Long-Term Trends in the Epidemiology of Major Traumatic Brain Injury.

Traumatic brain injury (TBI) is a leading cause of death and disability among adults. Falls and motor vehicle collisions (MVCs) are the most common causes of TBI hospitalizations in Canada. The purpose of this study was to determine whether, at the provincial level, there have been significant changes in the injury rate and causes of major TBI. This was a retrospective cohort study of all patients in Nova Scotia who presented with major TBI (Abbreviated Injury Scale Head score ≥ 3) between 2002 and 2018. Prospectively entered data were collected from the Nova Scotia Trauma Registry. Annual injury rates were calculated based on 100,000 population (all ages) using population estimates from Statistics Canada. Linear regression was performed to analyze annual trends of major TBI within the province. There were 5590 major TBI patients in Nova Scotia during the 16-year study period. The overall annual rate of major TBI was 37 per 100,000 population. There was a 39% increase in the rate of major TBI over the study period (r = - 0.72, R2 = 0.51, p < 0.002). Patients had a mean age of 51 ± 25 years; 72% were male. The proportion of TBIs in males decreased significantly from 76% in 2002 to 69% in 2017 (p < 0.001). Mechanisms of injury were predominantly falls (45%) and MVCs (29%); the proportion of violent injuries was 11.5%. The rate of fall-related TBIs more than doubled between 2002 and 2017, increasing from 9.1 to 20.5 injuries per 100,000 (p < 0.001). Our findings demonstrate an increasing incidence of major TBI over a 16-year period with a greater than two-fold increase in the rate of fall-related TBI. These results are important for targeting TBI prevention efforts in reducing falls, especially in older adults.

Predicting Recruitment Feasibility for Acute Spinal Cord Injury Clinical Trials in Canada Using National Registry Data.

Traumatic spinal cord injury (SCI) represents a significant burden of illness, but it is relatively uncommon and heterogeneous, making it challenging to achieve sufficient subject enrollment in clinical trials of therapeutic interventions for acute SCI. The Rick Hansen Spinal Cord Injury Registry (RHSCIR) is a national SCI Registry that enters patients with SCI from acute-care centers across Canada. To predict the feasibility of conducting clinical trials of acute SCI within Canada, we have applied the inclusion/exclusion criteria of six previously conducted SCI trials to the RHSCIR data set and generated estimates of how many Canadian persons would have been eligible theoretically for enrollment in these studies. Data for SCI cases were prospectively collected for RHSCIR at 18 acute and 13 rehabilitation sites across Canada. RHSCIR patients enrolled between 2009-2013 who met the following key criteria were included: non-penetrating traumatic SCI; received acute care at a RHSCIR site; age more than 18, less than 75 years, and had complete admission single neurological level of injury data. Inclusion and exclusion criteria for the Minocycline in Acute Spinal Cord injury (Minocycline), Riluzole, Surgical Timing in Acute Spinal Cord Injury Study (STASCIS), Cethrin, Nogo antibody study (NOGO), and Sygen studies were applied retrospectively to this data set. The numbers of patients eligible for each clinical trial were determined. There were 2166 of the initial 2714 patients (79.8%) who met the key criteria and were included in the data set. Projected annual numbers of eligible patients for each trial were: Minocycline, 117; Riluzole, 62; STASCIS, 109; Cethrin, 101; NOGO, 82; and Sygen, 70. An additional 8.0% of the sample had a major head injury (Glasgow Coma Scale [GCS] score ≤12) and would have been excluded from the trials. RHSCIR provides a comprehensive national data set that may serve as a useful tool in the planning of multicenter clinical SCI trials.

Long-Term Effects of Education and Legislation Enforcement on All-Age Bicycle Helmet Use: A Longitudinal Study.

Bicycle-related injuries are a leading cause of child and youth hospitalizations in Canada. The use of helmets while bicycling reduces the risk of brain injuries. This study investigated the long-term effect of legislation coupled with enforcement to improve helmet use rates. We conducted a longitudinal observational study of helmet use at 9, 11, and 14 years after bicycle helmet legislation was enacted. Data were compared to baseline observations collected after legislation was passed in 1997. A comprehensive enforcement and educational diversion program, Operation Headway-Noggin Knowledge (OP-NK), was developed and implemented in partnership with regional police during the study period. Helmet use was sustained throughout the post-legislation period, from 75.3 % in the year legislation was enacted to 94.2 % 14 years post-legislation. The increase in helmet use was seen among all age groups and genders. Helmet legislation was not associated with changes in bicycle ridership over the study years. OP-NK was associated with improved enforcement efforts as evidenced by the number of tickets issued to noncompliant bicycle riders. This observational study spans a 16-year study period extending from pre-legislation to 14 years post all-age bicycle helmet legislation. Our study results demonstrate that a comprehensive approach that couples education and awareness with ongoing enforcement of helmet legislation is associated with long-term sustained helmet use rates. The diversion program described herein is listed among best practices by the Public Health Agency of Canada.

Synoptic operative reports for spinal cord injury patients as a tool for data quality.

The advent of synoptic operative reports has revolutionized how clinical data are captured at the time of care. In this article, an electronic synoptic operative report for spinal cord injury was implemented using interoperable standards, HL7 and Systematized Nomenclature of Medicine-Clinical Terms. Subjects (N = 10) recruited for a pilot study completed recruitment and feedback questionnaires, and produced both an electronic synoptic operative report for spinal cord injury report and a dictated narrative operative report for an actual patient case. Results indicated heterogeneity by subjects in access and use of electronic sources of patient data. Feedback questionnaire results confirmed that subjects were comfortable using both methods for data entry of operative reports, and that some were unable to find the diagnosis terms they needed in electronic synoptic operative report for spinal cord injury. Data quality improved. Electronic synoptic operative report for spinal cord injury reports were more complete (95.26%) than dictated (80%) for all subjects. An accuracy assessment, which considered usability for secondary data use, was conducted and the electronic synoptic operative report for spinal cord injury was demonstrated to improve accuracy.

Achieving all-age helmet use compliance for snow sports: strategic use of education, legislation and enforcement.

BACKGROUND: Nova Scotia is the first jurisdiction in the world to mandate ski and snowboard helmet use for all ages at ski hills in the province. This study represents a longitudinal examination of the effects of social marketing, educational campaigns and the introduction of helmet legislation on all-age snow sport helmet use in Nova Scotia. METHODS: A baseline observational study was conducted to establish the threshold of ski and snowboarding helmet use. Based on focus groups and interviews, a social marketing campaign was designed and implemented to address factors influencing helmet use. A prelegislation observational study assessed the effects of social marketing and educational promotion on helmet use. After all-age snow sport helmet legislation was enacted and enforced, a postlegislation observational study was conducted to determine helmet use prevalence. RESULTS: Baseline data revealed that 74% of skiers and snowboarders were using helmets, of which 80% were females and 70% were males. Helmet use was high in children (96%), but decreased with increasing age. Following educational and social marketing campaigns, overall helmet use increased to 90%. After helmet legislation was enacted, 100% compliance was observed at ski hills in Nova Scotia. CONCLUSIONS: Results from this study demonstrate that a multifaceted approach, including education, legislation and enforcement, was effective in achieving full helmet compliance among all ages of skiers and snowboarders.

Implementation of an all-ages mandatory helmet policy for ice skating.

Ice skaters sustain a significant number of head injuries each winter. We are the first to implement an all-ages helmet policy at a university-based Canadian arena. We report our experience from a cross-sectional observational study as well as the policy's consequences on helmet use and skating participation. Educational programming was provided prior to policy implementation. Observations of helmet use, falls and skater demographics were conducted prior to education/implementation and after policy implementation. The number of skaters observed was essentially unchanged by the policy; 361 skaters were observed pre-implementation, while 358 were observed post-implementation during the same number of observation-hours. Pre-implementation, helmet use ranged from 97% among children under 12 to 10% among adults; post-implementation use in all skaters was 99%. Falls were observed among all age groups, with preponderance among those aged 4-12. An all-ages helmet policy was successful both in achieving helmet use among all skaters and in maintaining participation rates.

Design and implementation of synoptic operative report template using interoperable standards.

The increasing use of synoptic operative reports in clinical settings represents a major milestone in the advancement of health information technology. Synoptic operative report templates enable clinicians to capture and display succinct clinical information in a standardized and logical manner. Synoptic operative report templates also provide the optimum goal of enriching personalized health information of a given patient at the point of care so as to support the exchange of clinical information across the continuum of multiple healthcare providers. However, most of the available synoptic operative report templates in many clinical settings do not incorporate interoperable standards in their design and implementation. This paper proposes a novice template (i.e., eSOR-SCI) that uses interoperable standards for its design and implementation.

Helmets for skiing and snowboarding: who is using them and why.

BACKGROUND: In Canada, winter sports injuries are responsible for significant health care burden, with estimates of $400 million in direct and indirect annual health care costs. For ski-related injuries, helmets have been shown to provide significant protection. Current common practice in Canada, including the Province of Nova Scotia, is to leave the decision of whether to wear a helmet to the individual. The purposes of this study were to document skiers' and snowboarders' use of helmets and to isolate factors associated with helmet use and nonuse. METHODS: A mixed methods approach was used to collect data during a 2-month period at the province's three ski hills. Naturalistic observations documented helmet use and falls, whereas interviews identified factors influencing helmet use or nonuse. RESULTS: Helmets were used by most skiers (74%) and snowboarders (72%); the use varied significantly between ski hills, ranging from 69% to 79%. Females were more likely to wear helmets compare with males (80% vs. 70%). The highest rates of use were found among 4-year-old to 12-year-old children, with helmet use declining as age increases. Qualitative data revealed that helmet users were most influenced by the protective benefits of helmets (77%), personal choice (46%), family (44%), and rules (44%), while non-helmet users cited personal choice (29%), comfort (26%), rules (14%), and cost (11%) as reasons for nonuse. CONCLUSION: More than 25% of skiers and snowboarders remain at increased risk of a serious brain injury by not wearing a helmet. Changes in regulations may be required to ensure widespread use of helmets on ski hills. LEVEL OF EVIDENCE: Prognostic study, level II.

Major traumatic brain injury: time to tertiary care and the impact of a clinical guideline.

BACKGROUND: To achieve timely access to neurosurgical care for adult brain-injured patients, a Head Injury Guideline was implemented to standardize the emergency department evaluation and management of these patients. The goals of this study were to document times to neurosurgical care for patients with major traumatic brain injury presenting to a Provincial emergency room and to evaluate the impact of the Guideline on timely access to definitive care. METHODS: Data collected prospectively and stored in the Nova Scotia Trauma Registry and the Emergency Health Services Communications and Dispatch Centre database were analyzed for patients with head abbreviated injury scale score (AIS)≥3. Several time intervals from admission to a referring hospital to access to tertiary care were determined and compared for the periods before Guideline implementation, the implementation phase, and after implementation. RESULTS: The time elapsed before calling the provincial Trauma Hotline was not statistically different after Guideline implementation for polytrauma patients with head AIS score≥3 (n=388) during the preimplementation (2:34±1:30; median time in hours:minutes±standard deviation), implementation (1:57±2:33) and postimplementation (2:31±4:06) periods. Subset group analysis of patients with isolated head injuries AIS score≥3 (n=99) also showed no statistical difference in preimplementation (1:51±1:42), implementation (2:49±2:57), and postimplementation (3:10±4:58) times. Examination of overall time to tertiary care revealed prolonged transfer times and that the Guideline had no influence on either the polytrauma patient group (preimplementation, 4:20±1:41; implementation, 5:01±2:55; and postimplementation 4:46±4:22) or those with isolated head injuries (preimplementation, 3:39±1:47; implementation, 6:06±4:00; and postimplementation, 5:13±4:59). CONCLUSIONS: Times to tertiary care are lengthy and have not been reduced by Guideline implementation. System changes beyond Guideline implementation are required to provide timely access to tertiary care for patients with major head injury.

Acute pharmacological DVT prophylaxis after spinal cord injury.

A systematic review of the literature was performed to address pertinent clinical questions regarding deep vein thrombosis (DVT) prophylaxis in the setting of acute spinal cord injury (SCI). Deep vein thromboses are a common occurrence following SCI. Administration of low-molecular-weight heparin (LMWH) within 72 h of injury is recommended to minimize the occurrence of DVT. Furthermore, when surgical intervention is required, LMWH should be held the morning of surgery, and resumed within 24 h post-operatively.

Acute management of nutritional demands after spinal cord injury.

A systematic review of the literature was performed to address pertinent clinical questions regarding nutritional management in the setting of acute spinal cord injury (SCI). Specific metabolic challenges are present following spinal cord injury. The acute stage is characterized by a reduction in metabolic activity, as well as a negative nitrogen balance that cannot be corrected, even with aggressive nutritional support. Metabolic demands need to be accurately monitored to avoid overfeeding. Enteral feeding is the optimal route following SCI. When oral feeding is not possible, nasogastric, followed by nasojejunal, then by percutaneous endoscopic gastrostomy, if necessary, is suggested.