Investigating major trauma in Māori youth at Te Whatu Ora Counties Manukau

The Ninth Perioperative Mortality Review Committee (POMRC) report found the likelihood of death was over three times higher in Māori youth compared to non‐Māori (age: 15–18 years) in the 30‐days following major trauma. The aim of our study is to investigate variations in care provided to Māori youth presenting to Te Whatu Ora Counties Manukau (TWO‐CM) with major trauma, to inform policies and improve care.


Introduction
][4][5][6][7][8][9][10][11][12][13][14] The relevant literature base regarding such disparities in health outcomes following major trauma in Aotearoa New Zealand is limitedbut the small numbers of studies (refs), including the recent ninth POMRC report, have demonstrated that inequities exist related to ethnicity within Aotearoa New Zealand. 1 In 2015, the Health Quality & Safety Commission found that between 2010 and 2012, M aori children between 0 and 14 years of age had greater hospitalization rates from unintentional injury as compared non-M aori, and 3.5 times higher mortality rate from such injuries. 1,15The most recent Child and Youth Mortality Review Committee Data Report for the period 2015-2019 notes significantly higher rates of death from injury (unintentional injury and assault) among M aori youth aged 15-19 years compared with their non-M aori non-Pacific peers (rate ratio 2.14). 16These findings are also significant as there is a 1.25-fold increase in rate ratio (rate ratio of 1.71) from the 2012 to 2016 findings of the previous report conducted by the Child and Youth Mortality Review Committee. 17 major finding of the recent ninth POMRC report was that M aori youth between the ages of 15 to 18 have three times increased risk of 30-day mortality post-admission for major trauma than their non-M aori counterparts. 1This finding was not found for any other age group under 25 years of age.The POMRC report also showed determinants of 30-day mortality after major trauma included: older age, co-morbidities, higher ISS, and no index or delayed CT.When these determinants were analyzed by ethnicity, there was a significant difference in time to CT.No significant difference was found for any other determinants. 14hile the POMRC report identified an association of increased risk of mortality amongst M aori youth relating to more severe injuries within 15-18-year-olds (as reflected by ISS scores), there were still inequities in outcome even when accounting for the higher rate of more severe injuries amongst M aori youth.Here we define inequity predominantly as the concept of unfairness.Three potential pathways that could contribute to such health disparities include '(1) differential access to the determinants of health or exposures leading to differences in disease incidence, (2) differential access to health care, (3) differences in the quality of care received'. 18These factors arise from contributing issues such as M aori being more likely to reside in more socioeconomically deprived communities, while overall also experiencing a reduced level of access to healthcare. 19,20 aori are also historically more likely to live in rural communities, leading to a potentially longer time to access emergency services. 21Prolonged transfer time to tertiary centres also leads to disparities in care and outcomes, as necessary treatment for major trauma is optimized when patients receive time-critical intervention as advanced prehospital care. 1,22,23verall, the POMRC findings are consistent with previous data showing that M aori youth have worse outcomes following trauma as compared to their non-M aori counterparts. 1In accordance with the articles of Te Tiriti o Waitangi which affirms M aori rights to proper access to healthcare and equity of health outcomes, POMRC has prioritized addressing inequities for M aori which have contributed to poor health outcomes, particularly regarding perioperative mortality. 1,22,24This prioritization has led to eight major recommendations by POMRC for improving health outcomes in line with emerging research and their major findings.The focus of this study will be in line with the report's first recommendation on higher mortality in M aori youth.'Recommendation onegiven the high mortality rates in M aori youth, an in-depth investigation should be done by each DHB looking at the optimality of the hospital systems and processes involved in patient treatment. 1These investigations should focus on whether these processes were timely and efficient, and where they can be improved to provide equitable healthcare outcomes.'This study will investigate potential variations in patient care by looking at key performance indicators (KPI) through a lens of socioeconomic status and ethnicity.Specifically, the study will aim to identify any inequitable healthcare outcomes following major trauma in 15-18-year-olds presenting to TWO-CM, and whether there have been identifiable disparities in care which may have contributed to the healthcare outcomes.Finally, the study will aim to make recommendations as to how processes may be changed to reduce health inequity if present.

Methods
Middlemore Hospital (MMH) is a tertiary hospital within TWO-CM, containing the National Burn Centre and Northern Supraregional Spinal Cord Injury Centre for Aotearoa New Zealand (AoNZ).It does not have Cardiothoracic or Neurosurgery Services.MMH does not have a dedicated admitting trauma service but a consultative service which manages a high volume of trauma patients in AoNZ.In a 2018/2019 report, the Northern Region of AoNZ, of which MMH is a part with three other hospitals, had 988 trauma admission with Injury Severity Score of >12; the largest and nearly a third of the national total of 3320 (30%). 4thical approval was gained from AHREC (#23263).Institutional approval was obtained from the Research Office of TWO-CM (#1556).Funding was gained from The University of Auckland Faculty of Medical & Health Sciences -Summer Research Scholarship.Specific guidance on objectives, prioritization of M aori health, and dissemination of relevant findings was discussed with the M aori Research Advisory for Middlemore Hospital.The research objectives and recommendations identified by POMRC and relevant M aori board at TWO-CM have identified this research as being of priority to the youth community in South Auckland.The study was conducted and reported using the CON-SIDER guidelines. 25An independent retrospective observational study of 15-18 year old patients with major trauma admitted to MMH in Auckland, NZ between January 2018 to December 2021 was undertaken.Data utilized by POMRC was obtained specifically for TWO-CM from the NZTR.Patients who had an ISS > 12 or died were defined as major trauma. 1 Patients destined for MMH but died before arriving at hospital were excluded.The search returned 77 patients.
Data were collected from the hospital's physical clinical records, electronic records, and the data captured with the NZTR utilized by the trauma team at MMH. 26 Information was collated and collected to correlate to the patients' clinical journey.This included demographic data (age, gender, co-morbidities), predictors of trauma severity (ISS, type of individual injuries), hospital-relevant information (Length of Stay, ED Disposition), trauma call activation, and Red Blanket activation.Descriptive statistics, Fisher's exact test, and median tests were obtained using Stata 17.0 (Statacorp, Texas) and utilized to explain findings.We focused on six KPIs including Death, cause of death, trauma call, Red Blanket, average time to CT scan, and time to OT. 27  A clinical review of prioritization and demand was reviewed to analyze for appropriate prioritization and further review of time to OT was then looked at to factor for appropriateness of time to OT.Further investigations were made looking at the appropriateness of the latter four KPI's and whether they were conducted in an appropriate timeframe based on Northern Region Trauma Network trauma call guidelines. 28

Ethnicity and deaths
Of the 77 patients fulfilling the inclusion criteria of the study, 72 (94%) survived their major trauma, and five (6%) died postmajor trauma.One of the 29 M aori patients (3.4%), and 4 of the 48 Non-M aori (8.3%) patients died following admission with their injuries (P = 0.645).

Cause of death
The five deaths comprised of three patients with multi-organ dysfunction (MOD) (all Non-M aori), one patient with a CNS (Central Nervous System) death (Non-M aori), and one with Abdominal Haemorrhage (M aori).Cause of death showed varying mechanisms of injury.Two of the aforementioned MODS deaths died of severe burns with additional severe multi-regional trauma.

Trauma call activation
At MMH a mandatory trauma call is activated if one of four major criteria is met based on the Criteria for Adult Surgical Emergency Trauma call outlined Northern Region Trauma Network trauma call guidelines. 28Analysis included trauma calls that were appropriately activated according to the guidelines, including for patients who were transfers.
Of the 72 survivors, 67 (93%) had the decision for/against a trauma call made appropriately and five (7%) did not have the decision made appropriately (all non-M aori survivors).For the five deceased patients, four patients have a trauma call activated, and one did not.All five decisions (100%) for/against a trauma call were made appropriately (four non-M aori (9.1%), one M aori (3.6%), P = 0.642).

Red blanket activation
MMH has a Red Blanket Protocol to expedite and streamline emergency surgical management of haemodynamically unstable patients requiring urgent transfer to OT.The criteria for 'Red Blanket' activation are 'haemodynamically unstable' and requiring 'emergency surgery'.We used the ABC score as a proxy for assessing haemodynamic instability. 29Physiological parameters were measured on admission in ED, with a score of two or more indicating a Red Blanket activation. 29The ABC score is determined by four factors including: presence of a penetrating injury to the torso, Systolic BP ≤90 in ED, HR ≥120 in ED, and a Positive FAST score.The presence of a factor scores one point and summation of factors provides a score for that patient out of a maximum of four points.
Of the 72 patients who survived 71 did not have a red blanket activated, and the one patient for whom a red blanket was activated had it activated appropriately (non-M aori).Of the 71 who did not have a red blanket activation, all but one of the non-activations were made appropriately (non-M aori).The inappropriate nonactivation was a patient who received an ABC score of two but did not have a red blanket activated.
In the five deceased patients, none had a red blanket activation, and all the non-activations were appropriate.None of these five patients received an ED thoracotomy.Further investigation of the lack of red blankets activation for potential activations patients (as defined by the guidelines) were clinically sound decisions for both the surviving and deceased patients.

Median time to CT scan
Median time to CT scan represents the time it took from arrival to MMH.Patients excluded from the data were those who did not have MMH as their first hospital and received a scan at another hospital (n = 14, four M aori, 10 Non-M aori), patients who did not have time to CT recorded (n = 2, two M aori), and patients who had management did not require a CT at the time of primary presentation/ admission (n = 2, two Non-M aori).Optimal timeframe to CT for major trauma is 1 h. 30The median time to CT for M aori was 37 and 46 min for non-M aori (P = 0.917), with 8 (36.4%)M aori and 15 (40.5%) non-M aori waiting longer than 60 min (P = 0.789).
Median time to CT was also evaluated in the context of the Glasgow Coma Scale (<9, 9-13, >13).GCS < 9 (0 M aori (0%), two non-M aori (5.6%)) had a median time to CT of 33 minutes and all met the optimal treatment standard of time to CT within 1 h.For GCS 9-13 (one M aori (4.4%), five non-M aori (13.9%)) the median time to CT was 34 min and the two patients who did not meet the optimal treatment standard of time (76 and 258 min) were both non-M aori.For GCS >13 (22 M aori (95.7%), 29 non-M aori (80.6%)) the median time to CT was 45 min (41 min for M aori and 47 min for non-M aori) with 8 (36.4%)M aori and 12 (41.4%)non-M aori patients waiting longer than an hour (P = 0.778).

Time to OT
Time to OT indicates the mean time it took for each patient to get into the OT, from the time the electronic theatre booking form was lodged by the relevant department.Of the 77 patients, 46 (20 M aori, 26 non-M aori) were taken to theatre within the allocated priority time, five (two M aori, three non-M aori) were not operated on within the allocated priority time frame and 26 others were either non-operative or transferred to another hospital (P = 0.377).Patients transferred to another hospital were either for more appropriate management (i.e., Auckland City Hospital for Neurosurgery or transferred to be moved closer to their home/supports).

Discussion
The aim of our research was to investigate variations in care provided to M aori youth presenting to TWO-CM with major trauma, to inform policies and improve care.During the relevant time, we have shown 29 M aori and 48 non-M aori presented with major trauma, of which one and four died, respectively.This represents a 3.4% rate of mortality for M aori, as compared to 8.3% rate of mortality for non-M aori presenting with major trauma.M aori comprise 16.5% of the general population in the TWO-CM catchment.In our audit 29 of 77 M aori youth trauma cases show a higher presentation rate of M aori compared to population percentage (38%).As for Red Blanket activation, appropriate activation could benefit future cases if deemed clinically appropriate.The evidence from the measurable KPI's provided in this study show that majority of the cases followed guidelines.There is an indication that there were small variations in care between youth trauma patients presenting at Middlemore hospital, but this was not directly related to ethnicity.This variation in care was in our measurable factors including trauma call activation, Red Blanket activation, and time to OT.
We were unable to find statistically significant variations in care were present for M aori youth presenting with major trauma, these findings did not match the national trend.Notably, any minor differences in our findings, which were not statistically significant, may be due to an array of reasons including variable prioritization by clinicians, inadequate resources (staff, time, theatres) available, and/or pervasive differences or trends in the presentation by ethnicity.While we did find minor variations in care, which were not statistically significant, in the audit our findings did not indicate that M aori were more likely to die post major trauma, as found by POMRC in the rest of Aotearoa New Zealand which showed a threefold increase of 30 day mortality post major trauma. 1 Additionally these findings did not match the Health Quality & Safety Commission data from 2010 to 2012 around youth which showed that M aori youth had a 3.5 times higher mortality rate from injuries.For patients requiring a CT, all patients were given clinically appropriate initial CT scans with time to CT identical across both groups at TWO-CM.These findings were also not in line with POMRC's ninth report which showed that M aori were 37% less likely to receive an initial CT compared to non-M aori.
It is important to note the key limitation of this audit was its retrospective nature, such studies cannot fully appreciate operational demands at the time of patient encounter along with nuanced clinical decision making.Additionally, the small numbers of this audit means it may be inadequately powered to identify true differences in the quality of care provided.
This audit was done in response to the POMRC recommendation on conducting an in-depth review of all cases of major trauma resulting in hospitalisations for M aori aged 15-18 years old to address the inequity of outcome pertaining to 30 day mortality following major trauma.Similar studies should be conducted across different regions to improve care at a hospital level in order to improve outcomes via a bottom up approach to patient care on a national level as a follow on to the national POMRC reports.
In conclusion, we have been unable to find statistically significant variations in care for trauma call activation, Red blanket activation, time to CT, and time to OT at TWO-CM.However, numbers are small.Minor clinical variations show that there is still room for improvement.For improvements in patient outcomes and guidance to clinicians, trauma call activation should remain a strict policy to deter variations in care from individual clinical decisions.Additionally, resource constraints (staff, time, theatres) should be addressed with appropriate hospital management personnel to reduce delays for Time-to-CT and Time-to-OT to ensure equity in care.
For time to OT, appropriate time frames are indicated based on five different prioritization on the booking form: Priority 1 -LIFE-THREATENING CONDITION: Immediate surgery, Priority 2 -ORGAN THREATENING CONDITION: Urgent 1-2 h, Priority 3 -NON-CRITICAL: Urgent but noncritical 6-8 h, Priority 4 -ACUTE NOT URGENT: Acute 24 h or less, and No Prioritization indicated/N/A/No Surgery undertaken.Additionally, we analyzed time to OT in the context of the clinical picture for each patient, specifically looking at injury requiring theatre.