Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Jun 26, 2023
Background Systems ensuring continuity of care through the treatment chain improve outcomes for t... more Background Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals. Methods A population-based cohort study from the national Norwegian Trauma Registry (2015-2020) of adult patients (≥ 16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head ≥ 3, AIS Body < 3 and maximum 1 AIS Body = 2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability. The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P < 0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P < 0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤ 13: 55% vs. 27, P < 0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients < 77 years, and increasing NISSs until the effect was inverted at higher
Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and m... more Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level. Objective: The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system. Methods: This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes. The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020. Conclusions: By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma.
Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and m... more Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level. Objective: The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system. Methods: This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes. The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020. Conclusions: By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma.
Journal of Bone and Joint Surgery, American Volume, Aug 17, 2016
Background: Few studies have evaluated the long-term results for nonoperatively treated acetabula... more Background: Few studies have evaluated the long-term results for nonoperatively treated acetabular fractures. The purpose of this study was to describe the long-term survival of the native acetabulum as well as the clinical and radiographic outcome for patients with nonoperatively treated acetabular fractures. Methods: All patients with acetabular fractures are prospectively registered in our acetabular fracture database and followed up at regular intervals for up to 20 years. We identified 236 patients (237 fractures) who had been treated nonoperatively between 1994 and 2004; 51 patients with incomplete data were excluded. For the survival analysis, 186 fractures with an average follow-up of 9 years (range, 1 to 20 years) were included. For the long-term clinical outcome, 104 patients with an average follow-up of 12.1 years (range, 9 to 20 years) were included. Results: The 10-year survival of the native hips was 94% (111 hips were at risk). Eighty-nine percent of the patients had a good or excellent Harris hip score, and 88% had a good or excellent Merle d'Aubigné and Postel score. The most important negative predictor for clinical outcome and survival of the hip was a fracture step-off of ‡2 mm measured in the obturator oblique radiograph. Conclusions: Nonoperative treatment of minimally displaced acetabular fractures yields good to excellent long-term results. For patients with a questionable indication for fracture surgery, oblique radiographs (Judet views) are a helpful tool in the decisionmaking process, as a fracture step-off of ‡2 mm is a strong predictor for a poor clinical and radiographic result at 10 years.
A prospective single-cohort study of 31 patients surgically treated for pelvic injuries with disp... more A prospective single-cohort study of 31 patients surgically treated for pelvic injuries with displaced sacral fractures. To describe the medium term functional outcome in unstable sacral fractures. Displaced sacral fractures pose a special challenge in orthopedic surgery due to the high rate of associated injuries. Little information is available on the medium-term functional outcome of patients with injuries which include unstable sacral fractures. We examined 31 patients with displaced sacral fractures having 10 mm or more displacement, 1 year (mean, 1.4 years; range, 1.0-2.5 years) after injury. Data from a previous study were supplemented with functional outcome measures (work status, independence in ADL, and SF-36). An association between outcome and tested variables was sought. Fifteen months after injury, 65% of the patients had regained their independence in functions pertaining to daily activities; 33% had returned to work. All dimensions of perceived health were affected. Polytrauma and impairments relative to voiding and sexual function had a detrimental effect on outcome. Fracture characteristics were not predictive of poor outcome. Although the majority of patients achieved independent living, medium-term follow-up indicated significant residual disability. The complex nature of these fractures and the associated injuries should be considered in the rehabilitation of these patients.
Background: The assessment of factors associated with return to work (RTW/NRTW) after multiple tr... more Background: The assessment of factors associated with return to work (RTW/NRTW) after multiple trauma is important in trauma research. Goals in rehabilitation should comprise RTW. The purpose of this study was to examine the RTW rate and which factors that predicted RTW for patients with severe multiple injuries using a prospective cohort design. Methods: 100 patients with a New Injury Severity Score (NISS) >15, age 18–67 admitted to a Level I trauma center were included starting January 2002 through June 2003. Outcomes were assessed 6 weeks after discharge, 1 and 2 years post-injury. Instruments were the Brief Approach/Avoidance Coping Questionnaire, Multi-dimensional Health Locus of Control, SF-36, the WHODAS II and the COG for cognitive functioning. Results: Mean age was 34.5 years (SD 13.5), 83% were male. Mean NISS was 35.1 (SD 12.7). 66% were blue-collar workers. At 1 year 29% achieved complete RTW, 43% at 2 years. Mean time back to work was 12.8 months (SD 5.9). Differences between the RTW/ NRTW groups concerned personal and demographic variables, and physical and psychosocial functioning. Survival analysis showed that risk factors for NRTW were lower education, length of stay in hospital/rehabilitation >20 weeks and low social functioning shortly after the return home. Conclusions: The majority of the patients had not completely returned to work 2 years post-injury. Demographic and injury related factors and social functioning were significant predictors of RTW status.
Background: Hospital readmissions is an increasingly serious international problem, associated wi... more Background: Hospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs' gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs' and nursing home physicians' decision making. Method: The study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality. Results: Seven themes describing how different factors influence physicians' decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians' decision-making. Conclusion: Communication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs' and nursing home physicians' decision-making, nursing home nurses and home care nurses' experience of hospital readmissions and discharges is needed.
Strengths and limitations of this study ► This study, to our knowledge, is the first to explore h... more Strengths and limitations of this study ► This study, to our knowledge, is the first to explore hospital physicians' views on readmissions from the primary healthcare service to the hospitals. ► The sample consists of fellows and residents from several specialties within the surgical and medical fields, providing diverse perspectives on the addressed issues. ► The inclusion of a larger sample of physicians from additional medical specialties, as well as other healthcare personnel, patients and their next of kin, would have provided valuable insights into the issues identified in this study.
Background: Understanding the resilience of healthcare is critically important. A resilient healt... more Background: Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme. Main text: To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience. Conclusion: The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.
Tidsskrift for Den norske lægeforening, Dec 6, 2022
Per Nortvedt er professor emeritus ved Senter for medisinsk etikk og tidligere undervisningsleder... more Per Nortvedt er professor emeritus ved Senter for medisinsk etikk og tidligere undervisningsleder i medisinsk etikk ved Universitetet i Oslo. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter.
Scandinavian journal of plastic and reconstructive surgery and hand surgery, 2006
A 17-year-old man was severely injured including a fractured pelvis and a degloving injury to the... more A 17-year-old man was severely injured including a fractured pelvis and a degloving injury to the lumbar, sacral, and gluteal regions. After multiple revisions, a 6)/7 cm wide)/10 cm deep defect in the sacral area was successfully treated by transfer of a reversed turnover latissimus dorsi muscle flap. He is now fully mobilised three years later.
Injury-international Journal of The Care of The Injured, Mar 1, 2021
Introduction: Geriatric patients have a high risk of poor outcomes after trauma and is a rapid-in... more Introduction: Geriatric patients have a high risk of poor outcomes after trauma and is a rapid-increasing group within the trauma population. Given the need to ensure that the trauma system is targeted, efficient, accessible, safe and responsive to all age groups the aim of the present study was to explore the epidemiology and characteristics of the Norwegian geriatric trauma population and assess differences between age groups within a national trauma system. Materials and methods: This retrospective analysis is based on data from the Norwegian Trauma Registry (2015-2018). Injury severity was scaled using the Abbreviated Injury Scale (AIS), and the New Injury Severity Score (NISS). Trauma patients 16 years or older with NISS ≥9 were included, dichotomized into age groups 16-64 years (Group 1, G1) and ≥65 years (Group 2, G2). The groups were compared with respect to differences in demographics, injury characteristics, management and outcome. Descriptive statistics and relevant parametric and non-parametric tests were used. Results: Geriatric patients proved to be at risk of sustaining severe injuries. Low-energy falls predominated in G2, and the AIS body regions 'Head' and 'Pelvis and lower extremities' were most frequently injured. Crude 30-day mortality was higher in G2 compared to G1 (G1: 2.9 vs. G2: 13.6%, P < 0.01) and the trauma team activation (TTA) rate was lower (G1: 90 vs. G2: 73%, P < 0.01). A lower proportion of geriatric patients were treated by a physician prehospitally (G1: 30 vs. G2: 18%, [NISS 15-24], P < 0.01) and transported by air-ambulance (G1: 24 vs. G2: 14%, [NISS 15-24], P < 0.01). Median time from alarm to hospital admission was longer for geriatric patients (G1: 71 vs. G2: 78 min [NISS 15-24], P < 0.01), except for the most severely injured patients (NISS ≥25). Conclusion: In this nationwide study comparing adult and geriatric trauma patients, geriatric patients were found to have a higher mortality, receive less frequently advanced prehospital treatment and transportation, and a lower TTA rate. This is surprising in the setting of a Nordic country with free access to publicly funded emergency services, a nationally implemented trauma system with requirements to pre-and in-hospital services and a national trauma registry with high individual level coverage from all trauma-receiving hospitals. Further exploration and a deeper understanding of these differences is warranted.
Background Comparison of patient-reported outcomes in multilingual studies requires evidence of t... more Background Comparison of patient-reported outcomes in multilingual studies requires evidence of the equivalence of translated versions of the questionnaires. The present study examines the factorial validity and comparability of six language versions of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) administered to individuals following traumatic brain injury (TBI) in the Collaborative European NeuroTrauma Effectiveness Research (CENTER-TBI) study. Methods Six competing RPQ models were estimated using data from Dutch (n = 597), English (n = 223), Finnish (n = 213), Italian (n = 268), Norwegian (n = 263), and Spanish (n = 254) language samples recruited six months after injury. To determine whether the same latent construct was measured by the best-fitting model across languages and TBI severity groups (mild/moderate vs. severe), measurement invariance (MI) was tested using a confirmatory factor analysis framework. Results The results did not indicate a violation of the M...
Background Lack of physician involvement in quality improvement threatens the success and sustain... more Background Lack of physician involvement in quality improvement threatens the success and sustainability of quality improvement measures. It is therefore important to assess physicians´ interests and opportunities to be involved in quality improvement and their experiences of such participation, both in hospital and general practice. Methods A cross-sectional postal survey was conducted on a representative sample of physicians in different job positions in Norway in 2019. Results The response rate was 72.6% (1513 of 2085). A large proportion (85.7%) of the physicians wanted to participate in quality improvement, and 68.6% had actively done so in the last year. Physicians’ interest in quality improvement and their active participation was significantly related to the designated time for quality improvement in their work-hour schedule (p < 0.001). Only 16.7% reported time designated for quality improvement in their own work hours. When time was designated, 86.6% of the physicians r...
Traumatic brain injury (TBI) is frequently associated with neuropsychiatric impairments such as s... more Traumatic brain injury (TBI) is frequently associated with neuropsychiatric impairments such as symptoms of post-traumatic stress disorder (PTSD), which can be screened using self-report instruments such as the Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5). The current study aims to inspect the factorial validity and cross-linguistic equivalence of the PCL-5 in individuals after TBI with differential severity. Data for six language groups (n ≥ 200; Dutch, English, Finnish, Italian, Norwegian, Spanish) were extracted from the CENTER-TBI study database. Factorial validity of PTSD was evaluated using confirmatory factor analyses (CFA), and compared between four concurrent structural models. A multi-group CFA approach was utilized to investigate the measurement invariance (MI) of the PCL-5 across languages. All structural models showed satisfactory goodness-of-fit with small between-model variation. The original DSM-5 model for PTSD provided solid evidence of MI across the ...
There is increasing emphasis on assessing multi-dimensional outcomes in traumatic brain injury (T... more There is increasing emphasis on assessing multi-dimensional outcomes in traumatic brain injury (TBI), but achieving this aim is hampered by a plethora of overlapping assessment tools. There is a clear need for advice on the choice of outcomes and we examined level of functional recovery as a framework to guide selection of assessments. In this cohort study we analysed cross-sectional data from 2604 patients enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) project. Patients were followed up 6 months after injury and assessed on the Glasgow Outcome Scale-Extended (GOSE), cognitive tests, and patient-reported outcomes. We describe assessment completeness and prevalence of impairment. Relationships between outcomes were visualized using UpSet plots and hierarchical cluster analysis. GOSE categories varied markedly for both completion rates, 34-91% for patient-reported outcomes and 9-81% for cognitive tests, and prevalence of impairment, 3-82% for patient-reported outcomes and 9-59% for cognitive tests. In complete case samples, the GOSE identified impairment in 59-61%, whereas the most impaired patient-reported outcome was the Short Form-12 version 2 (SF-12v2) Physical Component Summary (28% overall), and the most impaired cognitive test was Trail Making Test (TMT) Part A (19% overall). The findings show that degree of disability is a key context of use for cognitive tests and patient-reported outcomes. Level of functional recovery provides a guide to the feasibility of different types of assessment and the likelihood of impairment, and can help tailor suitable assessment approaches in clinical practice and research studies.
Objective To compare outcomes between patients with primary external ventricular device (EVD)–dri... more Objective To compare outcomes between patients with primary external ventricular device (EVD)–driven treatment of intracranial hypertension and those with primary intraparenchymal monitor (IP)–driven treatment. Methods The CENTER-TBI study is a prospective, multicenter, longitudinal observational cohort study that enrolled patients of all TBI severities from 62 participating centers (mainly level I trauma centers) across Europe between 2015 and 2017. Functional outcome was assessed at 6 months and a year. We used multivariable adjusted instrumental variable (IV) analysis with “center” as instrument and logistic regression with covariate adjustment to determine the effect estimate of EVD on 6-month functional outcome. Results A total of 878 patients of all TBI severities with an indication for intracranial pressure (ICP) monitoring were included in the present study, of whom 739 (84%) patients had an IP monitor and 139 (16%) an EVD. Patients included were predominantly male (74% in t...
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Jun 26, 2023
Background Systems ensuring continuity of care through the treatment chain improve outcomes for t... more Background Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals. Methods A population-based cohort study from the national Norwegian Trauma Registry (2015-2020) of adult patients (≥ 16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head ≥ 3, AIS Body < 3 and maximum 1 AIS Body = 2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability. The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P < 0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P < 0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤ 13: 55% vs. 27, P < 0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients < 77 years, and increasing NISSs until the effect was inverted at higher
Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and m... more Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level. Objective: The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system. Methods: This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes. The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020. Conclusions: By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma.
Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and m... more Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level. Objective: The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system. Methods: This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes. The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020. Conclusions: By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma.
Journal of Bone and Joint Surgery, American Volume, Aug 17, 2016
Background: Few studies have evaluated the long-term results for nonoperatively treated acetabula... more Background: Few studies have evaluated the long-term results for nonoperatively treated acetabular fractures. The purpose of this study was to describe the long-term survival of the native acetabulum as well as the clinical and radiographic outcome for patients with nonoperatively treated acetabular fractures. Methods: All patients with acetabular fractures are prospectively registered in our acetabular fracture database and followed up at regular intervals for up to 20 years. We identified 236 patients (237 fractures) who had been treated nonoperatively between 1994 and 2004; 51 patients with incomplete data were excluded. For the survival analysis, 186 fractures with an average follow-up of 9 years (range, 1 to 20 years) were included. For the long-term clinical outcome, 104 patients with an average follow-up of 12.1 years (range, 9 to 20 years) were included. Results: The 10-year survival of the native hips was 94% (111 hips were at risk). Eighty-nine percent of the patients had a good or excellent Harris hip score, and 88% had a good or excellent Merle d'Aubigné and Postel score. The most important negative predictor for clinical outcome and survival of the hip was a fracture step-off of ‡2 mm measured in the obturator oblique radiograph. Conclusions: Nonoperative treatment of minimally displaced acetabular fractures yields good to excellent long-term results. For patients with a questionable indication for fracture surgery, oblique radiographs (Judet views) are a helpful tool in the decisionmaking process, as a fracture step-off of ‡2 mm is a strong predictor for a poor clinical and radiographic result at 10 years.
A prospective single-cohort study of 31 patients surgically treated for pelvic injuries with disp... more A prospective single-cohort study of 31 patients surgically treated for pelvic injuries with displaced sacral fractures. To describe the medium term functional outcome in unstable sacral fractures. Displaced sacral fractures pose a special challenge in orthopedic surgery due to the high rate of associated injuries. Little information is available on the medium-term functional outcome of patients with injuries which include unstable sacral fractures. We examined 31 patients with displaced sacral fractures having 10 mm or more displacement, 1 year (mean, 1.4 years; range, 1.0-2.5 years) after injury. Data from a previous study were supplemented with functional outcome measures (work status, independence in ADL, and SF-36). An association between outcome and tested variables was sought. Fifteen months after injury, 65% of the patients had regained their independence in functions pertaining to daily activities; 33% had returned to work. All dimensions of perceived health were affected. Polytrauma and impairments relative to voiding and sexual function had a detrimental effect on outcome. Fracture characteristics were not predictive of poor outcome. Although the majority of patients achieved independent living, medium-term follow-up indicated significant residual disability. The complex nature of these fractures and the associated injuries should be considered in the rehabilitation of these patients.
Background: The assessment of factors associated with return to work (RTW/NRTW) after multiple tr... more Background: The assessment of factors associated with return to work (RTW/NRTW) after multiple trauma is important in trauma research. Goals in rehabilitation should comprise RTW. The purpose of this study was to examine the RTW rate and which factors that predicted RTW for patients with severe multiple injuries using a prospective cohort design. Methods: 100 patients with a New Injury Severity Score (NISS) >15, age 18–67 admitted to a Level I trauma center were included starting January 2002 through June 2003. Outcomes were assessed 6 weeks after discharge, 1 and 2 years post-injury. Instruments were the Brief Approach/Avoidance Coping Questionnaire, Multi-dimensional Health Locus of Control, SF-36, the WHODAS II and the COG for cognitive functioning. Results: Mean age was 34.5 years (SD 13.5), 83% were male. Mean NISS was 35.1 (SD 12.7). 66% were blue-collar workers. At 1 year 29% achieved complete RTW, 43% at 2 years. Mean time back to work was 12.8 months (SD 5.9). Differences between the RTW/ NRTW groups concerned personal and demographic variables, and physical and psychosocial functioning. Survival analysis showed that risk factors for NRTW were lower education, length of stay in hospital/rehabilitation >20 weeks and low social functioning shortly after the return home. Conclusions: The majority of the patients had not completely returned to work 2 years post-injury. Demographic and injury related factors and social functioning were significant predictors of RTW status.
Background: Hospital readmissions is an increasingly serious international problem, associated wi... more Background: Hospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs' gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs' and nursing home physicians' decision making. Method: The study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality. Results: Seven themes describing how different factors influence physicians' decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians' decision-making. Conclusion: Communication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs' and nursing home physicians' decision-making, nursing home nurses and home care nurses' experience of hospital readmissions and discharges is needed.
Strengths and limitations of this study ► This study, to our knowledge, is the first to explore h... more Strengths and limitations of this study ► This study, to our knowledge, is the first to explore hospital physicians' views on readmissions from the primary healthcare service to the hospitals. ► The sample consists of fellows and residents from several specialties within the surgical and medical fields, providing diverse perspectives on the addressed issues. ► The inclusion of a larger sample of physicians from additional medical specialties, as well as other healthcare personnel, patients and their next of kin, would have provided valuable insights into the issues identified in this study.
Background: Understanding the resilience of healthcare is critically important. A resilient healt... more Background: Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme. Main text: To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience. Conclusion: The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.
Tidsskrift for Den norske lægeforening, Dec 6, 2022
Per Nortvedt er professor emeritus ved Senter for medisinsk etikk og tidligere undervisningsleder... more Per Nortvedt er professor emeritus ved Senter for medisinsk etikk og tidligere undervisningsleder i medisinsk etikk ved Universitetet i Oslo. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter.
Scandinavian journal of plastic and reconstructive surgery and hand surgery, 2006
A 17-year-old man was severely injured including a fractured pelvis and a degloving injury to the... more A 17-year-old man was severely injured including a fractured pelvis and a degloving injury to the lumbar, sacral, and gluteal regions. After multiple revisions, a 6)/7 cm wide)/10 cm deep defect in the sacral area was successfully treated by transfer of a reversed turnover latissimus dorsi muscle flap. He is now fully mobilised three years later.
Injury-international Journal of The Care of The Injured, Mar 1, 2021
Introduction: Geriatric patients have a high risk of poor outcomes after trauma and is a rapid-in... more Introduction: Geriatric patients have a high risk of poor outcomes after trauma and is a rapid-increasing group within the trauma population. Given the need to ensure that the trauma system is targeted, efficient, accessible, safe and responsive to all age groups the aim of the present study was to explore the epidemiology and characteristics of the Norwegian geriatric trauma population and assess differences between age groups within a national trauma system. Materials and methods: This retrospective analysis is based on data from the Norwegian Trauma Registry (2015-2018). Injury severity was scaled using the Abbreviated Injury Scale (AIS), and the New Injury Severity Score (NISS). Trauma patients 16 years or older with NISS ≥9 were included, dichotomized into age groups 16-64 years (Group 1, G1) and ≥65 years (Group 2, G2). The groups were compared with respect to differences in demographics, injury characteristics, management and outcome. Descriptive statistics and relevant parametric and non-parametric tests were used. Results: Geriatric patients proved to be at risk of sustaining severe injuries. Low-energy falls predominated in G2, and the AIS body regions 'Head' and 'Pelvis and lower extremities' were most frequently injured. Crude 30-day mortality was higher in G2 compared to G1 (G1: 2.9 vs. G2: 13.6%, P < 0.01) and the trauma team activation (TTA) rate was lower (G1: 90 vs. G2: 73%, P < 0.01). A lower proportion of geriatric patients were treated by a physician prehospitally (G1: 30 vs. G2: 18%, [NISS 15-24], P < 0.01) and transported by air-ambulance (G1: 24 vs. G2: 14%, [NISS 15-24], P < 0.01). Median time from alarm to hospital admission was longer for geriatric patients (G1: 71 vs. G2: 78 min [NISS 15-24], P < 0.01), except for the most severely injured patients (NISS ≥25). Conclusion: In this nationwide study comparing adult and geriatric trauma patients, geriatric patients were found to have a higher mortality, receive less frequently advanced prehospital treatment and transportation, and a lower TTA rate. This is surprising in the setting of a Nordic country with free access to publicly funded emergency services, a nationally implemented trauma system with requirements to pre-and in-hospital services and a national trauma registry with high individual level coverage from all trauma-receiving hospitals. Further exploration and a deeper understanding of these differences is warranted.
Background Comparison of patient-reported outcomes in multilingual studies requires evidence of t... more Background Comparison of patient-reported outcomes in multilingual studies requires evidence of the equivalence of translated versions of the questionnaires. The present study examines the factorial validity and comparability of six language versions of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) administered to individuals following traumatic brain injury (TBI) in the Collaborative European NeuroTrauma Effectiveness Research (CENTER-TBI) study. Methods Six competing RPQ models were estimated using data from Dutch (n = 597), English (n = 223), Finnish (n = 213), Italian (n = 268), Norwegian (n = 263), and Spanish (n = 254) language samples recruited six months after injury. To determine whether the same latent construct was measured by the best-fitting model across languages and TBI severity groups (mild/moderate vs. severe), measurement invariance (MI) was tested using a confirmatory factor analysis framework. Results The results did not indicate a violation of the M...
Background Lack of physician involvement in quality improvement threatens the success and sustain... more Background Lack of physician involvement in quality improvement threatens the success and sustainability of quality improvement measures. It is therefore important to assess physicians´ interests and opportunities to be involved in quality improvement and their experiences of such participation, both in hospital and general practice. Methods A cross-sectional postal survey was conducted on a representative sample of physicians in different job positions in Norway in 2019. Results The response rate was 72.6% (1513 of 2085). A large proportion (85.7%) of the physicians wanted to participate in quality improvement, and 68.6% had actively done so in the last year. Physicians’ interest in quality improvement and their active participation was significantly related to the designated time for quality improvement in their work-hour schedule (p < 0.001). Only 16.7% reported time designated for quality improvement in their own work hours. When time was designated, 86.6% of the physicians r...
Traumatic brain injury (TBI) is frequently associated with neuropsychiatric impairments such as s... more Traumatic brain injury (TBI) is frequently associated with neuropsychiatric impairments such as symptoms of post-traumatic stress disorder (PTSD), which can be screened using self-report instruments such as the Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5). The current study aims to inspect the factorial validity and cross-linguistic equivalence of the PCL-5 in individuals after TBI with differential severity. Data for six language groups (n ≥ 200; Dutch, English, Finnish, Italian, Norwegian, Spanish) were extracted from the CENTER-TBI study database. Factorial validity of PTSD was evaluated using confirmatory factor analyses (CFA), and compared between four concurrent structural models. A multi-group CFA approach was utilized to investigate the measurement invariance (MI) of the PCL-5 across languages. All structural models showed satisfactory goodness-of-fit with small between-model variation. The original DSM-5 model for PTSD provided solid evidence of MI across the ...
There is increasing emphasis on assessing multi-dimensional outcomes in traumatic brain injury (T... more There is increasing emphasis on assessing multi-dimensional outcomes in traumatic brain injury (TBI), but achieving this aim is hampered by a plethora of overlapping assessment tools. There is a clear need for advice on the choice of outcomes and we examined level of functional recovery as a framework to guide selection of assessments. In this cohort study we analysed cross-sectional data from 2604 patients enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) project. Patients were followed up 6 months after injury and assessed on the Glasgow Outcome Scale-Extended (GOSE), cognitive tests, and patient-reported outcomes. We describe assessment completeness and prevalence of impairment. Relationships between outcomes were visualized using UpSet plots and hierarchical cluster analysis. GOSE categories varied markedly for both completion rates, 34-91% for patient-reported outcomes and 9-81% for cognitive tests, and prevalence of impairment, 3-82% for patient-reported outcomes and 9-59% for cognitive tests. In complete case samples, the GOSE identified impairment in 59-61%, whereas the most impaired patient-reported outcome was the Short Form-12 version 2 (SF-12v2) Physical Component Summary (28% overall), and the most impaired cognitive test was Trail Making Test (TMT) Part A (19% overall). The findings show that degree of disability is a key context of use for cognitive tests and patient-reported outcomes. Level of functional recovery provides a guide to the feasibility of different types of assessment and the likelihood of impairment, and can help tailor suitable assessment approaches in clinical practice and research studies.
Objective To compare outcomes between patients with primary external ventricular device (EVD)–dri... more Objective To compare outcomes between patients with primary external ventricular device (EVD)–driven treatment of intracranial hypertension and those with primary intraparenchymal monitor (IP)–driven treatment. Methods The CENTER-TBI study is a prospective, multicenter, longitudinal observational cohort study that enrolled patients of all TBI severities from 62 participating centers (mainly level I trauma centers) across Europe between 2015 and 2017. Functional outcome was assessed at 6 months and a year. We used multivariable adjusted instrumental variable (IV) analysis with “center” as instrument and logistic regression with covariate adjustment to determine the effect estimate of EVD on 6-month functional outcome. Results A total of 878 patients of all TBI severities with an indication for intracranial pressure (ICP) monitoring were included in the present study, of whom 739 (84%) patients had an IP monitor and 139 (16%) an EVD. Patients included were predominantly male (74% in t...
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Papers by Olav Røise