BACKGROUND: Serious fall injury represents a little studied, yet common and potentially preventable, cause of morbidity and mortality among older persons. We determined the frequency of, and risk factors for, experiencing serious fall injury events among older persons in the community. SUBJECTS: A representative sample of 1103 community-living persons aged 72 years and older underwent comprehensive baseline and 1-year evaluations. MAIN OUTCOME MEASURES: During a median 31 months of follow-up, fall data were obtained using fall calendars. Injury data were obtained from telephone interviews and from surveillance of emergency room and hospital records. RESULTS: At least one fall was experienced by 546 (49%) participants. A total of 123 participants, representing 23% of fallers and 12% of the cohort, experienced 183 serious fall injury events. The factors independently associated with experiencing a serious injury during a fall included cognitive impairment (adjusted odds ratios 2.2; 95% confidence interval 1.5, 3.2); presence of at least two chronic conditions (2.0; 1.4, 2.9); balance and gait impairment (1.8; 1.3, 2.7); and low body mass index (1.8; 1.2, 2.5). In a separate analysis, including only subjects who fell, female gender (1.8; 1.1, 2.9) as well as most of the above factors were associated with experiencing a fall injury. CONCLUSIONS: Several readily identifiable factors appeared to distinguish the subgroup of older fallers at risk for suffering a serious fall injury. These factors should help guide who and what to target in prevention efforts. Language: en

Risk factors for serious injury during falls by older persons in the community.

BACKGROUND:: Effective combat trauma management strategies depend upon an understanding of the epidemiology of death on the battlefield. METHODS:: A panel of military medical experts reviewed photographs and autopsy and treatment records for all Special Operations Forces (SOF) who died between October 2001 and November 2004 (n = 82). Fatal wounds were classified as nonsurvivable or potentially survivable. Training and equipment available at the time of injury were taken into consideration. A structured analysis was conducted to identify equipment, training, or research requirements for improved future outcomes. RESULTS:: Five (6%) of 82 casualties had died in an aircraft crash, and their bodies were lost at sea; autopsies had been performed on all other 77 soldiers. Nineteen deaths, including the deaths at sea were noncombat; all others were combat related. Deaths were caused by explosions (43%), gunshot wounds (28%), aircraft accidents (23%), and blunt trauma (6%). Seventy of 82 deaths (85%) were classified as nonsurvivable; 12 deaths (15%) were classified as potentially survivable. Of those with potentially survivable injuries, 16 causes of death were identified: 8 (50%) truncal hemorrhage, 3 (19%) compressible hemorrhage, 2 (13%) hemorrhage amenable to tourniquet, and 1 (6%) each from tension pneumothorax, airway obstruction, and sepsis. The population with nonsurvivable injuries was more severely injured than the population with potentially survivable injuries. Structured analysis identified improved methods of truncal hemorrhage control as a principal research requirement. CONCLUSIONS:: The majority of deaths on the modern battlefield are nonsurvivable. Improved methods of intravenous or intracavitary, noncompressible hemostasis combined with rapid evacuation to surgery may increase survival. Language: en

Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004.

Background
The epidemiology of traumatic deaths was periodically described during the development of the American trauma system between 1977 and 1995. Recognizing the impact of aging populations and the potential changes in injury mechanisms, the purpose of this work was to provide a comprehensive, prospective, population-based study of Australian trauma-related deaths and compare the results with those of landmark studies.

Epidemiology of Traumatic Deaths: Comprehensive Population-Based Assessment

OBJECTIVES: The objectives were to identify situational risk factors associated with suffering a serious fall injury and to determine whether, and to what extent, predisposing and situational risk factors contributed independently to risk of suffering a serious fall injury.

DESIGN: Nested cohort study.

SETTING: General community.

PARTICIPANTS: 568 members of a representative sample of community-living persons 72 years of age or older who fell during a median follow-up of 36 months.

MEASUREMENTS: Candidate predisposing factors, identified during a baseline face-to-face home assessment, were the demographic, cognitive, medical, and physical performance measures associated with an increased risk of serious injury among fallers in a previous analysis of the cohort. Acute host, behavioral, and environmental factors present at the time of the participants' first reported fall constituted potential situational risk factors. The primary outcome was occurrence of a serious fall injury, defined as a fracture, joint dislocation, or head injury resulting in loss of consciousness and hospitalization, during the first fall recorded during follow-up.

RESULTS: Sixty-nine subjects (12%) suffered a serious injury during their first reported fall. No acute host factor was associated with increased risk of injury. The environmental and activity factors associated independently with serious injury in multivariate analysis included falling on stairs (adjusted relative risk 2.0; 95% confidence intervals 1.1 – 3.5), during displacing activity (1.8; 1.0 – 3.0), and from at least body height (2.1; 1.0 – 4.7). The independent predisposing factors included female gender (2.1; 1.0 – 4.4), low body mass index (1.8; 1.2 – 2.9), and cognitive impairment (2.8; 1.7 –4.7). Although 12% of first falls resulted in a serious injury overall, this percentage ranged from 0% to 36% as the number of predisposing risk factors increased from zero to three and from 5% to 40% as the number of situational risk factors increased from zero to three. Further, for any given number of predisposing risk factors, the percentage of fallers suffering a serious injury increased with the number of situational risk factors

CONCLUSIONS: Several environmental and behavioral factors contributed to the risk of serious fall injury; this contribution was independent of the effect of chronic predisposing risk factors. Preventive programs that address both predisposing and situational risk factors may result in the greatest injury reduction. These findings support previously recommended multicomponent intervention programs that combine medical, rehabilitative, and environmental components. J Am Geriatr Soc 43:1207–1213,1995.

The Contribution of Predisposing and Situational Risk Factors to Serious Fall Injuries

This paper reviews and critiques various approaches to the measurement of reliability among multiple raters in the case of nominal data. We consider measurement of the overall reliability of a group of raters (using kappa-like statistics) as well as the reliability of individual raters with respect to a group. We introduce modifications of previously published estimators appropriate for measurement of reliability in the case of stratified sampling frames and we interpret these measures in view of standard errors computed using the jackknife. Analyses of a set of 48 anaesthesia case histories in which 42 anaesthesiologists independently rated the appropriateness of care on a nominal scale serve as an example.

Measuring interrater reliability among multiple raters: An example of methods for nominal data

Given the wide usage and proven value of the Abbreviated Injury Scale (AIS) in rating severity of trauma, it is essential that certain reliability issues concerning its application be resolved. This article describes a study designed to address these reliability issues. Each of 15 raters with varying qualifications was asked to identify AIS code injuries sustained by 375 trauma patients admitted to four Baltimore area hospitals. Results showed that as a group, physicians and nurses tend to be more reliable in their ratings than either emergency medical technicians (EMTs) or nonclinical technicians, although a research assistant who is well trained in AIS coding and is a diligent worker can use the AIS to code severity as reliably as the physicians when sufficient information is provided in the medical chart. Reliability of AIS scoring was somewhat higher for blunt (vehicular and nonvehicular) versus penetrating injuries.

The Abbreviated Injury Scale and Injury Severity Score. Levels of inter- and intrarater reliability.

Concern exists that per case payment using Diagnosis Related Groups (DRGs) inadequately pays trauma centers. In this study, 45 Trauma Resource Groups (TRGs), an alternative patient classification system based on the Injury Severity Score and patient age, is developed and compared to 172 Diagnosis Related Groups (DRGs) that include trauma diagnoses. TRGs were developed using 1983 Maryland trauma patient hospital discharge abstracts (n= 34,702), the same source used to assign a DRG. We compared estimated TRG and DRG payments to actual charges for 17,398 trauma cases treated during 1986 at five trauma centers and 18 community hospitals in the Central Maryland Metropolitan Statistical Area. The unexpected findings of this study are that an anatomic severity-based classification of hospital trauma discharges (TRGs) does not perform as well as DRGs in: 1) explaining variations in length of stay for trauma cases, or 2) assuring an appropriate distribution of revenues to regional trauma centers and community hospitals. Solutions discussed include segregating community hospital and trauma center costs in computation of average per case rate setting, and inclusion of physiologic and mechanism of injury parameters in prospective payment classification systems to increase explained variance of resource use.

Trauma care reimbursement: comparison of DRGs to an injury severity-based payment system.

Given the wide usage and potential value of the AIS and ISS in rating severity of trauma, it is essential that certain reliability issues concerning application of the indices be resolved. At present, different data sources (e.g., Emergency Department forms, inpatient charts, autopsy reports) are being used to code AIS with little information available about the reliability of each. Furthermore, individuals with varying levels of training and clinical experience are employed as AIS coders; until now, no systematic comparisons have been made of the coding capabilities of these different individuals. Finally, the generalizability of the scale to non-vehicular, penetrating trauma has not been established. This paper describes a study which was designed to address these reliability issues. Each of 15 raters with varying qualifications (i.e. two research assistants, two medical records technicians, four nurses, four paramedics, and three physicians) was presented with the Emergency Department control sheets and inpatient charts (at appropriately spaced intervals) of 175 trauma cases, and asked to identify and AIS code all injuries. Three months after the first coding of the inpatient chart, the raters were asked to review and severity code the same 175 inpatient charts plus an additional 200 charts. The 375 trauma cases were admissions sampled from four hospitals in the Baltimore area and represent the full range of trauma severity and etiology.

James N. Eastham

Papers

The Abbreviated Injury Scale and Injury Severity Score. Levels of inter- and intrarater reliability.

Trauma care reimbursement: comparison of DRGs to an injury severity-based payment system.

Reliability testing of the AIS-80