Outcome Measurement in Major
Trauma
Karen Hoffman
Clinical Specialist Occupational Therapist –
Neurosciences and Critical Care
Objectives
1.
2.
3.
4.
5.
6.
Why measure outcome
What do we need to measure
When do we need to measure
What’s out there
Patient perspective
Provider perspictive
In the context of clinical outcome and ‘rehabilitation’
1. Why measure outcome?
1. Why measure outcome?
• Severe trauma remains the leading cause of
death in people under the age of 30 due to
incidental death (Mackenzie, et al., 1998)
• Trauma patients occupy more hospital beds then
all patients from heart diseases, and four times
more than patients with cancer’ (Pickering et al., 1999)
• World Health Organisation (WHO) predicts that
trauma will rank third among he causes of
disability in 2020 worldwide and has a significant
global disease burden
1. Why measure outcome?
• Measure the efficacy and effectiveness of acute care
interventions, therefore, justifying healthcare expenditure
(Halcomb et al., 2005)
• Holistic view of patient recovery and experience after
trauma (Richmond, 1997)
• To prove the value and benefits of the services we
provide
• Establish preferred practice patterns and improve quality
of services
• Benchmarking - provide a standard of care/performance
• Quality control measure for the government and the
patient
• Predict outcome
• Marketing tool
2. What do we need to
measure?
World Health Organisation
Health Condition
(disorder/disease)
Body
function&structure
(Impairment)
Environmental
Factors
Activities
(Limitation)
Participation
(Restriction)
Personal
Factors
Soberg et al, 2007. J
Trauma,62:471– 481.
Using the ICF as a framework
Impairment
Activity (Limitation)
/ function
Participation
(Restriction)
ISS
TRISS
APACHE II
ASIA
Barthel Index
FIM
SF-36
EQ-5D
AusTOMs
GOS
GAS
Life satisfaction Index
COPM
London Handicap Scale
Life Habits Assessment
(LIFE-H)
Craig Handicap
Assessment Reporting
Technique (CHART)
AusTOMs
Fatigue Impact Scale
HADS
BDI
McGill Pain
questionnaire
Grip strength
CAM
Davidson Trauma Scale
World Health Organisation
Disability Schedule ll
(WHO-DAS ll)
Personal Care Participation
Assessment & Resource Tool
(PC-PART)
2. What do we need to measure?
• Baseline assessment
• Treatment
– which interventions are the most effective with
resources available (rehabilitation programs)
• The processes, pathways and systems
– to ensure optimal outcome
• The overall socio-economic cost
– effectiveness and efficacy of rehabilitation, measured
against the patient outcome and the impact on the
society
3. When do we need to
measure?
3. When do we need to measure?
• Throughout the patient pathway, e.g. on
admission once stable, 2 weeks, 4 weeks, before
discharge, 3 months, 12 months, 2 years (Baldry
Currens & Coats 1999)
• ICU, ward, discharge, in patient rehab,
community, later
• Consider pre-injury co-morbidities, socioeconomic and demographic detail
• Longitudinal – lost to follow up
4. What’s out there?
(Horwitz et al 2008)
4. What’s out there…?
• Trauma rehabilitation outcome scoring (Horwitz et al
2008)
• Nottingham Health Profile and Rosser Disability
Scale (Dimopoulou et al, 2004)
• Kosar et al, (2009)
• Hannover Score for Polytrauma Outcome (HASPOC)
• Functional Capacity Index
• AO/ASIF classification of fractures
• Manual and the soft-tissue injury - Gustilo7
• Closed fractures - Tscheme and Oestems.
Seekamp Injury 1996;27:133-138
4. What’s out there…?
• Brief Symptoms Inventory to assess Post
Traumatic Stress Disorder (PTSD)
• Davidson Trauma Scale
– Posttraumatic psychopathology
• HADS
• World Health Organisation Disability Assessment
Schedule (WHODAS II )
• SF-36
• EQ-5D
• PROductivity and DISbility questionnaire
(PRODISQ )
4. What’s out there…?
• Multidimensional Health Locus of Control (MHLC)
– people’s beliefs about their health as being determined
by their own behaviours or not
• The Brief Approach/Avoidance Coping
Questionnaire (BACQ)
– general coping strategies of approach/avoidance
Cognition
• Head Injury Symptom Checklist (HISC)
• FIM – cognitive
• COG – self-assessed cognitive functioning
• CAM
Cognition..
The majority of trauma survivors without intracranial
haemorrhage display persistent cognitive impairment,
which is nearly twice as likely in those with skull fractures
or concussions. This cognitive impairment was
associated with functional defects, poor quality of life, and
an inability to return to work. Future research must
delineate modifiable risk factors for these poor outcomes,
especially in patients with skull fractures and concussions,
to help improve long-term cognitive and functional status.
Jackson et al, 2007. Long-Term Cognitive, Emotional, and Functional Outcomes
in Trauma Intensive Care Unit Survivors Without Intracranial haemorrhage. J
Trauma, 62:80–88.
5. Patient perspective
• Zatzick et al, (2001)
– Of all the things that have happened to you since you
were injured, what concerns you the most?
– What about this worries you?
– How concerning is this to you?
Rated: Physical health, psychological, work and finance,
social, legal, medical
• Anke & Fugl-Meyer (2003) Life satisfaction
several years after trauma
• Satisfaction with leisure, family life and vocation
5. Patient perspective
• Stineman et al (2007) and Kurtz et al (2008)
Recovery Preference Exploration (RPE)
• Focus on a person’s qualities to promote positive
adjustment rather than negative aspects of
disability djustment
6. Provider perspective
• Northwick Park Dependency Scale
Research Priority
Recommendations - Clohan et al, 2007
1. Development of cognitive and psychosocial outcome
measures, that are low in respondent burden and valid
across patient populations
2. Development of measures of long-term outcomes that
reflect participation, activity, and support system stability
that can be obtained efficiently
3. Development of robust severity and selection criteria
across different patient populations in PAC rehabilitation
Research Priority
Recommendations - Clohan et al, 2007
4. Evaluation of the reliability and validity of instruments
across settings, diagnostic groups, and time points
during the rehabilitation process
5. Assessment of environmental factors to allow
adjustment of outcomes related to supportive resources
6. Development of evidence-based treatment guidelines
and measurement systems to capture processes of care
and outcomes to support quality improvement efforts and
process- related payment systems
Clohan et al, 2007. Post acute Rehabilitation Research and Policy
Recommendations. Arch Phys Med Rehabil, 88: 1535-1541
In summary
• Measure across the pathway
• Consider the ICF as framework
• Injury specific measurements and generic
measurements
• Patient perspective
• Dependency
“To Care for Him Who Shall Have Borne the
Battle and for His Widow and His Orphan”
(Abraham Lincoln)
References
•
Seekamp A, Regel G, Tscherne H: Rehabilitation and reintegration of multiple injured
patients: an oucome study with special reference to multiple limb fractures. Injury
1996;27:133-138
•
Zelle B, Stalp M, Weihs Ch, Müller F, Reiter FO, Krettek Ch, Pape HC;
Arbeitsgemeinschaft "Polytrauma" der Deutschen Gesellschaft für Unfallchirurgie.
(Validation of the Hannover Score for Polytrauma Outcome (HASPOC) in a sample of
170 polytrauma patients and a comparison with the 12-Item Short-Form Health Survey)
Chirurg. 2003 Apr;74(4):361-9.