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Evidence for an association between opioid use and risk of falls or fractures in older adults is inconsistent. We examine the association between recent opioid use and the risk, as well as the clinical outcomes, of fall-related injuries in a large trauma population of older adults. In a retrospective, observational, multicentre cohort study conducted on registry data, we included all patients aged 65 years and older who were admitted (hospital stay > 2 d) for injury in 57 trauma centres in the province of Quebec, Canada, between 2004 and 2014. We looked at opioid prescriptions filled in the 2 weeks preceding the trauma in patients who sustained a fall, compared with those who sustained an injury through another mechanism. A total of 67 929 patients were retained for analysis. Mean age was 80.9 (± 8.0) years and 69% were women. The percentage of patients who had filled an opioid prescription in the 2 weeks preceding an injury was 4.9% (95% confidence interval [CI] 4.7%–5.1%) for patients who had had a fall, compared with 1.5% (95% CI 1.2%–1.8%) for those who had had an injury through another mechanism. After we controlled for confounding variables, patients who had filled an opioid prescription within 2 weeks before injury were 2.4 times more likely to have a fall rather than any other type of injury. For patients who had a fall-related injury, those who used opioids were at increased risk of in-hospital death (odds ratio 1.58; 95% CI 1.34–1.86). Recent opioid use is associated with an increased risk of fall and an increased likelihood of death in older adults.

Children with major trauma have better outcomes when treated in pediatric trauma centres, but population-based data on access to these centres in Canada are lacking. We aimed to estimate the proportion of children with major trauma who accessed a pediatric trauma centre in Canada (through direct transport or transfer) and compare access across provinces. We conducted a population-based cohort study of children (aged < 16 yr) who were admitted to hospital after a major trauma (Injury Severity Score > 12) in 9 Canadian provinces (excluding Quebec) from 2016 to 2021. We estimated the adjusted incidence of access to a pediatric trauma centre across provinces using robust Poisson regression and examined the effect of age and injury severity in subgroup analyses. Of 3007 children with major trauma, 2335 (77.6%) were directly transported (n = 879, 29.2%) or transferred (n = 1456, 48.4%) to a pediatric trauma centre. Crude access to pediatric trauma centres was higher for younger children (80.9% among those aged 0 to 5 yr, 81.7% among those aged 6 to 12 yr, 69.9% among those aged 13 to 15 yr) and those with critical injuries (88.8%). Adjusted pediatric trauma centre access was lower in British Columbia (relative risk [RR] 0.68, 95% confidence interval [CI] 0.63 to 0.74), the Atlantic provinces (RR 0.80, 95% CI 0.73 to 0.88), and Saskatchewan (RR 0.77, 95% CI 0.69 to 0.86) than Ontario, but was higher in Alberta (RR 1.06, 95% CI 1.02 to 1.10) and Manitoba (RR 1.14, 95% CI 1.09 to 1.19). Interprovincial differences were present across all subgroups (p < 0.0001). Across 9 Canadian provinces, 1 in 4 children with major trauma did not receive care in a pediatric trauma centre. These results suggest the opportunity for improvement in Canadian trauma systems to ensure that all children receive optimal injury care.

Severe traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine. To evaluate variation in mortality following the withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale). We randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval [CI] 28.4%–35.2%) and ranged from 10.8% to 44.2% across centres (χ2 test for overall difference, p < 0.001). Most deaths (70.2% [160/228], 95% CI 63.9%–75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) (χ2 test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care. We observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury.

Most deaths in critically ill patients with severe traumatic brain injury are associated with a decision to withdraw life-sustaining treatments. We aimed to identify the behavioural determinants that influence recommendations by critical care physicians to consider the withdrawal of life-sustaining treatments in this population. We conducted a descriptive qualitative study based on the Theoretical Domains Framework of critical care physicians caring for patients with severe traumatic brain injury across Canada. We stratified critical care physicians by regions and used a purposive sampling strategy. We conducted semistructured phone interviews using a piloted and pretested interview guide. We transcribed the interviews verbatim and verified the content for accuracy. We performed the analysis using a 3-step approach: coding, generation of specific beliefs and generation of specific themes. We recruited 20 critical care physicians across 4 geographic regions. After reaching saturation, we identified 7 core themes across 4 Theoretical Domains Framework domains for factors relevant to the decision to withdraw life-sustaining treatments. Four factors (i.e., clinical triggers, social triggers, interaction with families and intentions with medical decisions) were identified before the decision is made and 3 were identified during the decision-making process (i.e., considerations, priorities and knowledge needs). We identified multiple themes reflecting internal (n = 18, 8 Theoretical Domains Framework domains) and external (n = 15, 6 Theoretical Domains Framework domains) influences on the decision to withdraw life-sustaining treatments. We identified several core themes and domains considered by critical care physicians in Canada in the decision to withdraw life-sustaining treatments in critically ill patients with severe traumatic brain injury. Future research should aim at identifying the factors influencing surrogate decision-makers in the decision to withdraw life-sustaining treatments in these patients.

To evaluate the incidence, determinants and impact on outcome of in-hospital complications in adults with traumatic brain injury (TBI). We conducted a multicenter cohort study of TBI patients admitted between 2007 and 2012 in an inclusive Canadian trauma system. Risk ratios of complications, odds ratios of mortality and geometric mean ratios of length of stay (LOS) were calculated using generalized linear models with adjustment for prognostic indicators and hospital cluster effects. Of 12,887 patients, 3.2% had at least one neurological complication and 22.6% a non-neurological complication. Mechanical ventilation, head injury severity, blood transfusion and neurosurgical intervention had the strongest correlation with neurological complications. Mechanical ventilation, the Glasgow Coma Scale, blood transfusion and concomitant injuries had the strongest correlation with non-neurological complications. Neurological and non-neurological complications were associated with a 85% and 53% increase in the odds of mortality, and a 60% and two-fold increases in LOS, respectively. More than 20% of patients with TBI developed a complication. Many of these complications were associated with increased mortality and LOS. Results highlight the importance of prevention strategies adapted to treatment decisions and underline the need to improve knowledge on the underuse and overuse of clinical interventions. •1/33 and 1/5 TBI admissions develop neurological and non-neurological complications.•50% increase in mortality and 100% increase in LOS•Treatments explain more variation in complications rates than patient risk factors.•Highlights the importance of prevention strategies adapted to treatment decisions•Underlines the need to improve knowledge on intervention underuse and overuse

AbstractObjectivesThe aim of this study was: (1) to adapt the time‐driven activity‐based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time. MethodsTDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015–2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field. ResultsOverall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals. ConclusionsThe greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated‐time‐based and measured‐time‐based costing. TDABC should be applied using objective measurement of the time per procedure.

Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS). We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999–2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS. Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [CI]) of mortality for level III and IV centres were 1.71 (1.03–2.85) and 2.25 (1.08–4.73), respectively. Surgical delays did not vary across designation levels, but mean LOS and complications were lower in level II–IV centres than level I centres. Level I/II centres may offer a survival advantage over level III/IV centres for patients requiring emergency intervention for hemorrhagic shock. Further research with larger sample sizes is required to confirm these results and to identify optimal transport time thresholds for bypassing level III/IV centres in favour of level I/II centres. Le choc hémorragique est responsable de 45 % des décès chez les polytraumatisés en Amérique du Nord, et 50 % de ces décès surviennent dans les 2 h suivant le traumatisme. On ne dispose pas actuellement de données concernant la trajectoire des patients en état de choc hémorragique et les bénéfices potentiels de soins de niveaux I/II pour ces patients. Nous avons voulu comparer la mortalité selon les niveaux de désignation des centres de traumatologie pour les patients en état de choc hémorragique. Les objectifs secondaires étaient de comparer les délais d’accès à la chirurgie, les complications et la durée des séjours hospitaliers. Nous avons procédé à une étude de cohorte rétrospective basée sur un système de traumatologie inclusif au Canada (1999–2012), incluant des adultes dont la tension artérielle systolique (TAS) était < 90 mm Hg à l’arrivée et qui nécessitaient un traitement chirurgical urgent (< 6 h). La régression logistique a été utilisée pour analyser l’influence du niveau de désignation du centre de traumatologie sur le délai d’accès à la chirurgie, la mortalité et les complications ajustés selon le risque. La régression linéaire a été utilisée pour analyser la durée du séjour hospitalier. Comparativement aux centres de niveau I, les rapports des cotes ajustés (et les intervalles de confiance [IC] de 95 %) de mortalité pour les centres de niveaux III et IV ont été 1,71 (1,03–2,85) et 2,25 (1,08–4,73), respectivement. Les délais d’accès à la chirurgie n’ont pas varié en fonction des niveaux de désignation, mais la durée moyenne du séjour hospitalier et les complications étaient moindres dans les centres de niveaux II et IV comparativement aux centres de niveau I. Les centres de niveaux I/II peuvent offrir des avantages au plan de la survie comparativement aux centres de niveaux III/IV pour les patients en état de choc hémorragique qui ont besoin d’une intervention d’urgence. Il faudra approfondir la recherche auprès d’échantillons de plus grande taille pour confirmer ces résultats et établir les seuils optimaux en termes de temps de transport permettant de passer outre les centres de niveaux III/IV en faveur des centres de niveaux I/II.