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BACKGROUND: Trauma accounts for 10% of global mortality, with increasing rates disproportionally affecting low- and middle-income countries. In an attempt to improve clinical outcomes after injury, trauma systems have been implemented in multiple countries over recent years. However, whilst many studies have subsequently demonstrated improvements in overall mortality outcomes, less is known about the impact trauma systems have on morbidity, quality of life, and economic burden. This systematic review seeks to assess the existing evidence base for trauma systems with these outcome measures. METHODS: This review will include any study that assesses the impact implementation of a trauma system has on patient morbidity, quality of life, or economic burden. Any comparator study, including cohort, case-control, and randomised controlled studies, will be included, both retrospective or prospective in nature. Studies conducted from any region in the world and involving any age of patient will be included. We will collect data on any morbidity outcomes, health-related quality of life measures, or health economic assessments reported. We predict a high heterogeneity in these outcomes used and will therefore keep inclusion criteria broad. DISCUSSION: Previous reviews have shown the significant improvements that can be achieved in mortality outcomes with the implementation of an organised trauma system, however the wider impact they can have on morbidity outcomes, quality of life measures, and the economic burden of trauma, is less well described. This systematic review will present all available data on these outcomes, helping to better characterise both the societal and economic impact of trauma system implementation. HIGHLIGHTS: Trauma systems are known to improve mortality rates, however less in known on the impact they have on morbidity outcomes, quality of life, and economic burdenWe aim to perform a systematic review to identify any comparator study that assesses the impact implementation of a trauma system on these outcomesUnderstanding the impact trauma systems can have on wider parameters, such as economic and quality of life outcomes, is crucial to allow governments globally to appropriately allocate often limited healthcare resources.PROSPERO registration number: CRD42022348529.

Peer reviewed: True, OBJECTIVES: To examine whether the use of process mapping and a multidisciplinary Delphi can identify potential contributors to perioperative risk. We hypothesised that this approach may identify factors not represented in common perioperative risk tools and give insights of use to future research in this area. DESIGN: Multidisciplinary, modified Delphi study. SETTING: Two centres (one tertiary, one secondary) in the UK during 2020 amidst coronavirus pressures. PARTICIPANTS: 91 stakeholders from 23 professional groups involved in the perioperative care of older patients. Key stakeholder groups were identified via process mapping of local perioperative care pathways. RESULTS: Response rate ranged from 51% in round 1 to 19% in round 3. After round 1, free text suggestions from the panel were combined with variables identified from perioperative risk scores. This yielded a total of 410 variables that were voted on in subsequent rounds. Including new suggestions from round two, 468/519 (90%) of the statements presented to the panel reached a consensus decision by the end of round 3. Identified risk factors included patient-level factors (such as ethnicity and socioeconomic status), and organisational or process factors related to the individual hospital (such as policies, staffing and organisational culture). 66/160 (41%) of the new suggestions did not feature in systematic reviews of perioperative risk scores or key process indicators. No factor categorised as 'organisational' is currently present in any perioperative risk score. CONCLUSIONS: Through process mapping and a modified Delphi we gained insights into additional factors that may contribute to perioperative risk. Many were absent from currently used risk stratification scores. These results enable an appreciation of the contextual limitations of currently used risk tools and could support future research into the generation of more holistic data sets for the development of perioperative risk assessment tools.

Healthcare is increasingly digitised and recorded, producing huge volumes of ‘routinely- collected’ data. This data is increasingly viewed as a valuable resource for the improvement of healthcare, although a truly unifying framework to translate data into knowledge and thence change is lacking. From an initial introduction to key concepts and a critique of competing methodologies this thesis identifies a ‘systems-approach’ as a potential framework to guide data analysis, design, implementation, and overarching project management. The thesis provides evidence for the potential of a systems-approach through two main avenues, a systematic review of the medical improvement literature and the reporting and reflection on two data-intensive improvement initiatives pertaining to the perioperative care of older surgical patients. Four key stages of these case studies are used to determine the role of a systems-approach in the use of routinely-collected healthcare data, with the selection of these phases of work informed by a detailed review of the improvement and epidemiological literature. Evidence for the benefits of a systems-approach is advanced from reflections on project set-up, database construction, development of a causal-model, the design of covariates to capture complex system events (such as integrated working), and the translation of statistical results towards real-world solutions. These results provide evidence that a systems-approach appears to benefit work conducted at a ‘project’ and ‘task’ level, can increase transparency in key phases of a data-science workflow, aid in the identification of risks that could lead to biased results, and that an under- standing of the data-generating system appears crucial to understand causal relationships that may be captured in statistical results. These conclusions, as well as the results of each key project phase, form the clear original contributions of this work. The thesis concludes by positing a model of data-intensive improvement as incorporating iterative phases of systems-supported data-science, data- informed design, and data-evidenced implementation which is ready for evaluation in future studies., Wellcome Trust; Addenbrookes Charitable Trust

PRISMA-P checklist for a consensus building process relating to the care of patients with a chronic subdural haematoma. Supporting material for Stubbs DJ, Davies BM, Dixon-Woods M et al "Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma"

INTRODUCTION: A chronic subdural haematoma (cSDH) is a collection of altered blood products between the dura and brain resulting in a slowly evolving neurological deficit. It is increasingly common and, in high income countries, affects an older, multimorbid population. With changing demographics improving the care of this cohort is of increasing importance. METHODS: We convened a cross-disciplinary working group (the 'Improving Care in Elderly Neurosurgery Initiative') in October 2020. This comprised experts in neurosurgical care and a range of perioperative stakeholders. An Implementation Science framework was used to structure discussions around the challenges of cSDH care within the United Kingdom. The outcomes of these discussions were recorded and summarised, before being circulated to all attendees for comment and refinement. RESULTS: The working group identified four key requirements for improving cSDH care: (1) data, audit, and natural history; (2) evidence-based guidelines and pathways; (3) shared decision-making; and (4) an overarching quality improvement strategy. Frequent transfers between care providers were identified as impacting on both perioperative care and presenting a barrier to effective data collection and teamworking. Improvement initiatives must be cognizant of the complex, system-wide nature of the problem, and may require a combination of targeted trials at points of clinical equipoise (such as anesthetic technique or anticoagulant management), evidence-based guideline development, and a cycle of knowledge acquisition and implementation. CONCLUSION: The care of cSDH is a growing clinical problem. Lessons may be learned from the standardised pathways of care such as those as used in hip fracture and stroke. A defined care pathway for cSDH, encompassing perioperative care and rehabilitation, could plausibly improve patient outcomes but work remains to tailor such a pathway to cSDH care. The development of such a pathway at a national level should be a priority, and the focus of future work.