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BACKGROUND: Most deaths in critically ill patients with severe traumatic brain injury are associated with a decision to withdraw life-sustaining treatments. We aimed to identify the behavioural determinants that influence recommendations by critical care physicians to consider the withdrawal of life-sustaining treatments in this population. METHODS: We conducted a descriptive qualitative study based on the Theoretical Domains Framework of critical care physicians caring for patients with severe traumatic brain injury across Canada. We stratified critical care physicians by regions and used a purposive sampling strategy. We conducted semistructured phone interviews using a piloted and pre tested interview guide. We transcribed the interviews verbatim and verified the content for accuracy. We performed the analysis using a 3-step approach: coding, generation of specific beliefs and generation of specific themes. RESULTS: We recruited 20 critical care physicians across 4 geographic regions. After reaching saturation, we identified 7 core themes across 4 Theoretical Domains Framework domains for factors relevant to the decision to withdraw life-sustaining treatments. Four factors (i.e., clinical triggers, social triggers, interaction with families and intentions with medical decisions) were identified before the decision is made and 3 were identified during the decision-making process (i.e., considerations, priorities and knowledge needs). We identified multiple themes reflecting internal (n = 18, 8 Theoretical Domains Framework domains) and external (n = 15, 6 Theoretical Domains Framework domains) influences on the decision to withdraw life-sustaining treatments. INTERPRETATION: We identified several core themes and domains considered by critical care physicians in Canada in the decision to withdraw life-sustaining treatments in critically ill patients with severe traumatic brain injury. Future research should aim at identifying the factors influencing surrogate decisionmakers in the decision to withdraw life-sustaining treatments in these patients., Severe traumatic brain injury is a major public health issue, and the leading cause of death and disability among people under 45 years of age. (1) Mortality rates remain high, [...]

BackgroundPatients >64 years of age now represent more than 51% of injury hospitalisations in Canada. The tools used to identify older patients who could benefit the most from an interdisciplinary approach include complex parameters difficult to collect in the ED, which suggests that better tools with higher accuracy and using items that can be derived from routinely collected data are needed. We aimed to identify variables that are associated with adverse outcomes in older patients admitted to a trauma centre for an isolated orthopaedic injury.MethodsWe conducted a multicentre retrospective cohort study between 1 April 2013 and 31 March 2019 on older patients hospitalised with a primary diagnosis of isolated orthopaedic injury (n=19 928). Data were extracted from the provincial trauma registry (Registre des traumatismes du Québec). We used multilevel logistic regression to estimate the associations between potential predictors and adverse outcomes (extended length of stay, mortality, complications, unplanned readmission and adverse discharge destination).ResultsIncreasing age, male sex, specific comorbidities, type of orthopaedic injuries, increasing number of comorbidities, severe orthopaedic injury, head injuries and admission in the year before the injury were all significant predictors of adverse outcomes.ConclusionWe identified eight predictors of adverse outcomes in patients >64 years of age admitted to a trauma centre for orthopaedic injury. These variables could eventually be used to develop a clinical decision rule to identify elders who may benefit the most from interdisciplinary care.

BACKGROUND: Evidence for an association between opioid use and risk of falls or fractures in older adults is inconsistent. We examine the association between recent opioid use and the risk, as well as the clinical outcomes, of fall-related injuries in a large trauma population of older adults. METHODS: In a retrospective, observational, multicentre cohort study conducted on registry data, we included all patients aged 65 years and older who were admitted (hospital stay > 2 d) for injury in 57 trauma centres in the province of Quebec, Canada, between 2004 and 2014. We looked at opioid prescriptions filled in the 2 weeks preceding the trauma in patients who sustained a fall, compared with those who sustained an injury through another mechanism. RESULTS: A total of 67929 patients were retained for analysis. Mean age was 80.9 ([+ or -] 8.0) years and 69% were women. The percentage of patients who had filled an opioid prescription in the 2 weeks preceding an injury was 4.9% (95% confidence interval [CI] 4.7%-5.1%) for patients who had had a fall, compared with 1.5% (95% CI 1.2%-1.8%) for those who had had an injury through another mechanism. After we controlled for confounding variables, patients who had filled an opioid prescription within 2 weeks before injury were 2.4 times more likely to have a fall rather than any other type of injury. For patients who had a fall-related injury, those who used opioids were at increased risk of in-hospital death (odds ratio 1.58; 95% CI 1.34-1.86). INTERPRETATION: Recent opioid use is associated with an increased risk of fall and an increased likelihood of death in older adults., The rate of opioid prescription for pain treatment has been increasing rapidly in North America in the past 20 years. (1,2) For example, between 2001 and 2010, the percentage of [...]

Purpose: Tracheostomy is a surgical procedure that is commonly performed in patients admitted to the intensive care unit (ICU). It is frequently required in patients with moderate to severe traumatic brain injury (TBI), a subset of patients with prolonged altered state of consciousness that may require a long period of mechanical respiratory assistance. While many clinicians favour the use of early tracheostomy in TBI patients, the evidence in favour of this practice remains scarce. The aims of our study were to evaluate the potential clinical benefits of tracheostomy versus prolonged endotracheal intubation, as well as whether the timing of the procedure may influence outcome in patients with moderate to severe TBI. Methods: We conducted a retrospective multicentre cohort study based on data from the provincial integrated trauma system of Quebec (Québec Trauma Registry). The study population was selected from adult trauma patients hospitalized between 2013 and 2019. We included patients 16 yr and older with moderate to severe TBI (Glasgow Coma Scale score < 13) who required mechanical ventilation for 96 hr or longer. Our primary outcome was 30-day mortality. Secondary outcomes included hospital and ICU mortality, six-month mortality, duration of mechanical ventilation, ventilator-associated pneumonia, ICU and hospital length of stay as well as orientation of patients upon discharge from the hospital. We used propensity score covariate adjustment. To overcome the effect of immortal time bias, an extended Cox shared frailty model was used to compare mortality between groups. Results: From 2013 to 2019, 26,923 patients with TBI were registered in the Québec Trauma Registry. A total of 983 patients who required prolonged endotracheal intubation for 96 hr or more were included in the study, 374 of whom underwent a tracheostomy and 609 of whom remained intubated. We observed a reduction in 30-day mortality (adjusted hazard ratio, 0.33; 95% confidence interval, 0.21 to 0.53) associated with tracheostomy compared with prolonged endotracheal intubation. This effect was also seen in the ICU as well as at six months. Tracheostomy, when compared with prolonged endotracheal intubation, was associated with an increase in the duration of mechanical respiratory assistance without any increase in the length of stay. No effect on mortality was observed when comparing early vslate tracheostomy procedures. An early procedure was associated with a reduction in the duration of mechanical respiratory support as well as hospital and ICU length of stay. Conclusion: In this multicentre cohort study, tracheostomy was associated with decreased mortality when compared with prolonged endotracheal intubation in patients with moderate to severe TBI. This effect does not appear to be modified by the timing of the procedure. Nevertheless, the generalization and application of these results remains limited by potential residual time-dependent indication bias.

Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003–2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% (n = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14–15) vs. 15 (13–15), 15 (14–15) vs. 14 (13–15), 15 (14–15) vs. 14 (8–15), for AIS-head 3, 4 and 5 respectively (all P < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6–5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6–4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9–3.6) TBI (all P < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.

Objectives: Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease. Methods: A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health’s perspectives using time-driven activity-based costing. Results: The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6–8.6) and 2.7 (1.9–3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3–125.7) in the ED vs. 62.5 (57.7–67.3) in the walk-in clinic (mean difference of 56.4 (45.7–67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01–0.6). Conclusions: This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

Purpose: To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. Methods: We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. Results: Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. Conclusions: Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

Purpose: Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. Methods: In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. Results: The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. Conclusions: Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

IMPORTANCE: Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences. OBJECTIVE: To assess the validity of quality indicators on low-value trauma care using trauma registry data. DESIGN, SETTING, AND PARTICIPANTS: Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts. MAIN OUTCOMES AND MEASURES: Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time). RESULTS: The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs. CONCLUSIONS AND RELEVANCE: This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.

Background: Severe traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine. Methods: To evaluate variation in mortality following the withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale). Results: We randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval [CI] 28.4%-35.2%) and ranged from 10.8% to 44.2% across centres ([chi square] test for overall difference, p < 0.001). Most deaths (70.2% [160/228], 95% CI 63.9%-75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) ([chi square] test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care. Interpretation: We observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury., Traumatic brain injury is the leading cause of death and disability among patients younger than 45 years of age, with mortality rates ranging from 30% to 40%. (1-3) Moreover, the [...]

Objective: We sought to evaluate the performance of the Prehospital Index (PHI), the high-velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients. Methods: The study population included all prehospital trauma patients transported by an emergency medical service to 2 level-I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage. Results: Of 16 805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score [greater than or equal to] 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the lowest rate of overtriage. Conclusion: Although the combination of PHI score, HVI presence and EMT judgment offers the highest sensitivity for the identification of patients that could benefit from direct transport to a level-I trauma centre, overall sensitivity remains low and overtriage is high. More research is required to improve prehospital triage. Keywords: trauma, triage, prehospital, emergency medical system, emergency medical technician, ambulance, injury severity Objectif : Nous avons cherche a evaluer la performance de l'indice prehospitalier (IPH) et de la determination de la presence d'un impact a haute velocite (IHV) ainsi que la contribution du jugement du technicien ambulancier lors du triage prehospitalier de patients traumatises. Methodes : La population etudiee incluait tous les patients traumatises en prehospitalier transportes par un service medical d'urgence a 2 centres de traumatologie de niveau I pour adultes. Toutes les donnees recueillies en prehospitalier ont ete liees a celles du registre des traumatismes. Les principales mesures de resultats etaient un traumatisme grave, defini comme un traumatisme entramant la mort dans les 72 heures, l'admission a l'unite de soins intensifs dans les 24 heures ou un indice de gravite de la blessure superieur a 15. Nous avons evalue la sensibilite, la specificite et les taux de surtriage. Resultats : Parmi les 16 805 patients de la population etudiee, 1113 (6,62 %) avaient subi un traumatisme grave. La combinaison des 3 criteres de tri (score de l'IPH [greater than or equal to] 4, presence d'un IHV et jugement du technicien ambulancier) a donne les meilleurs resultats pour depister les patients victimes de traumatismes graves, avec une sensibilite de 74,2 %, mais un taux de surtriage de 85,1 %. Seul, le jugement du technicien ambulancier affichait la plus haute sensibilite, et un score IPH de 4 ou plus donnait le plus faible taux de surtriage. Conclusion : Bien que la combinaison IPH, presence d'un IHV et jugement du technicien ambulancier offre la plus grande sensibilite pour le depistage de patients qui pourraient beneficier du transport direct a un centre de traumatologie de niveau I, la sensibilite globale demeure faible et le surtriage eleve. Il faut entreprendre d'autres recherches pour ameliorer le triage prehospitalier., INTRODUCTION Trauma is the leading cause of death for people aged 1-45 years in Canada (1) and in the United States. (2) There is strong evidence that regionalized trauma systems [...]

Objective: We sought to assess the applicability of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the prehospital setting by comparing CTAS scores as signed during ambulance transportation by base hospital (BH) nurses with CTAS scores given by emergency department (ED) nurses on patients' arrival. Methods: We recruited a prospective sample of consecutive patients who were transported to the ED by ambulance between December 2006 and March 2007 for whom a contact was made with the BH. Patients were triaged by the BH nurse with online communication and vital signs transmission. On arrival, patients were blindly triaged again by the ED nurse. We used the quadratic weighted [kappa] statistic to measure the agreement between the 2 CTAS scores. Results: Ninety-four patients were triaged twice by 2 nursing teams (9 nurses at the BH and 39 nurses in the ED). The agreement obtained on prehospital and ED CTAS scores was moderate ([kappa] = 0.50; 95% confidence interval 0.37-0.63). Conclusion: The moderate interrater agreement we obtained may be a result of the changing conditions of patients during transport or may indicate that CTAS scoring requires direct contact to produce reliable triage scores. Our study casts a serious doubt on the appropriateness of BH nurses performing triage with CTAS in the prehospital setting. Keywords: triage, Canadian Emergency Department Triage and Acuity Scale, emergency medical services, emergency department Objectif : Nous avons cherche a evaluer l'applicabilite de l'echelle canadienne de triage et de gravite (ETG) pour les services d'urgence dans le contexte prehospitalier en comparant les niveaux de triage assignes pendant le transport en ambulance par les infirmieres de l'hopital de rattachement avec les niveaux de triage attribues par les infirmieres du service d'urgence a l'arrivee des patients. Methodes : Nous avons forme un echantillon prospectif de patients recrutes consecutivement. Ces patients avaient ete transportes a l'urgence par ambulance entre decembre 2006 et mars 2007 et une communication avait ete etablie avec l'hopital de rattachement. Les patients ont ete tries par l'infirmiere de l'hopital de rattachement, qui etait en communication en ligne et avait recu les donnees sur les signes vitaux. A l'arrivee, les patients ont ete tries de nouveau par une infirmiere de l'urgence travaillant a l'insu. Nous avons utilise une analyse statistique kappa ([kappa]) ponderee de type quadratique pour mesurer la concordance entre les 2 niveaux de triage attribues. Resultats : Quatre-vingt-quatre patients ont fait l'objet d'un triage a deux reprises par 2 equipes d'infirmieres, 9 infirmieres a l'hopital de rattachement et 39 infirmieres a l'urgence. L'accord obtenu entre les niveaux de triage prehospitaliers et les niveaux de triage a l'urgence etait modere ([kappa] = 0,50; intervalle de confiance a 95 % de 0,37 a 0,63). Conclusion : L'obtention d'un accord inter-evaluateurs modere peut etre fonction du changement de l'etat des patients en cours de transport ou peut indiquer que l'assignation de niveaux de triage selon l'ETG requiert un contact direct avec le patient pour assigner un niveau de triage fiable. Notre etude jette de serieux doutes sur la pertinence de faire effectuer le triage selon l'ETG par les infirmieres de l'hopital de rattachement dans le contexte prehospitalier., INTRODUCTION Triage systems have been in use in Canadian emergency departments (EDs) for decades; however, the method used to establish priority scores has varied widely among hospitals. The situation changed [...]

Objective: We prospectively derived a clinical decision rule to guide pre- and postreduction radiography for emergency department (ED) patients with anterior glenohumeral dislocation. Methods: This prospective cohort derivation study took place at 4 university-affiliated EDs over a 3-year period and enrolled consenting patients with anterior glenohumeral dislocation who were 18 years of age or older. We compared patients with a clinically important fracture-dislocation with those who had an uncomplicated dislocation to provide the clinical decision rule components using recursive partitioning. The final rule involved age, mechanism, prior dislocation and humeral ecchymosis. Results: A total of 222 patients were included in the study. Forty (18.0%) had clinically important fracture-dislocation. A clinical decision rule using 4 factors reached a sensitivity of 100% (95% confidence interval [CI] 89.4%-100%), a specificity of 34.2% (95% CI 27.7%-41.2%), a negative predictive value of 99.2% (95% CI 92.8%-99.9%) and a negative likelihood ratio of 0.04 (95% CI 0.002-0.27). Patients younger than 40 years are at high risk for clinically important fracturedislocation only if the mechanism of injury involves substantial force (i.e., a fall greater than their own height, a sport injury, an assault or a motor vehicle collision). Patients 40 years of age or older are at high risk only in the presence of humeral ecchymosis or after their first dislocation. Projected use of the rule would reduce the absolute number of prereduction radiographs by 27.9% and of postreduction by 81.9%. Conclusion: The Quebec shoulder dislocation rule for patients with acute anterior glenohumeral dislocation holds promise to reduce unnecessary imaging, pending validation. Keywords: anterior shoulder dislocation, emergency medicine, clinical decision rules, shoulder fractures Objectif : Notre etude visait a etablir de facon prospective une regle de decision clinique afin de guider le recours aux radiographies precedant et suivant la reduction chez les patients se presentant a l'urgence avec une luxation glenohumerale anterieure. Methode : Cette etude de derivation sur une cohorte prospective s'est deroulee sur une periode de 3 ans, dans 4 services d'urgence d'hopitaux universitaires. Nous avons inscrit des patients consentants de 18 ans ou plus qui presentaient une luxation glenohumerale anterieure. Nous avons compare les patients ayant une luxation ou une fracture cliniquement importante avec ceux qui avaient une luxation sans complication en vue d'etablir les criteres d'une regle de decision clinique en utilisant le partitionnement recursif. Les criteres de la regle definitive etaient l'age, le mecanisme de blessure, les antecedents de luxation et une ecchymose au niveau de l'humerus. Resultats : L'etude comptait 222 patients. Quarante (18,0 %) presentaient une fracture ou une luxation cliniquement importante. La regle de decision clinique fondee sur 4 facteurs avait une sensibilite de 100 % [intervalle de confiance (IC) a 95 % de 89,4 a 100 %), une specificite de 34,2 % (IC a 95 % de 27,7 a 41,2 %), une valeur predictive negative de 99,2 % (IC a 95 % de 92,8 a 99,9 %) et un rapport de vraisemblance negatif de 0,04 (IC a 95 % de 0,002 a 0,27). Les patients de moins de 40 ans presentent un risque eleve de fracture ou de luxation cliniquement importante seulement si le mecanisme de blessure implique une force d'impact importante (c'est-a-dire chute d'une hauteur superieure a celle de la victime, blessure liee a un sport, agression ou accident automobile). Les patients de 40 ans ou plus sont exposes a un risque eleve seulement en presence d'une ecchymose au niveau de l'humerus ou apres une premiere luxation. Les projections quant a l'utilisation de cette regle permettent de croire qu'on reduirait le nombre absolu de radiographies pre-reduction de 27,9 % et celui des radiographies post-reduction de 81,9 %. Conclusion : La regle concernant les luxations d'epaule appliquee au Quebec pour les patients presentant une luxation glenohumerale anterieure aiguest prometteuse. Elle pourrait en effet reduire le recours a l'imagerie, dans l'attente de sa validation., Introduction Glenohumeral dislocation is an important cause of shoulder injuries seen in the emergency department (ED) (1,2) and is the most frequent type of dislocation reduced by emergency physicians (EPs). [...]

IMPORTANCE: The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. OBJECTIVE: To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. DESIGN, SETTING, AND PARTICIPANTS: This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. MAIN OUTCOMES AND MEASURES: Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. RESULTS: Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). CONCLUSIONS AND RELEVANCE: In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

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Bipolar disorder (BD) is a psychiatric condition characterized by depressive and manic episodes that affect 2% of the world population. The first-line long-term treatment for mood stabilization is lithium (Li). Induced pluripotent stem cell modeling of BD using hippocampal dentate gyrus-like neurons derived from Li-responsive (LR) and Li-non-responsive (NR) patients previously showed neuronal hyperexcitability. Li treatment reversed hyperexcitability only on the LR neurons. In this study we searched for specific targets of Li resistance in NR neurons and found that the activity of Wnt/β-catenin signaling pathway was severely affected, with a significant decrease in expression of LEF1. Li targets the Wnt/β-catenin signaling pathway by inhibiting GSK-3β and releasing β-catenin that forms a nuclear complex with TCF/LEF1, activating the Wnt/β-catenin transcription program. Therefore, we propose that downregulation of LEF1may account for Li resistance in NR neurons. Our results show that valproic acid (VPA), a drug used to treat NR patients that also acts downstream of GSK-3β, upregulated LEF1and Wnt/β-catenin gene targets, increased transcriptional activity of complex β-catenin/TCF/LEF1, and reduced excitability in NR neurons. In addition, decreasing LEF1expression in control neurons using shLEF1 caused hyperexcitability, confirming that the impact of VPA on excitability in NR neurons was connected to changes in LEF1 and in the Wnt/β-catenin pathway. Our results suggest that LEF1 may be a useful target for the discovery of new drugs for BD treatment.

Currently, researchers rely on generalized methods to quantify transposable element (TE) RNA expression, such as RT-qPCR and RNA-seq, that do not distinguish between TEs expressed from their own promoter (bona fide) and TEs that are transcribed from a neighboring gene promoter such as within an intron or exon. This distinction is important owing to the differing functional roles of TEs depending on whether they are independently transcribed. Here we report a simple strategy to examine bona fide TE expression, termed BonaFide-TEseq. This approach can be used with any template-switch based library such as Smart-seq2 or the single-cell 5′ gene expression kit from 10x, extending its utility to single-cell RNA-sequencing. This approach does not require TE-specific enrichment, enabling the simultaneous examination of TEs and protein-coding genes. We show that TEs identified through BonaFide-TEseq are expressed from their own promoter, rather than captured as internal products of genes. We reveal the utility of BonaFide-TEseq in the analysis of single-cell data and show that short-interspersed nuclear elements (SINEs) show cell type–specific expression profiles in the mouse hippocampus. We further show that, in response to a brief exposure of home-cage mice to a novel stimulus, SINEs are activated in dentate granule neurons in a time course that is similar to that of protein-coding immediate early genes. This work provides a simple alternative approach to assess bona fide TE transcription at single-cell resolution and provides a proof-of-concept using this method to identify SINE activation in a context that is relevant for normal learning and memory.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.annemergmed.2007.09.007 Byline: Lynne Moore (a), Andre Lavoie (a), Natalie Le Sage (c), Eric Bergeron (d), Marcel Emond (c), Moishe Liberman (e), Belkacem Abdous (b) Abstract: Preexisting conditions have been found to be an independent predictor of mortality after trauma. However, no consensus has been reached as to what indicator of preexisting condition status should be used, and the contribution of preexisting conditions to mortality prediction models is unclear. This study aims to identify the most accurate way to model preexisting condition status to predict inhospital trauma mortality and to evaluate the potential gain of adding preexisting condition status to a standard trauma mortality prediction model. Author Affiliation: (a) Trauma and Emergency Medicine Research Unit, Centre Hospitalier Affilie Universitaire Quebec (Enfant-Jesus Hospital), Quebec City, Quebec, Canada (b) Department of Social and Preventative Medicine, Laval University, Quebec City, Quebec, Canada (c) Department of Emergency Medicine, Centre Hospitalier Affilie Universitaire de Quebec (Enfant-Jesus Hospital), Quebec City, Quebec, Canada (d) Department of Surgery, Charles-Lemoyne Hospital, Greenfield Park, Quebec, Canada (e) Department of Surgery, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada Article History: Received 16 May 2007; Revised 25 July 2007; Revised 4 September 2007; Accepted 13 September 2007 Article Note: (footnote) Supervising editor: David L. Schriger, MD, MPH, Author contributions: LM and AL were responsible for study concept and design. LM, AL, and NL obtained funding. LM and AL acquired data. LM and BA were responsible for statistical analysis. NL, EB, ME, and ML were responsible for clinical expertise. LM, AL, NL, EB, ME, ML, and BA interpreted data and were responsible for critical revision of the manuscript for important intellectual content. LM was responsible for drafting of the article. AL and BA were responsible for study supervision. LM takes responsibility for the paper as a whole., Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported by Fonds de la recherche en Sante du Quebec (grant number 015102) and Canadian Institutes of Health Research (doctoral research award)., Publication dates: Available online February 20, 2008., Reprints not available from the authors.

Introduction: Restrictive transfusion strategies have been advocated in critically ill patients. Nevertheless, considerable uncertainty exists regarding optimal transfusion thresholds in traumatic brain injury (TBI) patients because the injured brain is susceptible to hypoxemic damage. We aimed to identify the determinants of red blood cell (RBC) transfusion and the perceived optimal transfusion thresholds in adult patients with moderate-to-severe TBI. Methods: We conducted an electronic, self-administered survey targeting critical care specialists and neurosurgeons from Canada, Australia, and the United Kingdom caring for TBI patients. The questionnaire was initially developed by a panel of experts using a structured process (domains/items generation and reduction). The questionnaire was validated for clinical sensibility, reliability, and content. Results: The response rate was 28.7% (218/760). When presented with the hypothetical scenario of a young adult TBI patient, a wide range of transfusion practices was observed, with 47 (95% confidence interval [CI], 41 to 54)% favouring RBC transfusion at a hemoglobin level of ≤ 70 g·L–1in the acute phase of care, while 73 (95% CI, 67 to 79)% would use this trigger in the plateau phase of care. Multiple trauma, neuro-monitoring data, hemorrhagic shock, and planned surgery were the main factors that influenced the need for transfusion. The lack of clinical evidence and guidelines was responsible for uncertainty regarding RBC transfusion strategies in this patient population. Conclusion: In our survey about critically ill TBI patients, transfusion practice was found to be mainly influenced by the acuity of care, patient characteristics, and neuro-monitoring. Clinical equipoise regarding optimal transfusion strategy is believed to be mainly attributed to the lack of clear clinical evidence and guidelines. Appropriate randomized-controlled trials are required to determine the optimal transfusion strategies in TBI patients.

ABSTRACT:This study assessed whether S-100β protein could be measured in urine when detectable in plasma after a mild traumatic brain injury (mTBI). Clinical data, plasma and urine samples were collected for the 46 adult patients prospectively enrolled in the emergency department (ED) of a Level 1 trauma center. S-100β protein concentrations were analysed using ELISA. S-100β protein was detectable in 91% and 71% of plasma and urine samples, but values were not correlated (r= 0.002). Urine sampling would have been a non-invasive procedure, but it does not appear to be useful in the ED during the acute phase after an mTBI.

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This study sought to examine whether hysterosalpingosonography (sono-HSG) is as effective as hysterosalpingography (HSG) in facilitating conception by comparing pregnancy rates in the 6 months following the procedures.

The intensity of care provided to critically ill patients has been shown to be associated with mortality. In patients with traumatic brain injury (TBI), specialized neurocritical care is often required, but whether it affects clinically significant outcomes is unknown. We aimed to determine the association of the intensity of care on mortality and the incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI. We conducted a post hocanalysis of a multicentre retrospective cohort study of critically ill adult patients with severe TBI. We defined the intensity of care as a daily cumulative sum of interventions during the intensive care unit stay. Our outcome measures were all-cause hospital mortality and the incidence of withdrawal of life-sustaining therapies. Seven hundred sixteen severe TBI patients were included in our study. Most were male (77%) with a mean (standard deviation) age of 42 (20.5) yr and a median [interquartile range] Glasgow Coma Scale score of 3 [3-6]. Our results showed an association between the intensity of care and mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.63 to 0.74) and the incidence of withdrawal of life-sustaining therapy (HR, 0.73; 95% CI, 0.67 to 0.79). In general, more intense care was associated with fewer deaths and a lower incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI. L’intensité des soins fournis à des patients dans un état critique est associée à la mortalité. Chez des patients ayant subi un traumatisme craniocérébral (TCC), des soins intensifs neurologiques spécialisés sont souvent nécessaires, mais on ignore s’ils ont un impact cliniquement significatif sur le devenir de ces patients. Nous avons cherché à déterminer l’association entre, d’une part, l’intensité des soins et, d’autre part, la mortalité et l’incidence du retrait des thérapies de maintien des fonctions vitales chez des patients dans un état critique suivant un TCC. Nous avons réalisé une analyse post hoc d’une étude de cohorte multicentrique rétrospective chez des patients dans un état critique suivant un TCC grave. Nous avons défini l’intensité des soins par la somme cumulée journalière des interventions au cours du séjour en unité de soins intensifs. Nos intensifs d’évaluation étaient la mortalité hospitalière, toutes causes confondues, et l’incidence du retrait des thérapies de maintien des fonctions vitales. Sept cent seize patients atteints de TCC grave ont été inclus dans notre étude. La plupart étaient des hommes (77 %) d’un âge moyen (écart-type) de 42 (20,5) ans et ayant un score de Glasgow pour le coma (Glasgow coma scale) médian [écarts interquartiles] de 3 [3 à 6]. Nos résultats ont montré une association entre l’intensité des soins et la mortalité (rapport de risque [RR] : 0,69; intervalle de confiance [IC] à 95 % : 0,63 à 0,74) et l’incidence du retrait des thérapies de maintien des fonctions vitales (RR : 0,73; IC à 95 % : 0,67 à 0,79). D’une manière générale, des soins plus intenses ont été associés à moins de décès et à une plus faible incidence du retrait des thérapies de maintien des fonctions vitales chez des patients dans un état critique suivant un TCC grave.

We aimed to evaluate the association between transfusion practices and clinical outcomes in patients with traumatic brain injury.

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DesignSingle-blind randomised clinical trial.ObjectiveTo compare the effects of three 8-week rehabilitation programmes on symptoms and functional limitations of runners with patellofemoral pain (PFP).MethodsSixty-nine runners with PFP were randomly assigned to one of three intervention groups: (1) education on symptoms management and training modifications (education); (2) exercise programme in addition to education (exercises); (3) gait retraining in addition to education (gait retraining). Symptoms and functional limitations were assessed at baseline (T0), and after 4, 8 and 20 weeks (T4, T8and T20) using the Knee Outcome Survey of the Activities of Daily Living Scale (KOS-ADLS) and visual analogue scales (VASs) for usual pain, worst pain and pain during running. Lower limb kinematics and kinetics during running, and isometric strength were also evaluated at T0and T8. The effects of rehabilitation programmes were assessed using two-way analysis of variance.ResultsNo significant group × time interactions (p<0.447) were found for KOS-ADLS and VASs. All three groups showed similar improvements at T4, T8and T20compared with T0(p<0.05). Only the exercises group increased knee extension strength following rehabilitation (group × time: p<0.001) and only the gait retraining group (group × time: p<0.001) increased step rate (+7.0%) and decreased average vertical loading rate (−25.4%).ConclusionEven though gait retraining and exercises improved their targeted mechanisms, their addition to education did not provide additional benefits on symptoms and functional limitations. Appropriate education on symptoms and management of training loads should be included as a primary component of treatment in runners with PFP.Trial registration numberClinicalTrials.gov (NCT02352909).

Purpose of the studyThis study aims to describe all unsolicited electronic invitations received from potential predatory publishers or fraudulent conferences over a 12-month period following the first publication as a corresponding author of a junior academician.Study designUnsolicited invitations received at an institutional email address and perceived to be sent by predatory publishers or fraudulent conferences were collected.ResultsA total of 502 invitations were included of which 177 (35.3%) had subject matter relevant to the recipient’s research interests and previous work. Two hundred and thirty-seven were invitations to publish a manuscript. Few disclosed the publication fees (32, 13.5%) but they frequently reported accepting all types of manuscripts (167, 70.5%) or emphasised on a deadline to submit (165, 69.6%). Invitations came from 39 publishers (range 1 to 87 invitations per publisher). Two hundred and ten invitations from a potential fraudulent conference were received. These meetings were held in Europe (97, 46.2%), North America (65, 31.0%), Asia (20.4%) or other continents (5, 2.4%) and came from 18 meeting organisation groups (range 1 to 137 invitations per organisation). Becoming an editorial board member (30), the editor-in-chief (1), a guest editor for journal special issue (6) and write a book chapter (11) were some of the roles offered in the other invitations included while no invitation to review a manuscript was received.ConclusionsYoung researchers are commonly exposed to predatory publishers and fraudulent conferences following a single publication as a corresponding author. Academic institutions worldwide need to educate and inform young researchers of this emerging problem.

To evaluate the incidence, determinants and impact on outcome of in-hospital complications in adults with traumatic brain injury (TBI).

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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 &lt; .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 &lt; .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 &lt; .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 &lt; .001), British Columbia (12.5 [95% CI, 12-13.1] to 11.4 [10.9-11.9] days; P &lt; .001), and Ontario (10.1 [95% CI, 9.8-10.4] to 9.8 [95% CI, 9.5-10.1] days; P &lt; .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.

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Our primary objectives were to identify clinical practice guideline (CPG) recommendations for children with acute mTBI presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations.

AbstractObjectiveThe aim of this study was to determine the incidence of delayed complications, specifically hemothorax, and functional outcome in patients with isolated sternal fracture discharged from the emergency department (ED) compared to patients with other minor thoracic trauma.MethodsThis prospective cohort study was conducted in four university-affiliated Canadian EDs. Patients ages 16 and older discharged from the ED with an isolated minor thoracic injury were included and categorized as isolated sternal fracture, rib fracture, or no fracture. A standardized clinical and radiological follow-up was performed at 7 and 14 days as well as a phone follow-up at 30 and 90 days post-injury. Functional outcome was determined using the Medical Outcome Short-Form Health Survey (SF-12).ResultsA total of 969 patients were included, of whom 32 (3.3%) had an isolated sternal fracture, 304 (31.3%) had rib fracture, and 633 (65.3%) had no fracture. Within 14 days, 112 patients presented with a delayed hemothorax: 12.5% of sternal fracture patients, 23% of rib fracture(s) patients, and 6% of minor thoracic injury patients without fracture (p<0.05). At 90 days, 57.1% of patients with sternal fracture had moderate to severe disability compared to 25.4% and 21.2% for both of the other groups, respectively (p<0.001).ConclusionIn this prospective study, we found that 12.5% (n=4, p<0.05) of patients with sternal fracture developed a delayed hemothorax, but the clinical significance of this remains questionable. The proportion of patients with sternal fracture who had moderate to severe disability was significantly higher than that of patients with other minor thoracic trauma.

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.

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According to Donabedian’s health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains.

We propose a quality indicator (QI) on the basis of risk-adjusted hospital length of stay to evaluate trauma care that can be implemented with routinely collected data. The QI has excellent internal and temporal validity and is correlated with QI on clinical processes and risk-adjusted mortality, readmission, and complication rates.

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.

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.

In 2000, more than 50 million Americans were treated in hospitals following injury, with costs estimated at 80 billion, yet no performance indicator based on costs has been developed and validated specifically for acute trauma care. This study aimed to describe how data on costs have been used to evaluate the performance of acute trauma care hospitals.