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Clinicopathologic features stratified by treatment arm (RNA-seq analysis population).

BackgroundEvidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality.MethodsWithin the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants’ practice adherence to perinatal mortality.FindingsAcross 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality.InterpretationAdherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex.FundingBill & Melinda Gates Foundation.Trial registration detailsClinicalTrials.gov:NCT02148952; Universal Trial Number: U1111-1131-5647.

Objective To evaluate whether integration of the Opportunity‐Ability‐Motivation plus Supplies (OAMS) framework into coaching improved the delivery of essential birth practices in a low‐resource setting. Methods This prospective mixed‐methods study used routine coaching visit data obtained from the first eight intervention facilities of the BetterBirth trial in Uttar Pradesh, India, between December 19, 2014, and October 21, 2015. The 8‐month intervention was peer coaching that integrated the OAMS framework to support uptake of the WHO Safe Childbirth Checklist. Descriptive statistics were used to measure nonadherence to essential birth practices. The frequency and accuracy of coaches’ coding of barriers and the appropriateness of chosen resolution strategies to measure feasibility, acceptability, and fidelity of using OAMS, were assessed. Results Coaches observed 666 deliveries, including 12 602 practices. Overall, essential practice nonadherence decreased from 15.6% (262/1675 practices observed) to 4.5% (4/88 practices) (P, Using a modified behavior change framework, peer‐coaches were able to identify barriers to the provision of essential delivery practices and design problem‐solving interventions.

BACKGROUND This study aimed to determine the relative "weight" of risk factors known to be associated with venous thromboembolism (VTE) for patients with trauma based on injuries and comorbidities. METHODS A retrospective review of 16,608 consecutive admissions to a trauma center was performed. Patients were separated into those who developed VTE (n = 141) versus those who did not (16,467). Univariate analysis was performed for each risk factor reported in the trauma literature. Risk factors that were shown to be significant (p < 0.05) by univariate analysis underwent multivariate analysis to develop odds ratios for VTE. The Trauma Embolic Scoring System (TESS) was derived from the multivariate coefficients. The resulting TESS was compared with a data set from the National Trauma Data Bank (2002-2006) to determine its ability to predict VTE. RESULTS The multivariate analysis demonstrated that age, Injury Severity Score, obesity, ventilator use for more than 3 days, and lower-extremity trauma were significant predictors of VTE in our patient population. The TESS was from 0 to 14, with the best prediction for those patients with a score of more than 6 (sensitivity, 81.6%; specificity, 84%). Overall, the model had excellent discrimination in predicting VTE with a receiver operating characteristic curve of 0.89. The VTE rates for TESS in the National Trauma Data Bank data set were similar for all integers except for 3 and 4, in which the VTE rates were significantly higher (3, 0.2% vs. 0.6%; 4, 0.4% vs. 1.0%). CONCLUSION The TESS provides an objective measure of classifying VTE risk for patients with trauma. The TESS could allow informed decision making regarding prophylaxis strategies in patients with trauma.

Patient satisfaction surveys are increasingly being used as a measure of physician performance in a hospital setting. We sought to determine what role the clinical condition the physician is treating has on overall patient satisfaction scores. Patient satisfaction scores were calculated for elective and emergent general surgery and trauma patients for eight surgeons taking care of all three types of patients. Both physician satisfaction (PP) and hospital satisfaction (GP) scores were calculated. Mean scores (± standard deviation) between groups were compared with P < 0.05 significance. Of 1521 trauma patients and 3779 general surgery patients, there was 14.8 and 15.1 per cent response rate, respectively, to the survey. Trauma patients had a significantly lower PP than general surgery patients (81.0 ± 19.4 vs 85.7 ± 16.4; P < 0.001). However, the GP between trauma and general surgery was not significant (84.0 ± 13 vs 84.0 ± 12.3; nonsignificant) When general surgery patients were divided into emergent versus elective, the PP was significantly higher for elective than emergent (87.9 ± 14.6 vs 82.7 ± 18; P < 0.001). A patient's underlying clinical condition may influence response to patient satisfaction surveys. Further research needs to be performed before patient satisfaction surveys can be adopted as a overall measure of physician competency.

The geriatric trauma patient poses unique challenges to the trauma surgeon due to occult injuries and occult hypoperfusion. We hypothesized that those elderly patients with significant injuries, who were not initially evaluated via trauma activation, would suffer worse outcomes. All cases of elderly (age ≥ 65) admitted to the trauma service from the years 2000 to 2010 were included. Our trauma activation system encompasses anatomic, physiologic, and mechanism of injury criteria. We defined patients as undertriaged (UT) if they had an ISS > 15 and did not undergo a trauma team activation, but had a regular workup by an emergency department physician and trauma team consultation. Factors that contributed to being UT in the emergency department were investigated by univariate and multivariate analysis. A total of 4534 elderly patients constitute this analysis, of which 15.1 per cent were UT. The UT patients were more likely to die, when adjusted for Revised Trauma Score, Glasgow Coma score, the occurrence of $1 complication, and whether the patient was on Coumadin. UT has a high risk of death in elderly patients. Trauma triage guidelines need to be better tailored to identify the high-risk geriatric trauma patient.

BACKGROUND: Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury. We have developed the high-risk geriatric protocol (GP) that seeks to identify high-risk geriatric patients. We hypothesized that a high-risk GP would improve outcome in this select group of patients. METHODS: Patients from 2000 to 2010 were included. Patients 65 years or older who met high-risk GP based on comorbidities and/or physiologic parameters were compared with those patients who had not received GP before its implementation as well as other non-GP patients. This protocol includes a geriatric consultation, as well as a lactate levels, arterial blood gas levels, and echo test to assess for occult shock. Age, trauma activation, preexisting conditions, Injury Severity Score, Revised Trauma Score, and mortality were reviewed. Univariate and multivariate analyses were conducted to identify factors predictive of mortality. RESULTS: A total of 3,902 patients were evaluated. Patients receiving GP were less likely to die (odds ratio, 0.63 [0.39-0.99], p = 0.046). For all patients, there was a dramatic increase in mortality for those patients older than 75 years. CONCLUSION: The GP, adjusted for other covariates, significantly reduced mortality in our patient population. Thus, this study confirms the overall effectiveness of our GP, which is hallmarked by prompt identification of those patients with occult shock and a multidisciplinary care of the aged population. LEVEL OF EVIDENCE: Therapeutic study, level IV. Language: en

The Trauma and Injury Severity Score (TRISS) has been the approach to trauma outcome prediction during the past 20 years and has been adopted by many commercial registries. Unfortunately, its survival predictions are based upon coefficients that were derived from a data set collected in the 1980s and updated only once using a data set collected in the early 1990s. We hypothesized that the improvements in trauma care during the past 20 years would lead to improved survival in a large database, thus making the TRISS biased.The TRISSs from the Pennsylvania statewide trauma registry (Collector, Digital Innovations) for the years 1990 to 2010. Observed-to-expected mortality ratios for each year of the study were calculated by taking the ratio of actual deaths (observed deaths, O) to the summation of the probability of mortality predicted by the TRISS taken over all patients (expected deaths, E). For reference, O/E ratio should approach 1 if the TRISS is well calibrated (i.e., has predictive accuracy).There were 408,489 patients with complete data sufficient to calculate the TRISSs. There was a significant trend toward improved outcome (i.e., decreasing O/E ratio; nonparametric test of trend, p0.001) over time in both the total population and the blunt trauma subpopulation. In the penetrating trauma population, there was a trend toward improved outcome (decreasing O/E ratio), but it did not quite reach significance (nonparametric test of trend p = 0.073).There is a steady trend toward improved O/E survival in the Pennsylvania database with each passing year, suggesting that the TRISS is drifting out of calibration. It is likely that improvements in care account for these changes. For the TRISS to remain an accurate outcome prediction model, new coefficients would need to be calculated periodically to keep up with trends in trauma care. This requirement for occasional updating is likely to be a requirement of any trauma prediction model, but because many other deficiencies in the TRISS have been reported, we think that rather than updating the TRISS, it would be more productive to replace the TRISS with a modern statistical model.

Patient satisfaction surveys are increasingly being used as a measure of physician performance in a hospital setting. We sought to determine what role the clinical condition the physician is treating has on overall patient satisfaction scores. Patient satisfaction scores were calculated for elective and emergent general surgery and trauma patients for eight surgeons taking care of all three types of patients. Both physician satisfaction (PP) and hospital satisfaction (GP) scores were calculated. Mean scores (± standard deviation) between groups were compared with P0.05 significance. Of 1521 trauma patients and 3779 general surgery patients, there was 14.8 and 15.1 per cent response rate, respectively, to the survey. Trauma patients had a significantly lower PP than general surgery patients (81.0 ± 19.4 vs 85.7 ± 16.4; P0.001). However, the GP between trauma and general surgery was not significant (84.0 ± 13 vs 84.0 ± 12.3; nonsignificant) When general surgery patients were divided into emergent versus elective, the PP was significantly higher for elective than emergent (87.9 ± 14.6 vs 82.7 ± 18; P0.001). A patient's underlying clinical condition may influence response to patient satisfaction surveys. Further research needs to be performed before patient satisfaction surveys can be adopted as a overall measure of physician competency.