Scandinavian Journal of Surgery 99: 235239, 2010

Temporal patterns of death after trauma: evaluation

of circadian, diurnal, Periodical and seasonal trends
in 260 fatal injuries
K. Sreide1, 2
1
2

Department of Surgery, Stavanger University Hospital, Stavanger, Norway

Department of Surgical Sciences, University of Bergen, Bergen, Norway

ABSTRACT

Background: Temporal patterns of trauma deaths may indicate potential for prevention
or systems improvement, but have been poorly investigated in the Scandinavian trauma
population. This study examines patterns in trauma deaths to the occurrence in hour and
time of the day, day and time in the week, and month and season.
Materials and Methods: Investigation of the temporal patterns of death in 260 fatalities
undergoing autopsy. Time of death were explored according to time of the day (hour;
day/night), time of the week (day of week; weekday/weekend) and time of the year
(month; season) and analyzed for difference in gender, age, injury type and severity, and
mechanisms of injury and death.
Results: A total of 260 trauma deaths were included, of which 125 (48%) died in hospital and 194 (75%) were male. No particular peak-hour of the day when deaths occurred
was found. One-third of deaths occurred during weekends. For inhospital deaths during
weekends, significantly more patients had respiratory distress (RR > 20 or < 16 in 72.5%
for weekends and 47.0% for weekdays; p = 0.008) and hypotension (SBP < 90mmHg in
61% vs 40%; p = 0.048) during weekends. Deaths occurred with some monthly variance
demonstrated with two monthly peaks in February/March and July/August, respectively.
Overall, no statistically different seasonal differences in the occurrence of traumatic
deaths, nor any differences in cause of death, type or severity of injury, nor in physiological parameters was found. However, a higher number of inhospital deaths presented
with reduced consciousness level (GCS < 8) and severe head injuries (AIS-head 4) during spring and summer (P = 0.045, chi-square for trend) compared to winter and fall.
Conclusions: Trauma deaths in a Scandinavian population did not demonstrate statistically significant differences in overall circadian, weekly or seasonal patterns of trauma
death occurrence. However, the impact of fatal head injuries during spring and summer
warrants further investigation.
Key words: Trauma; death; injury; circadian; diurnal; periodical; week; month; season

Correspondence:
Kjetil Sreide, M.D.
Department of Surgery, Stavanger University Hospital
POB 8100
N - 4068 Stavanger, Norway
Email: ksoreide@mac.com

236

K. Sreide

INTRODUCTION
Major injury is a leading cause of death and disability
around the world (1). For both sexes, one in every ten
deaths is the result of injury. Globally, unintentional
injuries are ranked as the sixth leading cause of death
and the fifth leading cause of moderate and severe
disability. Road traffic accidents (RTA) alone cause 1.3
million deaths each year. For those under 35 years of
age, injury is the leading cause of death, and males
aged 1524 years are responsible for the greatest share
of injury burden (1).
While some studies have investigated and demonstrated temporal differences in the occurrence and
death in various surgical and non-surgical diseases
such as ruptured abdominal aortic aneurysms,
acute myocardial infarction, sudden cardiac death,
stroke, and pulmonary embolism (24) similar temporal relationships have been less well investigated
for trauma patients (5,6). The past decades have focused on the trimodal temporal death distribution
after trauma from early hours exanguination, to
fatal centralnervous system injuries within days and,
multiorgan failure deaths occurring weeks or months
after injury. Some recent reports have demonstrated
diverging results as to the validity of the trimodal
death pattern (710), as the model depends on choice
of method for verification (11). Also, an overall literature summary demonstrates a reduction in the rates
of exsanguinating trauma patients (12), possibly due
to improved diagnostics and implementation of standardized treatment algorithms. Further, the introduction of working-time restrictions in both North America and European training systems have raised concerns for maintenance of overall patient safety and
continuity of care (13). Added to this concern is the
theoretical effect of annually rotas within the training
system, providing for periods with more inexperienced trainees involved in patient care, termed the
July phenomenon (14, 15). While several of these
issues may or may not truly influence on mortality
for patients with surgical diseases, such as trauma,
before investigating any causal relationships it is important to analyze the temporal trends to detect any
statistically significant or clinically important differences, if present, in the first place. Thus, this study
was undertaken to investigate the temporal trends of
trauma deaths in a previously described Norwegian
cohort of trauma fatalities (10), recognizing the Scandinavian 40-hour working hour system. The aim was
to investigate if there were any particular clustering
of deaths according to hour of the day, day of the
week, month or season.

ture) are not included in the study population. Briefly, the

Stavanger University Hospital (SUH) is the primary trauma
hospital for about 300,000 inhabitants, with referrals received from a wider population of about 500,000 (16, 17).
The SUH has a designated trauma team consisting of general surgeons, orthopaedic surgeons, anaesthesiologists and
any required subspecialty care, as required. In the designated region, prehospital and inhospital trauma deaths are
undergoing autopsy at a very high frequency due to cooperative agreements between law enforcements and the department of pathology at SUH. The regional ethic committee recognized the study as quality assurance.
Demographics, injury description and severity

Age and gender, type and mechanism of injury, and cause

of death were recorded. Injury severity scoring was performed by a registrar (K.S.) trained and certified in the
methods by AAAM using the Abbreviated Injury Score
(AIS-90, 1998 update; (ref. 18)), for calculation of the Injury
Severity Score (ISS) and New Injury Severity Score (NISS)
(19). For inhospital deaths, systolic blood pressure (SBP),
respiratory rate (RR), and Glasgow Coma Scale (GCS) were
recorded on arrival in the emergency department, were
applicable. To avoid missing values in physiological parameters, SBP, GCS, and RR were categorized on a fivepoint scale according to the Revised Trauma Score coded
values. Respiratory distress was defined as any value not
indicating a RR of 1620; hypotension was defined as any
SBP value < 90 mmHg, and severely reduced consciousness
level as GCS < 8.
Temporal trend records

Time of injury and death, if documented, were recorded to

any full hour (from 0 to 23) of the day. Diurnal variation
was investigated for Daytime (07:00 hrs to 18:59 hrs) and
Nighttime (19:00 hrs to 06:59 hrs). Day of the week (Monday through Sunday) were recorded with Weekdays designated as Monday through Thursday and Weekends as
Friday through Sunday. Month of death was recorded, and
Season designated as Winter (December through February),
Spring (March through May), Summer (June through August) and Fall (September through November), as previously reported (5, 20).
Statistics

Statistical analysis was performed using SPSS version 16.0

(SPSS Inc., Chicago, USA). Data are reported as mean
standard deviation (SD) or median and ranges, were indicated. Comparison between continuous variables was
performed with non-parametric Mann-Whitney U test. The
Chi-square or Fischers exact test was used for comparison
of categorical data. All statistical tests are two-tailed, and
the statistical significance level set at P < 0.05.

Results
Material and methods
All trauma deaths occurring in the greater Stavanger area
(population of approx. 300,000) during 19962004 and who
were subject to autopsy were eligible for inclusion in this
study. The study population has been described previously
(5, 10). The study population consists of over 95% of all
trauma deaths occurring in the defined area during the
study period (10). Burns and isolated fractures (i.e. hip frac-

A total of 260 deaths underwent a full autopsy (either

regular or forensic) after sustaining fatal injury and
were included, of which 125 (48%) were inhospital
deaths and 194 (75%) were males. The distribution in
age, gender and injury profile has been reported previously (10). Briefly, the mean age was 45.6 25.1
years, and the mean ISS 43 23 and NISS 54 20, indicating a severely injured study population.

Figure 1. Diurnal (A) and weekday (B) distribution of trauma deaths

Temporal patterns of trauma deaths

237

Fig. 1. Diurnal (A) and weekday (B) distribution of trauma deaths.

Figure 2. Monthly (A) and seasonal (B) distribution of trauma deaths.

Circadian and diurnal patterns of death after

injury

Exact time of death was only present in about half the

patients (n = 123), largely due to lack of exact recording in prehospital cases (missing in 70%), but present
in two-thirds of the inhospital deaths. For those with
available records, there was no particular peak-hour
of the day when deaths occurred. However, for parts
of the day, there was considerable higher number for
the hours 20:00 p.m. to 01:59 a.m. accounting for
about one-third (32.6%) of all deaths, and the hours
16:00 to18:59 p.m. accounting for about one fifth of all
deaths (19.5%). The hours 03:00 to 06:59 a.m. had the
least number of deaths (< 10% for both pre- and inhospital deaths). However, the largest share of deaths
occurred during daytime (Fig. 1A).
For inhospital deaths alone, no statistically significant diurnal differences in the injury severity (ISS and
NISS) or cause of death could be detected. Neither
was there any significant difference in the numbers
of severe head, thoracic or abdominal injuries, nor in
the numbers of patients presenting in respiratory distress, with hypotension, or with decreased consciousness level comparing daytime with nighttime
deaths.
Day of the week, weekdays vs weekends

No particular clustering of deaths during any day of

the week was found with any statistically significant
difference (Monday through Sunday; Fig. 1B). Of the
260 deaths, 32.9% (n = 102) occurred during weekends. No significant
differences were found in gen
der, age, injury type or severity, or cause of death. For
inhospital deaths during weekends, significantly
more patients had respiratory distress (72.5% for

weekends and 47.0% for weekdays; p = 0.008) and

hypotension (61% vs 40%; p = 0.048) during weekends.
Month of the year and seasonal pattern

Deaths occurred with some monthly variance demonstrated with two monthly peaks (Fig. 2A) with the
first occurring during February/March and the other
during July/August.
Spread over the year, there were no statistically
different seasonal differences in the occurrence of
traumatic deaths (Fig. 2B), nor any differences in
cause of death, type and severity of injury (Fig. 3), or
physiological parameters, except for more inhospital
deaths having a lower consciousness level on arrival
during spring and summer (GCS < 8 in 86% and 69%)
compared to winter and fall (52% and 63%, respectively; P = 0.045, chi-square for trend), and more patients with severe head-injuries (AIS head of 4 or
higher) during spring and summer (75% and 78%)
compared to winter and fall (52% and 63%, respectively; P=0.045, chi-square for trend).
Discussion
This study demonstrates temporal trends in circadian, diurnal, weekly, and seasonal patterns of trauma
deaths occurring in a defined Norwegian population.
Notably, these patterns were investigated in a nonformal trauma system depending on trauma-care delivered by general and/or subspecialty surgeons

(non-designated for trauma only), as is the present

state in Norway and other Scandinavian countries
(21, 22). This study demonstrates no significant circa-

Figure 2. Monthly (A) and seasonal (B) distribution of trauma deaths.

K. Sreide

238

Fig. 2.3.Monthly
(A) andofseasonal
distribution
of traumato
deaths.
Figure
Distribution
injury (B)
mechanism
according
time of year

RTA denotes road traffic accident.

Fig. 3. Distribution of injury mechanism according to time of year

RTA denotes road traffic accident.


dian differences,
although one third of all deaths occurred during evening and early night. Of notice, the

staff number
is usually lower with less degree of experience during this time, than during day-hours.
 due to the number of missing data and the
However,
investigation of deaths only (and not survivors of
trauma) these number should be interpreted with

caution before drawing firm conclusions, and preferably larger cohorts of trauma patients (both survivors
and non-survivors) should be investigated to firmly
establish any clinically important pattern in this regard.
The increased number of trauma deaths presenting
with severe head-injuries and reduced GCS scores on

Temporal patterns of trauma deaths

arrival in the emergency department during spring

and summer are in line with previous findings demonstrated in children (5). These findings coincide with
the higher incidence of fatalities after road traffic accidents during spring and summer, as well as higher
incidence of fall-related deaths during summer (Fig.
3). The role of falls as a contributor to the incidence
of head injuries has been noted in a previous report
from the Stavanger region (23), with falls as the most
frequent contributor to head injuries in both extremes
of age. However, other reports have not demonstrated
any seasonal patterns in the occurrence of fatal and
non-fatal falls (20).
The monthly clustering of fatal trauma during the
months February/March and July/August represents
the peak seasons of vacation (winter and summer,
respectively) and increased activity, both in terms of
more busy traffic (with increased risk for road traffic
accidents) and increased leisure activities.
In Norway, there is no specific month, or time of
the year, for rotation for residents in training (not for
surgeons, nor for other related specialties including
orthopaedic surgeons, nor anaesthesiologists). Rather,
training is begun on a random basis, year-round, depending on vacant positions available (22). Thus, we
believe that the finding of an increased number of
deaths during July/August is not a reflection of training and experience status of the staff involved, but
may rather reflect a time of the year with peak incidence in accidents. This should, however, warrant
further studies in the Scandinavian population. Of
notice, recent reports (14, 15) from North American
trauma centres have not confirmed any July-phenomenon, nor have this been found in other fields
including obstetrics, intensive care, nor in neurosurgery (2426).
In conclusion, the patterns of trauma deaths in a
Scandinavian population with a 40-hour working
week pattern did not demonstrate statistically significant circadian, weekly or seasonal patterns of
trauma death occurrence in an overall perspective.
However, some clustering of the number of deaths
was demonstrated during evening and early nighthours, more critical and fatal head injuries during
weekends and particularly for spring and summertime, and clustering of deaths during typical months
of vacation (winter break and summer break). These
findings should be explored in further detail, using
the current trauma registries under establishment in
the Scandinavian systems, to allow for future evaluation, planning, and possible improvements of the
trauma system at hand.
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Received: October 8, 2009

Accepted: March 3, 2010