A SUMMARY OF PAEDIATRIC INJURIES TREATED … SUMMARY OF PAEDIATRIC INJURIES TREATED IN QUEENSLAND...

2007A SUMMARY OF PAEDIATRIC INJURIES TREATED IN QUEENSLAND

A PROGRAMME OF THE CENTRE OF NATIONAL RESEARCH ON DISABILITY AND REHABILITATION MEDICINE

Mayne Medical School, The University of Queensland, Herston Rd, Brisbane Qld 4006

Phone 61 7 3365 5560 Fax 61 7 3346 4603

www.conrod.uq.edu.au

© Centre of National Research on Disability and Rehabilitation Medicine 2009 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Centre of National Research on Disability and Rehabilitation Medicine. Requests and enquiries concerning reproduction and rights should be directed to the Business Manager, Centre of National Research on Disability and Rehabilitation Medicine, School of Medicine, The University of Queensland, Level 3 Mayne Medical School, Herston Road, Herston QLD 4006 Australia. Suggested citation: Dallow N, Lang J, Harvey K, Pollard C, Bellamy N. Queensland Trauma Registry: A summary of paediatric injuries treated in Queensland 2007. Herston: Centre of National Research on Disability and Rehabilitation Medicine, 2009 ISBN: 9781864999693 Any enquiries about or comments on this publication should be directed to: Kathy Harvey Manager Queensland Trauma Registry Centre of National Research on Disability and Rehabilitation Medicine School of Medicine The University of Queensland Level 3 Mayne Medical School Herston Road Herston QLD 4006 Australia Phone: 07 3346 4964 Fax: 07 3346 4603 Email: [email protected] Web: www.uq.edu.au/conrod/index.html?page=11386 The Queensland Trauma Registry is funded by:

© CONROD 2009 1

AAUUTTHHOORRSS Natalie Dallow Jacelle Lang Kathy Harvey Associate Professor Cliff Pollard Professor Nicholas Bellamy

AACCKKNNOOWWLLEEDDGGEEMMEENNTTSS The Queensland Trauma Registry (QTR), a programme of the Centre of National Research on Disability and Rehabilitation Medicine (CONROD), School of Medicine, The University of Queensland, gratefully acknowledges the support and/or contributions of the following organisations and individuals: Motor Accident Insurance Commission Queensland Health School of Medicine & Faculty of Health Sciences, The University of Queensland National Centre for Classification in Health This is the sixth statewide report of paediatric injuries produced by the QTR utilising data obtained from 14 public hospital sites throughout the state. This is also the seventh presentation of paediatric injuries treated at the two Paediatric Specialty Hospitals: Royal Children’s Hospital and Mater Children’s Hospital. This report would not have been possible without the contribution and dedication of staff at the QTR (please refer to the list of QTR staff on page 2. The QTR would also like to acknowledge all the clinical, administrative and managerial staff at each of the hospitals where the QTR is located, in particular the Royal Children’s Hospital and Mater Children’s Hospital, without whose support and contribution the Registry would not succeed.

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QQuueeeennssllaanndd TTrraauummaa RReeggiissttrryy SSttaaffff ((22000077)):: QTR Coordination Director Professor Nicholas Bellamy Quality Assurance & Training Officer Deirdre McDonagh Database Manager Robert Harding Research Officers Jacelle Lang & Natalie Dallow Cairns Base Hospital Trauma Registry Nurse Coordinators: Jennifer Hanby, Janet Irvin, Wendy Parker Gold Coast Hospital Trauma Registry Nurse Coordinator: Christel Jennekens Ipswich Hospital Trauma Registry Nurse Coordinators: Shelley Shepherd, Monica Prior Mackay Base Hospital Trauma Registry Nurse Coordinator: Traci Muscat Nambour Hospital Trauma Registry Nurse Coordinators: Lisa Rasmussen, Gina James, Mel Yip Princess Alexandra Hospital Trauma Registry Nurse Coordinators: Dale Mason, Jenni Ward, Allen Murphy, Daniela Tarlington Health Information Managers: Lucy Kefu, Janet Conroy Redcliffe Hospital / Caboolture Hospital Trauma Registry Nurse Coordinator: Delia O’Brien Rockhampton Base Hospital Trauma Registry Nurse Coordinators: Vivienne Oliver, Carmel Gall, Cherry Sedgman Royal Brisbane & Women’s Hospital Trauma Registry Nurse Coordinators: Melissa Dale, Kristy Jackman, Liz Hogan Health Information Managers: Seonaid Abbotts, Bridget Allison, Chantal Spanagel Royal Children’s Hospital / Mater Children’s Hospital Clinical Coder: Carolyn Starrett Toowoomba Hospital Trauma Registry Nurse Coordinators: Cherie Giles, Glenda Thomas, Janis Doolan The Townsville Hospital Trauma Registry Nurse Coordinators: Judith Brennan, Cindy Setter, Robyn Hay

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QQuueeeennssllaanndd TTrraauummaa RReeggiissttrryy AAddvviissoorryy BBooaarrdd The QTR Advisory Board was established in February 2009 to support the functions of the Registry by providing advice on the strategic focus of the Registry and facilitating the development of collaborative research networks and other partnerships. Membership

Professor Michael Schuetz (Chairperson) Chair Queensland Health Statewide Trauma Clinical Network and Director Trauma Services, Princess Alexandra Hospital Adjunct Professor Graham Hughes AM Chairperson, CONROD, School of Medicine, UQ Mr John Hand Commissioner, Motor Accident Insurance Commission (MAIC) Dr Adrian Nowitzke Chief Executive Officer, Gold Coast Health Service District, Queensland Health Mr David Melville Commissioner, Queensland Ambulance Service (QAS) Mr Gary Fites General Manager External Relations, Royal Automobile Club of Queensland (RACQ) Professor Nicholas Bellamy Director, CONROD, School of Medicine, UQ (ex-officio) Associate Professor Cliff Pollard Director, Queensland Trauma Registry, School of Medicine, UQ and Director Trauma Services, Royal Brisbane and Women’s Hospital (ex-officio) Ms Kathy Harvey Manager, Queensland Trauma Registry, School of Medicine, UQ (ex-officio)

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QQuueeeennssllaanndd TTrraauummaa RReeggiissttrryy RReesseeaarrcchh SSuubbccoommmmiitttteeee In August 2009, the QTR Research Subcommittee was convened to support the QTR Advisory Board. Its functions include protocols for handling of requests for Registry data, and to advise the Board on research policy and strategy and on the future direction for research utilising the QTR. Membership Professor Gerry FitzGerald (Chairperson) Professor Public Health (Emergency and Disaster Management), School of Public Health, QUT Associate Professor Vivienne Tippett Director, Australian Centre for Pre-hospital Care Research, School of Population Health, UQ Professor Narelle Haworth Professor in Injury Prevention and Rehabilitation, Centre for Accident Research and Road Safety (CARRS-Q), QUT Professor Jeffrey Lipman Director of Burns, Trauma and Critical Care Research Centre, UQ and Director of Intensive Care Medicine, Royal Brisbane & Women’s Hospital Dr Don Campbell Emergency Department Consultant, Gold Coast Hospital and Chair Gold Coast Hospital QTR Trauma Review Committee Mr John O’Brien Director, Integration and Linkage, Health Statistics Centre, Queensland Health Professor Roy Kimble Professor of Paediatrics & Child Health, UQ and Director of Queensland Children’s Hospital Trauma Service Professor Nicholas Bellamy Director, CONROD, School of Medicine, UQ Associate Professor Cliff Pollard Director, Queensland Trauma Registry, School of Medicine, UQ and Director Trauma Services, Royal Brisbane and Women’s Hospital (ex-officio) Ms Kathy Harvey Manager, Queensland Trauma Registry, School of Medicine, UQ (ex-officio) Professor Michael Schuetz Chair Queensland Health Statewide Trauma Clinical Network and Director Trauma Services, Princess Alexandra Hospital (ex-officio) CONROD Professor of Orthopaedic Trauma Surgery (to be advised)

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PPRREEFFAACCEE The QTR has been established as a statewide registry since January 2002. This report describes aggregate injury data for children aged zero to 14 years collected by the QTR at 14 Queensland public hospitals in 2007. The Registry includes children (and adults) admitted for at least 24 hours for the treatment of an acute minor or major injury. An overall total of 2,038 paediatric cases were eligible for inclusion on the QTR throughout the state in 2007, of which 135 met the criteria for major trauma. A central feature of the QTR is support for the quality assurance process through all phases of treatment from pre-hospital to discharge or death, through the systematic review of all trauma cases where care has varied from predefined standards of trauma management or where trauma patients die during hospitalisation. This has been achieved by: • Establishing benchmarks and identifying variations in accepted standards of care

for people who experience serious injury in Queensland • Establishing Trauma Review Committees and facilitating clinical review and

recommendations for changes in trauma management throughout Queensland, and

• Conducting scientific research to reduce future incidence and burden of injury and improve trauma management and outcomes.

QTR data should prove useful for clinicians involved in the care and quality review of trauma patients, hospital personnel involved in planning and allocating resources for patient care and those working in injury prevention. The success of the QTR would not be possible without the dedicated work of the QTR core management team or the Trauma Registry Nurse Coordinators, Health Information Managers, clinicians and managers who support the functions of the Registry in each of the participating hospitals. We thank all these people, as well as the clinical directors for the ‘non-clinical’ time they provide to undertake the activities of the Trauma Review Committees. On behalf of CONROD and the QTR, we are pleased to provide this, the sixth annual QTR report on paediatric injuries treated throughout Queensland, in the 12-month period from January to December 2007. Associate Professor Cliff Pollard Professor Nicholas Bellamy Director Director Queensland Trauma Registry CONROD

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EEXXEECCUUTTIIVVEE SSUUMMMMAARRYY This is the sixth annual report of aggregate injury data collected by the QTR on children (0 to 14 years) admitted for 24 hours or more to 14 hospital sites throughout Queensland in 2007. Queensland public hospitals participating in the QTR in 2007 were Caboolture, Cairns, Gold Coast, Ipswich, Mackay, Mater Children’s, Nambour, Princess Alexandra, Redcliffe, Rockhampton, Royal Brisbane & Women’s, Royal Children’s, Toowoomba, and Townsville. An overall total of 2,038 paediatric cases were eligible for inclusion on the QTR, of which 135 met the criteria for major trauma. Of all eligible QTR paediatric cases for 2007 (2,038):

• Sixty-five percent of cases were male

• Males tended to be older than females when injured

• Incidence of trauma in children was 241 admissions per 100,000 population

• Forty-two percent of cases admitted to the Royal Children’s and Mater Children’s Hospitals were referred from another hospital

• A greater number of children of Aboriginal and Torres Strait Islander origin were treated at non-Paediatric Specialty Hospitals compared to Paediatric Specialty Hospitals

• Falls accounted for the highest proportion of paediatric injuries

• Road traffic crashes accounted for the highest proportion of major paediatric injuries

• The majority of children were involved in a leisure activity when injured

• Fractures were the most common nature of main injury and the upper extremity was the most common body location of main injury

• The full cohort of paediatric injury cases had a median length of acute hospital stay of two days, while major injury cases had a median length of acute hospital stay of five days

• Eight percent of the total acute bed days used at the Royal Children’s and Mater Children’s Hospitals were trauma-related bed days

• Approximately 8% of the paediatric cohort were admitted to ICU

• Significantly more major injury cases were treated at Paediatric Specialty Hospitals compared to non-Paediatric Specialty Hospitals

• In-hospital mortality across the full paediatric cohort was 0.9%

• One performance indicator, ‘Referring hospital transfer greater than six hours’, was most commonly flagged in the three years from 2005 to 2007 as being outside agreed benchmarks.

These details confirm the extent and nature of hospitalisations due to paediatric injury throughout Queensland in 2007. While prevention programs assist with reducing the incidence of injuries, it is imperative that management of injured patients while in hospital is reviewed regularly to improve process and decision making, inform quality assurance programs, develop educational programs to meet identified needs and ensure optimal treatment and outcomes.

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TTAABBLLEE OOFF CCOONNTTEENNTTSS LIST OF FIGURES .......................................................................................... 9 LIST OF TABLES .......................................................................................... 10 BACKGROUND ............................................................................................. 11 METHODOLOGY ........................................................................................... 12

Study design ............................................................................................................ 12 Criteria / Case definition .......................................................................................... 12 Data collection ......................................................................................................... 13 Data quality .............................................................................................................. 13 Data capture ............................................................................................................ 14 Data analysis and reporting ..................................................................................... 14 Data usage .............................................................................................................. 14

Quality review and practice development ........................................................... 15 Analysis ................................................................................................................... 15 Ethical considerations .............................................................................................. 15

SUMMARY OF PAEDIATRIC TRAUMA IN QUEENSLAND ........................ 16

Major / Minor Classification ..................................................................................... 16 Demographic Characteristics .................................................................................. 16

Age and sex of injury cases ................................................................................ 16 Aboriginal and Torres Strait Islander People ...................................................... 17

Injury Event Characteristics ..................................................................................... 18 External cause of injury ....................................................................................... 18 Place of injury ...................................................................................................... 20 Intent of injury ...................................................................................................... 21 Activity when injured ........................................................................................... 21 Day and month of injury ...................................................................................... 21

Injury Description ..................................................................................................... 22 Body location and nature of main injury .............................................................. 22

Patient Status .......................................................................................................... 23 Triage .................................................................................................................. 23 TRISS .................................................................................................................. 24

Outcome Measures ................................................................................................. 25 Length of acute hospital stay .............................................................................. 25 ICU ...................................................................................................................... 26 Operations ........................................................................................................... 26 Mortality ............................................................................................................... 27

Performance Indicators ........................................................................................... 28 SUMMARY OF TRAUMA TREATED AT PAEDIATRIC SPECIALTY HOSPITALS ................................................................................................... 32


Age and sex of injury cases ................................................................................ 32 Place of residence ............................................................................................... 33 Aboriginal and Torres Strait Islander People ...................................................... 34

Referral Patterns ..................................................................................................... 34 Injury Event Characteristics ..................................................................................... 35

External cause of injury ....................................................................................... 35 Place of injury ...................................................................................................... 37 Intent of injury ...................................................................................................... 38 Activity when injured ........................................................................................... 38 Day and month of injury ...................................................................................... 38

Injury Description ..................................................................................................... 39 Body location and nature of main injury .............................................................. 39

Patient Status .......................................................................................................... 40

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Triage .................................................................................................................. 40 TRISS ................................................................................................................. 40

Outcome Measures ................................................................................................. 41 Length of acute hospital stay .............................................................................. 41 ICU ...................................................................................................................... 43 Operations .......................................................................................................... 43 Mortality .............................................................................................................. 44

Complications .......................................................................................................... 45 Performance Indicators ........................................................................................... 46

COMPARISON BETWEEN PAEDIATRIC SPECIALTY AND NON-PAEDIATRIC SPECIALTY HOSPITALS ....................................................... 50


Age and sex of injury cases ................................................................................ 50 Aboriginal and Torres Strait Islander People ...................................................... 51

Injury Event Characteristics .................................................................................... 52 External cause of injury ...................................................................................... 52 Nature of main injury ........................................................................................... 52 Body location of main injury ................................................................................ 52

Outcome Measures ................................................................................................. 53 Length of acute hospital stay .............................................................................. 53 ICU ...................................................................................................................... 54 Mortality .............................................................................................................. 54

Performance Indicators ........................................................................................... 55 REFERENCES ............................................................................................... 57 APPENDIX A – QTR DATA FIELDS IN 2007 ............................................... 59 APPENDIX B – OPERATIONS ...................................................................... 60 APPENDIX C – COMPLICATIONS ............................................................... 63 APPENDIX D – PERFORMANCE INDICATORS .......................................... 64

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LLIISSTT OOFF FFIIGGUURREESS Figure 1: Age and sex distribution for all paediatric injury cases (n = 2,038) .............. 16 Figure 2: Percentage of males and females within each age group (n = 2,038) ......... 17 Figure 3: Injury rate per 100,000 population per year in Queensland (n = 2,038) ...... 17 Figure 4: External cause of injury by sex for all cases (n = 2,018) .............................. 18 Figure 5: Percentage of patients for each type of RTC (n = 472) ................................ 19 Figure 6: External cause of injury for major and minor cases (n = 2,018) .................. 20 Figure 7: Place of injury occurrence (n = 1,448).......................................................... 20 Figure 8: Activity engaged in when injured (n = 1,171) ............................................... 21 Figure 9: Day of injury occurrence (n = 2,038) ............................................................ 22 Figure 10: Month of injury occurrence (n = 2,038) ...................................................... 22 Figure 11: Length of acute hospital stay (n = 2,038) ................................................... 25 Figure 12: Length of acute hospital stay for major and minor injury cases (n = 2,038)

............................................................................................................................ 25 Figure 13: ICU length of stay (n = 152) ....................................................................... 26 Figure 14: Percentage of operations performed by body region (n = 2,027) .............. 26 Figure 15: Percentage of operations performed by body region for major injury cases

(n = 129) .............................................................................................................. 27 Figure 16: Death rate by age group (n = 18) ............................................................... 27 Figure 17: Percentage of cases flagged (including raw numbers) for each of the 17

performance indicators (n = 135 major injury cases) .......................................... 29 Figure 18: Trends in the flagging of 17 performance indicators from 2005 to 2007

(n(2005) = 120, n(2006) = 142, n(2007) = 135) ............................................................. 31 Figure 19: Age and sex distribution for injury cases – Paediatric Specialty Hospitals

(n = 809) .............................................................................................................. 33 Figure 20: Percentage of males and females within each age group – Paediatric

Specialty Hospitals (n = 809) .............................................................................. 33 Figure 21: External cause of injury by sex for all cases – Paediatric Specialty Hospitals

(n = 798) .............................................................................................................. 35 Figure 22: Percentage of patients for each type of RTC – Paediatric Specialty

Hospitals (n = 172) .............................................................................................. 36 Figure 23: External cause of injury for major and minor cases – Paediatric Specialty

Hospitals (n = 798) .............................................................................................. 37 Figure 24: Place of injury occurrence – Paediatric Specialty Hospitals (n = 627) ....... 37 Figure 25: Activity engaged in when injured – Paediatric Specialty Hospitals (n = 423)

............................................................................................................................ 38 Figure 26: Day of injury occurrence – Paediatric Specialty Hospitals (n = 809) ......... 39 Figure 27: Month of injury occurrence – Paediatric Specialty Hospitals (n = 809) ...... 39 Figure 28: Length of acute hospital stay – Paediatric Specialty Hospitals (n = 809) .. 42 Figure 29: Length of acute hospital stay for major and minor injury cases – Paediatric

Specialty Hospitals (n = 809) .............................................................................. 42 Figure 30: ICU length of stay – Paediatric Specialty Hospitals (n = 110) .................... 43 Figure 31: Percentage of operations performed by body region – Paediatric Specialty

Hospitals (n = 846) .............................................................................................. 44 Figure 32: Percentage of operations performed by body region for major injury cases –

Paediatric Specialty Hospitals (n = 101) ............................................................. 44 Figure 33: Death rate by age group – Paediatric Specialty Hospitals (n = 4) ............. 44 Figure 34: Percentage of cases flagged (including raw numbers) for each of the 17

performance indicators – Paediatric Specialty Hospitals (n = 81 major injury cases) .................................................................................................................. 47

Figure 35: Trends in the flagging of 17 performance indicators from 2005 to 2007 – Paediatric Specialty Hospitals (n(2005) = 72, n(2006) = 97, n(2007) = 81) .................. 49

Figure 36: Distribution of male cases within each hospital category (n = 1,325) ........ 51 Figure 37: Distribution of female cases over the two hospital categories (n = 713) .... 51 Figure 38: External cause of injury over the two hospital categories (n= 2,018) ......... 52 Figure 39: Length of acute hospital stay over the two hospital categories (n = 2,038) 53 Figure 40: Death rate for each age group across both hospital categories (n = 18) ... 55

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LLIISSTT OOFF TTAABBLLEESS Table 1: External cause of injury by age group (n = 2,018) ......................................... 19 Table 2: Place of injury by age group (n = 1,448) ........................................................ 20 Table 3: Nature by body location of main injury (n = 2,038) ........................................ 23 Table 4: Triage categories for patients presenting through ED (n = 1,913) ................. 23 Table 5: Summary of TRISS in different patient subgroups for all cases and only for

cases with actual (not imputed) data used in the calculation .............................. 24 Table 6: Referring hospital name for patients transferred to Paediatric Specialty

Hospitals for definitive care (n = 341) .................................................................. 34 Table 7: External cause of injury by age group – Paediatric Specialty Hospitals

(n = 798) .............................................................................................................. 36 Table 8: Place of injury by age group – Paediatric Specialty Hospitals (n = 627) ....... 37 Table 9: Nature by body location of main injury – Paediatric Specialty Hospitals

(n = 809) .............................................................................................................. 40 Table 10: Triage categories for patients presenting through ED – Paediatric Specialty

Hospitals (n = 739) ............................................................................................... 40 Table 11: Summary of TRISS in different patient subgroups for all cases and only for

cases with actual (not imputed) data used in the calculation – Paediatric Specialty Hospitals .............................................................................................. 41

Table 12: Complications identified for major injury cases – Paediatric Specialty Hospital (n = 54) .................................................................................................. 46

Table 13: Injury severity details for major and minor injury cases over the two hospital categories (n = 2,038) .......................................................................................... 50

Table 14: Number of patients in each hospital category in the six most common nature of main injury categories (n= 2,038) .................................................................... 52

Table 15: Number of patients in each hospital category: Upper extremity, lower extremity and head (n = 2,038) ............................................................................ 53

Table 16: Length of acute hospital stay details between the two hospital categories (n = 2, 038) .......................................................................................................... 53

Table 17: ICU length of stay details over the two hospital categories (n = 152) .......... 54 Table 18: Percentage of flagged cases for each of the 17 performance indicators for

both hospital categories (n = 135) ....................................................................... 56

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BBAACCKKGGRROOUUNNDD

Overall, injury represents a major cost to injured individuals, the healthcare system and society1, with the expenditure for injuries projected to increase by 116% over the next 30 years2. Injury is a leading cause of preventable mortality and morbidity in Queensland3, Australia4 and the World5. Injury is a leading cause of child mortality and hospitalisation in Australia6. In particular, falls, transport accidents and accidental poisoning are the most common reasons for injury hospitalisation for children aged from zero to 14 years in Australia6. In Queensland in 1996-98, injury and poisoning caused one third of all deaths in children7. Initiatives like the ‘National Injury Prevention Plan: Priorities for 2001 – 2003’8 and the ‘Health Outcomes Plan: Injury Prevention and Control 2000 – 20049, aim to reduce the burden of falls and accidental poisoning in children. In this context, the value of trauma registries for the collection and analysis of injury data on a statewide level has been described as a major tool for assessing the management of patient care10. The Queensland Trauma Registry was established in 1998 in the Centre of National Research on Disability and Rehabilitation Medicine (CONROD), with the purpose of maximising the benefits of care provided to people hospitalised in Queensland following serious injury. Funding from Queensland Health supports the Trauma Registry Nurse Coordinator positions at The Townsville, Royal Brisbane & Women’s and Princess Alexandra Hospitals and the Clinical Coder position at Mater Children’s and Royal Children’s Hospitals. The Motor Accident Insurance Commission provides funding for the infrastructure, Trauma Registry Nurse Coordinator positions at the remaining sites and the core positions of Director, Manager, Senior Research Fellow, Database Manager, Quality Assurance & Training Officers, Research Officers and Health Information Managers. The QTR commenced data collection at the Royal Brisbane & Women’s and Princess Alexandra Hospitals in January 1998. In 2002 the QTR was established as a statewide registry, with the participation of 13 Queensland public hospitals. In 2009, membership increased to 20 sites, thus capturing the majority of severely injured patients in Queensland. The QTR fosters best practice in data collection, clinical review and scientific research through the collection and systematic review of data on the incidence, circumstances, types and severity, and treatment and outcomes of serious injury in Queensland, as well as all phases of treatment from pre-hospital to discharge or death.

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MMEETTHHOODDOOLLOOGGYY SSttuuddyy ddeessiiggnn A prospective cohort design with chart based data acquisition at point of hospital separation is used for the operation of the QTR.

CCrriitteerriiaa // CCaassee ddeeffiinniittiioonn The Emergency Department Information System (EDIS) is a management application to collect information about every patient presentation to an emergency department at a Queensland public hospital. While the QTR includes all cases of trauma, children are identified for inclusion on the QTR via a standard system report generated by EDIS using the following criteria: • ≤ 14 years of age and admitted to a Registry hospital site for ≥ 24 hours on initial

presentation for treatment of an injury AND are codeable to an ICD-10-AM category from S00-S99, T00-T75, T78

• Admission via Emergency Department (ED) or transferred from another hospital (bypassing ED) for the acute treatment of an injury.

Also included on the QTR are cases of injury where children: • Die during ED presentation after active treatment was undertaken in ED • Die during hospital admission. Exclusions Cases are excluded from the QTR where: • Fracture is pathological • Dislocation is spontaneous • Injury occurred in hospital and did not present through ED • Treatment is for psychiatric condition rather than injury • Treatment is for medical condition rather than injury • Treatment is for complication of injury (eg cellulitis) • Admission is for convalescence, not treatment • Admission is for social reasons. Minor paediatric trauma cases Injury Severity Score (ISS) < 16 or cases where an ISS is not able to be calculated, including those who die subsequent to overdose / poisoning. Major paediatric trauma cases ISS ≥ 16, d ied in the ED (where definitive care undertaken) or died during admission (other than deaths subsequent to overdose / poisoning). A guide to data fields collected for major and minor injury cases is included in Appendix A. Data definitions Standard data definitions are in use in the QTR. These include: • Abbreviated Injury Scale 1990 (AIS-90) for coding of all injuries sustained by the

patient including identification of main body location of injury • National Data Standards for Injury Surveillance version 2.1 (NDS-IS) for main

nature of injury • International Statistical Classification of Diseases and Related Health Problems

(10th Revision) – Australian Modification (ICD-10-AM) for External Cause, Place, Intent and Activity (2005 onwards).

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DDaattaa ccoolllleeccttiioonn The QTR data collection system consists of a live, stand-alone, centralised database which is populated electronically with information downloaded from EDIS, and with supplementary fields entered manually at chart audit. The manual data entry is performed at each QTR member hospital by designated Trauma Registry Nurse Coordinators (TRNCs) and Health Information Managers accredited in specialised injury coding. The basic QTR data counting unit is per trauma event, to ensure patients appear on the database only once. Those patients who are transferred between QTR sites for treatment of a trauma event appear on the Registry only for the site at which they received the majority of their definitive care.

DDaattaa qquuaalliittyy Data quality assurance is a major priority in achieving and maintaining the highest standard of care within the trauma system. A series of processes are in place to optimise the reliability and validity of the data, with CONROD employing a core data management team to implement these strategies. Data quality processes can be grouped under three main strategies – education, database validation rules and quality assurance checks. Specifically, these strategies include:

• Central orientation, training and management of QTR data collection staff (coders)

• Data collection performed by qualified TRNCs and Health Information Managers accredited in specialised injury coding

• Publication of coding manuals which specify inclusion and exclusion criteria and guide coding staff through the QTR data collection and documentation process

• Incorporation of automatic flags into the QTR database to guide coding staff and provide alerts of incomplete or invalid data

• Provision of a central coding help desk service

• Accessing and cross-checking multiple sources of data (ED, ICU and hospital discharge diagnosis lists) to ensure all relevant patients are identified, eg cases that may bypass EDIS or do not initially meet the inclusion criteria for the QTR

• Monthly statewide QTR staff meetings including coding exercises

• Quarterly publication of QTR coding newsletter

• Twice-yearly statewide staff workshops to provide education and share lessons learned across QTR member hospitals

• Annual site audits of subsets of included and excluded cases via dual coding of patient health records by a senior Health Information Manager

• Conducting a series of automatic and manual audits on all data including routine intensive data cleaning and edit checks

• If required, addressing data coding backlogs with qualified QTR TRNCs and Health Information Managers.

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DDaattaa ccaappttuurree Queensland public hospitals participating in the QTR in 2007 were Caboolture, Cairns, Gold Coast, Ipswich, Mackay, Mater Children’s, Nambour, Princess Alexandra, Redcliffe, Rockhampton, Royal Brisbane & Women’s, Royal Children’s, Toowoomba, and Townsville. These are the main hospitals where significant injuries are treated, however, the data presented in this report do not purport to be the complete picture of all injuries treated in Queensland. Injured patients who were not admitted to hospital or were admitted for less than 24 hours were excluded from the QTR and no hospitals in the Wide Bay region were included on the QTR in 2007. Hospitals in this region (Bundaberg, Hervey Bay and Maryborough Hospitals) and Logan Hospital were added to the Registry in 2009.

DDaattaa aannaallyyssiiss aanndd rreeppoorrttiinngg QTR data are available to participating hospitals immediately following entry to the database. For example, the ‘audit and reporting’ module of the QTR database flags cases which have tripped a performance indicator and automatically produces a report which is presented by the TRNC for audit and review by the hospital Trauma Review Committee. QTR data are reported on a regular basis to the Queensland Health Statistics Centre and to the Office of the Chief Health Officer. A summary of all data fields collected for trauma patients included on the QTR is included at Appendix A.

DDaattaa uussaaggee Trauma registries are well established in a number of countries and have been used to change legislation, promote trauma prevention and to evaluate trauma system effectiveness11-15. Trauma registries have also been shown to be more useful and accurate than administrative databases in assessing quality of care and diagnostic and therapeutic interventions16. In addition to the recognised function of trauma registries of enabling clinicians to evaluate the effectiveness of trauma systems17, trauma registries are essential to assessing and improving standards of trauma care18. Overall, trauma registries are necessary tools for preventive strategies, quality assurance practices, health planning and evaluation, and monitoring the epidemiology of serious injury19. The QTR was established for multiple purposes and data collected by the QTR are used for a variety of activities including: • Quality review and practice development • Identification of trauma care-related issues • Implementation of revised practice guidelines and procedures • Provision of education and development activities • Data requests and reports. From 2003 to 2007, a total of 203 requests for QTR data were completed for external data users. These data requests were used for a variety of purposes including: • Clinical research projects and chart audits • Epidemiological research projects • Writing journal articles • Conference presentations / posters • Presentations at trauma-related meetings / workshops / forums • Development of injury prevention strategies

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• Assessing hospital service usage • Evaluating effect of changes in trauma treatment protocols / guidelines • Estimating trauma workloads • Public hospital education. QQuuaalliittyy rreevviieeww aanndd pprraaccttiiccee ddeevveellooppmmeenntt The trauma review process is particularly important and is designed to identify areas of educational need, improve patient care and to review systems performance for those involved in trauma care. Trauma Review Committees (TRCs) provide a multidisciplinary forum to review patients: • who ‘tripped’ a performance indicator

(that is, above or below a predetermined threshold which may be associated with sub-optimal performance / treatment)

• who died in hospital • who had an otherwise notable condition

(for instance, a rare or complicated combination of injuries and/or co-morbidities). Significant trauma management or systems issues identified through the QTR trauma review processes are communicated to the Office of the Chief Health Officer through the Patient Transport Quality Council. AAnnaallyyssiiss Descriptive analysis of demographic, injury and treatment details are presented in this report. Where data were normally distributed, mean and standard deviation results have been provided. Where data were not normally distributed, median and inter-quartile range results have been provided. Statistically significant differences between groups have been determined using t-tests for normally distributed, continuous data and chi-square for categorical data. Where cell counts were below five, Fisher’s exact test was used. Generalised linear regression modelling was used to determine the relationship between outcome measures and possible predictors after controlling for known influential variables. A significance level of 5% has been set for all analyses. EEtthhiiccaall ccoonnssiiddeerraattiioonnss On 14 December 2006, Her Excellency the Governor, acting by and with the advice of the Executive Council and under the provisions of the Health Services Act 1991, made the Health Legislation Amendment Regulation (No. 7) 2006 (the HLA Regulation). The HLA Regulation amended the Health Services Regulation 2001 to prescribe The University of Queensland as an entity for the duty of confidentiality exemption purposes under section 62H(b) of the Health Services Act 1991, for the purpose of collecting data for the Queensland Trauma Registry to evaluate, manage, monitor or plan health services for trauma patients. A copy of the HLA Regulation was notified in the Queensland Government Gazette on 15 December 2006. The operation of the QTR is approved by the ethics committee of each relevant Health Service District and The University of Queensland, in accordance with the National Health and Medical Research Council Guidelines.

© CONROD 2009 16

SSUUMMMMAARRYY OOFF PPAAEEDDIIAATTRRIICC TTRRAAUUMMAA IINN QQUUEEEENNSSLLAANNDD

This section provides information on all paediatric trauma patients (0 to 14 years) who met the inclusion criteria and were eligible for entry on the QTR in 2007. A total of 2,038 children were admitted to one of 14 QTR hospitals throughout Queensland and were included on the QTR in 2007. The number of eligible paediatric cases entered on the QTR was 1,942 in 2005 and 1,929 in 2006. MMaajjoorr // MMiinnoorr CCllaassssiiffiiccaattiioonn Of the total cohort of 2,038 paediatric patients included on the QTR in 2007:

• 93.4% (1,903) were classified as minor injury cases (ISS <16 and deaths from poisoning), and

• 6.6% (135) were classified as major injury cases (ISS ≥ 16 or died in ED or died during hospitalisation).

For the total cohort, the median ISS was five (IQR = 4 – 9). 2005 – 2007 The percentage of major paediatric injury cases treated in Queensland was 6.2% (120) in 2005, 7.4% (142) in 2006, and 6.6% (135) in 2007. For the total cohort, median ISS was five in 2005, 2006 and 2007.

DDeemmooggrraapphhiicc CChhaarraacctteerriissttiiccss AAggee aanndd sseexx ooff iinnjjuurryy ccaasseess Males accounted for 65% (1,325) of all children injured, with the 10 to 14 years age group recording the highest number of injuries (614 cases) (Figure 1). For females, the highest number of injury cases was also recorded in the 10 to 14 years age group (252 cases). All age groups had a higher percentage of males compared to females (Figure 2). Overall, the average age at injury was 8.3 years (SD = 4.37) for males and 7.3 years (SD = 4.27) for females.

0

100

200

300

400

500

600

700

0-4 5-9 10-14

Age group

Num

ber o

f pat

ient

s MaleFemale

Figure 1: Age and sex distribution for all paediatric injury cases (n = 2,038)

© CONROD 2009 17

0%

20%

40%

60%

80%

100%

0-4 5-9 10-14

Age group

% o

f pat

ient

sFemaleMale

Figure 2: Percentage of males and females within each age group (n = 2,038)

Commentary

The finding that 65% of injuries occurred in males is consistent with previous literature20 where males accounted for more admissions to hospital because of injury than females.

Of the 2,038 children treated for injury across Queensland, 43% (866) were aged from 10 to 14 years. This was higher than the proportion of children in this age range across the state of Queensland (35%)21. Children aged five to nine years accounted for 31% (641) of the injured population, while those aged zero to four years accounted for 26% (531). Both of these proportions from the injured population were lower than the proportion of children in these age ranges across the state of Queensland (33% and 32% respectively)21. Overall in Queensland for 2007, there were 241 injury admissions to QTR hospitals per 100,000 residents aged from zero to 14 years per year21. For males, the highest incidence of injury occurred in the 10 to 14 years age group, with a rate of 410 injury admissions per 100,000 population. For females, the highest incidence of injury occurred in the five to nine years group, with a rate of 179 injury admissions per 100,000 population (Figure 3).

050

100150200250300350400450

0-4 5-9 10-14

Age group

No.

inju

ries

per 1

00,0

00

popu

latio

n pe

r yea

r MaleFemale

Figure 3: Injury rate per 100,000 population per year in Queensland (n = 2,038)

AAbboorriiggiinnaall aanndd TToorrrreess SSttrraaiitt IIssllaannddeerr PPeeooppllee Of the 2,038 injured children admitted to QTR hospitals in 2007, 7.5% (152) identified themselves as being of Aboriginal and Torres Strait Islander origin. This was more than the proportion of people of Aboriginal and Torres Strait Islander origin within the

© CONROD 2009 18

paediatric population of Queensland (6.8%)22. There were 125 children recorded as being of Aboriginal origin, 18 children recorded as being of Torres Strait Islander origin, and nine children identified themselves as being of both Aboriginal and Torres Strait Islander origin.

IInnjjuurryy EEvveenntt CChhaarraacctteerriissttiiccss EExxtteerrnnaall ccaauussee ooff iinnjjuurryy The external cause of injury was specified for 2,018 cases. Falls were the most common cause of injury (906 cases), with 52% (470) suffering a fall of less than one metre. The percentage of total injuries for each sex accounted for by falls was higher for females (48%) than males (43%) (Figure 4).

0 10 20 30 40 50 60

OtherDrowningMachine

PoisonCuttingBurns

AnimalCollision

RTCFall

Exte

rnal

cau

se

% of patients

FemaleMale

Figure 4: External cause of injury by sex for all cases (n = 2,018)*

* Those categories with n ≤ 10 were not included in this figure: ‘Threat to breathing’ and ‘Firearm’

Commentary

‘The Health Outcomes Plan: Injury Prevention and Control 2000 – 2004’ outlines the scope of the problem of falls in children and adolescents and presents prevention strategies, specific trauma management and rehabilitation strategies for falls in this group9. Establishing the burden of falls in children is necessary in order to improve the wellbeing of the paediatric population, however the need to implement these approaches to reduce the incidence of falls in younger people is also apparent.

Road traffic crashes (RTCs) were the second most common cause of injury (472 cases), with 75% (352) of these children being male. The RTC category included cyclists (188), motorbike (MB) riders (105), motor vehicle (MV) passengers (62), pedestrians (57), MB passengers (15), MV drivers (1), and other modes of transport (44) (Figure 5). In addition to falls and RTCs, collision with an object or person accounted for a further 8% (163) of all injuries. These three external causes accounted for three-quarters of all paediatric injury admissions recorded on the QTR for 2007. The remaining injuries were the result of other external causes.

© CONROD 2009 19

0 10 20 30 40 50

Other transport

MV driver

MB passenger

Pedestrian

MV passenger

MB rider

Cyclist

RTC

cat

egor

y

% of patients

Figure 5: Percentage of patients for each type of RTC (n = 472)

Commentary

The fact that cyclist injuries make up the highest percentage of RTC-related injury in this paediatric cohort is consistent with previous data23, confirming the extent of the problem in terms of morbidity and mortality. Consistent with data from Victoria24, males (95 cases in 2007), and those aged from 10 to 14 years (87 cases in 2007), were highly represented in the motorbike crash category. The fact that off-road motorbikes (eg four-wheeled bikes and trail bikes) do not require registration in Queensland, often leads to an underestimation of the occurrence of motorbike injuries in children. It has been suggested that children of this age may not have developed the skills (eg motor coordination) needed for safe motorcycle riding and should be discouraged from riding motorcycles25.

External cause of injury varied according to age. Burns, poisonings and drownings were most commonly recorded in the zero to four years age group. Falls were most common in those aged five to nine years with RTCs, collisions with an object or person, animal-related injuries, cutting injuries, machinery-related injuries and breathing-related injuries most commonly recorded for those aged from 10 to 14 years (Table 1). Thirty-five of the 38 poisoning cases aged from zero to nine years were accidental poisonings. This is in contrast to the 10 to 14 years age group, where 11 of the 12 cases of poisoning were coded as intentional self harm. Of these 11 patients, 91% (10) were female.

Commentary

The finding that 91% of the self-harm poisoning cases in the 10 to 14 years age group were female is in line with previously reported data describing the high presentation rate to hospital for preadolescent females following intentional poisoning in Queensland26.

Table 1: External cause of injury by age group (n = 2,018)*

Age group Fall RTC Collision Animal Burns Cutting Poisoning Machinery Drowning Other

0-4 243 41 49 25 59 10 31 8 7 41 5-9 334 133 52 33 11 33 7 9 4 22

10-14 329 298 62 38 19 45 12 16 2 36 Total 906 472 163 96 89 88 50 33 13 99

* Those categories with n ≤ 10 were not included in this figure: ‘Threat to breathing’ and ‘Firearm’ Differences were noted between major and minor injury cases for external cause of injury. The most common external causes for minor injury were falls (46% of all minor cases), followed by RTCs (22%) and collision with an object or a person (8%). For

© CONROD 2009 20

major cases, the most common external causes of injury were RTCs (43% of all major cases), followed by falls (31%), and collision with an object or a person (9%) (Figure 6).

0 10 20 30 40 50

OtherMachineryPoisoning

CuttingAnimal

DrowningBurns

CollisionFall

RTC

Exte

rnal

cau

se

% of patients

MajorMinor

Figure 6: External cause of injury for major and minor cases (n = 2,018) *

* Those categories with n ≤ 10 were not included in this figure: ‘Threat to breathing’ and ‘Firearm’ PPllaaccee ooff iinnjjuurryy The place where injury occurred was specified for 1,448 cases. In line with the number of injuries caused by falls and RTCs, 48% (693) of children were injured in the home and 13% (184) were injured on a street or highway. In addition, 14% (197) were injured in a sports area and 13% (182) were injured at a school. The remaining cases were injured elsewhere (Figure 7).

0 10 20 30 40 50 60

Other specified

Trade/service area

Farm

School

Street/highway

Sports area

Home

Plac

e of

inju

ry

% of patients

Figure 7: Place of injury occurrence (n = 1,448)* * Those categories with n ≤ 5 were not included in this figure: ‘Industrial area’ and ‘Residential Institution’.

The place of injury was similar over the age groups, with the most common place of injury being the home for all three age groups. This was followed by schools and streets/highways for the zero to four years and the five to nine years age groups, and sports areas and streets/highways for the 10 to 14 years age group (Table 2).

Table 2: Place of injury by age group (n = 1,448)*

Age group Home Sports area

Street/ highway School Farm Trade/

service area Other

0-4 335 4 20 23 5 14 15 5-9 197 36 52 78 13 11 55

10-14 161 157 112 81 14 6 51 Total 693 197 184 182 32 31 121

* Those categories with n ≤ 5 were not included in this table: ‘Industrial area’ and ‘Residential Institution’.

© CONROD 2009 21

For both major and minor paediatric injury cases, the most common place of injury was the home (47% and 48% respectively), with the second most common place of injury being a street or highway for major cases (28%) and a sports area for minor cases (14%).

Commentary

The large number of home-injuries is consistent with other data from Queensland27

and confirms the need for continuing interventions and programs aimed at improving safety in the home. As injuries occurring on streets and highways were also common, this highlights the importance of bicycle helmet policies, parental supervision, roadway construction and road safety education.

IInntteenntt ooff iinnjjuurryy The majority of paediatric injuries, 97.5% (1,987), were coded as accidental, with 1% (21) coded as assault and 1% (17) coded as intentional self-harm. The intent was not determined for 13 cases. AAccttiivviittyy wwhheenn iinnjjuurreedd The type of activity children were engaged in when injured was specified for 1,171 cases. Fifty-eight percent (653) were engaged in a sports/leisure activity and 5% (61) were engaged in a personal activity (eg eating, sleeping, personal hygiene) (Figure 8). The remaining children were injured while engaged in other types of activities.

0 10 20 30 40 50 60 70

Other specified activity

Working for income

Other types of work

Personal activity

Sports/Leisure activity

Act

ivity

whe

n in

jure

d

% of patients

Figure 8: Activity engaged in when injured (n = 1,171)

Commentary

According to ICD-10-AM coding guidelines, when external cause of injury is specified as a ‘Transport Accident’ and where the activity at the time of injury is not specified as sport, leisure or working for income, activity is assigned as ‘Unspecified Activity’. In most other cases, if the activity at the time of injury does not fit into sport, leisure or working for income, and ‘Other’ activity cannot be assigned, these too fall into the ‘Unspecified Activity’ category.

DDaayy aanndd mmoonntthh ooff iinnjjuurryy Analysis revealed that paediatric injuries were more likely to occur on certain days, as opposed to having an even spread of occurrence over the entire week (χ2 = 71.73, p <

© CONROD 2009 22

0.001). More injuries occurred on Sunday (376 cases), with 37% (743) of all injuries occurring on the weekend (Figure 9). Injuries were also more likely to occur during certain months of the year, as opposed to having an even spread over the entire year (χ2 = 23.69, p < 0.05), with the lowest number of injuries occurring in September (131) and the highest number of injuries occurring in October (196) (Figure 10).

0

5

10

15

20

Sun Mon Tues Wed Thurs Fri Sat

Day of injury

% o

f pat

ient

s

Figure 9: Day of injury occurrence (n = 2,038)

0

2

4

6

8

10

12

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Month of injury

% o

f pat

ient

s

Figure 10: Month of injury occurrence (n = 2,038)

IInnjjuurryy DDeessccrriippttiioonn BBooddyy llooccaattiioonn aanndd nnaattuurree ooff mmaaiinn iinnjjuurryy Of the 2,038 children included on the QTR in 2007, the most frequent body location of main injury was the upper extremity (41%). The most frequent nature of main injury was a fracture (57%). Of the 1,166 children who sustained a fracture, 61% (711) of these were fractures to the upper extremity, while 31% (365) were fractures to the lower extremity. Injuries to the head (237), face (116) and the pelvis/abdomen (89) were also commonly represented (Table 3).

© CONROD 2009 23

Table 3: Nature by body location of main injury (n = 2,038)

Nature of main injury

Body location of main injury

Head Face Neck Thorax Abdo Spine Upper Extremity

Lower Extremity External‡ Total

Fracture 49 27 - 4 - 10 711 365 - 1,166 Open wound/ superficial 11 44 4 5 17 - 37 73 2 193

Intracranial injury 177 - - - - - - - - 177 Injury nerve/vessel/ muscle/tendon - - - - - 2 73 45 - 120

Injury to internal organ - 2 4 26 71 - - - - 103

Burn/corrosion - - - - - - - - 95 95 Poisoning - - - - - - - - 40 40 Strain/dislocation - - - - - 15 4 9 - 28 Crush/amputation - - - - - - 16 7 - 23 Other† - 43 - 1 1 - 2 18 28 93 Total 237 116 8 36 89 27 843 517 165 2,038

† ‘Other’ includes eye injury, foreign body, drowning, asphyxia, electrical injury and effect of venom ‡ ‘External’ includes burns, inhalation injuries, electrical injuries, hanging, drowning, poisoning and envenomation injuries

Commentary

Injuries were coded using AIS 1990 which is divided into nine body regions: head, face, neck, thorax, abdomen and pelvic contents, spine, upper extremity, lower extremity and external (including burns and other trauma). Nature of main injury was coded using NDS-IS.

PPaattiieenntt SSttaattuuss TTrriiaaggee The Australasian Triage Scale is a five-point scale that categorises the urgency of treating a patient according to the following question: ‘This patient should wait for medical care no longer than..?’ The five-point scale consists of the following options: 1 – resuscitation (immediate), 2 – emergent (within 10 minutes), 3 – urgent (within 30 minutes), 4 – semi-urgent (within 60 minutes) and 5 – non-urgent (within 120 minutes). The triage score is recorded for patients who present through ED (that is, those who did not bypass ED). Of the 1,913 children for whom this information was recorded, most were classified as ‘urgent’ (52%) (Table 4).

Table 4: Triage categories for patients presenting through ED (n = 1,913) Triage category Number of patients (%) Resuscitation (immediate) 90 (5%) Emergent (within 10 min) 448 (23%) Urgent (within 30 min) 989 (52%) Semi-urgent (within 60 min) 374 (19%) Non-urgent (within 120 min) 12 (1%)

© CONROD 2009 24

TTRRIISSSS The Trauma and Injury Severity Score (TRISS) is used to quantify the probability of survival as related to severity of injury (range = 0-1; higher is better). It uses a combination of variables to calculate this probability:

• Anatomic: ISS and a correction for blunt/penetrating injury • Physiologic: Revised Trauma Score (RTS) – consisting of Glasgow Coma

Score (GCS), systolic blood pressure and respiratory rate, and • Demographic: Age (<55 or 55+ years).

These observations are taken when the patient arrives at the first Emergency Department – this will be the first referring hospital if a patient has been referred. Subjective assessment may be used in the calculation of TRISS if no observations are available for the components that comprise the RTS. These subjective assessments include judgements regarding extreme categories for GCS (only ‘alert’ or ‘unconscious’), systolic blood pressure (only ‘normal’ or ‘no cardiac input’), and respiratory rate (only ‘breathing normally’ or ‘apnoeic’), as they can generally be identified from chart review. There are some limitations to this imputation approach. In particular, the clinical condition may not require that all parameters for the TRISS calculation are recorded in the patient’s chart, or there may be insufficient detail in other cases to permit imputation, especially for cases where the patient’s condition falls between the extreme categories. Finally, the validity of the imputation method described here has not been formally validated. The most reliable TRISS analysis is therefore that based on the actual (observed) data. A TRISS was calculated for the 1,953 (96%) children who had complete data (including both actual and imputed data) on the characteristics used to calculate TRISS. For these 1,953 patients, scores ranged from 0.0566 to 0.9982, with a median TRISS of 0.9969. When imputed assessments were removed, there were 503 (25%) patients with a calculated TRISS. The range of scores for this group was 0.1307 to 0.9982, with a median TRISS of 0.9966 (Table 5).

Table 5: Summary of TRISS in different patient subgroups for all cases and only for cases with actual (not imputed) data used in the calculation

Patient Group All cases (including imputed data)

Only cases with actual data

All N 1,953 503 Median 0.9969 0.9966

Deaths N 9 3 Median 0.4275 0.7795

Survivors N 1,944 500 Median 0.9969 0.9966

Majors N 122 75 Median 0.9903 0.9747

Minors N 1,831 428 Median 0.9974 0.9903

When examining subgroups within the 1,953 children with complete data, those who died (Med = 0.4275, n = 9) had a lower TRISS than those who survived (Med = 0.9969, n = 1,944). Those who were classified as major injury cases (Med = 0.9903, n = 122) had a lower TRISS than minor injury cases (Med = 0.9974, n = 1,831). When examining these same subgroups restricted to the 503 children for whom actual data were used in the calculation of TRISS, those who died (Med = 0.7795, n = 3) had a lower TRISS than those who survived (Med = 0.9966 n = 500). Those who were classified as major injury cases (Med = 0.9747, n = 75) had a lower TRISS than minor injury cases (Med = 0.9903, n = 428) (Table 5).

© CONROD 2009 25

OOuuttccoommee MMeeaassuurreess LLeennggtthh ooff aaccuuttee hhoossppiittaall ssttaayy Length of acute hospital stay refers to the number of days a patient was admitted for the acute care of their injuries and, as such, may not reflect the entire length of stay at hospital. Length of acute hospital stay ranged from one to 337 days (Med = 2 days; IQR = 2 – 4 days) for the total cohort. Sixty percent (1,231) of children spent only one to two days under acute care (Figure 11).

10203040506070

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15+

Number of days

% o

f pat

ient

s

Figure 11: Length of acute hospital stay (n = 2,038)

A total of 93,957 bed days‡

was utilised by children admitted to QTR hospitals in 2007. Of these, 8,703 bed days (9%) were utilised for the hospitalisation and acute treatment of paediatric trauma patients included in this report. Of the 8,703 bed days utilised by this cohort, 16% (1,357) were used by major injury cases with 84% (7,346) used by minor injury cases.

Differences in length of acute hospital stay were noted between major and minor paediatric injury cases. For major cases of injury, length of acute hospital stay ranged from one to 66 days (Med = 5 days; IQR = 3 – 12 days), with a total of 1,357 acute bed days used. For minor injury cases, length of acute hospital stay ranged from one to 337 days (Med = 2 days; IQR = 2 – 3 days), with a total of 7,346 acute bed days used. The most common length of acute hospital stay category was one to two days for both minor and major injury cases (Figure 12).

10

20

30

40

50

60

70

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15+

Number of days

% o

f pat

ient

s

MajorMinor

Figure 12: Length of acute hospital stay for major and minor injury cases (n = 2,038)

‡ All data were obtained from the relevant Health Information Management service at each QTR hospital site – The number of bed days used in 2007 includes acute patients only and does not include patients who stay < 24 hours.

© CONROD 2009 26

2005 – 2007 The median length of acute hospital stay for children was two days in 2005, 2006 and 2007. For major injury cases, the median length of acute hospital stay was six days in 2005, seven days in 2006, and five days 2007.

IICCUU There were 152 paediatric cases (7.5%) admitted to ICU in 2007 (minor = 83, major = 69). A total of 345 bed days was utilised in ICU (minor = 137 days, major = 208 days). Overall, length of stay in ICU ranged from one to 21 days (Med = 1 day; IQR = 1 – 2 days), with 82% (125) of children admitted for one to two days only (Figure 13).

102030405060708090

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15+

Number of days

% o

f pat

ient

s

Figure 13: ICU length of stay (n = 152)

2005 – 2007 The median length of ICU stay was one day in 2005, 2006 and 2007. The percentage of children admitted to ICU was 7% (135) in 2005, 8% (153) in 2006, and 7.5% (152) in 2007.

OOppeerraattiioonnss Of the 2,038 paediatric patients included on the QTR in 2007, 72% (1,458) underwent at least one operation. There was a total of 2,027 procedures performed on these patients, with 67% (1,356) being to the extremities (Figure 14). In comparison, 34% (46) of major injury cases underwent 129 operations in total, with 60% (77) of these occurring externally (eg to the skin – skin grafts, burn repair/dressing etc) (Figure 15). See Appendix B for a complete list of operations collected by QTR.

1020304050607080

Extremities External Face Abdomen Head/Neck Spine Thorax

Body region

% o

f ope

ratio

ns

Figure 14: Percentage of operations performed by body region (n = 2,027)

© CONROD 2009 27

10

20

30

40

50

60

70

External Head/Neck Extremities Abdomen Face Thorax Spine

Body region

% o

f ope

ratio

ns

Figure 15: Percentage of operations performed by body region for major injury cases

(n = 129) MMoorrttaalliittyy There were 18 paediatric deaths (0.9% of cases) recorded as a result of injury. Males and females each accounted for 50% (9 cases each) of these deaths, with all 18 being major injury cases. Eight deaths occurred in the zero to four years age group, with five deaths each in the five to nine years and 10 to 14 years age groups. Overall, the mean age at death was 6 years (SD = 5.25). The death rate (the number of deaths per 100,000 injuries) was calculated for each age group. The group with the highest death rate was the zero to four years age group, with a rate of 1,507 deaths per 100,000 injuries (Figure 16).

0200400600800

1000120014001600

0-4 5-9 10-14

Age group

Dea

ths

per 1

00,0

00 in

jurie

s

Figure 16: Death rate by age group (n = 18)

TRISS can be used to identify the number of ‘unexpected deaths’ in any given time period, ‘where unexpected death’ in this report is defined as death of a patient with a calculated TRISS of 0.50 or above. This categorisation of unexpected deaths is consistent with previous uses of TRISS28. When considering the entire cohort, 1,948 (99.7%) of the 1,953 children with a calculated TRISS had a TRISS above 0.50, with an ‘unexpected death’ recorded for four cases. Five cases had a TRISS of less than 0.50, however, none of these cases were an ‘unexpected survival’. TRISS methodology is also used to calculate the Z-statistic, which is used to test whether the observed number of survivors in a specific trauma population is significantly different from the expected number of survivors based on baseline population data established by the Major Trauma Outcome Study (MTOS)28 (See Commentary). A positive Z-score is desirable, as it reflects more patients survived than predicted by TRISS. TRISS analysis revealed survival outcome to be more than

© CONROD 2009 28

predicted for the 1,953 patients with a calculated TRISS in 2007; Z-score = 1.34. This indicates that the number of survivors in the trauma population captured by QTR was more than expected based on the normative population established by the MTOS, however, this difference was not statistically significant.

Commentary

It should be noted that the normative population included in the MTOS was a cohort of trauma patients treated in the United States of America from 1982 to 1987. While corrections for some trauma characteristics (eg penetrating or blunt injury, age) are incorporated into this calculation, it still remains possible that different trauma characteristics account for a difference between the number of expected and observed survivors. Recent studies have identified the limited capacity of TRISS in predicting post-trauma survival29 and have reviewed the limitations and potential inappropriateness of using TRISS as a standard for trauma outcome prediction30. However, it has been deemed that no currently existing methods supersede TRISS as a tool for predicting outcomes following trauma30.

2005 – 2007 The percentage of in-hospital paediatric deaths was 0.9% in 2005, 2006 and 2007.

PPeerrffoorrmmaannccee IInnddiiccaattoorrss Ensuring the maintenance of the highest standards of care within the trauma system through quality assurance and improvement is a major priority. Performance indicators (or quality indicators) are designed to act as audit filters that:

• Can identify problems where a resolution may result in the improvement of patient care and outcomes

• Will identify any deviations from benchmarks of established standards, for which there is possibly a logical reason

• Are specific enough to accurately identify cases that are in need of review and efficient enough to justify the cost of the time required collecting such information.

Caution must be taken when interpreting these percentage deviations from the established benchmarks of trauma care, as they are often based on small numbers and not all performance indicators were relevant for each case. The potential causes of a deviation from established benchmarks are many, and include (but are not limited to) a logical clinical decision to alter care for an individual patient, limited resources, lack of supervision or education and refusal of treatment by the patient. The following performance indicator information refers only to major injury cases. One hundred and thirty-five paediatric cases met the criteria for major injury on the QTR in 2007. Please refer to Appendix D for a detailed explanation of each performance indicator. Both the number and percentage of cases flagged for the 17 performance indicators are presented in Figure 17.

© CONROD 2009 29

0

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60

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Performance Indicator

% fl

agge

d ca

ses

2225

8

2

3

26

1

2

5

142 1 2 1 5 3

Figure 17: Percentage of cases flagged (including raw numbers) for each of the 17 performance indicators (see text below for a list of the 17 performance indicators

denoted numerically in this figure) (n = 135 major injury cases)

1. Pre-hospital scene time greater than 20 minutes. Scene time was available for 74 of the 77 patients for whom pre-hospital care information was applicable. Scene time was greater than 20 minutes for 22 (30%) of these patients. Of these 22 patients, six (27%) were transported via helicopter. Although transport via helicopter can increase time at the injury scene, the patient arrives at hospital much sooner than if they travelled via road. There were seven patients who had a specified reason for the scene time delay, with the delay for the remaining patients being unknown or not applicable. Of the seven specified patients, the reasons for delay were:

• remote location (3), • multiple casualties (1), and • encapsulated within vehicle (1).

2. Total pre-hospital time greater than one hour. Total pre-hospital time was

available for 74 of the 77 patients who had a pre-hospital phase of care. Of these patients, 25 (34%) had a total pre-hospital time greater than one hour.

3. GCS less than nine with no endotracheal tube (ETT) within 10 minutes

(at any stage). Twenty-five patients had a GCS of less than nine recorded at any stage, with time of intubation known for 21. Eight (38%) of these patients were not intubated within the suggested time frame of 10 minutes.

4. Greater than 2000 mL of fluid administered without blood. Four patients

received greater than 2000 mL of fluid within the first 60 minutes of treatment, however, two patients (50%) did not receive blood with the fluid.

5. Retrieval team turnaround greater than 60 minutes. An interfacility

transfer/retrieval was recorded for 26 patients, with the arrival and departure time of the retrieval team recorded for only 12 patients. Arrival and departure time information was not applicable when an interfacility transfer occurred without a retrieval team and was not routinely available for retrievals performed by the RFDS. The retrieval team turnaround was greater than 60 minutes for three (25%) of these patients.

6. Referring hospital transfer greater than six hours. The time from arrival at

the referring facility to arrival at the receiving facility was available for 52 of the 70 patients who were referred from another hospital. The time taken to reach definitive care was greater than six hours for 26 (50%) of these patients.

© CONROD 2009 30

7. GCS less than 15 and no head CT within 24 hours. Of the 88 patients who had a GCS less than 15 recorded, whether or not a CT was performed was known for 87. Of these 87 patients, one (1%) did not receive a CT scan within 24 hours.

8. Urgent laparotomy greater than two hours after ED admission. An urgent

laparotomy was indicated and performed for two patients, with both receiving the procedure within two hours.

9. Urgent craniotomy greater than four hours after ED admission. An urgent

craniotomy was indicated and performed for 10 patients. Of these 10 patients, two (20%) did not receive the procedure within four hours.

10. Compound fracture surgery greater than six hours after ED admission.

Surgical intervention for compound fractures was performed for 12 patients, of whom five (42%) did not receive the procedure within six hours.

11. Hypothermia at any stage. Fourteen of the 120 patients (12%) for whom

temperature was known, suffered from hypothermia during their care. Of these 14 patients, seven had a body temperature less than 35°C on arrival at the ED of their definitive care hospital, while the remaining patients had a body temperature less than 35°C recorded at some other time during their episode of care.

12. Reintubation within 48 hours of extubation. Two of the 35 patients (6%)

who were intubated required reintubation within 48 hours of extubation.

13. Unplanned return to operating theatre (OT) within 48 hours. One of the 46 patients (2%) who had an operation returned to the OT within 48 hours.

14. Unplanned admission to ICU. Of the 69 admissions to ICU as a result of

major injury, information regarding whether the admission was planned or unplanned was know for 68. Of these 68 admissions to ICU, two (3%) were unplanned.

15. Missed injuries with an AIS score greater than two after 24 hours. Injuries

with an AIS score of greater than two were not diagnosed within the first 24 hours of admission for one of the 119 patients (1%) for whom this information was applicable.

16. Development of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE)

or decubitus ulcers during admission. Five (4%) of the 135 major injury cases developed a decubitus ulcer during admission.

17. Cervical spine injuries not cleared or diagnosed within 24 hours.

Information regarding the clearance/diagnosis of cervical spine injuries was known for 66 patients. Three of these 66 patients (5%) did not have their cervical spine injuries cleared/diagnosed within 24 hours.

Overall, there were three performance indicators in 2007 that were flagged in equal to or greater than 40% of cases:

• Greater than 2000 mL of fluid administered without blood • Referring hospital transfer greater than six hours • Compound fracture surgery greater than six hours after ED admission.

The administration of more than 2000 mL of fluid within the first hour in the ED may occur when blood is not available rapidly, when a clinical decision is made that the patient’s haemoglobin level is sufficient to withstand further crystalloid or colloid infusions or when there is lack of recognition of the importance of haemoglobin for oxygen carrying capacity.

© CONROD 2009 31

Referring hospital transfer exceeding six hours might be caused by a variety of reasons, including a lack of transfer vehicles, aircraft or personnel to meet current requirements, inappropriate weather or light conditions, a clinical decision to monitor the patient for a period of time prior to confirming the need to transfer or a lack of recognition of the need for timely transfer. Causes of delay in repairing compound fractures include other aspects of care taking precedence, OT space or personnel not available, multiple or unnecessary diagnostic evaluations being undertaken, insufficient ED personnel available to initiate the process of consultation for surgery or staff with inadequate training to recognise the urgency of the need for surgery. 2005 – 2007 Over the three years from 2005 to 2007, one performance indicator was commonly flagged (equal to or greater than 40% in each year) (Figure 18): ‘Referring hospital transfer greater than six hours’.

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17


% fl

agge

d ca

ses

200520062007

Figure 18: Trends in the flagging of 17 performance indicators from 2005 to 2007 (see

text above for a list of the 17 performance indicators denoted numerically in this figure) (n(2005) = 120, n(2006) = 142, n(2007) = 135)

Overall, seven performance indicators were consistently flagged at or below 10% over the three-year period:

• GCS less than 15 and no head CT within 24 hours • Reintubation within 48 hours of extubation • Unplanned return to OT within 48 hours • Unplanned admission to ICU • Missed injuries with an AIS score greater than two after 24 hours • Development of DVT, PE or decubitus ulcers during admission • Cervical spine injuries not cleared or diagnosed within 24 hours.

Commentary

One of the strengths of the QTR is its capacity to identify measures of deviation from established benchmarks of trauma care. Deviations from these benchmarks can occur at any stage during the patient’s care (during pre-hospital care or at either the transferring or definitive care hospital) and are not a representation of any individual hospital’s ability to meet these benchmarks, but rather a reflection of the effectiveness of the trauma system. Overall, this information is recorded on the QTR at the hospital providing definitive care.

© CONROD 2009 32

SSUUMMMMAARRYY OOFF TTRRAAUUMMAA TTRREEAATTEEDD AATT PPAAEEDDIIAATTRRIICC SSPPEECCIIAALLTTYY HHOOSSPPIITTAALLSS

The two Paediatric Specialty Hospitals in Brisbane, the Royal Children’s Hospital and the Mater Children’s Hospital, provide care for children either directly admitted or transferred from other hospitals throughout the state of Queensland. Injured children transferred for definitive care to the Royal Children’s or Mater Children’s Hospitals appear on the Registry only at these hospitals. This section provides information on all trauma patients aged from zero to 14 years admitted to either of the two Paediatric Specialty Hospitals from January to December 2007. While children over the age of 14 years may have been treated at these two hospitals, they are not included in this report. Eight hundred and nine injured children admitted to one of these two hospitals in 2007 met the inclusion criteria and were eligible for entry on the QTR. In comparison, the number of eligible paediatric cases was 621 in 2005 and 680 in 2006.

MMaajjoorr // MMiinnoorr CCllaassssiiffiiccaattiioonn Of the 809 children included on the QTR at Paediatric Specialty Hospitals in 2007:

• 90% (728) were classified as minor injury cases (ISS <16 and deaths from poisoning), and

• 10% (81) were classified as major injury cases (ISS ≥ 16 or died in ED or died during hospitalisation).

For the total cohort, the median ISS was five (IQR = 1 – 9). 2005 – 2007 The percentage of major injury cases treated at Paediatric Specialty Hospitals was 12% (72) in 2005, 14% (97) in 2006, and 10% (81) in 2007. For the total cohort, median ISS was four in 2005, and five in 2006 and 2007.

DDeemmooggrraapphhiicc CChhaarraacctteerriissttiiccss AAggee aanndd sseexx ooff iinnjjuurryy ccaasseess Males accounted for 62% (501) of all injury cases, with the 10 to 14 years age group recording the highest number of injuries (211 cases) (Figure 19). For females, the highest number of injury cases was recorded for the five to nine years age group (115 cases). All age groups had a higher percentage of males compared to females (Figure 20). Overall, the average age at injury was 7.7 years (SD = 4.41) for males and 6.6 years (SD = 4.18) for females. Differences in proportions of children in each age group were noted between those admitted to the Paediatric Specialty Hospitals as a result of injury, and those of the total population of Queensland and the Brisbane Statistical Division. The Brisbane Statistical Division covers an area of 5904.8 square kilometres and incorporates the majority of postcodes within the range of 4000 to 4521. Of the 809 cases aged zero to 14 years treated for injury at Paediatric Specialty Hospitals, 37% (298) were aged from 10 to 14 years; this was higher than the proportion of children in this age range across the state of Queensland (35%)21 and across the Brisbane Statistical Division (34%)31. Children aged five to nine years accounted for 33% (264) of the injured population, which was the same as the

© CONROD 2009 33

proportion of children in this age range across the state of Queensland21 and across the Brisbane Statistical Division31. Those aged zero to four years accounted for 30% (247), which was lower than the proportion of children in this age range across the state of Queensland (32%)21 and across the Brisbane Statistical Division (33%)31.

0

50

100

150

200

250

0-4 5-9 10-14

Age group

Num

ber o

f pat

ient

s MaleFemale

Figure 19: Age and sex distribution for injury cases – Paediatric Specialty Hospitals

(n = 809)

0%

20%

40%

60%

80%

100%

0-4 5-9 10-14

Age group

% o

f pat

ient

s fo

r eac

h se

x

FemaleMale

Figure 20: Percentage of males and females within each age group – Paediatric Specialty

Hospitals (n = 809)

Commentary

As in the previous section (all paediatric cases in Queensland), the finding that 62% of injuries occurred in males is consistent with previous literature20 where males accounted for more admissions to hospital because of injury than females.

PPllaaccee ooff rreessiiddeennccee Queensland postcodes of usual residence for children treated in 2007 ranged from 4001 to 4871. Seventy-six percent (612) of children admitted to Paediatric Specialty Hospitals resided within the Brisbane Statistical Division. Overall, 96% (776) of children resided within Queensland, with 4% (32) of cases residing interstate, and one case being an overseas visitor. Of the 32 interstate children, 30 were from New South Wales.

© CONROD 2009 34

AAbboorriiggiinnaall aanndd TToorrrreess SSttrraaiitt IIssllaannddeerr PPeeooppllee Of the 809 children admitted to Paediatric Specialty Hospitals in 2007, 3.6% (29) identified themselves as being of Aboriginal and Torres Strait Islander origin. This was lower than the proportion of people of Aboriginal and Torres Strait Islander origin in this age range across the state of Queensland (6.8%)21 but more than the proportion across the Brisbane Statistical Division (3.3%)31. There were 27 children recorded as being of Aboriginal origin.

RReeffeerrrraall PPaatttteerrnnss Of the 809 patients admitted to the Royal Children’s and Mater Children’s Hospitals for the treatment of injury in 2007, 42% (341) were referred from another hospital, confirming the role of these hospitals as paediatric specialty hospitals for serious injury. Of these 341 patients, the leading cause of injury was falls (30%), followed by RTCs (25%) and burns/scalds (11%). Minor injury cases accounted for 84.5% (288) of the 341 patients who were referred, while major injury cases accounted for 15.5% (52) of referred cases. The largest number of patients was referred from Logan Hospital (51) (Table 6). Table 6: Referring hospital name for patients transferred to Paediatric Specialty Hospitals

for definitive care (n = 341) Referring Hospital No. of patients Logan Hospital 51 Redland Hospital 28 Caboolture Hospital 18 Nambour Hospital 18 Gold Coast Hospital 15 Toowoomba Hospital 13 Bundaberg Base Hospital 12 Redcliffe Hospital 12 Tweed Heads District Hospital 12 Queen Elizabeth II Jubilee Hospital 11 Ipswich Hospital 10 Rockhampton Base Hospital 10 Wynnum Hospital 9 Hervey Bay Hospital 7 Beaudesert Hospital 6 The Prince Charles Hospital 6 Dalby Hospital 5 Gladstone Hospital 5 Kingaroy Hospital & Community Health Centre 5 Lismore Base Hospital 5 Mater Children's Hospital 5 Princess Alexandra Hospital 5 Grafton Base Hospital 4 Holy Spirit Northside Hospital 4 Cherbourg Hospital 3 Emerald Hospital 3 Greenslopes Private Hospital 3 Gympie Hospital 3 Roma Hospital 3 Royal Brisbane & Women's Hospital 3 Wesley Private Hospital 3 Ballina Hospital 2 Biloela Hospital 2 Laidley Hospital 2

© CONROD 2009 35

Table 6 (cont.): Referring hospital name for patients transferred to Paediatric Specialty Hospitals for definitive care (n = 341)

Referring Hospital No. of patients Longreach Hospital 2 Maryborough Hospital 2 Murwillumbah District Hospital 2 Noosa Mayne Health Private Hospital 2 St Andrew’s Private Hospital, Brisbane 2 St George Hospital 2 St Vincent's Private Hospital, Toowoomba 2 Stanthorpe Hospital 2 Texas Hospital 2 Aramac Hospital 1 Baralaba Hospital 1 Barcaldine Hospital 1 Blackall Hospital 1 Cairns Base Hospital 1 Dirranbandi Hospital 1 Mackay Base Hospital 1 Mater Private Hospital 1 McLean Hospital 1 Mount Isa Base Hospital 1 Moura Hospital 1 Mungindi Hospital 1 Quilpie Hospital 1 Royal Children's Hospital 1 Tara Hospital 1 Warwick Hospital 1 Other 4

IInnjjuurryy EEvveenntt CChhaarraacctteerriissttiiccss EExxtteerrnnaall ccaauussee ooff iinnjjuurryy The external cause of injury was specified for 798 cases. Falls were the most common cause of injury (338 cases), with 56% (189) suffering a fall of less than one metre. The percentage of total injuries for each sex accounted for by falls was higher for females (47%) than males (40%) (Figure 21).

0 10 20 30 40 50


AnimalCutting

BurnsCollision

RTCFall

Exte

rnal

cau

se

% of patients

FemaleMale

Figure 21: External cause of injury by sex for all cases – Paediatric Specialty Hospitals

(n = 798)* * Those categories with n ≤ 5 were not included in this figure: ‘Threat to breathing’, ‘Firearm’ and ‘Drowning’.

© CONROD 2009 36

Commentary

‘The Health Outcomes Plan: Injury Prevention and Control 2000 – 2004’ outlines the scope of the problem of falls in children and adolescents and presents prevention strategies, specific trauma management and rehabilitation strategies for falls in this group9. Establishing the burden of falls in children is necessary in order to improve the wellbeing of the paediatric population, however the need to implement these approaches to reduce the incidence of falls in younger people is also apparent.

Road traffic crashes (RTCs) were the second most common cause of injury (172 cases), with 70% (121) of these patients being male. The RTC category included cyclists (65), motor vehicle (MV) passengers (38), pedestrians (28), motorbike (MB) riders (22), MB passengers (4), and other modes of transport (15) (Figure 22). In addition to falls and RTCs, collision with an object or a person accounted for a further 9% (73) of all injuries. These three external causes accounted for almost three-quarters of all injury admissions recorded on the QTR at Paediatric Specialty Hospitals for 2007. The remaining injuries were the result of other external causes.

0 10 20 30 40

Other transport

MV driver

MB passenger

MB rider

Pedestrian

MV passenger

Cyclist

RTC

cat

egor

y

% of patients

Figure 22: Percentage of patients for each type of RTC – Paediatric Specialty Hospitals (n = 172)

External cause of injury varied according to age. Burns, poisonings, animal-related and machinery-related injuries were most commonly recorded in the zero to four years age group. Falls were most common in those aged five to nine years with RTCs, collisions with an object or a person and cutting injuries most commonly recorded for those aged from 10 to 14 years (Table 7).

Table 7: External cause of injury by age group – Paediatric Specialty Hospitals (n = 798)*

Age group Fall RTC Collision Burns Cutting Animal Poisoning Machinery Other

0-4 99 16 23 38 6 13 13 5 20 5-9 124 63 22 5 15 12 4 4 13

10-14 115 93 28 11 17 12 2 4 12 Total 338 172 73 54 38 37 19 13 45

* Those categories with n ≤ 5 were not included in this table: ‘Threat to breathing’, ‘Firearm’ and ‘Drowning’. Differences were noted between major and minor injury cases for external cause of injury. The most common external causes for minor injury were falls (43% of all minor cases), followed by RTCs (19%) and collision with an object or a person (9%). For major cases, the most common external causes of injury were RTCs (42% of all major cases), followed by falls (33%), and collision with an object or a person (12%) (Figure 23).

© CONROD 2009 37

0 10 20 30 40 50


AnimalCutting

BurnsCollision

FallRTC

Exte

rnal

cau

se

% of patients

MajorMinor

Figure 23: External cause of injury for major and minor cases – Paediatric Specialty

Hospitals (n = 798) * * Those categories with n ≤ 5 were not included in this figure: ‘Threat to breathing’, ‘Firearm’ and ‘Drowning’. PPllaaccee ooff iinnjjuurryy The place where injury occurred was specified for 627 cases. In line with the number of injuries caused by falls and RTCs, 51% (317) of children were injured in the home and 14% (88) were injured on a street or highway. In addition, 12% (78) were injured at a school, 9% (56) were injured in a sports area, and 3% (21) were injured in a trade/service area. The remaining cases were injured elsewhere (Figure 24).

0 10 20 30 40 50 60

Other specified

Farm

Trade/service area

Sports area

School

Street/highway

Home

Plac

e of

inju

ry

% of patients

Figure 24: Place of injury occurrence – Paediatric Specialty Hospitals (n = 627)* * Those categories with n ≤ 5 were not included in this figure: ‘Residential institution’ and ‘Industrial area’.

The place of injury was similar over the age groups, with the most common place of injury being the home for all three age groups. This was followed by schools and streets/highways for the zero to four years and the five to nine years age groups, and streets/highways and sports areas for the 10 to 14 years age group (Table 8).

Table 8: Place of injury by age group – Paediatric Specialty Hospitals (n = 627)*

Age group Home Street/ highway School Sports

area Trade/

service area Farm Other

0-4 165 10 11 1 10 2 5 5-9 85 31 36 11 10 4 23

10-14 67 47 31 44 1 3 25 Total 317 88 78 56 21 9 53

* Those categories with n ≤ 5 were not included in this figure: ‘Residential institution’ and ‘Industrial area’.

© CONROD 2009 38

For both major and minor injury cases, the most common place of injury was the home (55% and 50% respectively), with the second most common place of injury being a street or highway for major cases (25%) and a school for minor cases (14%). IInntteenntt ooff iinnjjuurryy The majority of injuries, 98% (794), were coded as accidental, with 1% (6) coded as assault and 0.5% (3) coded as intentional self-harm. The intent was not determined for six cases. AAccttiivviittyy wwhheenn iinnjjuurreedd The type of activity engaged in when injured was specified for 423 cases. Forty-seven percent (198) were engaged in a sports/leisure activity and 6% (26) were engaged in a personal activity (eg eating, sleeping, personal hygiene) (Figure 25). The remaining patients were injured while engaged in other types of activities.

0 10 20 30 40 50

Other specified activity

Working for income

Other types of work

Personal activity

Sports/Leisure activity

Act

ivity

whe

n in

jure

d

% of patients

Figure 25: Activity engaged in when injured – Paediatric Specialty Hospitals (n = 423)

Commentary

According to ICD-10-AM coding guidelines, when external cause of injury is specified as a ‘Transport Accident’ and where the activity at the time of injury is not specified as sport, leisure or working for income, activity is assigned as ‘Unspecified Activity’. In most other cases, if the activity at the time of injury does not fit into sport, leisure or working for income, and ‘Other’ activity cannot be assigned, these too fall into the ‘Unspecified Activity’ category.

DDaayy aanndd mmoonntthh ooff iinnjjuurryy Analysis revealed that injuries were more likely to occur on certain days, as opposed to having an even spread of occurrence over the entire week (χ2 = 28.69, p < 0.001). More injuries occurred on Sunday (150 cases), with 36% (293) of all injuries occurring on the weekend (Figure 26). Injury occurrence was reasonably uniform over the 12 months of the year, with the lowest number of injuries occurring in September (52) and the highest number of injuries occurring in October (83) (Figure 27).

© CONROD 2009 39

0

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Sun Mon Tues Wed Thurs Fri Sat

Day of injury

% o

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ient

s

Figure 26: Day of injury occurrence – Paediatric Specialty Hospitals (n = 809)

0

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12

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Month of injury

% o

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s

Figure 27: Month of injury occurrence – Paediatric Specialty Hospitals (n = 809)

IInnjjuurryy DDeessccrriippttiioonn BBooddyy llooccaattiioonn aanndd nnaattuurree ooff mmaaiinn iinnjjuurryy Of the 809 children admitted to Paediatric Specialty Hospitals in 2007, the most frequent body location of main injury was the upper extremity (33%). The most frequent nature of main injury was a fracture (46%). Of the 373 children who sustained a fracture, 57% (213) of these were fractures to the upper extremity while 31% (115) were fractures to the lower extremity. Injuries to the head (127), face (80) and pelvis/abdomen (43) were also commonly represented (Table 9).

Commentary

Injuries were coded using AIS 1990 which is divided into nine body regions: head, face, neck, thorax, abdomen and pelvic contents, spine, upper extremity, lower extremity and external (including burns and other trauma). Nature of main injury was coded using NDS-IS.

© CONROD 2009 40

Table 9: Nature by body location of main injury – Paediatric Specialty Hospitals (n = 809)

Nature of main injury

Body location of main injury

Head Face Neck Thorax Abdo Spine Upper Extremity

Lower Extremity External‡ Total

Fracture 22 19 - - - 4 213 115 - 373 Intracranial injury 103 - - - - - - - - 103 Open wound/ superficial 2 27 2 3 8 - 19 24 2 87

Burn/corrosion - - - - - - - - 56 56 Injury to internal organ - 1 3 14 34 - - - - 52

Injury nerve/vessel/ muscle/tendon - - - - - - 24 19 - 43

Strain/dislocation - - - - - 11 - 4 - 15 Poisoning - - - - - - - - 14 14 Crush/amputation - - - - - - 12 1 - 13 Other† - 33 - 1 1 - - 10 8 53 Total 127 80 5 18 43 15 268 173 80 809

† ‘Other’ includes eye injury, foreign body, drowning, asphyxia, electrical injury and effect of venom ‡ ‘External’ includes burns, inhalation injuries, electrical injuries, hanging, drowning, poisoning and envenomation injuries

PPaattiieenntt SSttaattuuss TTrriiaaggee The Australasian Triage Scale is a five-point scale that categorises the urgency of treating a patient according to the following question: ‘This patient should wait for medical care no longer than..?’ The five-point scale consists of the following options: 1 – resuscitation (immediate), 2 – emergent (within 10 minutes), 3 – urgent (within 30 minutes), 4 – semi-urgent (within 60 minutes) and 5 – non-urgent (within 120 minutes). The triage score is recorded for patients who present through ED (that is, those who did not bypass ED). Of the 739 patients for whom this information was recorded, most were classified as ‘urgent’ (43%) (Table 10).

Table 10: Triage categories for patients presenting through ED – Paediatric Specialty Hospitals (n = 739)

Triage category Number of patients (%) Resuscitation (immediate) 41 (6%) Emergent (within 10 min) 251 (34%) Urgent (within 30 min) 320 (43%) Semi-urgent (within 60 min) 122 (16%) Non-urgent (within 120 min) 5 (1%)

TTRRIISSSS The Trauma and Injury Severity Score (TRISS) is used to quantify the probability of survival as related to severity of injury (range = 0-1; higher is better). It uses a combination of variables to calculate this probability:

• Anatomic: ISS and a correction for blunt/penetrating injury • Physiologic: Revised Trauma Score (RTS) – consisting of Glasgow Coma

Score (GCS), systolic blood pressure and respiratory rate, and • Demographic: Age (<55 or 55+ years).

These observations are taken when the patient arrives at the first Emergency Department – this will be the first referring hospital if a patient has been referred. Subjective assessment may be used in the calculation of TRISS if no observations are available for the components that comprise the RTS. These subjective assessments

© CONROD 2009 41

include judgements regarding extreme categories for GCS (only ‘alert’ or ‘unconscious’), systolic blood pressure (only ‘normal’ or ‘no cardiac input’), and respiratory rate (only ‘breathing normally’ or ‘apnoeic’), as they can generally be identified from chart review. There are some limitations to this imputation approach. In particular, the clinical condition may not require that all parameters for the TRISS calculation are recorded in the patient’s chart, or there may be insufficient detail in other cases to permit imputation, especially for cases where the patient’s condition falls between the extreme categories. Finally, the validity of the imputation method described here has not been formally validated. The most reliable TRISS analysis is therefore that based on the actual (observed) data. A TRISS was calculated for the 778 (96%) children who had complete data (including both actual and imputed data) on the characteristics used to calculate TRISS. For these 778 patients, scores ranged from 0.4275 to 0.9982, with a median TRISS of 0.9969. When imputed assessments were removed, there were 156 (19%) patients with a calculated TRISS. The range of scores for this group was 0.7163 to 0.9982, with a median TRISS of 0.9963 (Table 11).

Table 11: Summary of TRISS in different patient subgroups for all cases and only for cases with actual (not imputed) data used in the calculation – Paediatric Specialty

Hospitals

Patient Group All cases (including imputed data)

Only cases with actual data

All N 778 156 Median 0.9969 0.9963

Deaths N 2 - Median 0.6358 -

Survivors N 776 156 Median 0.9969 0.9963

Majors N 76 41 Median 0.9872 0.9866

Minors N 702 115 Median 0.9976 0.9966

When examining subgroups within the 778 children with complete data, those who died (Med = 0.6358, n = 2) had a lower TRISS than those who survived (Med = 0.9969, n = 776). Those who were classified as major injury cases (Med = 0.9872, n = 76) had a lower TRISS than minor injury cases (Med = 0.9976, n = 702). When examining these same subgroups restricted to the 156 children for whom actual data were used in the calculation of TRISS, those who were classified as major injury cases (Med = 0.9866, n = 41) had a lower TRISS than minor injury cases (Med = 0.9966, n = 115). Actual data was not available for the two patients who died, therefore no comparison can be made to those who survived (Table 11). OOuuttccoommee MMeeaassuurreess LLeennggtthh ooff aaccuuttee hhoossppiittaall ssttaayy Length of acute hospital stay refers to the number of days a patient was admitted for the acute care of their injuries and, as such, may not reflect the entire length of stay at hospital. Length of acute hospital stay ranged from one to 337 days (Med = 2 days; IQR = 2 – 4 days) for the total cohort. Fifty-six percent (454) of children spent only one to two days under acute care (Figure 28).

© CONROD 2009 42

10

20

30

40

50

60

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15+

Number of days

% o

f pat

ient

s

Figure 28: Length of acute hospital stay – Paediatric Specialty Hospitals (n = 809)

A total of 48,837 bed days‡

was utilised by all patients admitted to Paediatric Specialty Hospitals in 2007. Of these, 4,044 bed days (8%) were utilised for the hospitalisation and acute treatment of trauma patients included in this report. Of the 4,044 bed days utilised by this cohort, 25% (1,016) were used by major injury cases with 75% (3,028) used by minor injury cases.

Commentary

Injured children accounted for 8% of the total occupied bed days at the Royal Children’s and Mater Children’s Hospitals in 2007. Hospitalisation of injured patients represents a high cost, with one estimate of the cost of hospitalisation and treatment of injured patients in the hospital sector throughout Australia being $4 billion dollars per year1.

Differences in length of acute hospital stay were noted between major and minor injury cases. For major cases of injury, length of acute hospital stay ranged from one to 66 days (Med = 7 days; IQR = 3 – 16.5 days). For minor injury cases, length of acute hospital stay ranged from one to 337 days (Med = 2 days; IQR = 2 – 4 days). The most common length of acute hospital stay category was 15 days or more for major injury cases and one to two days for minor injury cases (Figure 29).

10

20

30

40

50

60

70

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15+

Number of days

% o

f pat

ient

s

MajorMinor

Figure 29: Length of acute hospital stay for major and minor injury cases – Paediatric

Specialty Hospitals (n = 809)

‡ All data were obtained from the relevant Health Information Management service at the Royal Children’s Hospital and Mater Children’s Hospital – The number of bed days used in 2007 includes acute patients only and does not include patients who stay < 24 hours.

© CONROD 2009 43

2005 – 2007 The median length of acute hospital stay was two days in 2005, three days in 2006, and two days in 2007. For major injury cases, the median length of acute hospital stay was six days in 2005, and seven days in 2006 and 2007. IICCUU There were 110 cases (14%) admitted to ICU in 2007 (minor = 57, major = 53). A total of 235 bed days was utilised in ICU (minor = 82 days, major = 153 days). Overall, length of stay in ICU ranged from one to 20 days (Med = 1 day; IQR = 1 – 2 days), with 93 children (85%) admitted for one to two days (Figure 30).

20

40

60

80

100

1-2 3-4 5-6 7-8 9-10 11-12 13-14 15+

Number of days

% o

f pat

ient

s

Figure 30: ICU length of stay – Paediatric Specialty Hospitals (n = 110)

2005 – 2007 The median length of ICU stay was one day in 2005, 2006 and 2007. The percentage of children admitted to ICU was 15% (95) in 2005, 16% (107) in 2006, and 14% (110) in 2007. OOppeerraattiioonnss Of the 809 injured children admitted to Paediatric Specialty Hospitals in 2007, 67% (545) underwent at least one operation. There were a total of 846 procedures performed on these patients, with 48% (402) being to the extremities (Figure 31). In comparison, 37% (30) of major injury cases underwent 101 operations in total, with 68% (69) of these occurring externally (eg to the skin – skin grafts, burn repair/dressing etc.) (Figure 32). See Appendix B for a complete list of operations collected by QTR.

© CONROD 2009 44

5101520253035404550

Extremities External Face Abdomen Head/Neck Spine

Body region

% o

f pat

ient

s

Figure 31: Percentage of operations performed by body region – Paediatric Specialty

Hospitals (n = 846)

1020304050607080

External Head/Neck Extremities Abdomen Face Spine

Body region

% o

f pat

ient

s

Figure 32: Percentage of operations performed by body region for major injury cases –

Paediatric Specialty Hospitals (n = 101)

MMoorrttaalliittyy There were four deaths (0.5% of cases) recorded as a result of injury. Females accounted for 75% (3) of these deaths, with all four patients being major injury cases. There were two deaths in each of the zero to four years and five to nine years age groups. Overall, the mean age at death was 4 years (SD = 4.35). The death rate (the number of deaths per 100,000 injuries) was calculated for each age group. The group with the highest death rate was the zero to four years age group, with a rate of 810 deaths per 100,000 injuries (Figure 33).

0100200300400500600700800900

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Figure 33: Death rate by age group – Paediatric Specialty Hospitals (n = 4)

© CONROD 2009 45

TRISS can be used to identify the number of ‘unexpected deaths’ in any given time period, ‘where unexpected death’ in this report is defined as death of a patient with a calculated TRISS of 0.50 or above. This categorisation of unexpected deaths is consistent with previous uses of TRISS28. When considering the entire cohort, 777 (99.9%) of the 778 children with a calculated TRISS had a TRISS above 0.50, with an ‘unexpected death’ recorded for one case. One case had a TRISS of less than 0.50, however, this case was not an ‘unexpected survival’. TRISS methodology is also used to calculate the Z-statistic, which is used to test whether the observed number of survivors in a specific trauma population is significantly different from the expected number of survivors based on baseline population data established by the Major Trauma Outcome Study (MTOS)28 (See Commentary). A positive Z-score is desirable, as it reflects more patients survived than predicted by TRISS. TRISS analysis revealed survival outcome to be more than predicted for the 778 patients with a calculated TRISS in 2007; Z-score = 1.52. This indicates that the number of survivors in the trauma population captured by QTR at Paediatric Specialty Hospitals was more than expected based on the normative population established by the MTOS, however, this difference was not statistically significant.

Commentary

It should be noted that the normative population included in the MTOS was a cohort of trauma patients treated in the United States of America from 1982 to 1987. While corrections for some trauma characteristics (eg penetrating or blunt injury, age) are incorporated into this calculation, it still remains possible that different trauma characteristics account for a difference between the number of expected and observed survivors. Recent studies have identified the limited capacity of TRISS in predicting post-trauma survival29 and have reviewed the limitations and potential inappropriateness of using TRISS as a standard for trauma outcome prediction30. However, it has been deemed that no currently existing methods supersede TRISS as a tool for predicting outcomes following trauma30.

2005 – 2007 The percentage of in-hospital deaths was 1.3% in 2005, 1.2% in 2006 and 0.5% in 2007.

CCoommpplliiccaattiioonnss Information regarding the development of complications is recorded on the QTR database for major injury cases only. Of the 81 major injury cases admitted to Paediatric Specialty Hospitals in 2007, 54 (67%) experienced one or more complications (Note: A single case can have more than one type of complication and can have more than one complication within any given category). Six (11%) were identified as having one or more musculoskeletal/integumentary complications (Table 12).

© CONROD 2009 46

Table 12: Complications identified for major injury cases – Paediatric Specialty Hospital (n = 54)

Complication category No. cases with 1 or more complications Most common complications

Musculoskeletal/ Integumentary 6 Decubitus Ulcer (5 cases)

Other Musculoskeletal (1 case)

Cardiological 4 Shock; other (3 cases) Cardiac Arrest (1 case)

Neurological 4 Seizure in Hospital (2 cases) Diabetes Insipidus (1 case) Stroke / CVA (1 case) Other Neurological (1 case)

Pulmonary 4 Aspiration Pneumonia (2 cases) Pulmonary Oedema (1 case) Upper Airway Obstruction (1 case)

Infection 3 Cellulitis / Traumatic Injury (1 case) Line infection (1 case) Septicaemia (1 case)

Renal/Genitourinary 2 Urinary Tract Infection (2 cases) Abdominal 1 Ileus – persistent (1 case) Haematological 1 Coagulopathy (1 case) Incomplete hospital record 42

PPeerrffoorrmmaannccee IInnddiiccaattoorrss Ensuring the maintenance of the highest standards of care within the trauma system through quality assurance and improvement is a major priority. Performance indicators (or quality indicators) are designed to act as audit filters that:

• Can identify problems where a resolution may result in the improvement of patient care and outcomes

• Will identify any deviations from benchmarks of established standards, for which there is possibly a logical reason

• Are specific enough to accurately identify cases that are in need of review and efficient enough to justify the cost of the time required collecting such information.

Caution must be taken when interpreting these percentage deviations from the established benchmarks of trauma care, as they are often based on small numbers and not all performance indicators were relevant for each case. The potential causes of a deviation from established benchmarks are many, and include (but are not limited to) a logical clinical decision to alter care for an individual patient, limited resources, lack of supervision or education and refusal of treatment by the patient. The following performance indicator information refers only to major injury cases. Eighty-one cases met the criteria for major injury on the QTR at Paediatric Specialty Hospitals in 2007. Please refer to Appendix D for a detailed explanation of each performance indicator. Both the number and percentage of cases flagged for the 17 performance indicators are presented in Figure 34.

© CONROD 2009 47

0

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Figure 34: Percentage of cases flagged (including raw numbers) for each of the 17 performance indicators – Paediatric Specialty Hospitals (see text below for a list of the 17

performance indicators denoted numerically in this figure) (n = 81 major injury cases)

1. Pre-hospital scene time greater than 20 minutes. Scene time was available for 37 of the 40 patients for whom pre-hospital care information was applicable. Scene time was greater than 20 minutes for seven (19%) of these patients. Of these seven patients, two were transported via helicopter. Although transport via helicopter can increase time at the injury scene, the patient arrives at hospital much sooner than if they travelled via road.

2. Total pre-hospital time greater than one hour. Total pre-hospital time was

available for 37 of the 40 patients who had a pre-hospital phase of care. Of these patients, 13 (35%) had a total pre-hospital time greater than one hour.

3. GCS less than nine with no endotracheal tube (ETT) within 10 minutes

(at any stage). Sixteen patients had a GCS of less than nine recorded at any stage, with time of intubation known for 12. Six (50%) of these patients were not intubated within the suggested time frame of 10 minutes.

4. Greater than 2000 mL of fluid administered without blood. Three patients

received greater than 2000 mL of fluid within the first 60 minutes of treatment, however, two patients (67%) did not receive blood with the fluid.

5. Retrieval team turnaround greater than 60 minutes. An interfacility

transfer/retrieval was recorded for 15 patients, with the arrival and departure time of the retrieval team recorded for only five patients. Arrival and departure time information was not applicable when an interfacility transfer occurred without a retrieval team and was not routinely available for retrievals performed by the RFDS. The retrieval team turnaround was greater than 60 minutes for two (40%) of these patients.

6. Referring hospital transfer greater than six hours. The time from arrival at

the referring facility to arrival at the receiving facility was available for 35 of the 52 patients who were referred from another hospital. The time taken to reach definitive care was greater than six hours for 20 (57%) of these patients.

7. GCS less than 15 and no head CT within 24 hours. All of the 57 patients

who had a GCS less than 15 recorded received a CT scan within 24 hours.

8. Urgent laparotomy greater than two hours after ED admission. There were no patients for whom an urgent laparotomy was indicated and performed at Paediatric Specialty Hospitals in 2007.

9. Urgent craniotomy greater than four hours after ED admission. An urgent

craniotomy was indicated and performed for eight patients, with one (13%) of these patients not receiving the procedure within two hours.

© CONROD 2009 48

10. Compound fracture surgery greater than six hours after ED admission. Surgical intervention for compound fractures was performed for four patients, of whom three (75%) did not receive the procedure within six hours.

11. Hypothermia at any stage. Nine of the 72 patients (13%) for whom

temperature was known, suffered from hypothermia during their care. Of these nine patients, four had a body temperature less than 35°C on arrival at the ED of their definitive care hospital, while the remaining patients had a body temperature less than 35°C recorded at some other time during their episode of care.

12. Reintubation within 48 hours of extubation. One of the 25 patients (4%)

who were intubated required reintubation within 48 hours of extubation.

13. Unplanned return to operating theatre (OT) within 48 hours. None of the 30 patients who had an operation returned to the OT within 48 hours.

14. Unplanned admission to ICU. Of the 53 admissions to ICU as a result of

major injury, two (4%) were unplanned.

15. Missed injuries with an AIS score greater than two after 24 hours. Injuries with an AIS score of greater than two were diagnosed within the first 24 hours of admission for all 77 patients for whom this information was applicable.

16. Development of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE)

or decubitus ulcers during admission. Five (6%) of the 81 major injury cases developed a decubitus ulcer during admission.

17. Cervical spine injuries not cleared or diagnosed within 24 hours.

Information regarding the clearance/diagnosis of cervical spine injuries was known for 36 patients. Two of these 36 patients (6%) did not have their cervical spine injuries cleared/diagnosed within 24 hours.

Overall, there were five performance indicators in 2007 that were flagged in equal to or greater than 40% of cases:

• GCS less than nine with no ETT within 10 minutes (at any stage) • Greater than 2000 mL of fluid administered without blood • Retrieval team turnaround greater than 60 minutes • Referring hospital transfer greater than six hours • Compound fracture surgery greater than six hours after ED admission.

Potential reasons for tripping the ‘GCS less than nine with no ETT within 10 minutes (at any stage)’ indicator include a fluctuating GCS, inadequately trained staff or insufficient numbers of available staff to intubate the patient, lack of recognition of the urgency of achieving definitive airway control, or a specific clinical decision to monitor the patient’s respiratory function for a period of time without intervention. The administration of more than 2000 mL of fluid within the first hour in the ED may occur when blood is not available rapidly, when a clinical decision is made that the patient’s haemoglobin level is sufficient to withstand further crystalloid or colloid infusions or when there is lack of recognition of the importance of haemoglobin for oxygen carrying capacity. Turnaround time greater than 60 minutes by the retrieval team could be caused by insufficient preparation of the patient prior to retrieval, different equipment in use by the retrieval team and the transferring hospital necessitating change of equipment such as intravenous giving sets or a decision to implement further treatment prior to departure in order to optimise patient stability during the transport. Referring hospital transfer exceeding six hours might be caused by a variety of reasons, including a lack of transfer vehicles, aircraft or personnel to meet current

© CONROD 2009 49

requirements, inappropriate weather or light conditions, a clinical decision to monitor the patient for a period of time prior to confirming the need to transfer or a lack of recognition of the need for timely transfer. Causes of delay in repairing compound fractures include other aspects of care taking precedence, OT space or personnel not available, multiple or unnecessary diagnostic evaluations being undertaken, insufficient ED personnel available to initiate the process of consultation for surgery or staff with inadequate training to recognise the urgency of the need for surgery. 2005 – 2007 Over the three years from 2005 to 2007, two performance indicators were commonly flagged (equal to or greater than 40% in each year) (Figure 35):

• GCS less than nine with no ETT within 10 minutes (at any stage) • Referring hospital transfer greater than six hours.

Overall, seven performance indicators were consistently flagged at or below 10% over the three-year period (including one indicator that was never flagged):

• GCS less than 15 and no head CT within 24 hours • Urgent laparotomy greater than two hours after ED admission • Unplanned return to OT within 48 hours • Unplanned admission to ICU • Missed injuries with an AIS score greater than two after 24 hours • Development of DVT, PE or decubitus ulcers during admission • Cervical spine injuries not cleared or diagnosed within 24 hours.

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200520062007

Figure 35: Trends in the flagging of 17 performance indicators from 2005 to 2007 –

Paediatric Specialty Hospitals (see text above for a list of the 17 performance indicators denoted numerically in this figure) (n(2005) = 72, n(2006) = 97, n(2007) = 81)

© CONROD 2009 50

CCOOMMPPAARRIISSOONN BBEETTWWEEEENN PPAAEEDDIIAATTRRIICC SSPPEECCIIAALLTTYY AANNDD NNOONN--PPAAEEDDIIAATTRRIICC SSPPEECCIIAALLTTYY

HHOOSSPPIITTAALLSS This section provides information about differences in trauma related hospital admissions between Paediatric Specialty Hospitals (Specialty hospitals) and non-Paediatric Specialty Hospitals (NPS hospitals). The Specialty hospitals are the Royal Children’s and Mater Children’s Hospitals, while the NPS hospitals include: Royal Brisbane & Women’s Hospital, Princess Alexandra Hospital, The Townsville Hospital, Caboolture Hospital, Cairns Base Hospital, Gold Coast Hospital, Ipswich Hospital, Mackay Base Hospital, Nambour Hospital, Redcliffe Hospital, Rockhampton Base Hospital and Toowoomba Hospital. Of the 2,038 children (aged from zero to 14 years) admitted to hospital as a result of injury in Queensland in 2007, 40% (809) were admitted to the Specialty hospitals, with 60% (1,229) admitted to NPS hospitals.

MMaajjoorr // MMiinnoorr CCllaassssiiffiiccaattiioonn There was a significant difference in the percentage of major injury cases between the two hospital categories (χ2 = 24.90, p < 0.001), with Specialty hospitals treating significantly more major injury cases (10.0%) compared to NPS hospitals (4.4%) (Table 13).

Table 13: Injury severity details for major and minor injury cases over the two hospital categories (n = 2,038)

Statistic Specialty hospitals NPS hospitals Major Minor Major Minor

N 81 (10.0%) 728 (90.0%) 54 (4.4%) 1,175 (95.6%) Median ISS 24 4 17 5 IQR 16 – 26 1 – 9 16 – 23 4 – 9

2005 – 2007 The difference in percentage of major injury cases treated at Specialty hospitals compared to NPS hospitals was 8.0% in 2005 (11.6% at Specialty hospitals & 3.6% at NPS hospitals), 10.7% in 2006 (14.3% & 3.6%), and 5.6% in 2006 (10.0% & 4.4%).

DDeemmooggrraapphhiicc CChhaarraacctteerriissttiiccss AAggee aanndd sseexx ooff iinnjjuurryy ccaasseess There was a significant difference in the percentage of injured males treated over the two hospital categories (χ2 = 5.62, p < 0.05). A significantly higher percentage of male children were treated at NPS hospitals (67.0%), compared to Specialty hospitals (61.9%). For male children, the 10 to 14 years age group was the most common group treated at Specialty hospitals and NPS hospitals (Figure 36). Overall, there was a significant age difference in males over the two hospital categories (F = 15.92, p < 0.001) with males treated at Specialty hospitals being significantly younger (M = 7.7, SD = 4.4) than males treated at NPS hospitals (M = 8.7, SD = 4.3).

© CONROD 2009 51

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Figure 36: Distribution of male cases within each hospital category (n = 1,325)

There was a significant difference in the percentage of injured females treated over the two hospital categories (χ2 = 5.62, p < 0.05). A significantly higher percentage of female children were treated at Specialty hospitals (38.1%) compared to NPS hospitals (33.0%). For female children, the five to nine years age group was the most common group treated at Specialty hospitals, while the 10 to 14 years age group was the most common group treated at NPS hospitals (Figure 37). Overall, there was a significant age difference in females over the two hospital categories (F = 12.24, p < 0.001), with females treated at Specialty hospitals being significantly younger (M = 6.6, SD = 4.2) than those treated at NPS hospitals (M = 7.8, SD = 4.3).

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Figure 37: Distribution of female cases over the two hospital categories (n = 713)

AAbboorriiggiinnaall aanndd TToorrrreess SSttrraaiitt IIssllaannddeerr PPeeooppllee There was a significant difference in the number of children over the two hospital categories who identified themselves as being of Aboriginal and Torres Strait Islander origin (χ2 = 81.19, p < 0.001). A significantly higher percentage of children were of Indigenous origin at NPS hospitals (10.1%), compared to Specialty hospitals (3.5%). Of the 123 children of Indigenous origin admitted to one of the NPS hospitals, 98 children were of Aboriginal origin, 17 children were of Torres Strait Islander origin and eight children were of both Aboriginal and Torres Strait Islander origin.

© CONROD 2009 52

IInnjjuurryy EEvveenntt CChhaarraacctteerriissttiiccss EExxtteerrnnaall ccaauussee ooff iinnjjuurryy For both Specialty hospitals and NPS hospitals, falls were the most common external cause of injury (338 for Specialty hospitals & 568 for NPS hospitals), followed by RTCs (172 & 300), and collision with an object or a person (73 & 90) (Figure 38). There was no significant difference between the two hospital categories for the number of falls, RTCs, or collision injury cases treated.

0 10 20 30 40 50

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PoisoningAnimalCutting

BurnsCollision

RTCFall

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% of patients

SpecialtyNPS

Figure 38: External cause of injury over the two hospital categories (n= 2,018)*

* Those categories with n ≤ 5 were not included in this figure: ‘Firearm’. NNaattuurree ooff mmaaiinn iinnjjuurryy Fractures (373) were the most common nature of main injury for Specialty hospitals, followed by intracranial injury (103) and open wounds and superficial injuries (87). For NPS hospitals, the most common nature of main injury were fractures (793), followed by open wounds and superficial injuries (106), and injury to a nerve, vessel, muscle or tendon (77) (Table 14). There was a significant difference between the two hospital categories in terms of the percentage of intracranial injury identified as the nature of main injury (χ2 = 27.70, p < 0.001), with more intracranial injuries treated at Specialty hospitals (12.7%) compared to NPS hospitals (6.0%). There was no significant difference between the two hospital categories for the number of fractures identified as the nature of main injury. Table 14: Number of patients in each hospital category in the six most common nature of

main injury categories (n= 2,038) Nature of main injury Specialty Hospitals NPS Hospitals Fracture 373 (46.1%) 793 (64.5%) Intracranial injury 103 (12.7%) 74 (6.0%) Open wound/superficial 87 (10.8%) 106 (8.6%) Burn/corrosion 56 (6.9%) 39 (3.2%) Injury to internal organ 52 (6.4%) 51 (4.1%) Injury nerve/vessel/muscle/tendon 43 (5.3%) 77 (6.3%)

BBooddyy llooccaattiioonn ooff mmaaiinn iinnjjuurryy The most common body location of main injury for both Specialty hospitals and NPS hospitals was the upper extremity, followed by the lower extremity and the head (Table 15). There was a significant difference in the percentage of children with upper extremity injuries over the two hospital categories (χ2 = 37.53, p < 0.001), with significantly fewer children with upper extremity injuries admitted to Specialty hospitals

© CONROD 2009 53

(33.1%) compared to NPS hospitals (46.8%). There was also a significant difference between the two hospital categories in terms of the percentage of children with lower extremity injuries (χ2 = 11.24, p < 0.05) and the percentage of children with head injuries (χ2 = 21.62, p < 0.001). Table 15: Number of patients in each hospital category: Upper extremity, lower extremity

and head (n = 2,038) Body location Specialty hospitals NPS hospitals Upper extremity 268 (33.1%) 575 (46.8%) Lower extremity 173 (21.4%) 344 (28.0%) Head 127 (15.7%) 110 (9.0%)

OOuuttccoommee MMeeaassuurreess LLeennggtthh ooff aaccuuttee hhoossppiittaall ssttaayy The total number of acute bed days used was larger for NPS hospitals compared to Specialty hospitals, however, the range in length of acute stay was larger for Specialty hospitals. Median length of acute stay was two days for both Specialty hospitals and NPS hospitals (Table 16).

Table 16: Length of acute hospital stay details between the two hospital categories (n = 2, 038)

Statistic Specialty hospitals NPS hospitals Number of patients 809 cases 1,229 cases Range 1 – 337 days 1 – 96 days Median length of acute stay 2 days 2 days IQR 2 – 4 days 2 – 3 days Total acute bed days 4,044 days 4,659 days

The most common length of acute stay for both hospital categories was from one to two days, with 56.1% (454) of children admitted to Specialty hospitals and 63.2% (777) of children admitted to NPS hospitals staying in acute care for this amount of time (Figure 39). Only 4.3% (53) of children admitted to NPS hospitals and 5.3% (43) of children admitted to Specialty hospitals stayed for 15 days or more in acute care.

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Figure 39: Length of acute hospital stay over the two hospital categories (n = 2,038)

© CONROD 2009 54

Commentary

Any difference between the hospital categories for length of acute hospital stay characteristics is likely to be due to a higher percentage of major injury cases being treated at Speciality hospitals, where specialist services such as the state-wide burns and spinal units are located. While children with spinal injuries and those with burns are occasionally managed in a number of locations, the most severe are usually managed at the Specialty hospitals.

2005 – 2007 In all three years the median length of acute stay was two days at NPS hospitals. For Specialty hospitals the median length of acute stay was two days in 2005, three days in 2006, and two days in 2007. For major injury cases, the difference in median length of acute hospital stay between the two hospital categories was one day in 2005 (6 days at Specialty hospitals & 5 days at NPS hospitals), two days in 2006 (7 days & 5 days), and two and a half days in 2007 (7 days & 4.5 days). IICCUU There was a significant difference in the likelihood of admission to ICU between the two hospital categories (χ2 = 73.25, p < 0.001), with those admitted to Specialty hospitals more likely to be admitted to ICU (13.6%) than those admitted to NPS hospitals (3.4%). The median length of stay in ICU was one day for both Specialty hospitals and NPS hospitals, with a similar range of days for both hospital categories (Table 17).

Table 17: ICU length of stay details over the two hospital categories (n = 152) Statistic Specialty hospitals NPS hospitals Number of patients 110 (13.6%) 42 (3.4%) Range 1 – 20 days 1 – 21 days Median ICU stay 1 day 1 day IQR 1 – 2 days 1 – 2 days Total bed days 235 days 110 days

2005 – 2007 There was no difference between the two hospital categories for median length of ICU stay in 2005, 2006 and 2007 (median stay was one day for both Specialty and NPS hospitals in each year). For major injury cases, the difference between the hospital categories for median length of ICU stay was one day in 2005 (3 days at Specialty hospitals & 2 days at NPS hospitals), half a day in 2006 (2 days & 1.5 days), and one day in 2007 (2 days & 1 day). MMoorrttaalliittyy Four children (0.5%) at Specialty hospitals died at some stage during their hospital admission, compared to 14 (1.1%) deaths at NPS hospitals. For those age groups represented, the death rate (the number of deaths per 100,000 injuries) was highest for the zero to four years age group for both Specialty hospitals (810 deaths per 100,000 injuries) and NPS hospitals (2,113 deaths per 100,000 injuries) (Figure 40).

© CONROD 2009 55

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Figure 40: Death rate for each age group across both hospital categories (n = 18)

2005 – 2007 The difference in percentage of in-hospital deaths between the two hospital categories was 0.5% in 2005 (1.3% at Specialty hospitals & 0.8% at NPS hospitals), 0.5% in 2006 (1.2% & 0.7%), and 0.6% in 2007 (0.5% & 1.1%).

PPeerrffoorrmmaannccee IInnddiiccaattoorrss There was no significant difference in the percentage of flagged cases between the two hospital categories for any of the 17 performance indicators (Table 18). There were eight performance indicators that were infrequently flagged (at or below 10%) or were not flagged over both Specialty and NPS hospitals:

• GCS less than 15 and no head CT within 24 hours (none flagged & 3% flagged respectively)

• Urgent laparotomy greater than two hours after ED admission (none flagged & none flagged respectively)

• Reintubation within 48 hours of extubation (4% flagged & 10% flagged respectively)

• Unplanned return to OT within 48 hours (none flagged & 7% flagged respectively)

• Unplanned admission to ICU (4% flagged & none flagged respectively)

• Missed injuries with an AIS score greater than two after 24 hours (none flagged & 2% flagged respectively)

• Development of DVT, PE or decubitus ulcers during admission (6% flagged & none flagged respectively)

• Cervical spine injuries not cleared or diagnosed within 24 hours (6% flagged & 3% flagged respectively).

© CONROD 2009 56

Table 18: Percentage of flagged cases for each of the 17 performance indicators for both hospital categories (n = 135)


Specialty hospitals NPS hospitals Total

applicable cases

Total flagged cases

% flagged cases

Total applicable

cases

Total flagged cases

% flagged cases

1. Pre-hospital scene time > 20 min 37 7 19% 37 15 41% 2. Total pre-hospital time > 1 hr 37 13 35% 37 12 32% 3. GCS < 9 no ETT within 10 min 12 6 50% 9 2 22% 4. > 2000 mL fluid without blood first 60 min 3 2 67% 1 - - 5. Retrieval team turnaround > 60 min 5 2 40% 7 1 14% 6. Referring hospital transfer > 6 hr 35 20 57% 17 6 35% 7. GCS < 15 and no head CT 57 - - 30 1 3% 8. Urgent laparotomy > 2 hr post ED - - - 2 - - 9. Urgent craniotomy > 4 hr post ED 8 1 13% 2 1 50% 10. Compound fractures > 6 hr to OT post ED 4 3 75% 8 2 25% 11. Hypothermia at any stage 72 9 13% 48 5 10% 12. Reintubation within 48 hr 25 1 4% 10 1 10% 13. Unplanned return to OT within 48 hr 30 - - 14 1 7% 14. Unplanned admission to ICU 53 2 4% 15 - - 15. Missed injuries of AIS > 2 after 24 hr 77 - - 42 1 2% 16. Development of ulcers, PE, DVT 81 5 6% 54 - - 17. C-spine injuries not cleared within 24 hr 36 2 6% 30 1 3%

© CONROD 2009 57

RREEFFEERREENNCCEESS

1. Australian Institute of Health and Welfare. Health system expenditure on disease and injury in Australia, 2000-01. 2nd edn. AIHW cat. no. HWE 28. Canberra: AIHW (Health and Welfare Expenditure Series no. 21), 2005.

2. Goss J. Projection of Australian health care expenditure by disease, 2003 to 2033. Cat. no. HWE 43.Canberra: AIHW, 2008.

3. Pike A, Baade P, Harper C, Muller S, Kennedy B. Quantifying the burden of disease and injury in Queensland 1996-1998. Brisbane: Queensland Government, 2002.

4. Australian Institute of Health and Welfare. Australia’s Health 2008. Cat. no. AUS 99. Canberra: AIHW, 2008.

5. Peden M, McGee K, Krug E, eds. Injury: A Leading Cause Of The Global Burden Of Disease, 2000. Geneva: World Health Organisation, 2002.

6. Australian Institute of Health and Welfare. A picture of Australia’s children 2009. Cat. no. PHE 112. Canberra: AIHW, 2009.

7. Queensland Health: Harper C, Cardona M, Bright M, Neill A, McClintock C, McCulloch B, Hunter I, Bell M. Health Determinants Queensland 2004. Brisbane: Public Health Services, Queensland Health, 2004.

8. Department of Health and Aged Care. National Injury Prevention Plan: Priorities for 2001 –2003. Canberra: Commonwealth of Australia, 2001.

9. Queensland Health. Health Outcomes Plan: Injury Prevention and Control 2000 – 2004. Brisbane: Queensland Health, 2000.

10. Cameron PA, Finch CF, Gabbe BJ, Collins LJ, Smith KL, McNeil JJ. Developing Australia’s first statewide trauma registry: What are the lessons? ANZ J Surg 2004; 74:424-28.

11. Shapiro MJ, Cole KE Jr, Keegan M, Prasad CN, Thompson RJ. National survey of state trauma registries – 1992. J Trauma 1994; 37(5):835-40.

12. Jurkovich GJ, Mock C. Systematic review of trauma system effectiveness based on registry comparisons. J Trauma 1999; 47(3): S46-S55.

13. Blackwell T, Kellam JF, Thomason M. Trauma care systems in the United States. Injury 2003; 34: 735-39.

14. Peleg K, Aharonson-Daniel L, Stein M, Kluger Y, Michaelson M, Rivking A, Boyko V, Israel Trauma Group. Increased survival among severe trauma patients. Arch Surg 2004; 139: 1231-36.

15. Kortbeek JB, Buckley R. Trauma systems in Canada. Injury 2003; 34: 658-63.

16. Wynn A, Wise M, Wright MJ, Rafaat A, Wang YZ, Steeb G, McSwain N, Beuchter KJ, Hunt J. Accuracy of Administrative and Trauma Registry Databases. J Trauma 2001; 51:464-8.

17. Kortbeek JB. A review of trauma systems using the Calgary model. Can J Surg 2000; 43:23-8.

18. Condello AS, Hancock BJ, Hoppensack M, Tenenbein M, Charyk-Stewart T, Kirwin D, Williamson J, Findlay C, Moffatt M, Wiseman N, Postuma R. Pediatric Trauma Registries: The foundation of quality care. J Ped Surg 2001; 36(5):685-689.

19. Rutledge R. The goals, development and use of trauma registries and trauma data sources in decision making in injury. Surg Clin North Am 1995; 75(2):305-26.

20. Helps Y, Cripps R, Harrison J. Hospital separations due to injury and poisoning, Australia 1999 – 00. Injury Research and Statistics Series Number 15. AIHW Cat. no. INJCAT 48: 40. Adelaide: Australian Institute of Health and Welfare, 2000.

21. Health Statistics Centre. Population by Age and Sex, 2007, Statistical Output. Brisbane: Queensland Health, 2008.

22. Health Statistics Centre. Indigenous Estimated Resident Populations by Age Groups, Sex & Health Service Districts (2008), Statistical Output. Brisbane: Queensland Health, 2009.

23. Hockey R, Miles E. Bicycle injuries. Injury Bulletin No. 57. Brisbane: Queensland Injury Surveillance Unit, 2000.

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24. Begg S. Recreational injury to older children (10-14 year olds). Hazard Edition No. 31. Melbourne: Victorian Injury Surveillance System, Monash University Accident Research Centre, 1997.

25. Haworth N, Ozanne-Smith J, Fox B, Brumen I. Motorcycle related injuries to children and adolescents. Melbourne: Monash University Accident Research Centre (Report #56), 1994.

26. Hockey R, Reith D, Miles E. Childhood Poisoning and Ingestion. Injury Bulletin No. 60. Brisbane: Queensland Injury Surveillance Unit, 2000.

27. Hockey R, Miles E, Baylis P. Injuries in the home – Children. Injury Bulletin No. 66. Brisbane: Queensland Injury Surveillance Unit, 2001.

28. Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW, Flanagan ME, Frey CF. The Major Trauma Outcome Study: Establishing national norms for trauma care. J Trauma 1990; 30(11):1356-1365.

29. Millham FH, LaMorte WW. Factors associated with mortality in trauma: re-evaluation of the TRISS method using the National Trauma Data Bank. J Trauma 2004; 56(5): 1090-6.

30. Moore L, Clark DE. The value of trauma registries. Injury, Int. J. Care Injured 2008; 39: 686-695.

31. Australian Bureau of Statistics. 2006 Census: Basic Community Profile – Brisbane (Statistical Division). ABS cat. no. 2001.0. Canberra: Australian Bureau of Statistics, 2007.

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AAPPPPEENNDDIIXX AA –– QQTTRR DDAATTAA FFIIEELLDDSS IINN 22000077 ALL CASES Patient Details • Age • Gender • Aboriginal and Torres Strait Islander status Injury Details • Injury date/s • Injury time • Postcode of injury • Dominant injury type • Nature of injury (NDS-IS) • Intent of injury (ICD-10-AM) • External cause of Injury (ICD-10-AM) • Place of injury occurrence (ICD-10-AM) • Activity at time of injury (ICD-10-AM) • Injury type/s (AIS codes) • Body location of main injury (AIS regions) ED / Hospital Admission • Presentation date / time • Means of referral • Triage category • Pulse rate / time • Sp02 rate / time • Respiratory rate / time • Systolic BP rate / time • Diastolic BP • Glasgow Coma Score / time • Temperature / time • Time treatment started • Transfer from ED date / time • Admission date / time • Disposition Outcome • ICU days • Length of acute hospital stay • Injury outcome (survived; died) • Death information (place, date, time) • Operation/s (code, date, time) • Transfer information • Rehabilitation facility information Score • Injury Severity Score (ISS) • Trauma & Injury Severity Score (TRISS) • Revised Trauma Score

• Vehicle type • Scene time delay • Pulse rate / time • Sp02 rate / time • Respiratory rate / time • Systolic BP rate / time • Diastolic BP • Glasgow Coma Score / time • Temperature / time • CPR • Airway type / time • Inter-costal catheter • Fluid type / volume

Referral details • Hospital name (for Minors also) • Arrival date / time • Departure date / time • Pulse rate / time • Sp02 rate / time • Respiratory rate / time • Systolic BP rate / time • Diastolic BP • Glasgow Coma Score / time • Temperature / time • CPR • Airway type / time • Inter-costal catheter • Fluid type / volume • CT scan • Ultrasound • Triage category

Interfacility • Transfer date • Vehicle type • Transfer provider • Skill level • Activation time • Arrival time • Departure time • Definitive care arrival time • CPR • Airway type / time • Inter-costal catheter • Fluid type / volume

ED Treatment • CPR • Airway type / time • Intercostal catheter • Fluid type / volume • CT scan • Ultrasound • Angiography • Transoesophageal / Trans-thoracic ECG • Anti-coagulation • Trauma team activation

Performance Indicators Please contact QTR for a full explanation of the Indicators listed over the page

MAJOR CASES ONLY (ISS ≥ 16)

Pre-hospital • Incident date • Request date / time • Dispatch time • Scene arrival / departure time/s • Scene time delay • Hospital arrival time • Skill level

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AAPPPPEENNDDIIXX BB –– OOPPEERRAATTIIOONNSS The operations listed below are based on specifications used by the Victorian State Trauma Outcomes Registry (VSTORM), with additional items specified by QTR.

Body Region Operation Head Craniotomy-NFS Head Craniotomy-Evacuation mass lesion Head Craniotomy -Elevation of Fracture Head Craniotomy - Decompressive Surgery Head Craniotomy-EVD/ICP Head Craniotomy-Partial Lobectomy Head Craniotomy-Other Head Craniectomy-NFS Head Craniectomy-Evacuation of mass lesion Head Craniectomy-Decompressive Surgery Head Craniectomy-EVD/ICP Head Craniectomy-Other Head Burr Hole-NFS Head Burr Hole-Evacuation of mass lesion Head Burr Hole-EVD/ICP Head Burr Hole-Other Head Head Percutaneous - NFS Head Head Percutaneous -Embolisation Head Head Percutaneous - Stenting Head Head Percutaneous-Other Head Head Nerve Repair Head Head Vessel Repair Face Face-NFS Face Face-ORIF Face Face-External Fixateur Face Face-Other Face Face-Nerve Repair Face Face-Vessel Repair Neck Neck-NFS Neck Neck-Vessel Repair Neck Neck-Organ Repair Neck Neck-Tracheostomy Neck Neck-Cricothyroidotomy Neck Neck-Other Neck Laryngoscopy/Pharyngoscopy Neck Neck-Nerve Repair

Thorax Thoracotomy-NFS Thorax Thoracotomy-Vessel Repair Thorax Thoracotomy-Organ Repair,NFS Thorax Thoracotomy-Heart Repair Thorax Thoracotomy-Lung Repair Thorax Thoracotomy-Diaphragm Repair Thorax Thoracotomy-Trachea Repair Thorax Thoracotomy-Bronchus Repair Thorax Thoracotomy-Oesophagus Repair Thorax Thoracotomy-Pleural Repair Thorax Thoracotomy-Resuscitative 'buying time' repair Thorax Thoracotomy-Other Thorax Thoracoscopy / Bronchoscopy Thorax Thoracoscopy progressing to thoracotomy

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Body Region Operation Thorax Pericardiotomy-NFS Thorax Pericardiotomy-Other Thorax Thorax Percutaneous-NFS Thorax Thorax –Stent Thorax Thorax-Embolisation Thorax Thorax Percutaneous -Other Thorax ORIF ribcage including sternum Thorax Thorax-Other Thorax Thorax-Vessel Repair

Abdomen Laparotomy - Small Bowel Repair / Resection Abdomen Laparotomy - Large Bowel Repair / Resection Abdomen Laparotomy - Ileostomy Abdomen Laparotomy - Colostomy Abdomen Laparotomy - Splenic Repair Abdomen Laparotomy - Splenectomy Abdomen Laparotomy-NFS Abdomen Laparotomy - Nephrectomy Abdomen Laparotomy - Kidney Repair Abdomen Laparotomy - Liver Packing Abdomen Laparotomy - Liver Anatomical Resection Abdomen Laparotomy - Liver Debridement Abdomen Laparotomy - Liver Ligation / Suture etc Abdomen Laparotomy - Cholecystectomy (GB Removal) Abdomen Laparotomy - Stomach Repair Abdomen Laparotomy - Pancreas Repair / Resection / Drainage Abdomen Laparotomy - Mesentery/Omentum Repair Abdomen Laparotomy - Mesenteric Haematoma - No Treatment Abdomen Laparotomy - Mesenteric Haematoma - Evacuation/Haemostasis Abdomen Laparotomy - Damage Control Surgery Abdomen Laparotomy - Vessel Repair Abdomen Male Genital Repair Abdomen Laparotomy - Female Genital Repair Abdomen Laparotomy-Organ other Abdomen Laparotomy-NAD Abdomen Laparotomy - Non therapeutic Abdomen Laparotomy-Other Abdomen Laparotomy - Vessel Stent Abdomen Laparotomy - Vessel Graft Abdomen Laparotomy - Vessel Ligate Abdomen Laparotomy - Bladder Repair Abdomen Laparoscopy Abdomen Laparoscopy-Other Abdomen Laparoscopy progressing to Laparotomy Abdomen Cystoscopy Abdomen Cystoscopy-Other Abdomen Endoscopy Abdomen Endoscopy-Other Abdomen Abdomen Percutaneous - Other Abdomen Abdomen Percutaneous - Stenting Abdomen Abdomen Percutaneous - Embolisation Abdomen Abdomen-Other Abdomen Abdomen-Vessel Repair

Spine Spine-NFS

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Body Region Operation Spine Spine-External fixateur (including Halothoracic brace and tongs) Spine Spine-ORIF (including fusion and discectomy) Spine Spine-Decompression spinal cord (evacuation of extradural) Spine Spine-Nerve Repair

Upper Extremity Upper extremity-NFS Upper Extremity Upper extremity-ORIF Upper Extremity Upper extremity-Closed reduction/GAMP (K-wire) Upper Extremity Upper extremity-External fixateur Upper Extremity Upper extremity-Soft tissue repair Upper Extremity Upper extremity-Fasciotomy Upper Extremity Upper extremity-Amputation Upper Extremity Upper extremity-Other Upper Extremity Upper extremity-Nerve Repair Upper Extremity Upper extremity-Tendon Repair Upper Extremity Upper extremity-Vessel Repair Upper Extremity Upper extremity-Compound scrub Lower Extremity Lower extremity-NFS Lower Extremity Lower extremity-ORIF Lower Extremity Lower extremity-Closed reduction/GAMP (K-wire) Lower Extremity Lower extremity-External fixateur Lower Extremity Lower extremity-Soft tissue repair Lower Extremity Lower extremity-Fasciotomy Lower Extremity Lower extremity-Amputation (above knee) Lower Extremity Lower extremity-Amputation (below knee) Lower Extremity Lower extremity-Other Lower Extremity ORIF # pelvis Lower Extremity External fixation of pelvis Lower Extremity Lower extremity-Nerve Repair Lower Extremity Lower extremity-Tendon Repair Lower Extremity Lower extremity-Vessel Repair Lower Extremity Lower extremity-Compound scrub Other / External Wound-NFS Other / External Wound-Washout/debridement/closure (delayed) Other / External Wound-Other vessel repair Other / External Wound-Dressing (includes packing) Other / External Wound-Other Other / External Skin Graft NFS Other / External Skin graft-Split Other / External Skin graft-Complex Other / External Skin graft-other Other / External Burn repair-other Other / External Burn dressing Other / External Burn escherotomy Other / External Burn debridement / grafting Other / External Burn-other Other / External Organ Procurement Other / External Angiography and stenting/embolisation Other / External Other operation Other / External Vessel Repair NFS Other / External Vessel Stent NFS Other / External Vessel Graft NFS Other / External Vessel Ligate NFS Other / External Other nerve/tendon repair

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AAPPPPEENNDDIIXX CC –– CCOOMMPPLLIICCAATTIIOONNSS Most common complications Decubitus Ulcer Full thickness tissue loss extending through dermis to involve subcutaneous tissue. Presents as shallow crater unless covered by eschar. May include necrotic tissue, undermining, sinus tract formation, exudate, and/or infection. Shock; other Sustained blood pressure < 100 mm Hg for greater than 15 minutes. Episode occurring after initial resuscitation, excluding cardiogenic shock. Or a drop of 40mm Hg in a known hypertensive patient (eg in an 80 years old man whose normal BP 160/95, a BP of < 120 would indicate shock). Cardiac Arrest Requiring CPR. Seizure in Hospital Witnessed tonic- clonic activity. Diabetes Insipidus Excessive urine output treated with Desmopressin or DDAVP. Stroke / CVA Evidence of CVA which is in addition to original trauma. Aspiration Pneumonia Inhalation of gastric contents or blood causing any element of pulmonary failure which requires treatment. Pulmonary Oedema Documented by clinical or radiological signs and requires fluid restriction or medication. Upper Airway Obstruction Mechanical upper airway (above larynx) obstruction that is clinically significant enough to require endotracheal intubation. Cellulitis / Traumatic Injury Dermal site infection at trauma site or nonsurgical site; includes IV sites, infected abrasions, and lacerations. Line infection Patient must have intravenous line and recognised pathogen from bloodstream which is unrelated to pathogen at another site, with fever (T >38.5) chills, or hypotension. Septicaemia Positive blood culture. Excludes isolates that are felt to be contaminants. Urinary Tract Infection Confirmed by laboratory culture & treated with antibiotics. Ileus – Persistent Prolonged duration which lengthens hospital course and/or prevents timely feeding. Any patient who cannot be fed > 24 hours after surgery because of distended abdomen. Coagulopathy Prolonged PT, PTT or decreased platelet count with clinical bleeding or preventing invasive procedures.

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AAPPPPEENNDDIIXX DD –– PPEERRFFOORRMMAANNCCEE IINNDDIICCAATTOORRSS 1. Pre-hospital scene time greater than 20 minutes. The length of time a patient spends at the scene of the accident can have significant bearing on the eventual outcome. It is important that patients are transported to hospital for definitive management a soon as possible. Patients are not flagged if the responding pre-hospital team spent less than 20 minutes at the scene. Difficult extrications and other events affecting this indicator are also recorded. 2. Total pre-hospital time greater than one hour. The length of time it takes to transport a patient to hospital and the type of care the patient receives in this time can have a significant bearing on the eventual outcome of the patient. Pre-hospital time is calculated from ambulance (QAS) request time to ED arrival time. 3. GCS less than nine with no ETT within 10 minutes (at any stage) Patients with a decreased level of consciousness are deemed to be at an increased risk of airway compromise and should have a mechanical airway established as soon as practicable. Intubation should be performed within 10 minutes of recording a GCS of less than nine (at any stage from arrival at first hospital). Patients are not flagged if they were intubated within 10 minutes. A patient is deemed to be not applicable if their GCS was never less than nine, ETT was pre-hospital, where they died before intervention was possible or for those who mechanical ventilation was never intended eg NFR. 4. Greater than 2000 mL of fluid administered without blood When a patient requires fluid resuscitation for blood loss, blood is preferred rather than high-volume crystalloid and colloid because the haemo-dilution effect of the latter is harmful. This indicator measures the number of patients who are administered intravenous fluids in excess of 2000 mL and who do not receive blood in the first 60 minutes. (Note: Patients outside the normal weight range may invalidate the indicator). It refers ONLY to the administration of colloid or crystalloid without blood transfusion during the resuscitation period in any ED (pre-hospital fluids and maintenance fluid, ie one litre > four hours are not included). Children receiving greater than 40 mL/kg without blood should be included. A patient is deemed to be not applicable if ≤ 2000 mL or no intravenous fluid was administered or they were a burns patient. 5. Retrieval team turnaround greater than 60 minutes When the Medical Retrieval Team is used to transfer a patient from the referring hospital, we want to measure how long the retrieval team spends at the referring hospital. This indicator measures the length of time from arrival at the referring hospital bedside to departure from referring hospital bedside. 6. Referring hospital transfer greater than six hours A patient who requires secondary or tertiary referral should reach definitive care as soon as possible. This indicator measures the length of time from arrival at the referring facility to arrival at the receiving facility. 7. GCS less than 15 and no head CT within 24 hours A GCS of less than 15 may indicate significant head injury. This indicator flags those patients with a GCS of less than 15 either on arrival in the resuscitation room, or whose level of consciousness decreases below 15 while they are in ED. A patient is deemed to be not applicable if their GCS was 15 at all phases, they died or had no documented head injury. 8. Urgent laparotomy greater than two hours after ED admission When urgent laparotomy is required for a patient who has suspected intra-abdominal bleeding with haemodynamical instability, this should occur without delay. This refers to the amount of time from arrival in ED to commencement of anaesthetic for surgery. A patient is deemed to be not applicable if an urgent laparotomy was indicated and not performed (patient died) or if no urgent laparotomy was indicated.

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9. Urgent craniotomy greater than four hours after ED admission This refers to a patient with an acute subdural (SDH) or acute extradural haematoma (EDH) that warrants urgent drainage and refers to the amount of time from arrival in ED to commencement of the anesthetic for surgery. (Note: ‘Acute’ is defined as presentation ≤ 24 hours post injury). IP monitor insertion and elevation of depressed skull fractures are not included. A patient is deemed to be not applicable if an urgent craniotomy was indicated and not performed (patient died) or if no urgent craniotomy was indicated. 10. Compound fracture surgery greater than six hours after ED admission The risk of infection and subsequent disability is increased where the required surgical intervention is delayed during definitive care. This refers to the amount of time from arrival in ED to commencement of anaesthetic for surgery. A patient is deemed to be not applicable if they sustained no compound fractures. 11. Hypothermia at any stage Maintenance of adequate body temperature is important - hypothermia is associated with a poor outcome for patients with injury. It can occur as a result of several factors including prolonged scene time or patient exposure, loss of blood or rapid infusion of cold intravenous fluid. This indicator is used to flag any patient whose temperature is ≤ 35 °C at any time (ie including pre-hospital, referring hospital and definitive care phases). A patient is deemed to be not applicable if active cooling was undertaken or temperature was unknown (eg patient died in ED). 12. Reintubation within 48 hours of extubation This indicator includes endotracheal and tracheotomy tubes and specifically refers to the decision to extubate. If a patient is unintentionally or self-extubated and the decision is made to observe their respiratory status and later require reintubation, this case would not be flagged. A patient is deemed to be not applicable if they were never intubated or intubated for OT only. 13. Unplanned return to OT within 48 hours Ideally, all operations will be anticipated and planned following ED assessment. Unplanned operations include return to operating theatre for post-operative haemorrhage, unexpected surgery for missed injuries, or unexpected deterioration of patient’s condition. A patient is deemed to be not applicable if they had no initial visit to OT. 14. Unplanned admission to ICU This refers to those patients that were transferred to the ward and whose condition deteriorates, requiring prompt re/admission to the ICU. It includes patients who were: Transferred from ICU to the ward and back to ICU Transferred from ED to a ward then ICU Transferred from ED to OT, intended to go to the ward but were admitted to ICU. A patient is deemed to be not applicable if they had no admissions to ICU. 15. Missed injuries with an AIS score greater than two after 24 hours Ideally, all injuries will be diagnosed during the first 24 hours of care. Any injury that is not diagnosed during the first 24 hours constitutes a missed injury. If a patient has missed injuries, but these injuries do not have an AIS score of greater than two, then the case will NOT be flagged. A patient is deemed not applicable if investigations were incomplete eg Death or transfer within 24 hours. 16. Development of DVT, PE or decubitus ulcers during admission The development of these complications during an admission may result in longer hospital inpatient days and result in differing mortality rates. Where a complication was present during admission, the type was documented. 17. Cervical spine injuries not cleared or diagnosed within 24 hours This performance indicator includes the suspicion of a cervical spine injury, which is not cleared or diagnosed within 24 hours of admission to ED and results in unnecessary prolonged use of a hard cervical collar. A patient is deemed not applicable if there was no suspected cervical spine injury or they died in less than 24 hours.

2007A summary of injuries treated at the ROYAL BRISBANE & WOMEN’S HOSPITAL

A PROGRAMME OF THE CENTRE OF NATIONAL RESEARCH ON DISABILITY AND REHABILITATION MEDICINE

Mayne Medical School, The University of Queensland, Herston Rd, Brisbane Qld 4006

Phone 61 7 3365 5560 Fax 61 7 3346 4603

www.conrod.uq.edu.au

A SUMMARY OF PAEDIATRIC INJURIES TREATED … SUMMARY OF PAEDIATRIC INJURIES TREATED IN QUEENSLAND...

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