Validating the Functional Capacity Index as a measure of outcome following blunt multiple trauma.

BACKGROUND: The validity of the Functional Capacity Index (FCI) is evaluated by examining its distributional characteristics, its correlation with other well-known measures of outcome and its ability to discriminate among persons with injuries of varying type and severity. METHODS: A telephone survey which included the FCI and the SF-36 was administered 1 year post-injury to 1240 blunt trauma patients discharged from 12 trauma centers. A subsample of 656 patients also completed the Sickness Impact Profile (SIP) by mail. RESULTS: FCI scores correlated well with the physical health subscores of the SIP and SF-36. They also correlated well with self-reported change in health status and return to work. The FCI, when compared to either the SF-36 or the SIP, however, appears to discriminate better among patients according to the presence and severity of head trauma. CONCLUSIONS: While further testing of the FCI is needed, it holds promise as a preference based measure for assessing the physical impact of trauma.

An introduction to the Barell body region by nature of injury diagnosis matrix.

INTRODUCTION: The Barell body region by nature of injury diagnosis matrix standardizes data selection and reports, using a two dimensional array (matrix) that includes all International Classification of Diseases (ICD)-9-CM codes describing trauma. AIM: To provide a standard format for reports from trauma registries, hospital discharge data systems, emergency department data systems, or other sources of non-fatal injury data. This tool could also be used to characterize the patterns of injury using a manageable number of clinically meaningful diagnostic categories and to serve as a standard for casemix comparison across time and place. CONCEPT: The matrix displays 12 nature of injury columns and 36 body region rows placing each ICD-9-CM code in the range from 800 to 995 in a unique cell location in the matrix. Each cell includes the codes associated with a given injury. The matrix rows and columns can easily be collapsed to get broader groupings or expanded if more specific sites are required. The current matrix offers three standard levels of detail through predefined collapsing of body regions from 36 rows to nine rows to five rows. MATRIX DEVELOPMENT: This paper presents stages in the development and the major concepts and properties of the matrix, using data from the Israeli national trauma registry, and from the US National Hospital Discharge Survey. The matrix introduces new ideas such as the separation of traumatic brain injury (TBI), into three types. Injuries to the eye have been separated from other facial injuries. Other head injuries such as open wounds and burns were categorized separately. Injuries to the spinal cord and spinal column were also separated as are the abdomen and pelvis. Extremities have been divided into upper and lower with a further subdivision into more specific regions. Hip fractures were separated from other lower extremity fractures. FORTHCOMING DEVELOPMENTS: The matrix will be used for the development of standard methods for the analysis of multiple injuries and the creation of patient injury profiles. To meet the growing use of ICD-10 and to be applicable to a wider range of countries, the matrix will be translated to ICD-10 and eventually to ICD-10-CM. CONCLUSION: The Barell injury diagnosis matrix has the potential to serve as a basic tool in epidemiological and clinical analyses of injury data.

Predicting ambulatory function following lower extremity trauma using the functional capacity index.

This study evaluated the accuracy of experts' predictions of ambulatory function following lower extremity trauma using the Functional capacity index (FCI). Data from three orthopedic trauma studies designed to determine long-term function following specific types of lower extremity injuries were used to examine the extent of agreement between the reported and predicted ambulatory function of 921 subjects. Functional limitations reported by the cohort using a generalized health status measure and more detailed questions on lower extremity function were compared with those predicted by experts based on the injuries sustained. The overall agreement between predicted and self-reported FCI function for ambulation was relatively low (31%). In the majority of cases (80%), the disagreement differed by one functional level. Subjects were more likely to report worse function than predicted by the experts. Multivariate modeling identified different injuries, combinations of injuries, and patient characteristics that significantly influenced agreement. For example, subjects who sustained both a tibia and a femur fracture were three times more likely than subjects who did not sustain either fracture type to report poorer ambulatory function than predicted. Many challenges are faced in predicting long-term function following trauma. More empirical data are needed to inform the process. These data suggest that until the FCI can more accurately predict long-term ambulatory function following different lower extremity injuries, it should not be used for this purpose.

Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study.

OBJECTIVE: To document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation. DESIGN: Abstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded. RESULTS: There were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03) CONCLUSIONS: Although almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.

Validation of the ICD/AIS MAP for pediatric use.

OBJECTIVE: To determine the performance of the ICD/AIS MAP (EJ MacKenzie et al) as a method of classifying injury severity for children. METHODS: Data on all children less than 16 years of age admitted to all designated trauma centers in Pennsylvania from January 1994 through October 1996 were obtained from the state trauma registry. The ICD/AIS MAP was used to convert all injury related ICD-9-CM diagnosis codes into abbreviated injury scale (AIS) score and injury severity score (ISS). Agreement between trauma registry AIS and ISS scores and MAP generated scores was assessed using the weighted kappa (kappaw) coefficient for ordered data and the intraclass correlation coefficient for continuous data. RESULTS: Agreement in ISS scores was excellent, both overall (intraclass correlation coefficient = 0.86, 95% confidence interval (CI) 0.84 to 0.89)), and when grouped into three levels of severity (kappaw= 0.86, 95% CI 0.85 to 0.87). Agreement in AIS scores across all body regions and ages was also excellent, (kappaw= 0.86 (95% CI 0.83 to 0.87). Agreement increased with age (kappaw= 0.78 for children <2 years; kappaw= 0.86 for older children) and varied by body region, though was excellent across all regions. CONCLUSIONS: The performance of the ICD/AIS MAP in assessing severity of pediatric injuries was equal to or better than previous assessments of its performance on primarily adult patients. Its performance was excellent across the pediatric age range and across nearly all body regions of injury.

Emergency Medical Services Outcomes Project (EMSOP) II: developing the foundation and conceptual models for out-of-hospital outcomes research.

Development of methodologically acceptable outcomes models for emergency medical services (EMS) is long overdue. In this article, the Emergency Medical Services Outcomes Project proposes a conceptual framework that will provide a foundation for future EMS outcomes research. The "Episode of Care Model" and the "Out-of-Hospital Unit of Service Model" are presented. The Episode of Care Model is useful in conditions in which interventions and outcomes, especially survival and major physiologic dysfunction, are linked in a time-dependent manner. Conditions such as severe trauma, anaphylaxis, airway obstruction, respiratory arrest, and nontraumatic cardiac arrest are amenable to this methodology. The Out-of-Hospital Unit of Service Model is essentially a subunit of the Episode of Care Model. It is valuable for evaluating conditions that have minimal-to-moderate therapeutic time dependency. This model should be used when studying outcomes limited to the out-of-hospital interval. An example of this is pain management for injuries sustained in motor vehicle crashes. These models can be applied to a wide spectrum of conditions and interventions. With the scrutiny of health care expenditures ever increasing, the identification of clinical interventions that objectively improve patient outcome takes on growing importance. Therefore, the development, dissemination, and use of meaningful methodologies for EMS outcomes research is key to the future of EMS system development and maintenance.

Relationship between trauma center volume and outcomes.

CONTEXT: The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown. OBJECTIVE: To evaluate the association between trauma center volume and outcomes of trauma patients. DESIGN: Retrospective cohort study. SETTING: Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study. PATIENTS: Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998. MAIN OUTCOME MEASURES: Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores.

BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Trends in incidence of pediatric injury hospitalizations in Pennsylvania.

OBJECTIVES: This study analyzed short-term trends in pediatric injury hospitalizations. METHODS: We used a population-based retrospective cohort design to study all children 15 years or younger who were admitted to all acute care hospitals in Pennsylvania with traumatic injuries between 1991 and 1995. RESULTS: Injuries accounted for 9% of all acute hospitalizations for children. Between 1991 and 1995, admissions of children with minor injuries decreased by 29% (P < .001). However, admissions for children with moderate (P = .69) or serious (P = .41) injuries did not change. CONCLUSIONS: Significant declines in pediatric admissions for minor injuries were noted and may reflect both real reductions in injury incidence and changes in admission practices over the period of the study.

Characterization of patients with high-energy lower extremity trauma.

PURPOSE: (a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other. DESIGN AND STUDY POPULATION: A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers. PROCEDURES: Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared. RESULTS: Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05). CONCLUSION: In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.

Epidemiology of injuries: current trends and future challenges.

For the above challenges to be met, it will be important for the field of injury epidemiology to move from the largely descriptive studies that have predominated in the literature to the application of more rigorous analytical methods for defining the underlying casual patterns of injury. Studies focusing on the descriptive epidemiology of injury have and will continue to serve the field well, perhaps even more so than in other fields, since the proximal etiology of injuries (i.e., acute exposure to physical agents such as mechanical energy) is well known. However, major new advances in the prevention of injuries will continue to require a more analytical approach to understanding the complex array of factors that influence the incidence, severity, and outcomes of injury. At the same time, it will be important for investigators in this field to conduct rigorous evaluations of new interventions to better inform the establishment of programs and policies. These evaluations must include assessments of both the effectiveness and the costs of the intervention. For example, in a recently published systematic review of 10 different strategies for preventing motor vehicle injuries, 54,708 papers and reports were identified in the literature but only 161 met the initial screening criteria for inclusion in the published review (44). Of these, a much smaller number were randomized controlled trials or well executed controlled time series trials. Major advancements in the prevention and control of injuries will continue to rely on effective collaborations between epidemiologists and scientists from other disciplines, including the behavioral sciences, sociology, criminology, law, engineering, and biomechanics. Only through truly collaborative efforts across these disciplines will we be able to establish a foundation for cost-effective interventions. For example, understanding the principles of injury mechanics and the physical and physiologic responses of the human body to the impact of injury is fundamental to the study of injury causation (6). While significant advances have been made in this regard, more work needs to be done. The biomechanics of head injury are still not well understood, yet head injuries account for nearly 50 percent of all injury deaths and remain the leading cause of both injury death and disability among children and young adults. Animal and human cadaver research combined with rapidly evolving techniques of computerized modeling will continue to play a critical role in increasing our understanding of injury mechanisms. At the same time, the development of effective interventions is dependent on a better understanding of the role of behavior in injury causation and prevention (45). We know, for example, that the use of personal protective devices such as seat belts, car seats, and bicycle helmets reduces injury risk and that these behaviors can be influenced through educational, behavioral, and legislative strategies (46-49). Interventions addressing individuals at risk can be enhanced by additional research into risk perception, risk-taking, and behavioral responses to safety improvements. However, behavioral strategies may also be used effectively with key decision-makers who design and manufacture products and who pass and implement laws that affect the injury risk of entire populations; more research is needed to understand and influence the process of behavior change in these groups (50). The importance of injury as a major public health problem worldwide was highlighted in the seminal report "The Global Burden of Disease" (25). Worldwide, injuries account for approximately one in eight deaths among males and one in 14 deaths among females (51). Motor vehicle injuries alone constitute the ninth leading cause of disease burden as measured by the number of associated disability-adjusted life years (25). By the year 2020, motor vehicle injuries are projected to increase in rank to third. (ABSTRACT TRUNCATED)

Use and need for post-acute services following paediatric head injury.

This paper aims to document the types of inpatient and outpatient post-acute services children receive after discharge from an acute care hospital for head injury and to better understand the extent to which children fail to receive services and the reasons for not receiving needed services. A follow-up was conducted on 95 children (aged 5-15) 1 year after they were hospitalized for head injury. Parents were interviewed by phone concerning their child's use of and need for medical, rehabilitation, and social services since the injury. Questions were also asked regarding the child's current health status and behaviour. Inpatient records were reviewed to obtain information on the characteristics of the injury. Overall use of outpatient rehabilitation and social services was low during the year following injury, ranging from 0-18% of the study sample. Although need for and use of services was positively correlated with head injury severity, it appears that unmet need was highest for children with the least severe head injuries. Finally, need for physical or occupational therapy and mental health services was unrecognized for one third of children with physical limitations and 40% of children with at least 14 identified behaviour problems. These findings underscore the need for physicians and other health care professionals to thoroughly evaluate children during follow-up visits as well as during the initial hospitalization for head injury-related deficits. Identification of functional deficits or behavioural problems should be followed-up by evaluation and treatment by qualified rehabilitation professionals.

A trauma resource allocation model for ambulances and hospitals.

OBJECTIVE: To develop a mathematical model for the location of trauma care resources. DATA SOURCES/STUDY SETTING: Severely injured patients queried from Maryland hospital discharge and vital statistics data. A spatial injury profile was created by parsing these patients into ZIP codes. STUDY DESIGN: The Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) was formulated using integer and heuristic programming. To maximize coverage of severely injured patients, trauma centers and aeromedical depots were simultaneously sited using TRAMAH. A severe injury was considered covered if at least one trauma center was sited within a time standard by ground, or if an aeromedical depot-trauma center pair was sited in such a way that the sum of the flying time from the aeromedical depot to the scene of injury plus the flying time from the scene of injury to the trauma center was within the same time standard. PRINCIPAL FINDINGS: From 1992 to 1994, 26,774 severe injuries were considered for coverage. Across Maryland, 94.8 percent of severely injured residents had access to trauma system resources within 30 minutes and 70.3 percent had access within 15 minutes. For the same number of resources as the existing Maryland Trauma System, TRAMAH achieved a coverage objective of 99.97 percent within 30 minutes. This translated into an additional 461 severely injured people covered each year. Holding in place the trauma centers of the existing system, approximately the same percentage of coverage as that of the existing system was achieved within 15 minutes by optimally locating six fewer aeromedical depots. CONCLUSIONS: TRAMAH will allow trauma systems planners to better locate their resources with respect to spatial needs and response times.

Rehabilitation and the long-term outcomes of persons with trauma-related amputations.

OBJECTIVE: To examine the long-term outcomes of persons undergoing trauma-related amputations, and to explore factors affecting their physical, social, and mental health and the role of inpatient rehabilitation in improving such outcomes. DESIGN: Abstracted medical records and interview data sought for a retrospective cohort of persons who had undergone a lower-limb trauma-related amputation. PARTICIPANTS: Patients identified with a principal or secondary diagnosis of a trauma-related amputation to the lower extremity at the University of Maryland Shock Trauma Center between 1984 and 1994. Patients with spinal cord injury or traumatic brain injury were excluded. RESULTS: Of 146 patients who had trauma-related amputations to the lower limb at the University of Maryland Shock Trauma Center during the study period, nearly 9% died during the acute admission and 3.5% died after discharge. About 87% of all trauma-related amputations involved males, and roughly three quarters involved white persons. About 80% of all amputations occurred before age 40. The health profile of traumatic amputee subjects interviewed in the study (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores. The differences in profiles were largest among SF-36 scales sensitive to differences in physical health status, particularly physical functioning, role limitations due to physical health, and bodily pain. About one fourth of persons with a trauma-related amputation reported ongoing severe problems with the residual limb, including phantom pain, wounds, and sores. The number of inpatient rehabilitation nights significantly improved the ability of patients with amputation to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation was also significantly correlated with improved vocational outcomes. CONCLUSIONS: These findings suggest a substantial effect of inpatient rehabilitation in improving long-term outcomes of persons with trauma-related amputations.

Outcome validation of the AO/OTA fracture classification system.

OBJECTIVES: To determine whether a greater severity of injury as documented by the AO/OTA code would correlate with poor scores of impairment, functional performance, and self-reported health status. DESIGN: Prospective, functional outcome. SETTING: Three Level One Trauma Centers. PATIENTS/PARTICIPANTS: Two hundred patients with unilateral and isolated lower extremity fractures. MAIN OUTCOME MEASUREMENTS: Six- and twelve-month SIP, AMA impairment, and functional performance measures of self-selected walking speed, stair climbing, heel raises, rising from a chair, balance work. RESULTS: At six months post injury, overall impairment was significantly (p < 0.05) higher for patients with Type C versus Type B fractures. A significant difference was found among the A, B, C types and the ROM impairment rating at six months (p = 0.004). Using the Scheffe method, the significant difference was determined to be between the B- and C-type fractures. Overall functional performance scores at six months were shown to have significant (p = 0.01) variation using an ANOVA with the significant variation being between the B and C type. At twelve months, the overall functional performance was significant (p = 0.05). CONCLUSION: Patients with C-type fractures had significantly worse functional performance and impairment compared with patients with B-type fractures but were not significantly different from patients with A-type fractures. AO/OTA code may not be a good predictor of six- and twelve-month functional performance and impairment for patients with isolated unilateral lower extremity fractures.

To the rescue: optimally locating trauma hospitals and helicopters.

Injury (trauma) is the leading cause of death in the United States for people younger than 45 years of age. Each day, more than 170,000 men, women, and children are injured severely enough to seek medical care. About 400 of these people will die and another 200 will sustain a long-term disability as a result of their injuries. An estimated 20-40% of trauma-related deaths could be prevented if all Americans lived in communities that were served by a well-organized system of trauma care. This Issue Brief describes a new computer model that can help State and regional policymakers decide where to place designated trauma hospitals and helicopter depots to maximize their residents' access to trauma care.

Comparison of alternative methods for assessing injury severity based on anatomic descriptors.

BACKGROUND: There is mounting confusion as to which anatomic scoring systems can be used to adequately control for trauma case mix when predicting patient survival. METHODS: Several Abbreviated Injury Scale (AIS) and International Classification of Disease Clinical (ICD-9CM)-based methods of scoring severity were compared by using data from the Pennsylvania Trauma Outcome Study. By using a design dataset, the probability of survival was modeled as a function of each score or profile. Resulting coefficients were used to derive expected probabilities in a test dataset; expected and observed probabilities were then compared by using standard measures of discrimination and calibration. RESULTS: The modified Anatomic Profile, Anatomic Profile, and New Injury Severity Score outperformed the International Classification of Disease-based Injury Severity Score. This finding remains true when AIS values are obtained by means of a conversion from International Classification of Disease to AIS. CONCLUSION: Results support the integrity of the AIS and argue for its continued use in research and evaluation. The modified Anatomic Profile, Anatomic Profile, and New Injury Severity Score, however, should be used in preference to the Injury Severity Score as an overall measure of severity.

Systematic review of published evidence regarding trauma system effectiveness.

OBJECTIVE: Provide a systematic review of the published literature assessing the affect of trauma center/system implementation on patient outcomes. DATA SOURCES: A bibliographic search of MEDLINE (1966-May of 1998), HealthSTAR (1995-May of 1998), and CINAHL (1982-May of 1998). Additional manuscripts were identified in the references of reviewed manuscripts. Literature was limited to English language reports on trauma systems in the United States and Canada. STUDY SELECTION: Initial inclusion criteria were based on methodologic criteria (i.e., a comparative [controlled] study). Authors independently assessed the strength of evidence demonstrated by each article. DATA EXTRACTION: Included articles were classified into three groups based on study design: panel review studies, trauma registry comparison studies, and population-based studies. Key demographic, sampling frame, study design, and outcome variables were tabulated for each included study. Potential sources of bias were also identified and tabled. DATA SYNTHESIS: A total of 12, 11, and 17 studies were incorporated into individual evidence tables for panel review, registry comparison, and population-based studies, respectively. Included studies rely on weak evidence (Class III) to assess the impact of trauma systems on patient care and outcome. CONCLUSIONS: To date, studies assessing trauma system efficacy rely on hospital deaths as the primary indicator of effectiveness. Future research should use more sophisticated study designs (Class II) and expand available outcome measures to assess the entire continuum of care, including prehospital, rehabilitation outcomes, and long-term quality of life.