentified increasing age (P = 0.010) and patterns of injury (P = 0.040) as significant predictors of a poor physical outcome at 12 months. No significant independent predictors of outcome for mental health and maximum pain at 12 months were identified., Conclusion: Almost one-quarter of participants reported moderate to severe physical disability at 12 months postinjury. Increasing age and patterns of injury were found to be significant predictors of a poor physical outcome at 12 months.

Background: Despite the high incidence of major trauma, few studies have directly compared the performance of trauma systems. This study compared the trauma system performance in Victoria, Australia, (VIC) and Hong Kong, China (HK)., Methods: Prospectively collected data over 5 years from January 2001 from the 2 trauma systems were compared using univariate analysis. Variables were then entered into a multivariate logistic regression to assess differences in outcome between the systems and adjusted for effects of clinically important factors., Results: Five thousand five thirty-six cases from VIC and 580 cases from HK were taken for analysis. The HK group was older, but mechanisms of injury were similar in both systems. Thoracic and abdominal trauma was more common in VIC, compared with more head injuries in HK. More patients were admitted to intensive care in VIC and patients stayed in intensive care 1 day longer on average, despite more comorbidity in HK patients. Overall mortality was 20.2% for HK and 11.9% for VIC (X(2)(1) = 32.223, P < 0.001)., Conclusion: The performance of the HK trauma system was comparable to international standards, but there was a significant difference in the probability of survival of major trauma between the 2 systems. Possible modifiable factors may include criteria for activation of trauma calls and improved ICU utilization.

Objective: To describe the preinjury health-related quality of life (HRQL) of orthopaedic trauma patients admitted to Level I trauma centers relative to the general population., Design: Prospective cohort study using retrospectively collected preinjury HRQL measures., Setting: Two Level I adult trauma centers in Melbourne, Australia., Participants: A total of 2388 admitted orthopaedic trauma patients aged > or = 18 years were included, captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) between October 2003 and January 2006. Patients with a significant head injury (Abbreviated Injury Scale severity score >2), dementia, mental illness, mental disability, who were non-English speakers, or who were postoperatively confused were excluded., Main Outcome Measurements: The 12-item Short Form Health Survey (SF-12)., Results: The preinjury SF-12 was obtained for 1839 patients [median (interquartile range) of 6 (3-12) days postinjury]. The VOTOR population reported mean physical SF-12 scores above population norms (50.9 vs. 48.9, P < 0.001). The differences were predominant in men and confined to patients aged 18 to 54 years. The mean mental SF-12 scores of the VOTOR population were also greater than population norms (54.5 vs. 52.4, P < 0.001) and this was most apparent for women., Conclusions: Establishing the preinjury HRQL of trauma patients is important for evaluating the quality of orthopaedic trauma patient outcomes. Reliance on population norms for this purpose may lead to an underestimation of the impact of injury in particular age and sex subgroups, but given the size of the differences seen, any underestimation would be small. Where individual preinjury data cannot be collected, population norms could be used as a reasonable estimate of preinjury patient status for assessing quality of recovery.

Risk-adjusted survival rates have been the principle mode of comparison between trauma systems. In mature trauma systems, it is possible that there will be further improvements in survival but these are likely to be small. In the future, the largest gains will come from quality of life and improved function of the survivors. The issues related to measuring quality of survival for trauma systems are reviewed, including feasibility, ethical considerations, risk adjustment of outcomes of survivors, and challenges for selection of instruments and administration. In addition, the preliminary experiences of measuring outcomes in survivors through the Victorian State Trauma Registry are discussed. Although function and quality of life have been identified as important factors to measure in trauma populations, a standardised protocol has not been established. The experience in Victoria suggests that monitoring of population-based outcomes in survivors is feasible and may create the basis for benchmarking the level of morbidity in survivors.

Background: Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres., Methods: Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups; isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post-injury., Results: Of the 1303 patients recruited for VOTOR over a 12-month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post-injury. Patients reported ongoing pain (moderate-severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone., Conclusion: A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long-term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.