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Background and objectives In recent years, biochemical markers have been employed to predict the outcome of patients with traumatic brain injury (TBI). In mild TBI, S100B has shown the most promise as a marker of outcome. The objective of this study in patients with severe TBI was to: show the range of serum S100B levels during the acute phase after trauma: determine if S100B has potential to discriminate favourable from unfavourable outcome in patients with similar brain injury severity scores and to establish an S100B ‘cut-off' predictive for death. Methods All patients with severe TBI, admitted to this neurointensive care unit within 24h of injury were eligible for inclusion in the study. One serum blood sample was obtained from each patient at the 24h post-injury time-point. S100B levels were measured using enzyme-linked immunosorbent assay. Injuries were coded using an internationally recognised injury severity scoring system (ISS). Three-month follow-up was undertaken with outcome assessed using the Glasgow outcome score (GOS). Results One hundred patients were recruited. Serum S100B levels ranged from 0.08 to 12.62μgL −1 S100B levels were significantly higher in patients with a GOS of 1 (death) 2 and 3 (unfavourable outcome) compared with those with GOS 4 and 5 (good recovery). In this study a cut-off point of 0.53μgL −1 has sensitivity of >80% and specificity of 60% to predict unfavourable outcome and 49% to predict death. Conclusion In 100 patients studied with similar brain injury severity scores, serum S100B measured at the 24-h time-point after injury is significantly associated with outcome but a cut-off 0.53μgL −1 does not have good prognostic performance.

Using data from the Trauma Audit Research Network, we investigated the costs of acute care in patients>or = 18 years of age hospitalised for traumatic brain injury between January 2000 and December 2005 in England and Wales. Traumatic brain injury patients were defined and stratified using the Abbreviated Injury Scale. A total of 6484 traumatic brain injury patients were identified; 22.3% had an Abbreviated Injury Scale score of three, 38.0% of four and 39.7% of five. Median age (IQR) was 42 years (28-59) and 76.7% were men. Primary cause of injury was motor vehicle collisions (42.4%) followed by falls (38.0%). In total 23.7% of the patients died before discharge. Hospitalisation costs averaged 15,462 pounds sterling (SD 16,844 pounds sterling). Costs varied significantly by age, Glasgow Coma Score, Injury Severity Score, coexisting injuries of the thorax, spine and lower limb, hospital mortality, availability of neurosurgical services, and specialty of attendants seen in the Accident and Emergency department. Language: en

Trauma management systems have grown in response to regional variations in trauma population, geographical conditions and the provisions of care. National Trauma Registries are being established to improve patient outcomes. However international comparisons could provide the potential to record regional performance, identify and share examples of best practice. To assess whether it was possible to compare data currently being collected by a number of trauma services across Europe, a group was established to develop a common core dataset and to assess the feasibility of collecting anonymised data. METHOD: A series of meetings with European collaborators led to the creation of a group entitled EuroTARN. A website was developed in 2002 and interested parties were invited to submit suggestions for a European dataset using an online version of the Delphi technique. A core dataset was created in 2003 and in 2004 participants were invited to submit a summary of past cases online via the EuroTARN Website. RESULTS: Representatives from 14 countries met and corresponded to create the core dataset. During a trial data collection phase 14 institutions from 11 countries submitted unadjusted mortality data for over 21,500 cases with injury severity Scores of over 15 including information on multiply injured and head injured patients. The results demonstrated that there were observed differences in trauma outcome for similar groups of patients. CONCLUSION: It is possible to collect and collate outcome data from established trauma registries across Europe with minimal additional infrastructure using a web-based system. Initial analysis of the results reveals significant international variations. The network has potential as a source of data for epidemiological and clinical research and for optimal trauma system design across Europe. Language: en

We wished to determine the characteristics of patients with pelvic ring fractures (PGs) in England and Wales, make comparisons to major trauma patients without pelvic injury (NPGs), and determine factors predicting mortality, including the impact of presence of pelvic reconstruction facilities in the receiving hospitals on outcome.Prospective data from 106 trauma receiving hospitals forming the Trauma Audit and Research Network were studied. Between January 1989 and December 2001 data of 159,746 trauma patients were collected in the Trauma Audit and Research Network database. Because of incomplete data, 1,610 pelvic fracture patients and 13,499 patients without pelvic fracture were excluded from detailed analysis. In total, 11,149 patients in the PG and the remaining 133,486 patients in the NPG (control) group were included in the final analysis.There were statistically significantly more patients with an Injury Severity Score15 in the PG group (n = 3,576; 32.1%) than in NPG group (n = 19,238; 14.4%) (p0.001), indicating that pelvic injuries were more often associated with other injuries. The majority of patients sustained Abbreviated Injury Score (AIS) 2 pelvic injuries (65.0%), whereas AIS 4 and 5 injuries were found in less than 10% of patients. Pelvic ring injuries were most commonly associated with chest trauma withAIS 2 severity in 21.2% of the patients, head injuries (AIS 2) in 16.9%, liver or spleen injuries in 8.0%, and two or more long bone fractures in 7.8%. The 3-month cumulative mortality rate of the patients with pelvic injuries was 14.2% (1,586 patients) versus 5.6% (7,465 patients) of the NPG group.Age, early physiologic derangement, and presence of other injuries (head or trunk) were associated with reduced survival rates. When the expertise to deal with such a group of patients is not available, early transfer under safe conditions should be considered to improve survival rates.

Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients' outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems.Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP)90mmHg) and early trauma fatality rate (i.e. death during the first 24h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes.After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73-1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54-0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems.These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.

Introduction Severely bleeding trauma patients are a small proportion of the major trauma population but account for 40 % of all trauma deaths. Healthcare resource use and costs are likely to be substantial but have not been fully quantified. Knowledge of costs is essential for developing targeted cost reduction strategies, informing health policy, and ensuring the cost-effectiveness of interventions. Methods In collaboration with the Trauma Audit Research Network (TARN) detailed patient-level data on in-hospital resource use, extended care at hospital discharge, and readmissions up to 12 months post-injury were collected on 441 consecutive adult major trauma patients with severe bleeding presenting at 22 hospitals (21 in England and one in Wales). Resource use data were costed using national unit costs and mean costs estimated for the cohort and for clinically relevant subgroups. Using nationally available data on trauma presentations in England, patient-level cost estimates were up-scaled to a national level. Results The mean (95 % confidence interval) total cost of initial hospital inpatient care was £19,770 (£18,177 to £21,364) per patient, of which 62 % was attributable to ventilation, intensive care, and ward stays, 16 % to surgery, and 12 % to blood component transfusion. Nursing home and rehabilitation unit care and re-admissions to hospital increased the cost to £20,591 (£18,924 to £22,257). Costs were significantly higher for more severely injured trauma patients (Injury Severity Score ≥15) and those with blunt injuries. Cost estimates for England were £148,300,000, with over a third of this cost attributable to patients aged 65 years and over. Conclusions Severely bleeding major trauma patients are a high cost subgroup of all major trauma patients, and the cost burden is projected to rise further as a consequence of an aging population and as evidence continues to emerge on the benefits of early and simultaneous administration of blood products in pre-specified ratios. The findings from this study provide a previously unreported baseline from which the potential impact of changes to service provision and/or treatment practice can begin to be evaluated. Further studies are still required to determine the full costs of post-discharge care requirements, which are also likely to be substantial.

In 1988, the Royal College of Surgeons (England) Committee on Trauma—chaired by Professor Sir Miles Irving—reviewed the anonimised case notes of 1000 UK patients with major injuries who had died after reaching hospital alive. Each patient record was scrutinised by four clinical experts in trauma care with a brief to state whether or not the death could have been prevented by better care—such as that available in a late 1980s North American level 1 trauma centre. The majority of reviewers found that one-third of trauma deaths were preventable by this yard stick—two-thirds of those dying from haemorrhage. This ‘preventable death review’ has since been consigned to a 20th century research technique as it is highly prone to bias (impossible not to conclude errors were contributory if death is the known outcome)—however, it is nevertheless a seminal study—not least because the authors understood the limitations of their findings. In making their recommendations the Committee highlighted failings throughout the trauma patient pathway (scene to rehabilitation) and a general lack of evidence on institutional (hospital/network/system) performance.1 Their recognition of the need to address this gap led David Yates (DWY)—Professor of Emergency Medicine and Maralyn Woodford (MW)—co-author on the RCS report; both from Hope (now Salford Royal) Hospital—to pick up the baton. To this end Hope Hospital became the sole subscribing UK member of the then USA Major Trauma Outcome Study (US MTOS)—at that time in the vanguard of using risk-adjusted mortality rates to inform quality of care comparisons. The US MTOS led by Howard Champion, Wayne Sacco, William Boyd and colleagues at the Washington Hospital Centre built on the extraordinary development of the Injury Severity Score (ISS) by Susan Baker et al and the Abbreviated Injury Scale (AIS) from the Association for the Advancement of Automotive Medicine.2 ,3 We all …

This paper is a comment to the paper "Classification of Traumatic Brain Injury Severity Using Informed Data Reduction in a Series of Binary Classifier Algorithms" by Bloom et al. The authors inform the editors that they have conducted a similar study on behalf of, and funded BrainScope Company, Inc. and that the method used to acquire the QEEG data suffer from a technical fault. Same methods seem to have been used by Bloom et. al. It is noted that the authors do not refer to this technical fault even though it arose months before the publication of the papers.

Diversion of suspected traumatic brain injury (TBI) patients to trauma centres may improve outcomes by expediting access to specialist neurosurgical care. This study aimed to determine the accuracy of the Head Injury Straight to Neurosurgery (HITSNS) triage rule for identifying patients with significant TBI. A diagnostic cohort study was performed using data from the HITSNS trial, the Trauma Audit and Research Network registry and the North East Ambulance service database. Sensitivity and specificity of the HITSNS triage rule were calculated against a reference standard of significant TBI, defined by a cranial Abbreviated Injury Scale score of at least 3 or by the performance of a neurosurgical procedure. A total of 3628 patients were included in the complete case analyses. The HITSNS triage tool demonstrated a sensitivity of 28.3% (95% confidence interval 21.8-35.4) and a specificity of 94.4% (95% confidence interval 93.6-95.2). The low sensitivity of the HITSNS triage rule suggests that a considerable proportion of patients with significant TBI may not be triaged directly to trauma centres, and further research is needed to improve the accuracy of bypass protocols.

Introduction Major trauma in older people is a significant health burden in the developed world. The aging of the population has resulted in larger numbers of older patients suffering serious injury. Older trauma patients are at greater risk of death from major trauma, but the reasons for this are less well understood. The aim of this review was to identify the factors affecting mortality in older patients suffering major injury. Materials and methods A systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with meta-analysis. Multi-centre cohort studies of existing trauma registries that reported risk-adjusted mortality (adjusted odds ratios, AOR) in their outcomes and which analysed patients aged 65 and older as a separate cohort were included in the review. Results 3609 papers were identified from the electronic databases, and 28 from manual searches. Of these, 15 papers fulfilled the inclusion criteria. Demographic variables (age and gender), pre-existing conditions (comorbidities and medication), and injury-related factors (injury severity, pattern and mechanism) were found to affect mortality. The ‘oldest old', aged 75 and older, had higher mortality rates than younger patients, aged 65–74 years. Older men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37–1.66). Three papers reported a higher risk of death in patients with pre-existing conditions. Two studies reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05–1.66). Higher mortality was seen in patients with lower Glasgow coma scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26–6.60). Conclusions Multiple factors contribute to mortality risk in older trauma patients. The relation between these factors and mortality is complex, and a fuller understanding of the contribution of each factor is needed to develop a better predictive model for trauma outcomes in older people. More research is required to identify patient and process factors affecting mortality in older patients.

Objective To understand the epidemiology of pregnancy and obstetric complications encountered in the management of pregnant trauma patients. Methods and design Retrospective analysis of national trauma registry for recording of pregnancy status or obstetric complication in cases of trauma. Sub-division of patient cohort by severity of trauma and stage of pregnancy. Comparison of data sets between pregnant trauma patients and age-matched non-pregnant female trauma patients to determine patterns of injury and impact upon clinical outcomes. Settings National registry data for the United Kingdom. Outcome For the five year period between 2009 and 2014, a total of 15,140 female patients, aged between 15 years old and 50 years old were identified within the trauma registry. A record of pregnancy was identified in 173 patients (1.14%) from within this cohort. Mechanisms of injury within the cohort of pregnant trauma patients saw increased rate of vehicular collision and interpersonal violence, especially penetrating trauma. Higher abbreviated injury scores were recorded for the abdominal region in pregnancy than in the non-pregnant cohort. Maternal mortality rates were seen to be higher, when compared with the non-pregnant trauma patient. Foetal survival rate from this series was 56% following trauma. Foetal death in pregnant trauma patients most frequently occurred in the 2nd trimester. No cases of isolated foetal survival were recorded following maternal trauma. Conclusions Trauma to pregnant patients is rare in the United Kingdom, encountered in 1% of female trauma patients of child bearing age. Observations in altered mechanisms of injury and clinical outcomes were recorded. This provides useful information regarding the clinical management of pregnant trauma patients and offers potential areas to investigate to optimise their care, as well as to focus injury prevention measures. Level of evidence IV—Case series.

Summary Background In the Trauma Audit and Research Network (TARN), currently the largest trauma network in Europe, outcome prediction is performed using the TRISS methodology since 1989. Its database contains 200,000 hospital admissions from 110 hospitals over the country, but a large amount of data is lost for the modelling because of missing data. To improve some of the shortcomings of TRISS a new model was developed. Methods The data for modelling consisted of 100,399 hospital trauma admissions over the period 1996 to 2001. Using the Glasgow Coma Score (GCS) instead of RTS has dramatically reduced the number of missing cases. Gender and its interaction with age have also been included in the model. The model was tested on different subsets of cases traditionally excluded, such as children, those with penetrating injuries, and ventilated and transferred patients. The new model included all those subsets using age, a transformation of ISS, GCS, gender and gender by age interaction as predictors. Results The model has shown a good discriminant ability tested by the area under the receiver operating characteristic (AROC) curve. The values of the AROC for the new model were 0.947 (95% CI: 0.943–0.951) on the prediction set and 0.952 (95% CI: 0.946–0.957) on the validation set compared respectively with 0.937 (95% CI: 0.932–0.943) and 0.941 (95% CI: 0.936–0.952) for TRISS. Conclusion The new model has enabled us to include most of the cases that were excluded under the TRISS's inclusion criteria, less missing data are incurred and the predictive performance was significantly better than that of the TRISS model as shown by the AROC curves.

Objective: To establish the aetiological influences of persistent neck pain following a motor vehicle collision and to construct a model for use in the emergency department for identifying patients at high risk of persistent symptoms. Design: Prospective cohort study. Patients recruited from hospital emergency departments were sent a questionnaire to gather information on various exposures. They were followed up at 1, 3, and 12 months to identify those with persistent symptoms. Main outcome measure: Persistent neck pain (pain at 1, 3, and 12 months after collision). Results: The baseline survey included 765 patients. Subsequently, 480 completed a questionnaire at each follow up time point, of whom 128 (27%) reported neck pain on each occasion. Few collision specific factors predicted persistent neck pain. In contrast, a high level of general psychological distress, pre-collision history of widespread body pain, type of vehicle, whiplash associated symptoms, and initial neck disability best predicted the persistence of symptoms. Furthermore, these factors, in combination, accounted for more than a fivefold increase in the risk of persistent neck pain. Conclusion: The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself. With these factors, and those relating to initial injury severity, it is possible to identify a subgroup of patients presenting with neck pain with the highest risk of persistent symptoms. Thus, it is possible to identify whiplash patients with a poor prognosis and to provide closer follow up and specific attention to management in these individuals.

Background: The NICE head injury guidelines recommend a different approach in the management of head injury patients. It suggests that CT head scan should replace skull x ray (SXR) and observation/admission as the first investigation. We wished to determine the impact of NICE on SXR, CT scan, and admission on all patients with head injury presenting to the ED setting and estimate the cost effectiveness of these guidelines, which has not been quantified to date. Design: Study of head injury patients presenting to two EDs before and after implementation of NICE guidelines Methods: The rate of SXR, CT scan, and admission were determined six months before and one month after NICE implementation in both centres. The before study also looked at predicted rates had NICE been applied. This enabled predicted and actual cost effectiveness to be determined. Result: 1130 patients with head injury were studied in four 1 month periods (two in each centre). At the teaching hospital, the CT head scan rate more than doubled (3% to 7%), the SXR declined (37% to 4%), while the admission rate more than halved (9% to 4%). This represented a saving of £3381 per 100 head injury patients: greater than predicted with no adverse events. At the District General Hospital, the CT head scan rate more than quadrupled (1.4% to 9%), the SXR dropped (19 to 0.57%), while the admission rate declined (7% to 5%). This represented a saving of £290 per 100 head injury patients: less than predicted. Conclusion: The implementation of the NICE guidelines led to a two to fivefold increase in the CT head scan rate depending on the cases and baseline departmental practice. However, the reduction in SXR and admission appears to more than offset these costs without compromising patient outcomes.

Intraosseous lines are a reliable and rapid tool for obtaining vascular access in emergency situations, particularly in children. Their use is recommended when intravenous access cannot be easily secured and there is a need for fluid or pharmacological resuscitation. Training in this technique is included in the Advanced Trauma Life Support (ATLS) and Advanced Paediatric Life Support course (APLS) provider courses. The objective of this study is to analyse the national use of intraosseous lines in paediatric trauma in England and Wales. Data has been collected from the Trauma Audit and Research Network (TARN) group longitudinally over 14 years from 1988 to 2002. From 23,489 paediatric trauma cases, intraosseous lines were used in only 129 patients. Compared with the remainder of the paediatric data, we found that these were the younger (1-6 years), more severely injured patients (higher ISS, lower GCS, higher head, thorax, and abdominal AIS). The mortality of these patients was high at 64% compared with 4% overall. IO line use was greater in general than in Paediatric hospitals, perhaps due to good intravenous access skills in paediatric centres. We recommend that intraosseous line use should be a skill available to everybody involved in paediatric trauma resuscitation, particularly those who may not have refined paediatric intravenous cannulation skills.

Background: NICE guidelines for the management of head injury were published in June 2003. Their recommendations differ markedly from previous guidelines published by the Royal College of Surgeons (RCS). In place of skull radiography and admission, computed tomography (CT) is advocated. The impact of these guidelines on service provision in the UK is unknown. Methods: Data on all clinical correlates of children presenting with any severity of head injury was collected in three hospitals in the northwest of England. The current skull radiograph (SXR), CT scan, and admission rates were determined. The rates of SXR, CT scan, and admission that should have occurred when following either the RCS or NICE guidelines were then determined. Results: Data from 10 965 patients who attended three hospitals between February 2000 and August 2002 was studied. Twenty five per cent of patients received a SXR, 0.9% a CT scan, and 3.7% were admitted. Strict adherence to the RCS guidelines would have resulted in a 50% SXR rate, a 1.6% CT scan rate, and a 7.1% admission rate. Adherence to NICE guidelines would result in a 0.3% SXR rate, an 8.7% CT scan rate, and a 1.4% admission rate, although the CT rate would drop to 6.3% if vomiting three or more times in the under 12s was used instead of more than one vomit. Conclusions: The new NICE guidelines do not increase the workload caused by patients attending with head injury but they move their management from the observation ward to the radiology department.

The seventh paper in this series discusses the importance of statistical techniques in research.

To demonstrate trends in trauma care in England and Wales from 1989 to 2000. Study population: Database of the Trauma Audit and Research Network that includes hospital patients admitted for three days or more, those who died, were transferred or admitted to an intensive care or high dependency area. Method: To demonstrate trends in outcome, severity adjusted odds of death per year of admission to hospital were calculated for all hospitals (n=99) and 20 hospitals who had participated since 1989 (adjustments are for Injury Severity Score, age, and Revised Trauma Score). The grade of doctor initially seeing the injured patient in accident and emergency and median prehospital times per year of admission were calculated to demonstrate trends in the process of care. Trend analyses were carried out using simple linear regression (odds ratio versus year). Results: The analysis shows a significant reduction in the severity adjusted odds of death of 3% per year over the 1989-2000 time period (p=0.001). During the period 1989-1994 the odds of death declined most steeply (on average 6% per year p=0.004). Between 1994 to 2000 no significant change occurred (p=0.35). This pattern was mirrored by the 20 permanent members where the odds of death also declined more steeply over the 1989-1994 period. The percentage of severely injured patients (ISS > 15) seen by a consultant increased from 29 to 40 from 1989-1994 but has remained static subsequently. Median prehospital times for severely injured patients have not changed significantly since 1994 (51 to 45 minutes). Conclusion: Most of the case fatality reduction for trauma patients reaching hospital over the 1989-2000 time period occurred before 1995 when there was most marked change in the initial care of severely injured patients.

OBJECTIVE To compare the ability of plasma (lactate) and the plasma lactate/pyruvate (L/P) ratio to predict shock-related outcome after injury and also to examine the influence of plasma ethanol on any relationships found. DESIGN Prospective observational study. SETTING Emergency departments in the UK and the Republic of South Africa. PATIENTS Blood samples were taken at presentation from 232 adult patients 1-23 hrs (median, 3.5 hrs) after sustaining an injury or injuries deemed sufficiently severe to require inpatient care. MEASUREMENTS Plasma concentrations of lactate, pyruvate, and ethanol, anatomical severity of injury, development of multiple organ failure, and 30-day survival were determined. RESULTS At 90% specificity for predicting subsequent mortality and/or multiple organ failure, plasma lactate >or=3.85 mmol/L was 23% (5% to 41%) more sensitive than an L/P ratio of >or=42.76. At 90% sensitivity for ruling out morbidity, plasma lactate

Background A ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming the standard of care during the early management of adult patients with suspected severe blunt multitrauma. A number of studies have variously reported a mortality benefit or no benefit from a pan-scan approach compared to that of carrying out body region-focused CT and/or plain radiographs or a mixture of imaging modalities. However, unanswered questions still remain due to the significant heterogeneity in practice between institutions, and the limitations of published studies. The potential risk for harm from ionising radiation or intravenous contrast-induced nephropathy is still a concern, especially where mortality benefit from an unselective pan-scan approach is yet to be definitively proven. We present the results of our latest analysis of the Trauma Audit and Research Network (TARN) database; updated to take into account the establishment of the regional trauma network system and focusing on the Major Trauma Centre’s (MTC’s). Methods We analysed retrospective, multicentre data of severe blunt multitrauma (ISS >15) direct MTC admissions aged >15 years recorded in the UK TARN database from 2012–2017 to compare survival at 30 days between two groups of patients: (1) those undergoing pan-scan, and (2) those in receipt of a focussed/non-pan-scan approach as part of their initial management within the first 4 hours in the Emergency Department (ED). The final dataset included 44 407 cases. Results 15 645 (35.2%) of 44 407 cases underwent pan-scan from the ED. The median ISS for the pan-scan group was 18 (IQR 10–29) compared to 16 (IQR 9–25) for the non-pan-scan group. The calculated crude mortality rate for the pan-scan group was 11.2% compared to 10.6% in the focussed CT group (p=0.0673). Patient characteristics are shown in table 1. Propensity scoring (PS) was used to create a balance in patient characteristics between the two groups and various statistical models derived to analyse the effect of imaging type (exposure factor) on outcome (mortality at 30 days) as shown in table 2. The results show that pan-scan has an adverse effect on outcome in all of the models, although not statistically significant in all except Model 2 (adjustment based only on stratified PS). Conclusion The results of our investigation demonstrate that there is no risk adjusted mortality benefit observed from current practice in MTCs in England and Wales. Key issues remain to be addressed such as pan-scan selection criteria and the significant heterogeneity observed in practice across institutions.

INTRODUCTION: A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). A definitive randomised controlled trial (impact trial) is required to assess the clinical and cost effectiveness of the new model before it can be accepted in clinical practice. The purpose of this trial is to assess the feasibility and acceptability of such a definitive trial and inform its design.METHODS/ANALYSIS: This feasibility trial is designed to test the methods of a multicentre, cluster-randomised (stepped- wedge) trial, with a substantial qualitative component. Four EDs in England and Wales will collect data for all blunt chest wall trauma patients over a 5-month period; in the initial period acting as the controls (normal care), and in the second period acting as the interventions (in which the new model will be used). Baseline measurements including completion of the SF-12v2 will be obtained on initial assessment in the ED. Patient outcome data will then be collected for any subsequent hospitalisations. Data collection will conclude with a 6-week follow-up completion of two surveys (SF-12v2 and Client Services Receipt Inventory). Analysis of outcomes will focus on feasibility, acceptability and trial processes and will include recruitment and retention rates, attendance at clinician training rates and use of model in the ED. Qualitative feedback will be obtained through clinician interviews and a research nurse focus group. An evaluation of the feasibility of health economics outcomes data will be completed.ETHICS AND DISSEMINATION: Wales Research Ethics Committee 6 granted approval for the trial in September 2016. Patient recruitment will commence in February 2017. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at professional meetings.TRIAL REGISTRATION NUMBER: ISRCTN95571506; Pre-results.

Across the developed world, demographic change is having a profound impact on emergency care,1 with recognition that older people have different needs, and may need different services.2 The article by Hawley et al 3 in this edition, and the recent publication of a report4 on major trauma in older people from the Trauma Audit and Research Network (TARN), suggest that we may also need to think differently about our major trauma systems. In England and Wales, recent improvements in data collection from trauma units (hospitals that are not major trauma centres) means that in 2016 the ‘typical’ case of major trauma is no longer a young male admitted after a road traffic accident, but is an older male admitted after a fall of less than 2 …

BACKGROUND Recently, two simple clinical scores were published to predict survival in trauma patients. Both scores may successfully guide major trauma triage, but neither has been independently validated in a hospital setting. METHODS This is a cohort study with 30-day mortality as the primary outcome to validate two new trauma scores-Mechanism, Glasgow Coma Scale (GCS), Age, and Pressure (MGAP) score and GCS, Age and Pressure (GAP) score-using data from the UK Trauma Audit and Research Network. First, an assessment of discrimination, using the area under the receiver operating characteristic (ROC) curve, and calibration, comparing mortality rates with those originally published, were performed. Second, we calculated sensitivity, specificity, predictive values, and likelihood ratios for prognostic score performance. Third, we propose new cutoffs for the risk categories. RESULTS A total of 79,807 adult (≥16 years) major trauma patients (2000-2010) were included; 5,474 (6.9%) died. Mean (SD) age was 51.5 (22.4) years, median GCS score was 15 (interquartile range, 15-15), and median Injury Severity Score (ISS) was 9 (interquartile range, 9-16). More than 50% of the patients had a low-risk GAP or MGAP score (1% mortality). With regard to discrimination, areas under the ROC curve were 87.2% for GAP score (95% confidence interval, 86.7-87.7) and 86.8% for MGAP score (95% confidence interval, 86.2-87.3). With regard to calibration, 2,390 (3.3%), 1,900 (28.5%), and 1,184 (72.2%) patients died in the low, medium, and high GAP risk categories, respectively. In the low- and medium-risk groups, these were almost double the previously published rates. For MGAP, 1,861 (2.8%), 1,455 (15.2%), and 2,158 (58.6%) patients died in the low-, medium-, and high-risk categories, consonant with results originally published. Reclassifying score point cutoffs improved likelihood ratios, sensitivity and specificity, as well as areas under the ROC curve. CONCLUSION We found both scores to be valid triage tools to stratify emergency department patients, according to their risk of death. MGAP calibrated better, but GAP slightly improved discrimination. The newly proposed cutoffs better differentiate risk classification and may therefore facilitate hospital resource allocation. LEVEL OF EVIDENCE Prognostic study, level II.

This review considers current trauma scoring systems and databases and their relevance to improving patient care. Single physiological measures such as systolic arterial pressure have limited ability to diagnose severe trauma by reflecting raised intracranial pressure, or significant haemorrhage. The Glasgow coma score has the greatest prognostic value in head-injured and other trauma patients. Trauma triage tools and imaging decision rules—using combinations of physiological cut-off measures with mechanism of injury and other categorical variables—bring both increased sophistication and increased complexity. It is important for clinicians and managers to be aware of the diagnostic properties (over- and under-triage rates) of any triage tool or decision rule used in their trauma system. Trauma registries are able to collate definitive injury descriptors and use survival prediction models to guide trauma system governance, through individual patient review and case-mix-adjusted benchmarking of hospital and network performance with robust outlier identification. Interrupted time series allow observation in the changes in care processes and outcomes at national level, which can feed back into clinical quality-based commissioning of healthcare. Registry data are also a valuable resource for trauma epidemiological and comparative effectiveness research studies.

BACKGROUND: The impact of diabetes mellitus in patients with multiple system injuries remains obscure. This study was designed to increase knowledge of outcomes of polytrauma in patients who have diabetes mellitus. METHODS: Data from the Trauma Audit and Research Network was used to identify patients who had suffered polytrauma during 2003 to 2011. These patients were filtered to those with known outcomes, then separated into those with diabetes, those known to have other co-morbidities but not diabetes and those known not to have any co-morbidities or diabetes. The data were analyzed to establish if patients with diabetes had differing outcomes associated with their diabetes versus the other groups. RESULTS: In total, 222 patients had diabetes, 2,558 had no past medical co-morbidities (PMC), 2,709 had PMC but no diabetes. The diabetic group of patients was found to be older than the other groups (P

Recent National Institute for Health and Care Excellence (NICE) guidelines recommended computed tomography for patients with head injury who are taking warfarin. We understand Heywood’s concerns that other anticoagulants and antiplatelet drugs were not included.1 2 The …

OBJECTIVES: Recent interest has focused on reorganizing emergency medical services (EMS) for English traumatic brain injury (TBI) patients, with bypass of nonspecialist hospitals and direct transportation to distant neuroscience centres. This may expedite specialist neurocritical care and neurosurgical interventions, but risks harms from prehospital deterioration and delayed resuscitation. We therefore aimed to investigate the effect of EMS interval on outcome following head injury. METHODS: We performed a multicentre cohort study examining adult patients with significant TBI (head region abbreviated injury scale ≥3) enrolled in the Trauma Audit and Research Network trauma registry between 2005 and 2011. The association between EMS interval and mortality in patients directly admitted to specialist neuroscience centres was explored using bivariate and multivariate logistic regression and propensity score matching analyses. RESULTS: In all, 7149 eligible patients presented directly to specialist neuroscience centres during the study period. Adjusted odds ratios for mortality showed no association between EMS interval and mortality, varying from 0.46 (95% confidence interval 0.1-2.6) for EMS intervals under 20 min to 0.67 (95% confidence interval 0.4-1.2) for EMS intervals more than 120 min (reference EMS interval 40-60 min). This lack of association was also observed following matching using propensity scores, with no significant difference apparent in mortality between EMS intervals less than 60 min and more than 60 min (17.85 vs. 17.0%, P=0.826). These results were unaffected in sensitivity analyses examining missing covariate data or unmeasured outcomes. CONCLUSION: The lack of observed association between EMS interval and mortality may not preclude bypass of significant TBI patients, with concomitantly prolonged primary transfers from the scene of injury to distant specialist centres. However, given the limitations of registry data, our results should be interpreted with caution. Language: en

Objectives In covering these objectives the following terms will be introduced: We have shown previously that statistical inference enables general conclusions to be drawn from specific data. For example estimating a population's mean from a sample mean. At first glance this may not appear important. In practice however the ability to make these estimations is fundamental to most medical investigations. These tend to concentrate on dealing with one or more of the following questions: Have the observations changed with time and/or intervention? Do two or more groups of observations differ from each other? Is there an association between different observations? To answer these questions many different types of statistical inference tests have been developed to deal with varying sample sizes and different types of data. Though the tests differ they have the common aim of assessing whether the null hypothesis is likely to be correct (box 1). They are known collectively as “tests of significance”.1 ### Box 1 The null hypothesis There is no difference between the groups with respect to the measurement made. The significance test chosen is dependent upon the type of data we are dealing with, whether it has a normal distribution and the type of question being asked.2 Once the distribution of the data is known, you can tell if the null hypothesis should be tested using parametric or non-parametric methods. ### PARAMETRIC ANALYSIS A normal distribution is a regular shape. As such it is possible to draw the curve exactly by simply knowing the mean, standard deviation and variance of the data. When considering a normal distribution of a population these features are known as parameters. Parametric analysis relies on the data being normally (or nearly) …

Provided the sample size is large enough (that is, n greater than 100), the z statistic can be used to determine the confidence interval estimation of the population mean even when the sigma is not known. In these cases the estimation of the standard error of the mean is used. The z statistic is also valid when determining the population's proportion based upon a large sample. However, when dealing with smaller samples, the z statistic is replaced by the t statistic. This makes it possible to estimate, in a population with an unknown standard deviation: The probability of getting a sample mean greater than or equal to a particular value The value of a sample mean with a particular probability of occurring The probability of getting a sample mean between two particular values The confidence interval for the estimation of the population mean can also be determined using the t statistic.

In covering these objectives we will introduce the following terms: In the previous article the term inferential statistic was introduced.1 This form of numeric manipulation is often used to estimate a population's parameter from a sample's statistic. For example, inferential statistics would be used to estimate a population's mean from a sample's mean. It can also be used to do the opposite—that is, estimate a sample statistic from a population's parameter. This is not commonly done because it requires the population's mean and standard deviation to be known and this is rarely the case. In both calculations the values obtained are only estimations because of the normal variation that occurs. We can however work out the probability of a particular value based upon information from either the sample or population. Central to this is converting the original data to a standard normal distribution so that these estimations can be made. A standard normal distribution is a particular type of normal distribution that has the following properties: It is possible to convert any normal distribution to a standard normal distribution by adjusting it such that the population mean becomes zero and the standard deviation is equal to 1. To do this, each of the data points (elements) is modified by: The final value is known as the z statistic. The z statistic is therefore describing the size of the difference between the element (X) and population's mean (μ) …

In covering these objectives we will introduce the following terms: The previous two articles discussed summarising data so that useful comparisons can be made. Another common problem encountered is estimating a value in a larger group based upon information collected from a small number of subjects. To see how statistics can be used to achieve this, it is helpful to begin by reviewing the meaning of five commonly used terms: The word “population” describes a large group that includes every possible case. In contrast, a “sample” is a smaller group of subjects who are part of the population. Therefore the population of UK emergency departments would have every emergency department in the UK whereas those in the north west would represent a sample. A value measured in a population is known as a “parameter”. Consequently the trolley waiting time in UK emergency departments would be a parameter. The term “statistic” is used to denote the same variable when it is measured in a sample. Finally each separate observation in either a population or sample is called an “element” and it is often labelled with the letter X. The number of elements in a population is given the letter N and in a sample, n. Key point A population contains all the elements from X1 to XN and a sample has n of the N elements. It is often not possible to record all the elements of a population. For example, a study investigating the peak flow in asthmatic patients attending UK emergency departments cannot review every patient. …

Summary Background In 1988, the Royal College of Surgeons reported major deficiencies in trauma care in UK hospitals. We investigated whether and how that care has changed in the last decade by use of data collected by the UK Trauma Audit and Research Network. Methods We analysed injury-severity, process, and outcome variables from 91 602 patients' records on the database at the end of 1997, collected from 97 (49% of trauma-receiving) hospitals in England, Wales, and two in Ireland. We did longitudinal analyses of odds of death, process variables, and individual hospitals' performance. We took account of potential selection bias from missing data and recruitment of new hospitals. Findings The severity-adjusted odds of death after trauma declined gradually from 1989 (odds ratio 1997/1989 0·63 [95% CI [0·49–0·82]). In 1997, the reduction in odds of death was significant even after adjustment for missing data (ratio 1997/1989 0·72 [0·55–0·92]) and recruitment of new hospitals (0·64 [0·44–0·93]). There was significant variability in the proportion of survivors (adjusted for severity of injury and age) between the highest and lowest 10% of UK hospitals. The time between the call to the emergency services and arrival at hospital increased from 32 min in 1989 to 45 min in 1997, irrespective of injury severity. The proportion of severely injured patients seen first by senior doctors increased from 32% to 60%. Interpretation Hospital care has made a valuable but variable contribution to reductions in case fatality after injury in the UK in the past 10 years, though further improvement is possible.

Objectives & Background Whole Body Computed Tomography (WBCT) scanning is considered to be the chief imaging modality for patients with major trauma. There is growing evidence that the rate of survival is higher for patients undergoing early WBCT by facilitating rapid and accurate anatomical characterisation of potentially life-threatening injuries. There remains ongoing controversy whether this outweighs the potential risks from high-dose ionising radiation. Methods Data from the Trauma Audit and Research Network (TARN) trauma registry was analysed for all patients presenting from January 2005 to July 2014 inclusive aged 16 years or more admitted directly to hospital Emergency Departments (ED) with suspected severe blunt polytrauma. Survival was compared between two groups: (1) patients who underwent WBCT scans, and (2) those who underwent a focused CT (“non-WBCT”) scanning approach within the first four hours of arrival at the ED. Results 14,598 (23·2%) of 62,942 eligible cases underwent WBCT directly from the ED within four hours of arrival. The calculated crude survival rate for the WBCT group was 89·2%, compared to 88·9% in the non-WBCT group (p=0·260). The results of multivariate regression analysis, taking account of all possible confounders, demonstrated a trend towards improved survival in the WBCT scan group, with an OR=1·080 (95% CI 0·986–1·183) compared to the non-WBCT group (p=0·098). Conclusion The results of our investigation demonstrate a trend towards improved survival for adult patients with suspected severe blunt polytrauma undergoing WBCT scanning early in their management in the ED. Our analysis of the largest series of trauma cases investigating WBCT so far is the first to take account of all possible confounding factors including centre effect – often a major limitation for generalisability in previous studies of this kind. The existing evidence for the use of WBCT during the management of major trauma is also discussed in the context of these new results.

To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures.A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39,073 patients with major trauma.Of the 39,073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs).The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.

UK trauma services are currently undergoing reconfiguration, but the optimum management pathway for head-injured patients is uncertain. We therefore performed a systematic review to assess the effects of routine inter-hospital transfer and specialist neuroscience care on mortality and disability in patients with non-surgical severe traumatic brain injury injured nearest to a non-specialist acute hospital.A protocol was registered with PROSPERO (CRD42012002021) and review methodology followed Cochrane Collaboration recommendations. A peer reviewed search strategy was implemented in an exhaustive range of information sources, including all major bibliographic databases, between 1973 and July 2013. Selection of eligible studies, extraction of relevant data and bias assessment were then performed by two independent reviewers. In the absence of homogeneous effect estimates at low risk of bias a narrative synthesis was pre-specified.Four cohort studies, including a total of 4688 patients, were identified as potentially eligible after screening and bias assessment. Confounding by indication, arising from selective transfer of less severely injured patients, was the main limitation of included studies, with overall risk of bias rated as high for both mortality and disability effect estimates. Adjusted odds ratios for mortality favoured secondary transfer, ranging from 1.92 (95% CI 1.25-2.95) to 2.09 (95% CI 1.59-2.74). No convincing association was observed between non-specialist care and unfavourable outcome with a conditional odds ratio of 1.13 (95% CI 0.36-3.6).There is limited evidence supporting a strategy of secondary transfer of severe non-surgical traumatic brain injury patients to specialist neuroscience centres. Randomised controlled trials powered to detect clinically plausible treatment effects should be considered to definitively investigate effectiveness.

Recent interest has focused on reorganizing emergency medical services (EMS) for traumatic brain injury (TBI) patients, with bypass of nonspecialist hospitals and direct transportation to distant neuroscience centers. Although this could expedite neurosurgery and neurocritical care, deteriorating physiology could be deleterious.We performed a multicenter cohort study examining adult patients with significant TBI enrolled in the English National Trauma Registry. The distributions and correlation of first recorded prehospital and emergency department (ED) vital signs were compared, and the effect of time on changes in vital signs was examined in bivariate and multivariate analyses.A total of 7149 eligible patients were studied. No clinically significant differences were apparent between distributions of prehospital and ED vital signs. Moderate linear correlation was observed for field and ED pulse rate (r(2) = 0.34) and GCS values (Spearman's rho = 0.76), with weak correlation apparent for systolic blood pressure (r(2) = 0.28) and respiratory rate (r(2) = 0.28). Eight percent of cases' vital signs deteriorated in the prehospital interval; however, odds of deterioration in vital sign status did not vary significantly with duration of EMS interval.The similarity between prehospital and ED vital signs, and lack of association between EMS interval and physiological deterioration, may support a strategy of direct transportation of TBI cases to specialist centers. Further research is necessary to identify patients at risk from deterioration during bypass and to investigate effects on mortality.

Objective To investigate the performance characteristics in children with moderate and minor injuries of prehospital paediatric triage tools currently in use in England for identifying seriously injured children. Methods Eight prehospital paediatric triage tools were identified from literature review and a survey of the lead trauma clinicians across the 10 English strategic health authorities. Retrospective clinical data from 2934 patient records collected by four emergency departments were used to analyse each tool. A target sensitivity of >95% and specificity of 50–75% was set based on the literature. Results Three tools (East Midlands, North West and Northern) demonstrated acceptable sensitivity (all 100%). The other five tools fell below the target sensitivity of >95%. All eight tools had acceptable specificity (with results between 79% and 99%). Conclusions Three tools (East Midlands, North West and Northern) demonstrated acceptable over- and under-triage rates in this population of minor and moderately injured children. All tools reached recommended standards for over-triage, but the majority favoured under-triage.

All emergency departments (EDs) have an obligation to deliver care that is demonstrably safe and of the highest possible quality. Emergency medicine is a unique and rapidly developing specialty, which forms the hub of the emergency care system and strives to provide a consistent and effective service 24 h a day, 7 days a week. The International Federation of Emergency Medicine, representing more than 70 countries, has prepared a document to define a framework for quality and safety in the ED. Following a consensus conference and with subsequent development, a series of quality indicators have been proposed. These are tabulated in the form of measures designed to answer nine quality questions presented according to the domains of structure, process and outcome. There is an urgent need to improve the evidence base to determine which quality indicators have the potential to successfully improve clinical outcomes, staff and patient experience in a cost-efficient manner--with lessons for implementation.

Currently available prognostic models in Traumatic Brain Injury (TBI) are derived from historical data sets or from heterogeneous data sets, depending upon the trauma care delivered. The objective of our study was to develop models to predict survival in a recent cohort of TBI patients within a relatively homogeneous trauma care system. Records of patients with brain injury were extracted from the Trauma Audit and Research Network (TARN) database. The relationship of the variables (i.e., age, Glasgow Coma Score [GCS], pupillary reactivity, Injury Severity Score [ISS], Computed Tomography [CT] classifications, classification of various intracranial pathologies, systolic and mean blood pressure, oxygen saturation, and the presence of extracranial injury) to survival at discharge were determined. Stepwise logistical regression analysis was performed to determine the best prognostic model. Two models were derived from data of 802 patients (models A and B). Age, GCS, pupillary reactivity, hypoxia, and brainstem injury are significant predictors in both. However, model A contains ISS in contrast to model B, which contains the presence of brain swelling and major extracranial injury instead. Both models have good predictive performance (model A: area under the Receiver Operating Characteristic [ROC] curve [AUC]=0.92 [95% CI, 0.90-0.95], Nagelkerke R(2), 0.62; model B: AUC=0.93 [95% CI: 0.91-0.95], Nagelkerke R(2): 0.63). Hence, two accurate and reliable prognostic models were developed from a recent cohort of the TBI population.

OBJECTIVES: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. DESIGN: Cohort study. SETTING: Sixty-seven adult critical care units. PARTICIPANTS: Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. INTERVENTIONS: Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. MAIN OUTCOME MEASURES: Mortality, Glasgow Outcome Scale - Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. RESULTS: The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the 'early' (within 18 hours of presentation) and 'no or late' (after 24 hours) transfer groups. After adjustment, the 'early' transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. CONCLUSIONS: The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Systolic blood pressure (SBP), heart rate (HR), and respiratory rate are poor predictors of trauma outcome. We postulate that HR/SBP (shock index [SI]) and novel new markers SI × age (SIA), SBP / age (BPAI), maximum HR (220 - age) - HR (minpulse [MP]), and HR / maximum HR (pulse max index [PMI]) are better predictors of 48-hour mortality compared with traditional vital signs.Data were extracted from the Trauma Audit and Research Network database. Exclusions included any head or spine injury and prehospital intubation or cardiac arrest. Area under receiver operator characteristic curve (AUROC) was determined for 48-hour mortality for all variables and age. A threshold for each marker was derived using the specificity (rule-in) cutoffs at both 90% and 95% from the receiver operator characteristic curve. Positive likelihood ratios were described for each marker's derived threshold.Vital signs, markers, and age were all significantly associated with 48-hour mortality (p0.001). HR, SBP, and respiratory rate fared worst overall (AUROC = 0.69, 0.66, and 0.66, respectively). SIA, MP, PMI, BPAI, and SI were significantly (p0.05) better than age at predicting 48-hour mortality (AUROC = 0.79, 0.77, 0.77, 0.74, 0.73, and 0.68, respectively; AUROC for age = 0.68). Thresholds derived for these five markers were values 55 or greater, 44 or less, 70% or greater, 1.5 or less, and 0.9 or greater, respectively, each with a specificity of 95% for 48-hour mortality (positive likelihood ratios were 8.4, 6.1, 6.7, 6.6, and 7.5, respectively). The likelihood of death in 48 hours was 8.4 times more likely if SIA was greater than 55 than if it was lower.Older age seems to be significantly associated with early mortality. Newer markers, especially those combining traditional vital signs with age (SIA, BPAI, MP, and PMI), may contribute to better trauma triage of patients with blunt injuries than traditional vital signs.Prognostic/epidemiologic study, level III.

I agree that the increase in mortality out of hours is an association and not necessarily an indictment of current out of hours hospital services.1 We analysed this association in trauma cases some years ago, using robust adjustment of data from the Trauma …

Objectives & Background Trauma is a leading cause of death in children. Paediatric out-of-hospital traumatic cardiac arrest (POOHTCA) is a subsection of this. The Ps14 survival prediction model is used to predict survival in trauma patients on the Trauma Audit and Research Network (TARN) database. TARN collects and audits data from all trauma receiving hospitals in the UK and many others internationally. It has been hypothesised that there is a difference between the Ps14 survival prediction for POOHTCA and actual survival for POOHTCA patients on the TARN database. Methods Data from the TARN database between 1989–2015 was analysed. A comparison between the Ps14 and actual survival was made. Univariate and logistic regression analyses were conducted on the data using SPSS. A new model to predict survival after POOHTCA was constructed and a comparison between the Ps14 and the new model was made. Results There was a significant difference between the Ps14 prediction model and actual survival. For Known outcomes, predicted survival was 44.9% (95% CI 40.2–49.5%) compared with actual survival of 5.0% (95% CI 3.0%–7.0%). On univariate analysis, age, drowning, year of presentation and time from scene to Emergency Department were found to be significantly different between survivors and non-survivors. Further logistic regression showed only year of presentation and those who received care in the most recent time cohort, remained significant with the remaining variables losing significance. Three models of varying care and patient factors were constructed. The new models were not significantly different to the Ps14 model, C-statistic: 0.709 (95% CI 0.614–0804), 0.709 (0.614–0804) 0.798 (0.672–0.920) and 0.715 (0.603–0.827) for models 1,2,3 and Ps14 respectively. Conclusion The current Ps14 model is not a good predictor of survival for POOHTCA patients. This is most likely due to the small number of POOHTCA patients that survive to discharge. Although the model could be improved with a larger data set, it has been suggested that a traumatic arrest variable could be inserted into the Ps14 model which would reduce predicted survival to between 3% and 7% for this patient population. This would be much closer to actual survival rates and could improve the audit of paediatric trauma care.

Objectives & Background While there is extensive research on the differences between older and younger patients with serious injuries, little is known about variations within the older age group. However, increased frailty over the age of 85 suggests that these ‘oldest old’ patients are likely to be significantly different to younger seniors. Methods The aim of this study was do determine whether the demographic, premorbid and injury characteristics of older patients (aged ≥65) varied with age. A cross-sectional study of of patients from the Trauma Audit and Research Network (TARN) admitted between June 2013 and May 2015 was undertaken, comparing those aged 65 to 74; 75–84 and ≥85 years old. Demographic, premorbid and injury characteristics were compared using Chi-squared analysis, while multiple logistic regression was used to calculate risk adjusted mortality, utilising the PS14 TARN predictive model. Results 51,491 patients on the TARN database were eligible for inclusion. Of these, 18,664 (36.3%) were≥85 years; 19,157 (37.2%) 75–84 years and 13670 (26.5%) 65–74 years. Patients ≥85 years were significantly more likely to be female (68.8% vs 46.6% aged 65–74 years, p Conclusion There are significant variations in the demographic, comorbid and injury characteristics between different age groups of older trauma patients, which are associated with marked differences in crude and risk adjusted mortality. The most senior (over 85) were the most likely to sustain major trauma and the least likely to survive.

Objectives & Background Since the introduction of the regional trauma networks in the UK, the practice of transporting traumatic brain injury (TBI) patients past the nearest non-specialist acute hospital (NSAH) in order to reach the closest specialist neuroscience centre (SNC) has been implemented. However, it has not yet been established whether this practice of ‘bypass’ improves survival in TBI patients, and there are concerns that it may cause delays in the stabilisation of the airway, breathing and circulation (ABC) leading to worse survival. This study sought to address this uncertainty in survival benefit. Methods A comparative cohort study method was used to observe the differences in risk-adjusted survival in TBI patients who either bypassed the nearest NSAH to attend a SNC, or underwent selective secondary transfer from a NSAH to a SNC. The data of 400 patients with significant TBI (abbreviated injury scale score ≥3 in the head region) from two Trauma Networks in the North of England was retrospectively extracted from the Trauma Audit and Research Network (TARN) database, and cases of bypass ( n =112) or secondary transfer ( n =96) were identified. Using direct standardisation to adjust for casemix variation, and logistic regression to control prognostic variables, the differences between the expected and observed rates of survival in each group were compared. Results Bypass of TBI patients did not significantly increase the observed minus expected survival rate (+4.4, 95% CI –1.6 to 10.5). However, selective secondary transfer of TBI patients was associated with more survivors than expected (+11.3, 95% CI 3.4 to 19.3), although the difference between groups was not statistically significant. Conclusion Bypass of NSAHs in favour of SNCs, does not appear to significantly improve survival in TBI patients; and selective secondary transfer to a SNC, following stabilisation of ABCs at a nearer NSAH, may be a more appropriate strategy.

Background Comparison of trauma centres requires accurate injury severity metrics. The Trauma Audit and Research Network (TARN) in the UK, and the Trauma Injury Severity Score (TRISS) provide such risk adjustment. These models incorporate the Injury Severity Score (ISS) as the measure of anatomic injury severity but categorise it differently. The Trauma Mortality Prediction Model (TMPM) better predicts mortality than the ISS. We compared the anatomic injury components of TARN, and TRISS models to TMPM. Methods Data from the National Trauma Data Bank for 2002–2012. Probability of death was estimated for TARN, and TRISS from ISS values according to each model’s treatment and compared these to TMPM using measures of discrimination (area under ROC curves), proximity to the true model (Akaike Information Criterion (AIC)), and calibration (Hosmer-Lemeshow statistic (HL)). Confidence intervals (CI) were estimated by bootstrapping. ISS and TMPM values were estimated for the Abbreviated Injury Scale (AIS) and the International Classification of Diseases, 9th Revision (ICD-9) lexicons. Data are shown as medians and 95% CI. Results N = 1,145,959 Conclusions TMPM better predicted mortality than did the anatomic injury component of TRISS, or TARN and this was true whether individual injuries were coded in the AIS lexicon or in the ICD-9. As trauma care evolves, so must models of mortality prediction that best capture injury severity.