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...
Oddvar Uleberg er ph.d., spesialist i anestesiologi og overlege ved Klinikk for akutt-og mottaksm... more Oddvar Uleberg er ph.d., spesialist i anestesiologi og overlege ved Klinikk for akutt-og mottaksmedisin, St. Olavs hospital i Trondheim og postdoktor ved Akuttklinikken, Oslo universitetssykehus. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Thomas Kristiansen er ph.d., spesialist i anestesiologi og overlege ved Akuttklinikken, Oslo universitetssykehus og forsker ved Det medisinske fakultet, Universitetet i Oslo. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Trond Nordseth er ph.d., spesialist i anestesiologi og overlege. Forfatteren har fylt ut ICMJE-skjemaet og oppgir følgende interessekonflikter: Han har mottatt interne midler fra Oslo universitetssykehus. Jo Steinson Stenehjem er ph.d. i epidemiologi og forsker ved forskningsavdelingen, Kreftregisteret. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Jon Michael Gran er førsteamanuensis i biostatistikk ved Universitetet i Oslo. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Thomas Clausen er senterleder og professor ved Senter for rus-og avhengighetsforskning (SERAF), Universitetet i Oslo.
BACKGROUND Older trauma patients are reported to receive lower levels of care than younger adults... more BACKGROUND Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients holds important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations. METHODS Retrospective analysis of the Norwegian Trauma Registry for 2015-2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score (NISS) ≥9 were included, dichotomized into age groups 16-64 years and ≥ 65 years. Prehospital and emergency department clinical management, advanced airway management (AAM), chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests. RESULTS 9543 patients were included, of which 28% (n = 2711) were ≥ 65 years. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (OR 0.64, 95% CI 0.57-0.71), conveyed by air ambulance (OR 0.65, 95% CI 0.58-0.73), and transported directly to a trauma center (OR 0.86, 95% CI 0.79 - 0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with NISS≥25, showing lower rates for older adults (AAM: OR 0.60, 95% CI 0.47-0.76; Chest decompression: OR 0.46, 95% CI 0.25-0.85; X-ray chest: OR 0.54, 95% CI 0.39-0.75; X-ray pelvis: OR 0.69, 95% CI 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups. CONCLUSIONS Older trauma patients were less likely to receive advanced prehospital care compared to younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities. LEVEL OF EVIDENCE Epidemiological study, level III.
BACKGROUND Frailty is known to be associated with poorer outcomes in individuals admitted to hosp... more BACKGROUND Frailty is known to be associated with poorer outcomes in individuals admitted to hospital for medical conditions requiring intensive care. However, little evidence is available for the effect of frailty on patients' outcomes after traumatic brain injury. Many frailty indices have been validated for clinical practice and show good performance to predict clinical outcomes. However, each is specific to a particular clinical context. We aimed to develop a frailty index to predict 6-month outcomes in patients after a traumatic brain injury. METHODS A cumulative deficit approach was used to create a novel frailty index based on 30 items dealing with disease states, current medications, and laboratory values derived from data available from CENTER-TBI, a prospective, longitudinal observational study of patients with traumatic brain injury presenting within 24 h of injury and admitted to a ward or an intensive care unit at 65 centres in Europe between Dec 19, 2014, and Dec 17, 2017. From the individual cumulative CENTER-TBI frailty index (range 0-30), we obtained a standardised value (range 0-1), with high scores indicating higher levels of frailty. The effect of frailty on 6-month outcome evaluated with the extended Glasgow Outcome Scale (GOSE) was assessed through a proportional odds logistic model adjusted for known outcome predictors. An unfavourable outcome was defined as death or severe disability (GOSE score ≤4). External validation was performed on data from TRACK-TBI, a prospective observational study co-designed with CENTER-TBI, which enrolled patients with traumatic brain injury at 18 level I trauma centres in the USA from Feb 26, 2014, to July 27, 2018. CENTER-TBI is registered with ClinicalTrials.gov, NCT02210221; TRACK-TBI is registered at ClinicalTrials.gov, NCT02119182. FINDINGS 2993 participants (median age was 51 years [IQR 30-67], 2058 [69%] were men) were included in this analysis. The overall median CENTER-TBI frailty index score was 0·07 (IQR 0·03-0·15), with a median score of 0·17 (0·08-0·27) in older adults (aged ≥65 years). The CENTER-TBI frailty index score was significantly associated with the probability of an increasingly unfavourable outcome (cumulative odds ratio [OR] 1·03, 95% CI 1·02-1·04; p<0·0001), and the association was stronger for participants admitted to hospital wards (1·04, 1·03-1·06, p<0·0001) compared with those admitted to the intensive care unit (1·02, 1·01-1·03 p<0·0001). External validation of the CENTER-TBI frailty index in data from the TRACK-TBI (n=1667) cohort supported the robustness and reliability of these findings. The overall median TRACK-TBI frailty index score was 0·03 (IQR 0-0·10), with the frailty index score significantly associated with the risk of an increasingly unfavourable outcome in patients admitted to hospital wards (cumulative OR 1·05, 95% CI 1·03-1·08; p<0·0001), but not in those admitted to the intensive care unit (1·01, 0·99-1·03; p=0·43). INTERPRETATION We developed and externally validated a frailty index specific to traumatic brain injury. Risk of unfavourable outcome was significantly increased in participants with a higher CENTER-TBI frailty index score, regardless of age. Frailty identification could help to individualise rehabilitation approaches aimed at mitigating effects of frailty in patients with traumatic brain injury. FUNDING European Union, Hannelore Kohl Stiftung, OneMind, Integra LifeSciences Corporation, NeuroTrauma Sciences, NIH-NINDS-TRACK-TBI, US Department of Defense.
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...
Oddvar Uleberg er ph.d., spesialist i anestesiologi og overlege ved Klinikk for akutt-og mottaksm... more Oddvar Uleberg er ph.d., spesialist i anestesiologi og overlege ved Klinikk for akutt-og mottaksmedisin, St. Olavs hospital i Trondheim og postdoktor ved Akuttklinikken, Oslo universitetssykehus. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Thomas Kristiansen er ph.d., spesialist i anestesiologi og overlege ved Akuttklinikken, Oslo universitetssykehus og forsker ved Det medisinske fakultet, Universitetet i Oslo. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Trond Nordseth er ph.d., spesialist i anestesiologi og overlege. Forfatteren har fylt ut ICMJE-skjemaet og oppgir følgende interessekonflikter: Han har mottatt interne midler fra Oslo universitetssykehus. Jo Steinson Stenehjem er ph.d. i epidemiologi og forsker ved forskningsavdelingen, Kreftregisteret. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Jon Michael Gran er førsteamanuensis i biostatistikk ved Universitetet i Oslo. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter. Thomas Clausen er senterleder og professor ved Senter for rus-og avhengighetsforskning (SERAF), Universitetet i Oslo.
BACKGROUND Older trauma patients are reported to receive lower levels of care than younger adults... more BACKGROUND Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients holds important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations. METHODS Retrospective analysis of the Norwegian Trauma Registry for 2015-2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score (NISS) ≥9 were included, dichotomized into age groups 16-64 years and ≥ 65 years. Prehospital and emergency department clinical management, advanced airway management (AAM), chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests. RESULTS 9543 patients were included, of which 28% (n = 2711) were ≥ 65 years. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (OR 0.64, 95% CI 0.57-0.71), conveyed by air ambulance (OR 0.65, 95% CI 0.58-0.73), and transported directly to a trauma center (OR 0.86, 95% CI 0.79 - 0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with NISS≥25, showing lower rates for older adults (AAM: OR 0.60, 95% CI 0.47-0.76; Chest decompression: OR 0.46, 95% CI 0.25-0.85; X-ray chest: OR 0.54, 95% CI 0.39-0.75; X-ray pelvis: OR 0.69, 95% CI 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups. CONCLUSIONS Older trauma patients were less likely to receive advanced prehospital care compared to younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities. LEVEL OF EVIDENCE Epidemiological study, level III.
BACKGROUND Frailty is known to be associated with poorer outcomes in individuals admitted to hosp... more BACKGROUND Frailty is known to be associated with poorer outcomes in individuals admitted to hospital for medical conditions requiring intensive care. However, little evidence is available for the effect of frailty on patients' outcomes after traumatic brain injury. Many frailty indices have been validated for clinical practice and show good performance to predict clinical outcomes. However, each is specific to a particular clinical context. We aimed to develop a frailty index to predict 6-month outcomes in patients after a traumatic brain injury. METHODS A cumulative deficit approach was used to create a novel frailty index based on 30 items dealing with disease states, current medications, and laboratory values derived from data available from CENTER-TBI, a prospective, longitudinal observational study of patients with traumatic brain injury presenting within 24 h of injury and admitted to a ward or an intensive care unit at 65 centres in Europe between Dec 19, 2014, and Dec 17, 2017. From the individual cumulative CENTER-TBI frailty index (range 0-30), we obtained a standardised value (range 0-1), with high scores indicating higher levels of frailty. The effect of frailty on 6-month outcome evaluated with the extended Glasgow Outcome Scale (GOSE) was assessed through a proportional odds logistic model adjusted for known outcome predictors. An unfavourable outcome was defined as death or severe disability (GOSE score ≤4). External validation was performed on data from TRACK-TBI, a prospective observational study co-designed with CENTER-TBI, which enrolled patients with traumatic brain injury at 18 level I trauma centres in the USA from Feb 26, 2014, to July 27, 2018. CENTER-TBI is registered with ClinicalTrials.gov, NCT02210221; TRACK-TBI is registered at ClinicalTrials.gov, NCT02119182. FINDINGS 2993 participants (median age was 51 years [IQR 30-67], 2058 [69%] were men) were included in this analysis. The overall median CENTER-TBI frailty index score was 0·07 (IQR 0·03-0·15), with a median score of 0·17 (0·08-0·27) in older adults (aged ≥65 years). The CENTER-TBI frailty index score was significantly associated with the probability of an increasingly unfavourable outcome (cumulative odds ratio [OR] 1·03, 95% CI 1·02-1·04; p<0·0001), and the association was stronger for participants admitted to hospital wards (1·04, 1·03-1·06, p<0·0001) compared with those admitted to the intensive care unit (1·02, 1·01-1·03 p<0·0001). External validation of the CENTER-TBI frailty index in data from the TRACK-TBI (n=1667) cohort supported the robustness and reliability of these findings. The overall median TRACK-TBI frailty index score was 0·03 (IQR 0-0·10), with the frailty index score significantly associated with the risk of an increasingly unfavourable outcome in patients admitted to hospital wards (cumulative OR 1·05, 95% CI 1·03-1·08; p<0·0001), but not in those admitted to the intensive care unit (1·01, 0·99-1·03; p=0·43). INTERPRETATION We developed and externally validated a frailty index specific to traumatic brain injury. Risk of unfavourable outcome was significantly increased in participants with a higher CENTER-TBI frailty index score, regardless of age. Frailty identification could help to individualise rehabilitation approaches aimed at mitigating effects of frailty in patients with traumatic brain injury. FUNDING European Union, Hannelore Kohl Stiftung, OneMind, Integra LifeSciences Corporation, NeuroTrauma Sciences, NIH-NINDS-TRACK-TBI, US Department of Defense.
Uploads
Papers by Olav Røise