Discussion: Analyzing a Health-Related Scenario

D I S C U S S I O N P A P E R

A model to advance nursing science in trauma practice and injury

outcomes research

Therese S. Richmond & Leanne M. Aitken

Accepted for publication 26 April 2011

Correspondence to T. Richmond:

e-mail: [email protected]

Therese S. Richmond PhD CRNP FAAN

Andrea B. Laporte Endowed Term Associate

Professor

Division of Biobehavioral & Health Sciences

School of Nursing, University of

Pennsylvania, Philadelphia, Pennsylvania,

USA

Leanne M. Aitken RN PhD

Professor of Critical Care Nursing

Research Centre for Clinical and Community

Practice Innovation

Griffith University and Princess Alexandra

Hospital, Brisbane, Queensland, Australia

R I C H M O N D T . S . & A I T K E N L . M . ( 2 0 1 1 )R I C H M O N D T . S . & A I T K E N L . M . ( 2 0 1 1 ) A model to advance nursing science in

trauma practice and injury outcomes research. Journal of Advanced Nursing 67(12),

2741–2753. doi: 10.1111/j.1365-2648.2011.05749.x

Abstract Aims. This discussion paper reports development of a model to advance nursing

science and practice in trauma care based on an analysis of the literature and expert

opinion.

Background. The continuum of clinical care provided to trauma patients extends

from the time of injury through to long-term recovery and final outcomes. Nurses

bring a unique expertise to meet the complex physical and psychosocial needs of

trauma patients and their families to influence outcomes across this entire contin-

uum.

Data sources. Literature was obtained by searching CINAHL, PubMed and Ovid-

Medline databases for 1990–2010. Search terms included trauma, nursing, scope of

practice and role, with results restricted to those published in English. Manual

searches of relevant journals and websites were undertaken.

Discussion. Core concepts in this trauma outcomes model include environment,

person/family, structured care settings, long-term outcomes and nursing interven-

tions. The relationships between each of these concepts extend across all phases of

care. Intermediate outcomes are achieved in each phase of care and influence and

have congruence with long-term outcomes.

Implications for policy and practice. This model is intended to provide a framework

to assist trauma nurses and researchers to consider the injured person in the context

of the social, economic, cultural and physical environment from which they come

and the long-term goals that each person has during recovery. The entire model

requires testing in research and assessment of its practical contribution to practice.

Conclusion. Planning and integrating care across the trauma continuum and rec-

ognition of the role of the injured person’s background, family and resources will

lead to improved long-term outcomes.

Keywords conceptual model, health outcomes, injury outcomes, Trauma Outcomes

Model, trauma nursing

� 2011 Blackwell Publishing Ltd 2741

J A N JOURNAL OF ADVANCED NURSING

Introduction

Injury is a significant health problem across the lifespan,

ranking in the top ten causes of death currently and projected

to become the 4th leading cause of disability adjusted life

years by 2030 globally (Mathers & Loncar 2006, Mathers

et al. 2009). Injury is caused by a variety of mechanisms, but

whatever the cause, the common endpoint is damage to cells,

tissues, and organs because of the transmission of external

forces to the body. Severity of injury is categorized as minor,

moderate, serious and incompatible with life. The terms

injury and trauma are often used interchangeably but the

term trauma is typically used when referring to more serious

injuries. Scoring systems such as the Injury Severity Score

(Baker et al. 1974) and the Revised Trauma Score (Champion

et al. 1989) are widely used to both describe type and severity

of injury and predict mortality. Because of the life-threaten-

ing nature of injury where time to treatment is important,

trauma systems have developed over the past three decades.

These trauma systems encompass broad geographical areas

and/or smaller areas with high population density, with

trauma-dedicated services established in designated acute

hospital facilities leading to reduced mortality (Nathens et al.

2000, Peleg et al. 2004).

Providers and patients alike indicate that a sole focus on

injury survival as the dominant outcome is insufficient.

Instead, return to previous level of function and reintegration

into pre-injury lifestyle, such as return to family, community,

education, work, leisure, or retirement activities are recog-

nized as important outcomes of trauma care. These outcomes

are not immediate and can take years to achieve. Up to half of

all patients report compromise in functional, quality of life

(QOL), psychological and economic aspects of recovery.

Injured cohorts in Europe, the United States of America, and

Australia report incomplete recovery with 18–65% of

patients reporting limitations in self-care, mobility, pain,

discomfort, and cognition (Holtslag et al. 2007, O’Mullane

et al. 2009). Only 55% of trauma patients achieve maximum

function even at 3 year’s postinjury (Livingston et al. 2009).

Health-related QOL is lower for trauma patients 18 months

after injury compared with the general population norm;

problems include delusional memories (Ringdal et al. 2009)

and injury-related pain (Rivara et al. 2008). Similarly,

10–20% of injured patients report post-traumatic stress

disorder and up to 18% report depression 12 months

postinjury (O’Donnell et al. 2004, Zatzick et al. 2008,

Richmond et al. 2009).

Financial problems are reported, both in terms of expen-

ditures required for ongoing health service utilization and

inability to return to work and earn an income. In a Canadian

cohort, those recovering from injury used more health

services every year for 10 years postinjury than a non-injured

comparative group (Cameron et al. 2006). Similarly, Gabbe

et al. (2007) found 69% of a major injury cohort continued

to require health services 6 months after hospital discharge.

Some patients required more than 12 months before they

were able to return to work (Shults et al. 2004, O’Donnell

et al. 2005, Soberg et al. 2007), with only 43% of a cohort of

100 Norwegian injured patients having returned to work at

2 years (Soberg et al. 2007).

These descriptions of long-term recovery help us under-

stand what aspects of function remain compromised; how-

ever, to improve long-term recovery, it is essential that we

consider what factors affect this recovery. While scoring

systems such as the Injury Severity Score and the Revised

Trauma Score predict mortality, they do not effectively

predict postinjury functional recovery in the general trauma

population (Richmond 1997, Richmond et al. 1998). How-

ever, there is evidence that patients with compromised

recovery can be identified at the time of acute hospitalization

by other risk factors. Demographic variables such as pre-

injury education and employment (Connelly et al. 2006),

treatment factors such as sedation and analgesia management

(Samuelson et al. 2006), admission to the intensive care unit

(ICU) (Connelly et al. 2006, O’Donnell et al. 2010) pre-

injury function (Richmond 1997), family involvement

(Mitchell et al. 2009) and acute psychological distress

(Richmond et al. 2003) have been identified as predicting

short- and long-term recovery. Identification of factors that

are related to long-term recovery enable interventions across

the continuum of trauma care to be individually tailored to

optimize recovery. The barrier, however, is that systems of

nursing care are isolated from one another – with trauma

patients cared for in prehospital settings, acute care hospitals,

rehabilitation settings and in the community. Given these

structural issues, nurses typically focus on achieving imme-

diate outcomes relevant to their setting (e.g. resuscitation or

critical care in the acute care setting) without carefully

considering the important long-term outcomes of trauma

care.

Background

Trauma nursing as a specific term has been used in varied

ways in the literature. In this article, we refer to trauma

nursing as the care provided to injured patients by profes-

sional nurses who are members of the multidisciplinary team.

Nurses take care of trauma patients across nursing specialties,

such as emergency, critical care, perioperative, medical-

surgical, rehabilitative and community nursing. As we will

T.S. Richmond and L.M. Aitken

2742 � 2011 Blackwell Publishing Ltd

propose in the Trauma Outcomes Model, nurses in these

specialties provide care and bring a unique expertise to meet

the complex physical and psychosocial needs of trauma

patients and their families that vary depending on the phase

of care.

Descriptions of what constitutes trauma nursing have been

limited. Although there are various descriptions of the trauma

case manager role, (Griffith et al. 2001, Fraser & Curtis

2006, Cobb & Pridgen 2008) these roles are limited to a

single coordinating position in a trauma service rather than

reflecting the role undertaken by all nurses caring for injured

patients and consequently do not clarify the trauma nurse’s

role. Some aspects of the trauma nurse role can be drawn

from the role responsibilities articulated by the American

Association of Critical Care Nurses (2008). Pertinent respon-

sibilities include helping the patient to obtain necessary care,

monitoring and safeguarding the quality of that care,

respecting the rights, values and beliefs of the patient and

taking actions to ensure that other members of the healthcare

team recognize these and acting as a liaison between the

patient, family members and members of the healthcare team.

Long et al. (2002) provide a complementary description of

the nursing role which, although specific to the rehabilitation

setting, applies well to the acute trauma setting. The

interlinked roles in rehabilitation include assessment, coor-

dination and communication, technical and physical care;

integration and delivery of therapy; emotional support;

involvement of the family and creation of a supportive

environment (Long et al. 2002).

The nursing science that underpins the role of trauma

nurses across the continuum of care is in its beginning stages,

but represents an essential area of development. In consid-

ering the entire continuum nurses intervene in multiple ways

including injury prevention, prevention of complications,

optimization of acute care and its effect on recovery and

reduction of the ongoing burden on injured individuals, their

family, the healthcare system and society. No existing

theoretical framework could be located that articulates the

structured approaches and considerations required to care for

the injured patient. Of relevance, current acute nursing care

frameworks do not recognize fully the importance of

prehospitalization factors such as the socio-demographic or

injury characteristics, nor do they recognize the relationship

between the intermediate outcomes achieved on discharge

from the acute hospital, the post discharge processes and

characteristics and the long-term recovery of the patient.

Only one paper was found that addressed the care

continuum over time and place (Halcomb & Davidson

2005). These authors used the illness trajectory framework,

originally proposed by Corbin and Strauss (1991) to describe

recovery from injury. The strengths of their description

include the long-term approach to recovery, acknowledge-

ment of the biopsychosocial impact of injury and recognition

that pre-injury factors affect recovery. This framework

acknowledges the inter-relationship of the actions of both

the injured person and the healthcare team (Halcomb &

Davidson 2005). The significant limitation is the lack of

detail outlining the interventions that occur during both the

acute and postdischarge phases of care and the relationship

between the injured person, their family, interventions and

recovery.

In this discussion paper, we report on the development of a

model to advance nursing science and practice in trauma care

based on an analysis of the literature and expert opinion. The

authors bring decades of expertise in trauma care from two

countries (United States, Australia) and lend that expertise,

coupled with a systematic inclusion of the literature, to

consider the limitations in our current systems of care. We

propose to expand the well-known Quality Health Outcomes

Model (QHOM) (Mitchell et al. 1998) that is widely used in

health services research to create a model that crosses phases

of care to better meet the needs of seriously injured trauma

patients.

Data sources

Literature was obtained by searching CINAHL, PubMed and

OvidMedline databases for the years 1990–2010. Search

terms included ‘(trauma OR wounds and injuries) AND

nursing AND (scope of practice OR role)’ with results

restricted to those published in English. Search terms were

refined by initially finding a small number of relevant papers

and determining the keywords that had been used in the

referencing process for those papers. Searches identified 569,

1504 and 613 potential articles in CINAHL, PubMed and

OvidMedline respectively. Abstracts were reviewed to iden-

tify relevant papers. In addition, a manual search was

undertaken of the Journal of Trauma Nursing since 2005.

A targeted search was undertaken of the Journal of Trauma

and Injury for nursing specific publications. Reference lists of

included papers were reviewed to identify further relevant

papers. Websites of professional organizations involved in

trauma care were also searched for descriptions of scope of

practice and educational content of relevant courses. A total

of 57 papers were reviewed in full, although only 32 of these

were ultimately relevant to the development of this model.

Each paper was carefully analysed to determine relevance to

the expansion of the QHOM and to verify or alter the key

concepts proposed in the original QHOM. The quality of the

evidence that was reviewed was generally low, with most

JAN: DISCUSSION PAPER Model to advance nursing science

� 2011 Blackwell Publishing Ltd 2743

papers being opinion pieces, discussion papers or retrospec-

tive analyses of trauma databases (Table 1).

Presentation of the model

The trauma model and foundational theoretical assumptions

described in Figure 1 are designed specifically to cross time

and place, such that linkages inherent in specialties also cross

phases of care. Indeed, the prevailing underlying assumption

of the Trauma Outcomes Model is that only by explicating

the linkages across phases of care can long-term outcomes

be enhanced and high quality trauma care be provided.

Although long-term outcomes are not achievable during the

acute phase of care, it is essential that these outcomes inform,

and have congruence with, the intermediate goals set during

acute care. It is also assumed that the desired outcomes and

the interventions that are provided are driven by the needs of

the injured person and his/her family. Next, we define and

discuss the concepts central to the model and their related

theoretical linkages.

Table 1 Summary of papers that informed development of the trauma outcomes model

Author Title Method

Anzai et al. 2006 Factors influencing discharge location following high

lesion spinal cord injury rehabilitation in British

Columbia, Canada

Retrospective chart review of 52 individuals

Barondess 2008 Health through the urban lens Expert opinion

Branas et al. 2004 Urban–rural shifts in intentional firearm death:

Different causes, same results

Retrospective analysis of death data

Cameron et al. 2006 Ten-year health service use outcomes in a population-based

cohort of 21,000 injured adults: the Manitoba injury

outcome study

Retrospective population based cohort study

Cobb & Pridgen 2008 Polytrauma care: a delicate balance for the military

nurse case manager

Expert opinion

Colombo et al. 2008 Critical care medicine at Walter Reed Army Medical

Center in support of the global war on terrorism

Expert opinion

Cukier 2002 Small arms and light weapons: A public health approach Expert opinion

Danne 2003 Trauma management in Australia and the tyranny of

distance

Expert opinion

Eastridge et al. 2006 Trauma system development in a theater of war:

Experiences from Operation Iraqi Freedom and

Operation Enduring Freedom

Retrospective analysis of system issues

Fang et al. 2008 Critical care at Landstuhl Regional Medical Center Expert opinion

Fecura et al. 2008 Nurses’ role in the Joint Theatre Trauma System Expert opinion

Fraser & Curtis 2006 A day in the life of a trauma case manager Expert opinion

Griffith et al. 2001 The Trauma Program Manager role: a current

examination

Retrospective review of administrative

records

Gururaj 2004 Injuries in India: A national perspective Retrospective review of existing datasets

Haider et al. 2008 Race and insurance status as risk factors for trauma

mortality

Retrospective database analysis

Halcomb & Davidson 2005 Using the illness trajectory framework to describe

recovery from traumatic injury

Discussion paper

He et al. 2005 65 + in the United States: 2005 Retrospective analysis of US census data

Lim et al. 2007 Factors influencing discharge location after

hospitalization resulting from a traumatic fall

among older persons

Population based case-only study

Long et al. 2002 The role of the nurse within the multi-professional

rehabilitation team

Ethnographic study and expert workshops

MacKenzie et al. 2006 A national evaluation of the effect of trauma-centre

care on mortality

Retrospective data base analysis

Manwell et al. 2005 Patient reaction to traumatic injury and inpatient

AODA consult: 6-month follow-up

Prospective cohort study with follow-up

at 6 months

Minkler et al. 2006 Gradient of disability across the socio-economic

spectrum in the United States

Retrospective analysis of national survey

data

Mitchell et al. 1998 Quality health outcomes model Discussion paper

T.S. Richmond and L.M. Aitken

2744 � 2011 Blackwell Publishing Ltd

Concepts central to the model

The trauma model we present in this article builds on the

QHOM, a widely used model built on structure, process, and

outcomes, but in a non-linear manner (Mitchell et al. 1998).

As our proposed model is built on the QHOM, we start with

its concepts and relationships. The QHOM has been widely

validated in the clinical and research communities. In

expanding this model, we subjected our trauma model and

a draft of this manuscript to review by two of the QHOM

developers (Dr. Pamela Mitchell and Dr. Bonnie Jennings)

who also are experts in neurotrauma and trauma care in

civilian and military sectors respectively. Final iterations of

the trauma outcomes model were presented for critique and

discussion at grand rounds at a Level I trauma centre.

Core concepts from the QHOM are client, system, process

and outcome. We add a new concept – environment – as

integral to this model and make explicit that the client

concept is inclusive of patient and family. We expand the

model to include multiple and separate care systems that span

pre-injury emergency care through to community reentry. We

label these structured care systems. We acknowledge that the

nursing interventions take place in each structured care

system with system-specific outcomes, but we now expand

outcomes to be inclusive of long-term outcomes. Relation-

ships between these core concepts are made explicit as

important underlying assumptions of the model (Table 2).

Environment

Trauma, a societal health problem, is directly and indirectly

influenced by the environments of those societies. Because of

variations in the social, economic, cultural and physical

environments, the profile of injury mechanism and injury type

within and across countries differs. Within countries, the

environmental influence on trauma can be seen by the different

injury profiles found in poor urban areas in the United States

when compared with more rural areas (Branas et al. 2004,

Barondess 2008). Differences are found across countries

because of varying levels of development, cultural norms or

civil stability. Examples are many: a spike in traffic crashes in

India where increasing numbers of motorcycles and cars are

being used by the over billion population living in an

unchanging landmass (Gururaj 2004); an increase in gun

violence during the years following a country’s civil unrest that

leaves a large number of residual small arms (Cukier 2002);

and rape and mutilation of women and girls in countries

experiencing ethnic cleansing and civil unrest (Olujic 1998).

Structure

Person & family

Intermediate outcomes

Interventions

Definitive Care

Person & family

Social , Economic , Cultural & Physical Environment

Trauma Outcomes Model

Injury

Structured Care Setting Structure

Person & family

Intermediate outcomes

Interventions

Pre Definitive Care

Structured Care Setting

Structure

Person & family

Intermediate outcomes

Interventions

Post Discharge

Structured Care Setting

Long Term Outcomes

Survival is enhanced and morbidity is reduced

Humanity and individual dignity is maintained and enhanced

Physical , functional , psychological recovery and quality of life is maximised

(Adapted from Quality Health Outcomes Model, Mitchell et al. 1998)

Figure 1 Trauma outcomes model.

JAN: DISCUSSION PAPER Model to advance nursing science

� 2011 Blackwell Publishing Ltd 2745

Environment affects quality and rapidity of trauma care

delivery based on the structure, prehospital triage protocols,

land characteristics (Danne 2003), and whether care is

civilian or wartime military (Colombo et al. 2008, Fang

et al. 2008). Organized trauma systems (civilian or military)

are directed by formal triage protocols to transport the

injured to the appropriate level of care in the shortest time

possible to reduce mortality and morbidity (Eastridge et al.

2006, MacKenzie et al. 2006). Both the absence of a system

of care with triage protocols or the presence of a trauma

system with large distances and areas with low population

density resulting in longer transport times reduce the likeli-

hood of rapid, definitive care, ultimately reducing the

probability of achieving optimal long-term outcomes (Price

et al. 2003). A military trauma system is one example of a

setting where trauma care is provided across both large

distances and multiple care settings throughout the trauma

continuum (Fecura et al. 2008).

Other environmental factors (e.g. non-injury factors)

influence postdischarge location and long-term outcomes. In

the US, economics such as insurance coverage in conjunction

with other social factors such as race, gender and age can

directly affect care and outcomes of injured patients. Vari-

ation in outcomes based on economic and social factors has

been shown in disposition of trauma patients from the

Emergency Department (ED) (Selassie et al. 2003), mortality

(Haider et al. 2008) and discharge destination (Lim et al.

2007, Shafi et al. 2007). Similar variations have been shown

in a cohort of spinal injury patients in Canada (Anzai et al.

2006), although limited examination of the issue outside the

US is reported. Other environmental factors can influence

long-term outcomes, such as physical living structures and

accessibility, access to public transportation in the commu-

nity and degree of instrumental social support. Attention to

all relevant environmental factors is in the purview of nursing

practice.

Person/Family

Each person brings to the injury a unique genetic profile, life

trajectory, co-morbid conditions, substance use/abuse profile

and resources. Classically, trauma has been considered a

young person’s disease; in developing countries this is true.

However, many countries have a top-heavy population pyr-

amid and in these countries an ageing population translates

into older injured patients with increasingly complex

co-morbidities and physiological needs (He et al. 2005).

Regardless of age, injured persons bring family structures

that vary in composition and members who vary in beliefs,

availability and cohesion. As persons become ‘patients’ in an

acute care setting, maintenance of their personhood in the

context of the family system should be of top priority.

However, this, we posit, is almost diametrically opposed to

acute trauma care systems where patients are often cared for

in ICUs that restrict families by strict visitation policies. In the

proposed trauma model, we argue that nurses and all trauma

providers are the visitors in the lives of injured persons and

their families and are privileged to care for them during this

vulnerable postinjury time.

Persons’ characteristics and environmental factors interact.

For example, there is a known gradient of disability, where

disability increases as socio-economic status (SES) decreases

(Minkler et al. 2006). Thus, nurses might anticipate that

persons with lower SES are more likely to bring pre-existing

disabilities to the injury hospitalization. Similarly, persons

with substance abuse are at higher risk for an injury and will

require additional resources to manage this co-morbid

condition in addition to the injury (Manwell et al. 2005).

Structured care settings

Trauma care is provided in the structure of prehospital care,

acute care hospitals, rehabilitation centres and community

health systems. The QHOM has been conceptualized pri-

marily as a discrete organization – the hospital. However, as

Table 2 Theoretical linkages and underlying assumptions

• All elements of the injury continuum from pre-injury risk through to long-term outcomes of trauma care take place within and are directly affected, both positively and negatively, by all aspects of the socio-economic-cultural environment.

• Pre-injury person and family factors come with the person to all phases of care and these factors directly affect the interventions, structure and intermediate outcomes of care. These factors include genetic predispositions, substance use and the life journey of the person and family.

These factors directly affect risk for injury and long-term outcomes and indirectly affect outcomes of each structured care setting.

• Injury results from the application of external forces to the body that exceed the tissues abilities to withstand those forces. Injuries are heterogeneous in terms of cause, type, and severity and these characteristics both directly affect long-term outcomes and indirectly affect long-

term outcomes through structured care settings.

• Each of the three structured care settings (predefinitive care, definitive acute care, and postdischarge care) incorporates the quality health outcomes model and its underlying premises. Intermediate outcomes from each setting both directly, and indirectly though each of the

subsequent structured care settings, affect long-term outcomes.

• Intermediate outcomes of each phase of care should be synchronous with enhancing the likelihood of long-term outcomes.

T.S. Richmond and L.M. Aitken

2746 � 2011 Blackwell Publishing Ltd

reported in the research from transitional care, this primary

focus on episodic phases of care contributes to sub-optimal

patient outcomes as nurses and other providers are not tem-

porally focused on meeting health needs across discrete epi-

sodes (Naylor et al. 2009). While trauma care may not be

‘episodic’ in the way that some chronic diseases are (e.g.

congestive heart failure with repeated exacerbations of fail-

ure), care of seriously injured trauma patients must be con-

ceived across the artificial geographic boundaries of EDs,

ICUs, medical surgical units, rehabilitation units, hospitals

and communities. To overcome these limitations, we con-

ceptualize the trauma model as occurring over time, place

and structures, but with each component integrally linked. It

is in this foundation that we substantively alter the current

QHOM to explicitly address the reality of care provided

across previously discrete systems and strongly propose the

need to consider care not only in one system, but across

systems as critically important.

In Figure 1, we highlight three structured care settings –

predefinitive care, definitive care and postdischarge. We use

the language of structured care settings to emphasize that

these settings may or may not be physically demarcated

institutions such as an acute care hospital that provides

definitive care. In the model, both the predefinitive care and

postdischarge structured care settings are surrounded by a

dotted line as it is possible that these settings may not be a

physical institution (e.g. rural hospital that stabilized the

patient, rehabilitation hospital or skilled nursing facility) but

is often a set of structured services provided in the person’s

home (e.g. visiting nurses, in-home rehabilitation therapies).

Regardless of the physical structure, the QHOM components

apply in any structured care setting where trauma care is

provided.

We agree with many of the component definitions pre-

sented in the original QHOM model and also with the central

proposition that nursing care influences patient outcomes

only through the organizational structure and patient/family

(Mitchell et al. 1998). We expand the original definitions and

provide additional definitions for clarity and for applicability

to trauma care to highlight the implications of phases of care

in relation to long-term outcomes (see Table 3).

Given the multiple structured care settings through which

trauma patients pass, it is essential to consider the QHOM

components in each setting (i.e. the hospital providing

definitive care) but also across each setting (i.e. moving from

prehospital, to acute care, to rehabilitative or supportive

services). Of particular relevance is the outcomes focus within

and across settings. Nursing practice and nursing science have

moved beyond sole focus on process to linking process

interventions to outcomes. This progress in our discipline is

laudatory but continues to be limited to a focus on outcomes

of each isolated phase of care as opposed to long-term

outcome focused. In this model, the emphasis is on the long-

term outcomes and the variety of paths and contributors to

these long-term outcomes. Importantly, the intermediate

outcomes achieved within each structured care setting influ-

ence the long-term outcomes through each of the subsequent

care settings.

Outcomes

Long-term outcomes are central to the conceptualization and

delivery of quality nursing trauma care. As a result of the

diversity of injury mechanism, type and severity, these long-

term outcomes occur across a time continuum that may span

only weeks or extend for years (Ottosson et al. 2005). This

presents a challenge because important outcomes span set-

tings, time and providers that are often not organisationally

connected and that almost always extend beyond a single

care setting. The Trauma Outcomes Model posits that the

long-term outcomes are of greatest import and that care

provided in the acute and postdischarge phases should focus

on maximizing long-term outcomes. Our focus on long-term

outcomes is not meant to minimize the importance of the

intermediate outcomes achieved during each phase of care

but to refocus our attention on linking these intermediate

outcomes to the final outcomes.

Interventions

Nursing interventions represent the direct and indirect pro-

cesses of care that are delivered by nurses to influence patient

outcomes. Early resuscitation nursing care processes tend to

be algorithmic and assessment and interventions occur

simultaneously to maximize survival. Classic examples

include the A,B,Cs (airway, breathing and circulation) of

emergent trauma care. Nurses, as all members of the multi-

disciplinary trauma team focus on the delivery of evidence-

based trauma care. A recent analysis indicates that a major

barrier to implementing evidence-based guidelines in trauma

is the segmentation of trauma care and the consequent

breakdown at every boundary as patients move through the

phases of care (March 2006). The Trauma Outcomes Model

is designed to help us consider how to move past these

organizational barriers to quality care.

Application of the model to trauma care systems

The expansion of the QHOM to the Trauma Outcomes

Model recognizes the complex and phase-specific nature of

trauma care. The Trauma Outcomes Model is intended

to prompt nurse researchers to expand their science to

JAN: DISCUSSION PAPER Model to advance nursing science

� 2011 Blackwell Publishing Ltd 2747

incorporate the concept of a trajectory over time and place

and to assist clinical nurses in designing care that considers

long-term outcomes. Nurses provide trauma care throughout

this trajectory and consequently work in structured care

settings that span prehospital care (e.g. helicopter transport

from the scene or a non-trauma setting to definitive care),

acute hospital care (e.g. acute resuscitation, surgical critical

care) and postdischarge care (e.g. rehabilitation hospital,

visiting nurse). Regardless of where in the trajectory care is

provided, all nurses need to consider designing care to

optimize long-term outcomes, thus in this model, we believe

it is important to explicate priority outcomes. These out-

comes are grounded in a biopsychosocial framework and are

further derived from the subsequent work on evaluating the

contribution of the QHOM for improving healthcare quality

by Mitchell and Lang (2004).

For trauma, we identify three priority long-term

outcomes: (1) survival is enhanced and morbidity is reduced,

(2) humanity and individual dignity are maintained and

enhanced, and (3) physical, functional, psychological recov-

ery and QOL are maximized (Table 4). Although perceptions

of being well-cared for was posited initially in considering

outcomes in the QHOM, we have broadened this to a more

sophisticated and ethically based outcome of maintaining

humanity and individual dignity.

Early phase interventions (e.g. prehospital, emergency and

critical care) have the potential to lead to very different long-

term outcomes (National Center for Injury Prevention &

Control 2009). Therefore, as nurses conceive of intermediate

outcomes specific to their care setting, the intermediate

outcomes should be aligned with moving the patient towards

one or more of the long-term outcomes. For example,

consider the first long-term outcome ‘survival is enhanced

and morbidity is reduced’. The prehospital nurse may set

intermediate goals that concentrate on airway, oxygenation

and bleeding (see Table 5 for specific examples). In turn, the

critical care nurse is likely to focus on different intermediate

outcomes depending on the array of injuries of varying

severity and co-morbidities; these may incorporate respira-

tory and haemodynamic stability, but expand to include

issues of nutrition and wound care. As the injured person

becomes physiologically stable, he/she is likely transferred to

a surgical unit and another set of intermediate aims are set

that build on the critical care achievements and prepare the

person for hospital discharge. Once discharged from the

hospital he/she may continue to require rehabilitative or

Table 3 Concept definitions of the original QHOM model (Mitchell et al. 1998) and as applied in the trauma care model

Term QHOM definition As applied to the trauma care model

System characteristics ‘…an organized agency, such as a hospital or provider network, then the size, ownership,

skill mix, client demographics and technology

would be among structural elements that

interact with treatment intervention

processes to affect health outcomes’.

Same

Interventions ‘…clinical processes are direct and indirect interventions and related activities by which

they are delivered’.

Same

Client (original QHOM term)

Person and family (trauma care model

term)

‘…outcomes will be affected by the characteristics of the clients to whom

the interventions are directed’.

Person and family bring a unique life

trajectory, co-morbid conditions, re

sources, values and beliefs to the

trauma system.

Intermediate outcomes (we use an

original QHOM definition, but clarify

the term as intermediate for outcomes

at the end of a phase of care.)

‘Outcome measures should be results of care

structures and processes that integrate the

function, social, psychological, physical and

physiological aspects of people’s experiences

with health and illness’.

Same

Long-term outcomes ‘Outcome measures should be operationalized

in five categories: achievement of appropriate

self-care, demonstration of health-promoting

behaviours, health-related quality of life,

perception of being well-cared for and

symptom management’.

The focal points of long-term outcomes

include three major categories: (1)

survival is enhanced and morbidity is

reduced, (2) humanity and individual

dignity are maintained and enhanced

and (3) physical, functional,

psychological recovery and quality of

life are maximized.

T.S. Richmond and L.M. Aitken

2748 � 2011 Blackwell Publishing Ltd

other community health services. In this phase, the nurse also

sets intermediate outcomes that are likely to focus on

ensuring the patient, with the support of their family, is able

to meet their own care needs and that normal activities are

gradually re-established.

Intermediate outcomes contribute to the long-term out-

comes of care. In each long-term outcome, a number of major

nursing priorities are identified that outline the broad

parameter of nursing care (Table 4) but which must be made

more precise and individualized to the person’s injury status

and location on the trajectory of care. Staying with the long-

term outcome of ‘survival is enhanced and morbidity is

reduced’, three major nursing priorities are identified includ-

ing (1) establish physiological stability from the injury and

responses to the injury, (2) diagnose injuries and definitively

treat in a timely manner and (3) prevent complications that

will worsen morbidity both acutely and over the long-term.

Specific actions of the nurse will be dependent on phase of

care, structural components and person characteristics, but

all actions are focused on achieving the intermediate and

long-term outcomes. Take for example a potential cervical

spine injury. In the prehospital phase, the nurse places a

stabilizing collar on the patient, while in the critical care

phase the nurse now focuses on final clearance of the cervical

spine and aggressively working the system to remove the

collar as early as is safe – to minimize the chance for skin

breakdown. Both approaches are aimed at the long-term

outcomes of enhancing survival (cervical spinal cord injury is

associated with lower life expectancy; Richmond & Lemaire

2008) and reducing morbidity (all the associated complica-

tions of cervical spinal cord injury), but the actions vary

within each phase of care.

Similarly, the second and third long-term outcomes also

require care to be individualized to each patient, their current

Table 4 Long-term outcomes and associated nursing priorities

Long-term outcomes Nursing priorities

Survival is enhanced and morbidity is reduced Establish physiological stability from the injury and responses to the injury

Diagnose injuries and definitively treat in a timely manner

Prevent complications that will worsen morbidity both acutely and over the long-term

Humanity and individual dignity are

maintained and enhanced

Optimally manage pain and suffering

Treat as a sentient human being who is able to make decisions about him/herself

and care at the highest level possible

Provide care in the pre-existing social and family structure that is supported and

enhanced during vulnerable times

Treat with dignity and to have a voice throughout all aspects of care

Physical, functional, psychological recovery

and quality of life are maximized

Maximize physical mobility and function, and independent activities and roles

Prevent bad memories, recognize and address psychological consequences that

emerge after or worsen because of the injury event

Support patient and family in anticipating challenges and issues that will arise

across phases of postinjury recovery

Table 5 Example of interim goals related to long-term outcome of ‘survival is enhanced and morbidity is reduced’

Predefinitive care Definitive care Postdischarge

• Airway is secured • Oxygen saturation is maintained >90% • External bleeding is stopped • Systolic BP is maintained >90 mmHg • Cervical spine is maintained in

neutral/protected position

Critical care goal examples:

• Lungs remain clear of infection • Haemodynamic stability is maintained • Intracranial pressure is maintained <15 mmHg • Skin is intact • Calculated caloric need is met by day 7 Surgical ward/unit goal examples:

• Joints maintain full range of motion • Orientation to person and place is achieved • Able to feed self with assistance in setting up meals • Skin is intact • Calculated caloric needs are fully and consistently met

• Family able to administer antibiotics as scheduled

• Wound closes • Walks independently around home • Lung sounds remain clear

JAN: DISCUSSION PAPER Model to advance nursing science

� 2011 Blackwell Publishing Ltd 2749

position on the care trajectory and person and family

characteristics. The second long-term outcome of ‘humanity

and individual dignity is maintained and enhanced’ involves

nursing priorities that focus on the patient as a person within

a family, who has a right to make decisions, express their

sense of self and maintain dignity throughout the entire

trauma care continuum (Table 4). It is likely that this long-

term outcome is the one that gets lost or perhaps viewed as a

‘soft’ outcome. However, we suggest that nurses are central

at each phase of care in maintaining personhood and that the

injured person’s memories of the event are directly affected

by the manner in which they were treated.

The essence of the third long-term outcome of ‘physical,

functional, psychological recovery and QOL is maximized’

requires recognition of all aspects of the injured person’s

recovery, including strategies to optimize physical and

functional recovery, re-establish pre-injury activities, be

psychologically healthy and satisfied with the QOL that they

attain (Table 4). Interventions at each phase have direct

impact on this long-term outcome. Skin breakdown, loss of

range of motion and foot drop can be easily understood to

contribute to sub-optimal functional recovery and interven-

tions to prevent these are directly and independently under

the purview of nursing practice. Nurses also hold responsi-

bility for those complications that are linked to interventions

(or lack of interventions) from the broader multidisciplinary

team. For example, hypoxic or anoxic events can worsen

cognitive function or hypotension that is proven to worsen

functional and physical outcome after brain injury.

Implications for research and/or practice

The Trauma Outcomes Model is on outgrowth of the well-

known and widely used QHOM and is informed by the

relevant literature, knowledge of current research and edu-

cational priorities in trauma nursing, and the expertise and

research output of the two authors coming from two different

systems of care in the US and Australia. We build on the

seminal work of the QHOM and articulate foundational

assumptions and proposed linkages between concepts. The

Trauma Outcomes Model needs further refinement and

validation with expert trauma nurses and nurse scientists to

assess its practical contribution to practice and research.

This Trauma Outcomes Model provides a framework to

assist trauma nurses and researchers to consider the injured

person in the context of the social, economic, cultural and

physical environment from the time of injury through to

recovery. The achievement of intermediate outcomes are the

result of the characteristics of the injured person and their

family, the healthcare structure, and the nursing interventions

delivered in each phase of trauma care and influence and have

congruence with long term outcomes. This model is applica-

ble to all trauma settings including civilian, military and

veteran health environments and may extend across multiple

geographical regions or countries.

The model is not intended to exclude consideration of

other influencing factors or to narrow the scrutiny that nurses

bring to their field of practice, instead it is intended to

encourage them to view the injured person in the context of

the environment from which they come and the long-term

goals that each person has as he/she recovers from injury. It is

also not intended to suggest that there is a universal approach

to the care of the injured person, or to suggest that nurses

should be making generalizations in their care, rather it is

intended to encourage trauma nurses to consider each

person’s individual characteristics, strengths and needs as

they determine appropriate care.

What is already known about this topic

• Trauma care is delivered in multiple settings across a time continuum.

• Recovery following injury often continues for months or years.

• Trauma nurses are optimally placed to improve the communication and integration of patient care across

the continuum.

What this paper adds

• Articulation of the settings in which trauma care is delivered and the linkages between those settings.

• Identification of the long-term goals of trauma care and the associated nursing priorities.

• Description of the relationship between the intermediate outcomes achieved in each care setting and the long-

term goals.

Implications for practice and/or policy

• Provides trauma nurses clear direction on why and how to think about care beyond their specific setting.

• Proposes a model and underlying theoretical assumptions to inform research to build knowledge in

trauma nursing which will help improve the evidence-

base for practice.

• In this model, we strongly suggest that trauma care cannot be viewed as distinct episodes of care but must

be conceptualized across the time/space continuum.

T.S. Richmond and L.M. Aitken

2750 � 2011 Blackwell Publishing Ltd

Conclusion

We intend that the Trauma Outcomes Model proposed in

this article will provide guidance to nurses practicing and

researching across the trauma continuum. The model explic-

itly stimulates nurses and researchers to consider the care that

is delivered beyond one setting and to consider designing and

testing interventions that include long-term outcomes in

addition to setting or phase-specific outcomes. Finally, this

model emphasizes the importance of working towards

integration of episodes of care.

Acknowledgements

We acknowledge the contribution of Bonnie Jennings and

Pamela Mitchell in their critical review and constructive

feedback of this manuscript.

Funding

This project received no specific grant from any funding

agency, however, Dr. Aitken was undertaking an Australian–

American Fulbright Commission funded Fulbright Senior

Scholarship in the School of Nursing, University of Pennsyl-

vania at the time of developing the model and manuscript.

Conflicts of interest

No conflict of interest has been declared by the author(s).

Author contributions

TSR & LA were responsible for the study conception and

design. TSR & LA performed the data collection. TSR &

LA were responsible for the drafting of the manuscript. TSR

& LA made critical revisions to the paper for important

intellectual content. TSR & LA obtained funding. TSR & LA

provided administrative, technical or material support.

References

American Association of Critical Care Nurses (2008) AACN Scope

and Standards for Acute and Critical Care Nursing Practice.

AACN, Aliso Viejo, CA. AACN#130300.

Anzai K., Young J., McCallum J., Miller B. & Jongbloed L. (2006)

Factors influencing discharge location following high lesion spinal

cord injury rehabilitation in British Columbia, Canada. Spinal

Cord 44(1), 11–18.

Baker S.P., O’Neill B., Haddon W. & Long W. (1974) The injury

severity score: a method for describing patients with multiple inju-

ries and evaluating emergency care. Journal of Trauma 14, 187–196.

Barondess J.A. (2008) Health through the urban lens. Journal of

Urban Health: Bulletin of the New York Academy of Medicine 85,

787–801.

Branas C.C., Nance M.L., Elliott M.R., Richmond T.S. & Schwab

C.W. (2004) Urban-rural shifts in intentional firearm death: dif-

ferent causes, same results. American Journal of Public Health 94,

1750–1755.

Cameron C.M., Purdie D.M., Kliewer E.V. & McClure R.J. (2006)

Ten-year health service use outcomes in a population-based cohort

of 21,000 injured adults: the Manitoba injury outcome study.

Bulletin of the World Health Organization 84(10), 802–810.

Champion H.R., Sacco W.J., Copes W.S., Gann D.S., Gennarelli T.A.

& Flanagan M.E. (1989) A revision of the trauma score. Journal of

Trauma 29, 623–629.

Cobb A.M. & Pridgen N. (2008) Polytrauma care: a delicate balance

for the military nurse case manager. Journal of Trauma Nursing

15(4), 192–196.

Colombo C.J., Mount C.A. & Popa C.A. (2008) Critical care med-

icine at Walter Reed Army Medical Center in support of the

global war on terrorism. Critical Care Medicine 36(Suppl. 7),

S388–S394.

Connelly J., Chell S., Tennant A., Rigby A.S. & Airey C.M. (2006)

Modelling 5-year functional outcome in a major traumatic injury

survivor cohort. Disability and Rehabilitation 28(10), 629–636.

Corbin J.M. & Strauss A. (1991) A nursing model for chronic illness

management based upon the Trajectory Framework. Scholarly

Inquiry for Nursing Practice 5(3), 155–174.

Cukier W. (2002) Small arms and light weapons: a public health

approach. The Brown Journal of World Affairs IX, 261–280.

Danne P. (2003) Trauma management in Australia and the tyranny

of distance. World Journal of Surgery 27(4), 385–389.

Eastridge B.J., Jenkins D., Flaherty S., Schiller H. & Holcomb J.B.

(2006) Trauma system development in a theater of war: experi-

ences from Operation Iraqi Freedom and Operation Enduring

Freedom. Journal of Trauma: Injury, Infection, & Critical Care 61,

1366–1373.

Fang R., Pruitt V.M., Dorlac G.R., Silvey S.V., Osborn E.C., Allan

P.F., Flaherty S.F., Perello M.M., Wanek S.M. & Dorlac W.C.

(2008) Critical care at Landstuhl Regional Medical Center. Critical

Care Medicine 36(Suppl. 7), S383–S387.

Fecura S.E., Martin C.M., Martin K.D., Bolenbaucher R.M. &

Cotner-Pouncy T. (2008) Nurses’ role in the Joint Theatre Trauma

System. Journal of Trauma Nursing 15(4), 170–173.

Fraser M. & Curtis K. (2006) A day in the life of a trauma case

manager. Australasian Emergency Nursing Journal 9, 73–78.

Gabbe B.J., Sutherland A.M., Williamson O.D. & Cameron P.A.

(2007) Use of health care services 6 months following major

trauma. Australian Health Review 31(4), 628–632.

Griffith P.M., Alo K. & Cohen M. (2001) The trauma program

manager role: a current examination. Journal of Trauma Nursing

8(3), 75–84.

Gururaj G. (2004) Injuries in India: a national perspective. Report of

the National Institute of Mental Health and Neurosciences, Ban-

galore, India, 325–347.

Haider A.H., Chang D.C., Efron D.T., Haut E.R., Crandall M. &

Cornwell E.E. III (2008) Race and insurance status as risk

factors for trauma mortality. Archives of Surgery 143(10), 945–

949.

JAN: DISCUSSION PAPER Model to advance nursing science

� 2011 Blackwell Publishing Ltd 2751

Halcomb E. & Davidson P. (2005) Using the illness trajectory

framework to describe recovery from traumatic injury. Contem-

porary Nurse 19(1–2), 232–241.

He W., Sengupta M., Velkoff V.A. & DeBarros K.A. (2005) 65 + in

the United States: 2005. Current Population Reports. U.S.

Department of Health & Human Services and U.S. Department of

Commerce, Washington DC.

Holtslag H.R., van Beeck E.F., Lindeman E. & Leenen L.P.H. (2007)

Determinants of long-term functional consequences after major

trauma. Journal of Trauma: Injury, Infection, & Critical Care

62(4), 919–927.

Lim H.J., Hoffmann R. & Brasel K. (2007) Factors influencing dis-

charge location after hospitalization resulting from a traumatic fall

among older persons. Journal of Trauma: Injury, Infection, &

Critical Care 63, 902–907.

Livingston D.H., Tripp T., Biggs C. & Lavery R.F. (2009) A fate

worse than death? Long-term outcome of trauma patients admitted

to the surgical intensive care unit. Journal of Trauma: Injury,

Infection, & Critical Care 67(2), 341–348.

Long A.F., Kneafsey R., Ryan J. & Berry J. (2002) The role of the

nurse within the multi-professional rehabilitation team. Journal of

Advanced Nursing 37(1), 70–78.

MacKenzie E.J., Rivara F.P., Jurkovich G.J., Nathens A.B., Frey K.P.,

Egleston B.L., Salkever D.W. & Scharfstein D.O. (2006) A

national evaluation of the effect of trauma-center care on

mortality. New England Journal of Medicine 354, 366–378.

Manwell L.B., Mindock S. & Mundt M. (2005) Patient reaction to

traumatic injury and inpatient AODA consult: six-month follow-

up. Journal of Substance Abuse Treatment 28, 41–47.

March A. (2006) Facilitating implementation of evidence-based

guidelines in hospital settings: learning from trauma centers. The

Commonwealth Fund 28, 1–54.

Mathers C.D. & Loncar D. (2006) Projections of global mortality

and burden of disease from 2002 to 2030. PLoS Medicine 3,

e442.

Mathers C.D., Boerma T. & Fat D.M. (2009) Global and regional

causes of death. British Medical Journal 92, 7–32.

Minkler M., Fuller-Thomson E. & Guralnik J.M. (2006) Gradient of

disability across the socioeconomic spectrum in the United States.

New England Journal of Medicine 355, 695–703.

Mitchell P.H. & Lang N.L. (2004) Framing the problem of mea-

suring and improving health care quality: has the quality health

outcomes model been useful? Medical Care 42, II-4–II-11.

Mitchell P.H., Ferketich S. & Jennings B.M. (1998) Quality health

outcomes model. Image: Journal of Nursing Scholarship 30,

43–46.

Mitchell M., Chaboyer W., Burmeister E. & Foster M. (2009)

Positive effects of a nursing intervention on family-centered care in

adult critical care. American Journal of Critical Care 18(6), 543–

552.

Nathens A.B., Jurkovich G.J., Cummings P., Rivara F.P. & Maier

R.V. (2000) The effect of organized systems of trauma care on

motor vehicle crash mortality. Journal of the American Medical

Association 283, 1990–1994.

National Center for Injury Prevention & Control (2009) CDC Injury

Research Agenda, 2009-2018. U.S. Department of Health &

Human Services, Centers for Disease Control and Prevention,

Atlanta, GA.

Naylor M.D., Kurtzman E.T. & Pauly M.V. (2009) Transitions of

elders between long-term care and hospitals. Policy, Politics, &

Nursing Practice 10, 187–194.

O’Donnell M.L., Creamer M. & Pattison P. (2004) Posttraumatic

stress disorder and depression following trauma: understanding

comorbidity. American Journal of Psychiatry 161(8), 1390–

1396.

O’Donnell M.L., Creamer M., Elliott P. & Atkin C. (2005) Health

costs following motor vehicle accidents: the role of posttraumatic

stress disorder. Journal of Traumatic Stress 18(5), 557–561.

O’Donnell M.L., Creamer M., Holmes A.C., Ellen S., McFarlane

A.C., Judson R., Silove D. & Bryant R.A. (2010) Posttraumatic

stress disorder after injury: does admission to intensive care unit

increase risk? Journal of Trauma: Injury, Infection, & Critical

Care 69, 627–632.

Olujic M.B. (1998) Embodiment of terror: gendered violence in

peacetime and wartime Croatia and Bosnia-Herzegovina. Medical

Anthropology Quarterly 12(1), 31–50.

O’Mullane A., Mikocka-Walus A.A., Gabbe B.J. & Cameron P.A.

(2009) Incidence and outcomes of major trauma assaults: a pop-

ulation-based study in Victoria. Medical Journal of Australia 190,

129–132.

Ottosson C., Nyren O., Johansson S.-E. & Ponzer S. (2005) Outcome

after minor traffic accidents: a follow-up study of orthopedic

patients in an inner-city area emergency room. Journal of Trauma:

Injury, Infection, & Critical Care 58, 553–560.

Peleg K., Aharonson-Daniel L., Stein M., Kluger Y., Michaelson M.,

Rivkind A., Boyko V. & The Israel Trauma Group (2004)

Increased survival among severe trauma patients: the impact of a

national trauma system. Archives of Surgery 139(11), 1231–1236.

Price S.J., Suttner N. & Aspoas A.R. (2003) Have ATLS national

transfer guidelines improved the quality of resuscitation and

transfer of head-injured patients? A prospective survey from a

regional neurosurgical unit. Injury 34, 834–838.

Richmond T.S. (1997) An explanatory model of variables influencing

post-injury disability. Nursing Research 46, 262–269.

Richmond T.S. & Lemaire J. (2008) Years of life lost because of

gunshot injury to the spinal cord and brain. American Journal of

Physical Medicine & Rehabilitation 87, 609–618.

Richmond T.S., Kauder D. & Schwab C.S. (1998) A prospective

study of predictors of disability at 3 months following non-central

nervous system trauma. The Journal of Trauma: Injury, Infection

& Critical Care 44, 635–643.

Richmond T.S., Kauder D., Hinkle J. & Shults J. (2003) Early pre-

dictors of long-term disability after injury. American Journal of

Critical Care 12(3), 197–205.

Richmond T.S., Amsterdam J.D., Guo W., Ackerson T., Gracias V.,

Robinson K.M. & Hollander J.E. (2009) The effect of post-injury

depression on return to pre-injury function: a prospective cohort

study. Psychological Medicine 39(10), 1709–1720.

Ringdal M., Plos K., Lundberg D., Johansson L. & Bergbom I. (2009)

Outcome after injury: memories, health-related quality of life,

anxiety, and symptoms of depression after intensive care.

Journal of Trauma: Injury, Infection, & Critical Care 66(4), 1226–

1233.

Rivara F.P., Mackenzie E.J., Jurkovich G.J., Nathens A.B., Wang J.

& Scharfstein D.O. (2008) Prevalence of pain in patients 1 year

after major trauma. Archives of Surgery 143(3), 282–287.

T.S. Richmond and L.M. Aitken

2752 � 2011 Blackwell Publishing Ltd

Samuelson K., Lundberg D. & Fridlund B. (2006) Memory in rela-

tion to depth of sedation in adult mechanically ventilated intensive

care patients. Intensive Care Medicine 32(5), 660–667.

Selassie A.W., McCarthy M.L. & Pickelsimer E.E. (2003) The

influence of insurance, race, and gender on emergency department

disposition. Academic Emergency Medicine 10(11), 1260–1270.

Shafi S., de la Plata C.M., Diaz-Arrastia R., Bransky A., Frankel H.,

Elliott A.C., Parks J. & Gentilello L.M. (2007) Ethnic disparities

exist in trauma care. Journal of Trauma: Injury, Infection, &

Critical Care 63(5), 1138–1142.

Shults R.A., Jones B.H., Kresnow M., Langlois J.A. & Guerrero

J.L. (2004) Disability among adults injured in motor vehicle

crashes in the United States. Journal of Safety Research 35, 447–

452.

Soberg H.L., Finset A., Bautz-Holter E., Sandvik L. & Roise O.

(2007) Return to work after severe multiple injuries: a multi-

dimensional approach on status 1 and 2 years postinjury. Journal

of Trauma: Injury, Infection, & Critical Care 62(2), 471–

481.

Zatzick D., Jurkovich G.J., Rivara F.P., Wang J., Fan M.Y., Joesch J.

& Mackenzie E. (2008) A national US study of posttraumatic

stress disorder, depression, and work and functional outcomes

after hospitalization for traumatic injury. Annals of Surgery

248(3), 429–437.

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