British Columbia Trauma Registry Research Articles

Chest trauma clinical practice guideline protects against delirium in patients with rib fractures

IntroductionTraumatic rib fractures present a considerable risk to patient well-being, contributing to morbidity and mortality in trauma patients. To address the risks associated with rib fractures, evidence-based interventions have been...

Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury.

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes. Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer. Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition. No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

Evaluation of tranexamic acid in trauma patients: A retrospective quantitative analysis

IntroductionTranexamic acid (TXA) has been shown to decrease mortality in adult trauma patients with or at significant risk of hemorrhage when administered within 3 h of injury. The use and appropriateness of TXA in adult trauma patients presenting to Royal Columbian Hospital (RCH) was investigated. MethodsThis retrospective chart review utilized the British Columbia Trauma Registry to identify 100 consecutive trauma patients that presented to the emergency department at RCH between April 2012 to June 2015 and met the following indications for TXA: systolic blood pressure <90 mm Hg and/or heart rate >110 bpm and presentation within 8 h of injury. Primary outcomes included: percentage that met indications for TXA, received TXA according to the CRASH-2 protocol, received a pre-hospital dose, and received TXA ≤1, >1 to ≤3, or >3 h from injury. ResultsDuring the given time period, 117 subjects (2.7%) met indications for TXA. 67 patients (57%) received TXA in any dose, with 10 subjects (8.5%) receiving TXA according to the CRASH-2 protocol. Of the 67 patients who received any TXA, 76% did so ≤3 h. 22 patients (19%) received TXA as a pre-hospital dose. Conclusions<10% of adult trauma patients that met the indication for TXA received it according to the CRASH-2 protocol. Of those patients that received TXA, 76% did so within 3 h. Further inquiry to identify reasons trauma patients are not receiving TXA as well as quality improvement initiatives in trauma care are required. Level of evidenceIII Study typeTherapeutic

Socio Economic Status and Traumatic Brain Injury amongst Pediatric Populations: A Spatial Analysis in Greater Vancouver

Introduction: Within Canada, injuries are the leading cause of death amongst children fourteen years of age and younger, and also one of the leading causes of morbidity. Low Socio Economic Status (SES) seems to be a strong indicator of a higher prevalence of injuries. This study aims to identify hotspots for pediatric Traumatic Brain Injury (TBI) and examines the relationship between SES and pediatric TBI rates in greater Vancouver, British Columbia (BC), Canada. Methods: Pediatric TBI data from the BC Trauma Registry (BCTR) was used to identify all pediatric TBI patients admitted to BC hospitals between the years 2000 and 2013. Spatial analysis was used to identify hotspots for pediatric TBI. Multivariate analysis was used to distinguish census variables that were correlated with rates of injury. Results: Six hundred and fifty three severe pediatric TBI injuries occurred within the BC Lower Mainland between 2000 and 2013. High rates of injury were concentrated in the East, while low rate clusters were most common in the West of the region (more affluent neighborhoods). A low level of education was the main predictor of a high rate of injury (OR = 1.13, 95% CI = 1.03–1.23, p-Value 0.009). Conclusion: While there was a clear relationship between different SES indicators and pediatric TBI rates in greater Vancouver, income-based SES indicators did not serve as good predictors within this region.

A geospatial analysis of the relationship between neighbourhood socioeconomic status and adult severe injury in Greater Vancouver

BackgroundEvery year, injuries cost the Canadian healthcare system billions of dollars and result in thousands of emergency room visits, hospitalisations and deaths. The purpose of this study was to explore...

Patterns of Outdoor Recreational Injury in Northern British Columbia

The objective of this study was to examine the patterns of severe injury documented at a northern British Columbia regional trauma center based on age, sex, month of year, activity type, injury type, and injury severity as they relate to participation in outdoor recreational activities. A retrospective analysis of data abstracted from the British Columbia Trauma Registry for patients sustaining injuries between April 1, 2004, and March 31, 2007, while engaged in outdoor recreational activities in the Northern Health Authority. The British Columbia Trauma Registry inclusion criteria are as follows: 1) admitted for treatment of injuries sustained from the transfer of external energy or force; 2) admitted to the facility within 7 days of injury; and 3) length of stay more than 2 days or in-hospital mortality. In all, 159 patients met study criteria. August and September were peak injury months (mean 7.3 and 7.0 per month, respectively). The highest injury patterns involved cycling (n = 31), all-terrain vehicle operation (n = 30), horseback riding (n = 22), and snowmobiling (n = 22). Of the 159 patients, 76.1% were male, with a peak age distribution between 10 years and 19 years (22%). Males were more commonly injured than females among cycling (83.9%), all-terrain vehicle (86.7%), and snowmobile (100%) traumas. Females were more commonly injured from horseback riding events (42.1%). This study emphasizes the need for rapid translation of research findings into injury prevention awareness and programming in northern British Columbia, particularly relating to cycling, horseback riding, snowmobiling, and all-terrain vehicle operation. Further investigation is required to analyze long-term outcomes for this common injury population.

Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001–2006

In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres. We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model. After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54- 3.22) or hospital stay (RR 0.96, 95% CI 0.65-1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00-1.48). Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.

Are we homogenising risk factors for public health surveillance? Variability in severe injuries on First Nations reserves in British Columbia, 2001–5

BackgroundAboriginal Canadians are considered to be at increased risk of injury. The de facto standard for measuring injury risk factors among Aboriginal Canadians is to compare hospitalisation and mortality against...

A Population-Based Analysis of Injury-Related Deaths and Access to Trauma Care in Rural-Remote Northwest British Columbia

Injury rates and injury mortality rates are generally higher in rural and remote communities compared with urban jurisdictions as has been shown to be the case in the rural-remote area of Northwest (NW) British Columbia (BC). The purpose of study was to identify: (1) the place and timing of death following injury in NW BC, (2) access to and quality of local trauma services, and (3) opportunities to improve trauma outcomes. Quantitative data from demographic and geographic databases, the BC Trauma Registry, Hospital discharge abstract database, and the BC Coroner's Office, along with qualitative data from chart reviews of selected major trauma cases, and interviews with front-line trauma care providers were collated and analyzed for patients sustaining injury in NW BC from April 2001 to March 2006. The majority of trauma deaths (82%) in NW BC occur prehospital. Patients arriving alive to NW hospitals have low hospital mortality (1.0%), and patients transferring from NW BC to tertiary centers have better outcomes than matched patients achieving direct entry into the tertiary center by way of geographic proximity. Access to local trauma services was compromised by: incident discovery, limited phone service (land lines/cell), incomplete 911 emergency medical services system access, geographical and climate challenges compounded by limited transportation options, airport capabilities and paramedic training level, dysfunctional hospital no-refusal policies, lack of a hospital destination policies, and lack of system leadership and coordination. Improving trauma outcomes in this rural-remote jurisdiction requires a systems approach to address root causes of delays in access to care, focusing on improved access to emergency medical services, hospital bypass and destination protocols, improved transportation options, advanced life support transfer capability, and designated, coordinated local trauma services.

Pedestrian injury and the built environment: an environmental scan of hotspots

BackgroundPedestrian injury frequently results in devastating and costly injuries and accounts for 11% of all road user fatalities. In the United States in 2006 there were 4,784 fatalities and 61,000 injuries from pedestrian injury, and in 2007 there were 4,654 fatalities and 70,000 injuries. In Canada, injury is the leading cause of death for those under 45 years of age and the fourth most common cause of death for all ages Traumatic pedestrian injury results in nearly 4000 hospitalizations in Canada annually. These injuries result from the interplay of modifiable environmental factors. The objective of this study was to determine links between the built environment and pedestrian injury hotspots in Vancouver.MethodsData were obtained from the Insurance Corporation of British Columbia (ICBC) for the 6 year period from 2000 to 2005 and combined with pedestrian injury data extracted from the British Columbia Trauma Registry (BCTR) for the same period. High incident locations (hotspots) for pedestrian injury in the City of Vancouver were identified and mapped using geographic information systems (GIS), and the characteristics of the built environment at each of the hotspot locations were examined by a team of researchers.ResultsThe analysis highlighted 32 pedestrian injury hotspot locations in Vancouver. 31 of 32 hotspots were situated on major roads. Likewise, the majority of hotspots were located on downtown streets. The 'downtown eastside' was identified as an area with multiple high-incident locations, including the 2 highest ranked pedestrian injury hotspots. Bars were present at 21 of the hotspot locations, with 11 of these locations being judged to have high alcohol establishment density.ConclusionThis study highlighted the disproportionate burden of pedestrian injury centred on the downtown eastside area of Vancouver. The environmental scan revealed that important passive pedestrian safety countermeasures were only present at a minority of high-incident locations. More importantly, bars were highly associated with risk of pedestrian injury. This study is the basis for potential public health intervention by clearly indicating optimal locations for signalized pedestrian crosswalks.

A Multilevel Analysis of the Socio-spatial Pattern of Assault Injuries in Greater Vancouver, British Columbia

The purposes of this study are to a) determine the extent to which individual and neighbourhood-level socio-economic indicators broadly reflect the social conditions associated with assault injuries within an urban Canadian city, b) examine the significance of this relationship and c) determine if this relationship is best explained at the individual or neighbourhood scale. Assault-related hospitalization data (2001-2006) were obtained from the British Columbia Trauma Registry (BCTR). Data from the 2001 Census were used as proxy measures of individual and neighbourhood socio-economic status (SES). A generalized hierarchical nonlinear model was used to differentiate between individual and neighbourhood effects. A social gradient according to individual and neighbourhood SES and frequency of assault injuries was observed for adults of all ages. After controlling for age and individual SES, probability of greater risk of assault injury among individuals living in progressively less privileged neighbourhoods remained 1.5-3 times higher than individuals living in the least deprived neighbourhoods. For adults under the age of 35, neighbourhood SES was a more statistically significant indicator of increased odds of assault injury than individual income. Assessing compositional and contextual variations in health outcomes provides health researchers engaged in injury surveillance a way of showing how, and for which type of people, neighbourhood environments influence the likelihood that an individual will be hospitalized due to an intentional injury. This analysis suggests that prevention efforts exclusively focused on the individual may have a limited effect in reducing the occurrence of assault-related injuries, especially among young adults.

Are injuries spatially related? Join–count spatial autocorrelation for small-area injury analysis

Objective:To present a geographic information systems (GIS) method for exploring the spatial pattern of injuries and to demonstrate the utility of using this method in conjunction with classic ecological models...

A Model for Identifying and Ranking Need for Trauma Service in Nonmetropolitan Regions Based on Injury Risk and Access to Services

Timely access to definitive trauma care has been shown to improve survival rates after severe injury. Unfortunately, despite development of sophisticated trauma systems, prompt, definitive trauma care remains unavailable to over 50 million North Americans, particularly in rural areas. Measures to quantify social and geographic isolation may provide important insights for the development of health policy aimed at reducing the burden of injury and improving access to trauma care in presently under serviced populations. Indices of social deprivation based on census data, and spatial analyses of access to trauma centers based on street network files were combined into a single index, the Population Isolation Vulnerability Amplifier (PIVA) to characterize vulnerability to trauma in socioeconomically and geographically diverse rural and urban communities across British Columbia. Regions with a sufficient core population that are more than one hour travel time from existing services were ranked based on their level of socioeconomic vulnerability. Ten regions throughout the province were identified as most in need of trauma services based on population, isolation and vulnerability. Likewise, 10 communities were classified as some of the least isolated areas and were simultaneously classified as least vulnerable populations in province. The model was verified using trauma services utilization data from the British Columbia Trauma Registry. These data indicate that including vulnerability in the model provided superior results to running the model based only on population and road travel time. Using the PIVA model we have shown that across Census Urban Areas there are wide variations in population dependence on and distances to accredited tertiary/district trauma centers throughout British Columbia. Many of the factors that influence access to definitive trauma care can be combined into a single quantifiable model that researchers in the health sector can use to predict where to place new services. The model can also be used to locate optimal locations for any basket of health services.

Proportion of injured alcohol-impaired drivers subsequently convicted of an impaired driving criminal code offence in British Columbia

Alcohol is a frequent contributing factor to motor vehicle collision injuries. Our objective was to determine the proportion of intoxicated drivers hospitalized following motor vehicle crashes who were subsequently convicted of an impaired driving criminal code offence. We reviewed British Columbia Trauma Registry records from Jan. 1, 1992, to Mar. 31, 2000, and identified drivers of motor vehicles who were hospitalized for treatment of crash-related injuries. Patient identifiers were then used to link with the Insurance Corporation of British Columbia's (ICBC) contraventions database and the ICBC Traffic Accident System collisions database. Of 6067 patients identified in the Trauma Registry, 4042 had not been administered a blood ethanol test, 209 had no driver's licence match in the relevant databases and 119 died, leaving 1697 eligible patients. Mean age was 34 years, and 79.6% were male. The average Injury Severity Score was 20, the average hospital stay was 14 days and, among ethanol-positive patients, the mean ethanol level was 34.0 mmol/L (156.4 mg/dL). In patients with levels >17.3 mmol/L, the police had listed ethanol as a contributing factor in 70.6% of cases. Despite this, only 11.0% were convicted of impaired driving and 8.4% of another criminal offence; 10.7% received a 24-hour roadside prohibition, 3.9% received a 90-day administrative driving prohibition and 25.0% were convicted of a contravention of the Motor Vehicle Act. Forty-one percent were not convicted of any offence at all. Intoxicated drivers in British Columbia requiring hospitalization as a result of alcohol-related motor vehicle crashes are seldom convicted of impaired driving or other criminal code offences.

Identifying patients at risk for intracranial and extracranial blunt carotid injuries

Blunt carotid injuries are rare, often occult, and potentially devastating. Angiographic screening programs have detected this injury in up to 1% of blunt trauma patients. Implementing a liberal angiographic screening program at our hospital is impractical and we want to identify a high-risk group to target for screening. We hypothesize that intracranial and extracranial carotid injuries have different risks, presentations, and outcomes. Patients with intracranial and extracranial carotid injuries were identified from the British Columbia trauma registry. Presentation and outcome were reviewed. To facilitate statistical modeling the analysis was done by matching cases to 5 randomly selected controls. Risk factors for injury were evaluated by univariate and multiple logistic regression. A total of 35 carotid injuries were identified. Thirteen intracranial injuries were identified in 10 patients. Twenty-two extracranial injuries were identified in 18 patients. Sixty-seven percent of patients with intracranial injuries and 31% of those with extracranial injuries died (P = 0.11). Eleven percent of intracranial injuries and 56% of extracranial injuries were occult (P = 0.04). Glasgow outcome scores were 2.04 intracranial and 3.12 extracranial (P = 0.18). For intracranial injuries the multiple variable predictive model had two predictors: Glasgow Coma Score </=8 and facial fractures. For extracranial the predictors were GCS < or =8 and thoracic injury (Abbreviated Injury Score > or =3). Intracranial injuries were frequently detected on initial investigations and have very poor outcomes. Extracranial injuries were more frequently occult and stand to benefit from early detection by screening programs. As independent risk factors for these two injuries differ, limited screening resources should focus on risk factors for occult extracranial injury: namely, low GCS and significant thoracic injury.

Head injuries in skiers and snowboarders in British Columbia.

At the Vancouver General Hospital Neurosurgical Service there have been a significant number of seriously brain injured snowboarders, seemingly out of proportion to the number of skiers. The purpose of this study was to determine whether snowboarders suffered more serious head injuries than skiers in the Vancouver catchment area. The British Columbia Trauma Registry was searched for patients incurring head injuries while skiing or snowboarding on British Columbia mountains during the period from January 1992 to December 1997. Patients were included if they were admitted to hospital and underwent neurosurgical consultation. A total of 40 skiers and 14 snowboarders met the above criteria. Of the skiers, 15% sustained a severe head injury by Glasgow Coma Score, another 30% sustaining moderate head injuries, while 29% of snowboarders had a severe injury and 36% a moderate injury. A concussion was present in 60% of the skiers and 21% of the snowboarders. Snowboarders suffered an intracranial hemorrhage in 71% of the cases compared to 28% of the skiers. A craniotomy was performed acutely in 10% of skiers and in 29% of snowboarders. Three deaths occurred as a direct result of head injury, one while snowboarding. All but one of the surviving skiers were able to return home, whereas four of 13 surviving snowboarders required additional inpatient rehabilitation or transfer to another acute hospital for ongoing care. Snowboarders suffer more significant head injuries compared to skiers in this series and are much more likely than skiers to require an intracranial procedure. In our opinion, this indicates that additional safety measures, in particular the use of mandatory helmets, should be considered by ski areas and their patrons.