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Background: Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs., Methods: We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria., Results: We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries., Conclusion: We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population., Level of Evidence: Systematic Review/Meta-analysis; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To develop a hospital indicator of resource use for injury admissions., Methods: We focused on resource use for acute injury care and therefore adopted a hospital perspective. We included patients ≥16 years old with an Injury Severity Score >9 admitted to any of the 57 trauma centers of an inclusive Canadian trauma system from 2014 to 2018. We extracted data from the trauma registry and hospital financial reports and estimated resource use with activity-based costing. We developed risk-adjustment models by trauma center designation level (I/II and III/IV) for the whole sample, traumatic brain injuries, thoraco-abdominal injuries, orthopedic injuries, and patients ≥65 years old. Candidate variables were selected using bootstrap resampling. We performed benchmarking by comparing the adjusted mean cost in each center, obtained using shrinkage estimates, to the provincial mean., Results: We included 38 713 patients. The models explained between 12% and 36% (optimism-corrected r 2 ) of the variation in resource use. In the whole sample and in all subgroups, we identified centers with higher- or lower-than-expected resource use across level I/II and III/IV centers., Conclusions: We propose an algorithm to produce the indicator using data routinely collected in trauma registries to prompt targeted exploration of potential areas for improvement in resource use for injury admissions. The r 2 of our models suggest that between 64% and 88% of the variation in resource use for injury care is dictated by factors other than patient baseline risk., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Introduction: Globally every year, millions of patients sustain traumatic injuries and require acute care surgeries. A high incidence of chronic opioid use (up to 58%) has been documented in these populations with significant negative individual and societal impacts. Despite the importance of this public health issue, optimal strategies to limit the chronic use of opioids after trauma and acute care surgery are not clear. We aim to identify existing strategies to prevent chronic opioid use in these populations., Methods and Analysis: We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify studies, reviews, recommendations and guidelines on strategies aimed at preventing chronic opioid use in patients after trauma and acute care surgery. We will search MEDLINE, EMBASE, PsycINFO, CINHAL, Cochrane Central Register of Controlled Trials, Web of Science, ProQuest and websites of trauma and acute care surgery, pain, government and professional organisations. Databases will be searched for papers published from 1 January 2005 to a maximum of 6 months before submission of the final manuscript. Two reviewers will independently evaluate studies for eligibility and extract data from included studies using a standardised data abstraction form. Preventive strategies will be classified according to their types and targeted trauma populations and acute care surgery procedures., Ethics and Dissemination: Research ethics approval is not required as this study is based on the secondary use of published data. This work will inform research and clinical stakeholders on the required next steps towards the uptake of effective strategies aimed at preventing chronic opioid use in trauma and acute care surgery patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Injuries represent one of the leading causes of preventable morbidity and mortality. For countries with ageing populations, admissions of injured older patients are increasing exponentially. Yet, we know little about hospital resource use for injured older patients. Our primary objective was to evaluate inter-hospital variation in the risk-adjusted resource use for injured older patients. Secondary objectives were to identify the determinants of resource use and evaluate its association with clinical outcomes., Methods: We conducted a multicenter retrospective cohort study of injured older patients (≥65 years) admitted to any trauma centres in the province of Quebec (2013-2016, N = 33,184). Resource use was estimated using activity-based costing and modelled with multilevel linear models. We conducted separate subgroup analyses for patients with trauma and fragility fractures., Results: Risk-adjusted resource use varied significantly across trauma centres, more for older patients with fragility fractures (intra-class correlation coefficients [ICC] = 0.093, 95% CI [0.079, 0.102]) than with trauma (ICC = 0.047, 95% CI = 0.035-0.051). Risk-adjusted resource use increased with age, and the number of comorbidities, and varied with discharge destination (P < 0.001). Higher hospital resource use was associated with higher incidence of complications for trauma (Pearson correlation coefficient [r] = 0.5, 95% CI = 0.3-0.7) and fragility fractures (r = 0.5, 95% CI = 0.3-0.7) and with higher mortality for fragility fractures (r = 0.4, 95% CI = 0.2-0.6)., Conclusions: We observed significant inter-hospital variations in resource use for injured older patients. Hospitals with higher resource use did not have better clinical outcomes. Hospital resource use may not always positively impact patient care and outcomes. Future studies should evaluate mechanisms, by which hospital resource use impacts care., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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.)

Background: Tests and treatments that are not supported by evidence and could expose patients to unnecessary harm, referred to here as low-value clinical practices, consume up to 30% of health care resources. Choosing Wisely and other organizations have published lists of clinical practices to be avoided. However, few apply to injury and most are based uniquely on expert consensus. We aimed to identify low-value clinical practices in acute injury care., Methods: We conducted a scoping review targeting articles, reviews and guidelines that identified low-value clinical practices specific to injury populations. Thirty-six experts rated clinical practices on a five-point Likert scale from clearly low value to clearly beneficial. Clinical practices reported as low value by at least one level I, II, or III study and considered clearly or potentially low-value by at least 75% of experts were retained as candidates for low-value injury care., Results: Of 50,695 citations, 815 studies were included and led to the identification of 150 clinical practices. Of these, 63 were considered candidates for low-value injury care; 33 in the emergency room, 9 in trauma surgery, 15 in the intensive care unit, and 5 in orthopedics. We also identified 87 "gray zone" practices, which did not meet our criteria for low-value care., Conclusion: We identified 63 low-value clinical practices in acute injury care that are supported by empirical evidence and expert opinion. Conditional on future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 "gray zone" practices, which may be interesting targets for value-based decision-making. Our study represents an important step toward the deimplementation of low-value clinical practices in injury care., Level of Evidence: Systematic Review, Level IV.

Background: Blood transfusion is common in the resuscitation of patients with traumatic injury. However, the clinical impact of the length of storage of transfused blood is unclear in this population., Study Design and Methods: We undertook a prespecified nested analysis of 372 trauma victims of the 2510 critically ill patients from 64 centers treated as part of the Age of Blood Evaluation (ABLE) randomized controlled trial. Patients were randomized according to their trauma status to receive either a transfusion of fresh blood stored not more than 7 days or standard-issue blood. Our primary outcome was 90-day all-cause mortality., Results: Overall, 186 trauma patients received fresh blood and 186 received standard-issue blood. Adherence to transfusion protocol was 94% (915/971) for all fresh blood transfused and 100% (753/753) for all standard-issue blood transfused. Mean ± SD blood storage duration was 5.6 ± 3.8 days in the fresh group and 22.7 ± 8.4 days in the standard-issue group (p < 0.001). Ninety-day mortality in the fresh group was 21% (38/185), compared to 16% (29/184) in the standard-issue group, with an unadjusted absolute risk difference of 5% (95% confidence interval [CI], -3.1 to 12.6) and an adjusted absolute risk difference of 2% (95% CI, -3.5 to 6.8)., Conclusion: In critically ill trauma patients, transfusion of fresh blood did not decrease 90-day mortality or secondary outcomes, a finding similar to the overall population of the ABLE trial., (© 2018 AABB.)

Background: The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes., Methods: We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria., Results: We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization., Conclusions: This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.

Background: Acute care injury outcomes vary substantially across Canadian provinces and trauma centres. Our aim was to develop Canadian benchmarks to monitor mortality and hospital length of stay (LOS) for injury admissions., Methods: Benchmarks were derived using data from the Canadian National Trauma Registry on patients with major trauma admitted to any level I or II trauma centre in Canada and from the following patient subgroups: isolated traumatic brain injury (TBI), isolated thoracoabdominal injury, multisystem blunt injury, age 65 years or older. We assessed predictive validity using measures of discrimination and calibration, and performed sensitivity analyses to assess the impact of replacing analytically complex methods (multiple imputation, shrinkage estimates and flexible modelling) with simple models that can be implemented locally., Results: The mortality risk adjustment model had excellent discrimination and calibration (area under the receiver operating characteristic curve 0.886, Hosmer-Lemeshow 36). The LOS risk-adjustment model predicted 29% of the variation in LOS. Overall, observed:expected ratios of mortality and mean LOS generated by an analytically simple model correlated strongly with those generated by analytically complex models ( r > 0.95, κ on outliers > 0.90)., Conclusion: We propose Canadian benchmarks that can be used to monitor quality of care in Canadian trauma centres using Excel (see the appendices, available at canjsurg.ca). The program can be implemented using local trauma registries, providing that at least 100 patients are available for analysis.

Introduction: Preventable injuries lead to 200 000 hospital stays, 60 000 disabilities, and 13 000 deaths per year in Canada with direct costs of $20 billion. Overall, potentially unnecessary medical interventions are estimated to consume up to 30% of healthcare resources and may expose patients to avoidable harm. However, little is known about overuse for acute injury care. We aim to identify low-value clinical practices in injury care., Methods and Analysis: We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify research articles, reviews, recommendations and guidelines that identify at least one low-value clinical practice specific to injury populations. We will search Medline, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, websites of government agencies, professional societies and patient advocacy organisations, thesis holdings and conference proceedings. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles using a prepiloted and standardised electronic data abstraction form. Low-value clinical practices will be categorised using an extension of the Agency for Healthcare Research and Quality conceptual framework and data will be presented using narrative synthesis., Ethics and Dissemination: Ethics approval is not required as original data will not be collected. This study will be disseminated in a peer-reviewed journal, international scientific meetings, and to knowledge users through clinical and healthcare quality associations. This review will contribute new knowledge on low-value clinical practices in acute injury care. Our results will support the development indicators to measure resource overuse and inform policy makers on potential targets for deadoption in injury care., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Importance: In response to the burden of injury, the structure of injury care has changed considerably across Canada in the past decade. However, little is known about how patient outcomes have evolved., Objective: To evaluate trends in mortality, hospital length of stay, and unplanned readmission in Canadian trauma systems between 2006 and 2012., Design, Setting, and Participants: A pan-Canadian retrospective cohort study was conducted among adults admitted for major injury to a Canadian level I or II trauma center between April 1, 2006, and March 31, 2012. Data analysis was conducted from April 15 to December 3, 2015., Exposures: Trauma centers and systems., Main Outcomes and Measures: Multilevel generalized linear models were used to evaluate trends in the risk-adjusted incidence of mortality and readmission and risk-adjusted mean length of stay. Trend analyses were conducted globally and by province., Results: Among 78 807 patients (mean [SD] age, 50.7 [22.0] years; 22 540 women and 56 267 men) admitted for major injury during the study period, risk-adjusted mortality decreased from 12.1% (95% CI, 9%-16.1%) to 9.9% (95% CI, 7.4%-13.3%; P < .001) and mean length of hospital stay decreased from 11.6 (95% CI, 9.9-13.6) to 10.6 (95% CI, 9.1-12.5) days (P < .001). Statistically significant reductions in mortality were observed for Ontario (12% [95% CI, 10.7%-13.6%] to 8% [95% CI, 6.9%-9.2%]; P < .001), Alberta (12% [95% CI, 10%-14.3%] to 9.1% [95% CI, 7.7%-10.8%]; P = .02), and Manitoba (13% [95% CI, 9.1%-18.4%] to 11.1% [95% CI, 8.3%-14.7%]; P = .04). Risk-adjusted hospital stay decreased significantly in Québec (11.6 [95% CI, 11.1-12] to 9.1 [95% CI, 8.9-9.5] days; P < .001), British Columbia (12.5 [95% CI, 12-13.1] to 11.4 [10.9-11.9] days; P < .001), and Ontario (10.1 [95% CI, 9.8-10.4] to 9.8 [95% CI, 9.5-10.1] days; P < .001). No change in the incidence of readmission was observed., Conclusions and Relevance: We observed an 18.2% relative decrease in risk-adjusted mortality in Canadian trauma centers during the study period, representing 248 additional lives saved in 2012 vs 2006. Risk-adjusted mean hospital stay decreased by 8.6%, representing nearly 10 000 hospital days saved. A better understanding of the structures and processes behind observed improvements is needed to further reduce the burden of injury in Canada.

Background: Injury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization., Methods: We will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool., Discussion: We expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts., Systematic Review Registration: This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display&#95;record.asp?ID=CRD42016041336 .

Objective: To measure the variation in trauma center mortality across Canadian trauma systems, assess the contribution of traumatic brain injury and thoracoabdominal injury to observed variations, and evaluate whether the presence of recommended trauma system components is associated with mortality., Summary Background Data: Injuries represent one of the leading causes of mortality, disability, and health care costs worldwide. Trauma systems have improved injury outcomes, but the impact of trauma system configuration on mortality is unknown., Methods: We conducted a retrospective cohort study of adults admitted for major injury to trauma centers across Canada (2006-2012). Multilevel logistic regression was used to estimate risk-adjusted hospital mortality and assess the impact of 13 recommended trauma system components., Results: Of 78,807 patients, 8382 (10.6%) died in hospital including 6516 (78%) after severe traumatic brain injury and 749 (9%) after severe thoracoabdominal injury. Risk-adjusted mortality varied from 7.0% to 14.2% across provinces (P < 0.0001); 11.1% to 26.0% for severe traumatic brain injury (P < 0.0001), and 4.7% to 5.9% for thoracoabdominal injury (P = 0.2). Mortality decreased with increasing number of recommended trauma system elements; adjusted odds ratio = 0.93 (0.87-0.99)., Conclusions: We observed significant variation in trauma center mortality across Canadian provinces, specifically for severe traumatic brain injury. Provinces with more recommended trauma system components had better patient survival. Results suggest that trauma system configuration may be an important determinant of injury mortality. A better understanding of which system processes drive optimal outcomes is required to reduce the burden of injury worldwide.

Importance: The rate of complications among injury admissions has been estimated to be more than 3 times that observed for general admissions, and complications have been targeted as an important quality-of-care metric. Despite the negative effect of complications on resource use and patient mortality and morbidity, there is no standardized method to benchmark trauma centers in terms of in-hospital complications, to our knowledge., Objectives: To develop a quality indicator (QI) for in-hospital complications that can be used to evaluate the quality of acute injury care and to assess its validity., Design, Setting, and Participants: Multicenter retrospective cohort study. The setting was a well-established inclusive trauma system in Canada. Participants included all 66 048 moderate or major injury admissions to an adult trauma center between April 1, 2006, and March 31, 2012. The dates of the analysis were January to April 2015., Main Outcomes and Measures: The primary outcome was the occurrence of at least 1 in-hospital complication. We selected risk-adjustment variables by expert consultation and bootstrap resampling. We evaluated internal validity using measures of discrimination, construct validity, and forecasting., Results: The study cohort comprised 66 048 patients. Their mean (SD) age was 59 (22) years, and 48.0% were female. Fifteen percent of patients had at least 1 in-hospital complication. The risk-adjustment model has excellent discrimination (area under the curve, 0.81) and calibration. The QI was correlated with the risk-adjusted incidence of mortality (r = 0.71), unplanned readmission (r = 0.43), and mean length of stay (r = 0.68). Hospital performance on the QI from 2007 to 2009 was predictive of performance from 2010 to 2012 (r = 0.82)., Conclusions and Relevance: We developed a QI to benchmark trauma centers on in-hospital complications among injury admissions. The QI is based on data that are routinely collected in most trauma systems and demonstrates good internal validity. The integration of this QI in trauma quality improvement programs will facilitate the identification of quality problems, the implementation of solutions, and the evaluation of their effectiveness. Therefore, the QI has the potential to lead to reductions in mortality, morbidity, and resource use after injury.

Objective: Evaluate the predictive validity of complications derived using expert consensus methodology to monitor the quality of trauma care. Secondary objectives were to assess the predictive validity of complications not selected by consensus and identify determinants of complications., Background: A list of complications to monitor the quality of trauma care has recently been derived using Delphi consensus methodology. However, the predictive validity of consensus complications has not yet been demonstrated., Methods: We conducted a multicenter cohort study of adults admitted to the 57 adult trauma centers of a Canadian integrated trauma system (2007-2012; n = 84,216). Multiple generalized linear models were used to assess the influence of complications on mortality and acute care length of stay (LOS) and to identify determinants of consensus complications., Results: The presence of at least 1 consensus complication was associated with a 2.7-fold [95% confidence interval (CI): 2.45-2.90] and 2.2-fold (95% CI: 2.11-2.19) increase in the odds of mortality and mean LOS, respectively. Nonselected complications were associated with no increase in mortality (odds ratio = 0.90, 95% CI: 0.80-1.01) and a 60% increase in LOS (geometric mean ratio = 1.60, 95% CI: 1.57-1.62). Patient-related factors and factors related to treatment explained 66% and 34% of the variation in complication rates, respectively., Conclusions: In addition to the face and content validity ensured by consensus methodology, this study suggests that consensus complications have good predictive validity. Monitoring these complications as part of quality improvement activities would provide an opportunity to improve outcome and resource use for injury admissions.

Background: Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007-2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression., Results: Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles., Conclusions: Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.

Background: The introduction of trauma systems in many countries worldwide has been shown to improve injury survival. However, few data are available on the long-term evolution of outcomes other than mortality. The objective of this study was to describe trends in mortality, unplanned readmission, complications, and length of stay in a mature inclusive trauma system from 1999 to 2012., Methods: This retrospective cohort study was based on the inclusive trauma system of Quebec, Canada. Data were drawn from the trauma registry linked to the hospital discharge database. Time trends were evaluated using generalized linear mixed models with a correction for hospital clusters and cohort effects., Results: Between 1999 and 2012, risk-adjusted mortality decreased from 5.8 to 4.2% for all patients and from 14.9 to 13.1% for major trauma (p < 0.0001). Mean LOS decreased from 9.5 days to 8.0 days for all patients and from 15.5 days to 11.5 days for major trauma (p < 0.0001). Unplanned readmission and complication rates remained stable over the observation period at around 6.6 and 11.6% for all patients and 7.6 and 25.6% for major trauma, respectively., Conclusion: The results of this study suggest that there have been significant decreases in patient mortality and hospital length of stay in the inclusive trauma system of Québec over the last decade. Results also suggest that efforts should be made to reduce in-hospital complications and unplanned readmissions. Future research should attempt to identify determinants of observed decreases in mortality and LOS and assess whether similar improvements have occurred in functional outcomes.

Objective: To derive and internally validate a quality indicator (QI) for acute care length of stay (LOS) after admission for injury., Background: Unnecessary hospital days represent an estimated 20% of total LOS implying an important waste of resources as well as increased patient exposure to hospital-acquired infections and functional decline., Methods: This study is based on a multicenter, retrospective cohort from a Canadian provincial trauma system (2005-2010; 57 trauma centers; n = 57,524). Data were abstracted from the provincial trauma registry and the hospital discharge database. Candidate risk factors were identified by expert consensus and selected for model derivation using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting., Results: The risk adjustment model explains 37% of the variation in LOS. The QI discriminates well across trauma centers (coefficient of variation = 0.02, 95% confidence interval: 0.011-0.028) and is correlated with the QI on processes of care (r = -0.32), complications (r = 0.66), unplanned readmissions (r = 0.38), and mortality (r = 0.35). Performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.80)., Conclusions: We have developed a QI on the basis of risk-adjusted LOS to evaluate trauma care that can be implemented with routinely collected data. The QI is based on a robust risk adjustment model with good internal and temporal validity, and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This QI can be used to target interventions to reduce LOS, which will lead to more efficient resource use and may improve patient outcomes after injury.

Background: Complications affect up to 37% of patients hospitalized for injury and increase mortality, morbidity, and costs. One of the keys to controlling complications for injury admissions is to monitor in-hospital complication rates. However, there is no consensus on which complications should be used to evaluate the quality of trauma care. The objective of this study was to develop a consensus-based list of complications that can be used to assess the acute phase of adult trauma care., Methods: We used a three-round Web-based Delphi survey among experts in the field of trauma care quality with a broad range of clinical expertise and geographic diversity. The main outcome measure was median importance rating on a 5-point Likert scale (very low to very high); complications with a median of 4 or greater and no disagreement were retained. A secondary measure was the perceived quality of information on each complication available in patient files., Results: Of 19 experts invited to participate, 17 completed the first (brainstorming) round and 16 (84%) completed all rounds. Of 73 complications generated in Round 1, a total of 25 were retained including adult respiratory distress syndrome, hospital-acquired pneumonia, sepsis, acute renal failure, deep vein thrombosis, pulmonary embolism, wound infection, decubitus ulcers, and delirium. Of these, 19 (76%) were perceived to have high-quality or very high-quality information in patient files by more than 50% of the panel members., Conclusion: This study proposes a consensus-based list of 25 complications that can be used to evaluate the quality of acute adult trauma care. These complications can be used to develop an informative and actionable quality indicator to evaluate trauma care with the goal of decreasing rates of hospital complications and thus improving patient outcomes and resource use. DRG International Classification of Diseases codes are provided.

Objective: To describe acute care length of stay (LOS) over all consecutive hospitalizations for the injury and according to level of care [intensive care unit (ICU), intermediate care, general ward], compare observed and expected LOS, and identify predictors of LOS., Background: Prolonged LOS has important consequences in terms of costs and outcome, yet detailed information on LOS after trauma is lacking., Methods: This multicenter retrospective cohort study was based on adults discharged alive from a Canadian trauma system (1999-2010; n = 126,513). Registry data were used to calculate index LOS (LOS in trauma center with highest designation level) and were linked to hospital discharge data to calculate total LOS (all consecutive hospitalizations for the injury). Expected LOS was obtained by matching general provincial discharge statistics to study data by year, age, and sex. Potential predictors of LOS were evaluated using linear regression., Results: Mean index and total LOS were 8.6 and 9.4 days, respectively. ICU, intermediate care unit, and general ward care constituted 8.9%, 2.5%, and 88.6% of total hospital days. Observed mean index and ICU LOS in our trauma patients were 2.9 and 1.3 days longer than expected LOS (P < 0.0001). The strongest determinants of index LOS were discharge destination, age, transfer status, and injury severity., Conclusions: Results suggest that acute care LOS after injury is underestimated when only information on the index hospitalization is used and that ICU or intermediate care constitute an important part of LOS. This information should be used to inform the development of an informative and actionable quality indicator.

Background: Unplanned readmissions represent 20% of all admissions and cost $12 billion annually in the United States. Despite the burden of injuries for the health care system, no quality indicator (QI) based on readmissions is available to evaluate trauma care. The objective of this study was to derive and internally validate a QI for a 30-day unplanned hospital readmission to evaluate trauma care., Methods: We performed a multicenter retrospective cohort study in a Canadian integrated provincial trauma system. We included adults admitted to any of the 57 provincial trauma centers between 2005 and 2010 (n = 57,524). Data were abstracted from the provincial trauma registry and linked to the hospital discharge database. The primary outcome was unplanned readmission to an acute care hospital within 30 days of discharge. Candidate risk factors were identified by expert consensus and selected for derivation of the risk adjustment model using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting., Results: The risk adjustment model includes patient age, sex, the Injury Severity Score (ISS), region of the most severe injury, and 11 comorbid conditions. The QI discriminates well across trauma centers (coefficient of variation, 0.02) and is correlated with QIs that measure hospital performance in terms of clinical processes (r = -0.38), risk-adjusted mortality (r = 0.32), and complication rates (r = 0.38). In addition, performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.59)., Conclusion: We have developed a QI based on risk-adjusted 30-day rates of unplanned readmission, which can be used to evaluate trauma care with routinely collected data. The QI is based on a comprehensive risk adjustment model with good internal and temporal validity and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This research represents an essential step toward reducing unplanned readmission rates to improve resource use and patient outcomes following injury., Level of Evidence: Prognostic study, level III.

Objective: This study aimed to (i) describe unplanned readmission rates after injury according to time, reason, and place; (ii) compare observed rates with general population rates, and (iii) identify determinants of 30-day readmission., Background: Hospital readmissions represent an important burden in terms of mortality, morbidity, and resource use but information on unplanned rehospitalization after injury admissions is scarce., Methods: This multicenter retrospective cohort study was based on adults discharged alive from a Canadian provincial trauma system (1998-2010; n = 115,329). Trauma registry data were linked to hospital discharge data to obtain information on readmission up to 12 months postdischarge. Provincial admission rates were matched to study data by age and gender to obtain expected rates. Determinants of readmission were identified using multiple logistic regression., Results: Cumulative readmission rates at 30 days, 3 months, 6 months, and 12 months were 5.9%, 10.9%, 15.5%, and 21.1%, respectively. Observed rates persisted above expected rates up to 11 months postdischarge. Thirty percent of 30-day readmissions were due to potential complications of injury compared with 3% for general provincial admissions. Only 23% of readmissions were to the same hospital. The strongest independent predictors of readmission were the number of prior admissions, discharge destination, the number of comorbidities, and age., Conclusions: Unplanned readmissions after discharge from acute care for traumatic injury are frequent, persist beyond 30 days, and are often related to potential complications of injury. Several patient-, injury-, and hospital-related factors are associated with the risk of readmission. Injury readmission rates should be monitored as part of trauma quality assurance efforts.

Objective: With the recognition of early coagulopathy, trauma resuscitation has shifted toward liberal platelet transfusions. The overall benefit of this strategy remains controversial. Our objective was to compare the effects of a liberal use of platelet (higher platelet:RBC ratios) with a conservative approach (lower ratios) in trauma resuscitation., Data Sources: We systematically searched Medline, Embase, Web of Science, Biosis, Cochrane Central, and Scopus., Study Selection: Two independent reviewers selected randomized controlled trials and observational studies comparing two or more platelet:RBC ratios in trauma resuscitation. We excluded studies investigating the use of whole blood or hemostatic products., Data Extraction: Two independent reviewers extracted data and assessed the risk of bias. Primary outcomes were early (in ICU or within 30 d) and late (in hospital or after 30 d) mortality. Secondary outcomes were multiple organ failure, lung injury, and sepsis., Data Synthesis: From 6,123 citations, no randomized controlled trials were identified. We included seven observational studies (4,230 patients) addressing confounders through multivariable regression or propensity scores. Heterogeneity of studies precluded meta-analysis. Among the five studies including exclusively patients requiring massive transfusions, four observed a lower mortality with higher ratios. Two studies considering nonmassively bleeding patients observed no benefit of using higher ratios. Two studies evaluated the implementation of a massive transfusion protocol; only one study observed a decrease in mortality with higher ratios. Of the two studies at low risk of survival bias, one study observed a survival benefit. Three studies assessed secondary outcomes. One study observed an increase in multiple organ failure with higher ratios, whereas no study demonstrated an increased risk in lung injury or sepsis., Conclusions: There is insufficient evidence to strongly support the use of a precise platelet:RBC ratio for trauma resuscitation, especially in nonmassively bleeding patients. Randomized controlled trials evaluating both the safety and efficacy of liberal platelet transfusions are warranted.

Background: Elderly trauma patients represent a unique clientele requiring specialised care but they rarely benefit from standardised care strategies within trauma systems. We aimed to evaluate whether trauma centres with lower/higher than expected mortality amongst patients <65 years of age have similar results for geriatric patients. A secondary objective was to compare transfer to level I/II trauma centres across age groups., Methods: The study was based on data from a Canadian provincial trauma registry (1999-2006). Outcome performance was evaluated with estimates of risk-adjusted 30-day mortality generated for each of the system's 57 adult trauma centres. Agreement in performance results was evaluated with correlation coefficients., Results: The study sample comprised 55,283 young adults (3.5% mortality) and 30,960 geriatric patients (8.2% mortality). The two age groups only had one out of six outliers in common. Hospital ranks amongst young adults were not correlated to those assigned amongst geriatric patients (r = 0.01, 95%CI -0.25;0.27). Correlation was also low for patients with major trauma (r = 0.20, 95%CI -0.06;0.44). Amongst patients with severe head injuries initially received in a level III/IV centre, 81% of young adults versus 71% of geriatric patients were transferred to a level I/II centre (p<0.0001)., Conclusions: Trauma centres that have low risk-adjusted mortality for young adults do not necessarily do so for geriatric patients. In addition, geriatric patients with severe head injuries are less likely to be treated in neurosurgical trauma centres. Further research is needed to identify determinants of inter-hospital variation in outcome for geriatric trauma patients., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Trauma center performance evaluations generally include adjustment for injury severity, age, and comorbidity. However, disparities across trauma centers may be due to other differences in source populations that are not accounted for, such as socioeconomic status (SES). We aimed to evaluate whether SES influences trauma center performance evaluations in an inclusive trauma system with universal access to health care., Study Design: The study was based on data collected between 1999 and 2006 in a Canadian trauma system. Patient SES was quantified using an ecologic index of social and material deprivation. Performance evaluations were based on mortality adjusted using the Trauma Risk Adjustment Model. Agreement between performance results with and without additional adjustment for SES was evaluated with correlation coefficients., Results: The study sample comprised a total of 71,784 patients from 48 trauma centers, including 3,828 deaths within 30 days (4.5%) and 5,549 deaths within 6 months (7.7%). The proportion of patients in the highest quintile of social and material deprivation varied from 3% to 43% and from 11% to 90% across hospitals, respectively. The correlation between performance results with or without adjustment for SES was almost perfect (r = 0.997; 95% CI 0.995-0.998) and the same hospital outliers were identified., Conclusions: We observed an important variation in SES across trauma centers but no change in risk-adjusted mortality estimates when SES was added to adjustment models. Results suggest that after adjustment for injury severity, age, comorbidity, and transfer status, disparities in SES across trauma center source populations do not influence trauma center performance evaluations in a system offering universal health coverage., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Organized trauma systems are designed to improve the quality and efficiency of trauma care. Several studies have reported mortality reductions during or immediately after implementation of a trauma system but little data are available on long-term trends. The aim of this study was to evaluate the long-term trend in risk-adjusted mortality in a mature inclusive trauma system., Methods: The trauma system of the province of Quebec, Canada, was implemented in 1992 and completed in 1996. Data were drawn from the Quebec Trauma Registry with mandatory participation of all 59 centres, uniform inclusion criteria, and standardized data collection and validation procedures. Temporal trends from 1999 to 2006 were evaluated using adjusted estimates of hospital mortality generated with a random-intercept hierarchical logistic regression model. Estimates were adjusted using the Trauma Risk Adjustment Model (TRAM) score., Results: The study population comprised 88,235 patients, including 4731 hospital deaths (5.4%). Crude mortality risk varied between 5.2% in 1999 and 4.6% in 2006. Adjusted mortality risk remained stable between 1999 and 2002, but a statistically significant decrease of 4.6% per year (95% CI = 0.9-8.5) was observed between 2002 and 2006., Conclusions: The risk of hospital mortality in the Quebec trauma system decreased by 24% between 2002 and 2006. Results suggest that as inclusive and regionalized trauma systems mature, they may provide better care to trauma victims. Further research should attempt to identify determinants of the observed decrease within the system and evaluate quality of life among survivors.

Objective: To develop a method of evaluating trauma center mortality that addresses the limitations of currently available methodology-Standardized Mortality Ratios (SMRs) based on the Trauma and Injury Severity Score., Summary of Background Data: TRISS SMRs have important limitations including inadequate risk adjustment, comparison to an inappropriate standard, lack of consideration for inter- and intrahospital variation, and incomparability across hospitals., Methods: The methodology was developed using data from a provincial trauma registry with mandatory participation of all trauma centers, uniform inclusion criteria, and standardized data collection methods. Institutional performance was described with estimates of risk-adjusted mortality derived from a hierarchical logistic regression model. Risk adjustment was performed with a risk score generated by the Trauma Risk Adjustment Model (TRAM), as well as a term for incoming transfers and an interaction between transfer and the risk score. Outliers were identified by comparing each hospital to all remaining hospitals., Results: The study population comprised 88,235 patients including 4731 deaths (5.4%) from 59 trauma centers. Crude mortality varied between 1.3% and 14.3%. TRAM-adjusted mortality estimates varied between 3.7% (95% CI: 3.2%-4.3%) and 6.9% (5.8%-8.2%). Three trauma centers had significantly higher adjusted mortality and one center had statistically significant lower mortality when compared with all other centers., Conclusions: The proposed method of trauma center profiling offers comprehensive adjustment for patient-level risk factors and consideration of transfer status, is based on comparisons to an internal standard, accounts for inter- and intrahospital variation, and replaces SMRs with estimates of regression-adjusted mortality that are comparable across hospitals. TRAM-adjusted mortality estimates can be used to describe institutional outcome performance and to identify institutional outliers. Such information is the key to identifying ways to improve the quality of modern trauma care.