Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008-17

Outcomes following resuscitative thoracotomy for abdominal exsanguination, a systematic review

Background

Resuscitative thoracotomy is a damage control procedure with an established role in the immediate treatment of patients in extremis or cardiac arrest secondary to cardiac tamponade however Its role in resuscitation of patients with abdominal exsanguination is uncertain.

Objective

The primary objective of this systematic review was to estimate mortality based on survival to discharge in patients with exsanguinating haemorrhage from abdominal trauma in cardiac arrest or a peri arrest clinical condition following a resuscitative thoracotomy.

Methods

A systematic literature search was performed to identify original research that reported outcomes in resuscitative thoracotomy either in the emergency department or pre-hospital environment in patients suffering or suspected of suffering from intra-abdominal injuries. The primary outcome was to assess survival to discharge. The secondary outcomes assessed were neurological function post procedure and the role of timing of intervention on survival.

Results

Seventeen retrospective case series were reviewed by a single author which described 584 patients with isolated abdominal trauma and an additional 1745 suffering from polytrauma including abdominal injuries. Isolated abdominal trauma survival to discharge ranged from 0 to 18% with polytrauma survival of 0–9.7% with the majority below 1%. Survival following a thoracotomy for abdominal trauma varied between studies and with no comparison non-intervention group no definitive conclusions could be drawn.

Timing of thoracotomy was important with improved mortality in patients not in cardiac arrest or having the procedure performed just after a loss of signs of life. Normal neurological function at discharge ranged from 100 to 28.5% with the presence of a head injury having a negative impact on both survival and long-term morbidity.

Conclusions

Pre-theatre thoracotomy may have a role in peri-arrest or arrested patient with abdominal trauma. The best outcomes are achieved with patients not in cardiac arrest or who have recently arrested and with no head injury present. The earlier the intervention can be performed, the better the outcome for patients, with survival figures of up to 18% following a resuscitative thoracotomy. More high-quality evidence is required to demonstrate a definitive mortality benefit for patients.

Are Primary Trauma Care (PTC) courses beneficial in low- and middle-income countries - A systematic review

BACKGROUND

Injuries remain an important public health concern, resulting in considerable annual morbidity and mortality. In low- and middle-income countries (LMICs), the lack of appropriate infrastructure, equipment and skilled personnel compound the burden of injury, leading to higher mortality rates. As Advanced Trauma Life Support (ATLS) courses remain uneconomical and inappropriate in LMICs, the Primary Trauma Care (PTC) course was introduced to provide an alternative that is both sustainable and appropriate to local resources.

METHODS

A systematic review was performed in May 2019, utilising MEDLINE, EMBASE, Cochrane Library and Google Scholar. All studies reporting patient related outcomes (mortality and morbidity rates) and course participant related outcomes (knowledge, confidence and skills) in LMICs were included. PRISMA guidelines were adhered to throughout.

RESULTS

Nine observational studies were identified (Level 3 evidence). Six studies reported improved knowledge in injury management post-PTC course (p < 0.05). Two studies reported improvements in confidence (p < 0.05) and one on skill attainment (p < 0.0001). One study reported a reduction in mortality rates post-PTC course (p < 0.01).

CONCLUSION

Departmental, institutional and personal improvements may occur in clinical practice as a result of formal PTC training of trauma team members in LMICs. Further high-quality research is needed to evaluate this course's effects on observed change in clinical practice and patient outcomes. This may require long-term observational and epidemiological studies to assess improvements in morbidity and mortality. PROSPERO Registration Number: CRD42019133986.

Assessing barriers to quality trauma care in low and middle-income countries: A Delphi study

BACKGROUND

Most deaths from injury occur in Low and Middle Income Countries (LMICs) with one third potentially avoidable with better health system access. This study aimed to establish consensus on the most important barriers, within a Three Delays framework, to accessing injury care in LMICs that should be considered when evaluating a health system.

METHODS

A three round electronic Delphi study was conducted with experts in LMIC health systems or injury care. In round one, participants proposed important barriers. These were synthesized into a three delays framework. In round 2 participants scored four components for each barrier. Components measured whether barriers were feasible to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability, and potentially readily changed to improve care. In round 3 participants re-scored each barrier following review of feedback from round 2. Consensus was defined for each component as ≥70% agreement or disagreement.

RESULTS

There were 37 eligible responses in round 1, 30 in round 2, and 27 in round 3, with 21 countries represented in all rounds. Of the twenty conceptual barriers identified, consensus was reached on all four components for 11 barriers. This included 2 barriers to seeking care, 5 barriers to reaching care and 4 barriers to receiving care. The ability to modify a barrier most frequently failed to achieve consensus.

CONCLUSION

11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable. We recommend these barriers are considered in assessments of LMIC trauma systems.

The problems of smaller, rural and remote hospitals: Separating facts from fiction

Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems - cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.

Trends in admission timing and mechanism of injury can be used to improve general surgical trauma training

INTRODUCTION

The temporal patterns and unit-based distributions of trauma patients requiring surgical intervention are poorly described in the UK. We describe the distribution of trauma patients in the UK and assess whether changes in working patterns could provide greater exposure for operative trauma training.

METHODS

We searched the Trauma Audit and Research Network database to identify all patients between 1 January 2014 to 31 December 2016. Operative cases were defined as all patients who underwent laparotomy, thoracotomy or open vascular intervention. We assessed time of arrival, correlations between mechanism of injury and surgery, and the effect of changing shift patterns on exposure to trauma patients by reference to a standard 10-hour shift assuming a dedicated trauma rotation or fellowship.

RESULTS

There were 159,719 patients from 194 hospitals submitted to the Network between 2014 and 2016. The busiest 20 centres accounted for 57,568 (36.0%) of cases in total. Of these 2147/57,568 patients (3.7%) required a general surgical operation; 43% of penetrating admissions (925 cases) and 2.2% of blunt admissions (1222 cases). The number of operations correlated more closely with the number of penetrating rather than blunt admissions (r = 0.89 vs r = 0.51). A diurnal pattern in trauma admissions enabled significant increases in trauma exposure with later start times.

CONCLUSIONS

Centres with high volume and high penetrating rates are likely to require more general surgical input and should be identified as locations for operative trauma training. It is possible to improve the number of trauma patients seen in a shift by optimising shift start time.

Defining major trauma: a pre-hospital perspective using focus groups

Background:

Pre-hospital trauma is complex and challenging, with limited clinical exposure for clinicians. In addition, there is no standardised definition for major trauma, and retrospective scores commonly quantify injury severity, such as the injury severity score. This qualitative study aimed to explore the pre-hospital perspectives of major trauma and how pre-hospital trauma care providers define major trauma.

Method:

Three focus groups of 40–60 minutes’ duration were conducted with paramedics, ambulance technicians, police, firefighters and emergency dispatchers. Digital recordings were transcribed verbatim, coded and reviewed to identify emerging themes. Constant comparison was undertaken throughout and codes were identified for qualitative thematic analysis.

Results:

Three overarching themes emerged: clinician factors, patient factors and situational factors. Clinician factors highlighted issues of experience and exposure (or lack of) to major trauma and its relationship to clinical concern, communication issues and the complex nature of pre-hospital trauma. Patient factors identified deranged physiology, actual injuries, life changing trauma, potential need for surgical intervention and rehabilitation as defining major trauma. These variables are often complicated by the extremities of age as well as previous medical history and medications. The situational factors identified that every traumatic encounter is unique, requiring bespoke management where high and low energy mechanisms of injury should be considered.

Conclusion:

Based on the analysis of the focus groups, a working pre-hospital definition is: Any injury (or injuries) that have the potential to be life-threatening or life-changing, including those sustained from low energy mechanisms in people rendered vulnerable by extremes of age, comorbidities or frailty, resulting in significant physiological compromise (haemodynamic instability, reduced consciousness, respiratory compromise) and/or significant anatomical abnormality that may require immediate intervention.

Presence of a pre-hospital enhanced care team reduces on scene time and improves triage compliance for stab trauma

BACKGROUND

A reduction in pre-hospital scene time for patients with penetrating trauma is associated with reduced mortality, when combined with appropriate hospital triage. This study investigated the relationship between presence of pre-hospital enhanced care teams (ECT) (Critical Care Paramedics (CCPS) or Helicopter Emergency Medical Service (HEMS)), on the scene time and triage compliance, of penetrating trauma patients in a UK ambulance service. The primary outcome was whether scene time reduces when an ECT is present. A secondary outcome was whether the presence of an ECT improved compliance with the trust's Major Trauma Decision Tree (MTDT).

METHODS

All suspected penetrating trauma incidents involving a patient's torso were identified from the Trust's computer-aided dispatch (CAD) system between 31st March 2017 and 1st April 2018. Only patients who sustained central penetrating trauma were included. Any incidents involving firearms were excluded due to the prolonged times that can be involved when waiting for specialist police units. Data relevant to scene time for each eligible incident were retrieved, along with the presence or absence of an ECT. The results were analysed to identify trends in the scene times and compliance with the MTDT.

RESULTS

One hundred seventy-one patients met the inclusion criteria, with 165 having complete data. The presence of an ECT improved the median on-scene time in central stabbing by 38% (29m50s vs. 19m0s, p = 0.03). The compliance with the trust's MTDT increased dramatically when an ECT is present (81% vs. 37%, odds ratio 7.59, 95% CI, 3.70-15.37, p < 0.0001).

CONCLUSIONS

The presence of an ECT at a central stabbing incident significantly improved the scene time and triage compliance with a MTDT. Ambulance services should consider routine activation of ECTs to such incidents, with subsequent service evaluation to monitor patient outcomes. Ambulance services should continue to strive to reduce scene times in the context of central penetrating trauma.

Geographical Variance in the Use of Tranexamic Acid for Major Trauma Patients

Background and Objectives: The CRASH-2 trial is the largest randomised control trial examining tranexamic acid (TXA) for injured patients. Since its publication, debate has arisen around whether results could be applied to mature trauma systems in developed nations, with global opinion divided. The aim of this study was to determine if, among trauma patients in or at significant risk of major haemorrhages, there is an association of geographic region with the proportion of patients that received tranexamic acid. Materials and Methods: We conducted a systematic review of the literature. Potentially eligible papers were first screened via title and abstract screening. A full copy of the remaining papers was then obtained and screened for final inclusion. The Newcastle-Ottawa Scale for non-randomised control trials was used for quality assessment of the final studies included. A meta-analysis was conducted using a random-effects model, reporting variation in use sub-grouped by geographical location. Results: There were 727 papers identified through database searching and 23 manuscripts met the criteria for final inclusion in this review. There was a statistically significant variation in the use of TXA for included patients. Europe and Oceania had higher usage rates of TXA compared to other continents. Use of TXA in Asia and Africa was significantly less than other continents and varied use was observed in North America. Conclusions: A large geographical variance in the use of TXA for trauma patients in or at significant risk of major haemorrhage currently exists. The populations in Asia and Africa, where the results of CRASH-2 could be most readily generalised to, reported low rates of use. The reason why remains unclear and further research is required to standardise the use of TXA for trauma resuscitation.

What Is the Clinical Evidence Supporting Trauma Team Training (TTT): A Systematic Review and Meta-Analysis

Background and Objectives: Major trauma centres manage severely injured patients using multi-disciplinary teams but the evidence-base that targeted Trauma Team Training (TTT) improves patients’ outcomes is unclear. This systematic review aimed to identify the association between the implementation of TTT programs and patient outcomes. Materials and Methods: We searched OVID Medline, PubMed and The Cochrane Library (CENTRAL) from the date of the database commencement until 10 of April 2019 for a combination of Medical Subject Headings (MeSH) terms and keywords relating to TTT and clinical outcomes. Reference lists of appraised studies were also screened for relevant articles. We extracted data on the study setting, type and details about the learners, as well as clinical outcomes of mortality and/or time to critical interventions. A meta-analysis of the association between TTT and mortality was conducted using a random effects model. Results: The search yielded 1136 unique records and abstracts, of which 18 full texts were reviewed. Nine studies met final inclusion, of which seven were included in a meta-analysis of the primary outcome. There were no randomised controlled trials. TTT was not associated with mortality (Pooled overall odds ratio (OR) 0.83; 95% Confidence Interval; 0.64–1.09). TTT was associated with improvements in time to operating theatre and time to first computerized tomography (CT) scanning. Conclusions: Despite few publications related to TTT, its introduction was associated with improvements in time to critical interventions. Whether such improvements can translate to improvements in patient outcomes remains unknown. Further research focusing on the translation of standardised trauma team reception “actions” into TTT is required to assess the association between TTT and patient outcome.

Assessing trauma care health systems in low- and middle-income countries, a protocol for a systematic literature review and narrative synthesis

BACKGROUND

Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment.

METHODS

The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a "Three Delays" framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis.

DISCUSSION

The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018112990.

The future of the NHS: Plan B

The NHS for England now has future plans for the next 10 years: but the documents say little about the problems -likely to be encountered. The paper outlines two main -problems - the poor record for expanding services out of -hospital and the crowding out effect of hospital spending - and it sets out some directions for future action to make sure that development continues in the out-of-hospital space.

How organisations contribute to improving the quality of healthcare

Naomi Fulop and Angus Ramsay argue that we should focus more on how organisations and organisational leaders can contribute to improving the quality of healthcare

Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review

AIM

To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?'

METHODS

The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34).

CONCLUSIONS

Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.

Does injury pattern among major road trauma patients influence prehospital transport decisions regardless of the distance to the nearest trauma centre? - a retrospective study

BACKGROUND

Prehospital undertriage occurs when the required level of care for a major trauma patient is underestimated and the patient is transported to a lower-level emergency care facility. One possible reason is that the pattern of injuries exceeding a certain severity threshold is not easily recognizable in the field. The present study aims to examine whether the injury patterns of major road trauma patients are associated with trauma centre transport decisions in Sweden, controlling for the distance from the crash to the nearest trauma centre and other patient characteristics.

METHODS

The Swedish Traffic Accident Data Acquisition (STRADA) database was queried from April 2011 to March 2017. Teaching hospitals with neurosurgery capabilities were classified as trauma centres (TC), all other hospitals were classified as other emergency departments (ED). Injury Severity Score ≥ 13 was used as the threshold for major trauma. Ten common injury patterns were derived from the STRADA data; six patterns included serious neuro trauma to the head or spine. The remaining four patterns were: other severe injuries, moderate to serious abdomen injuries, serious thorax injuries and all other remaining injury patterns. Logistic regression was used to analyse the effect of injury patterns, age, sex and distance from crash to nearest TC on transport decision (TC or ED).

RESULTS

Of the 2542 patients, 38.0% were transported to a TC, equating to a prehospital undertriage of 62%. Over half (59.4%) of the patients had four or more Abbreviated Injury Scale (AIS) 2+ injuries. After controlling for age, sex and distance to nearest TC, only patients sustaining serious head injuries together with other severe injuries had significantly higher odds of being transported to a TC (OR = 4.18, 95% CI: 2.03, 8.73). The odds of being transported to a TC decreased by 5% with every kilometre further away the crash location was to the nearest TC.

CONCLUSION

These results highlight that there is considerable prehospital undertriage in Sweden and suggest that distance to nearest TC is more influential in transport decisions than injury pattern. These results can be used to further develop prehospital transportation guidelines and designation of trauma centres.

Socioeconomic status and 30-day mortality after minor and major trauma: A retrospective analysis of the Trauma Audit and Research Network (TARN) dataset for England

INTRODUCTION

Socioeconomic status (SES) is associated with rate and severity of trauma. However, it is unclear whether there is an independent association between SES and mortality after injury. Our aim was to assess the relationship between SES and mortality from trauma.

MATERIALS AND METHODS

We conducted a secondary analysis of the Trauma Audit and Research Network dataset. Participants were patients admitted to NHS hospitals for trauma between January 2015 and December 2015, and resident in England. Analyses used multivariate logistic regression with thirty-day mortality as the main outcome. Co-variates include SES derived from area-level deprivation, age, injury severity and comorbidity. All analyses were stratified into minor and major trauma.

RESULTS

There were 48,652 admissions (68% for minor injury, ISS<15) included, and 3,792 deaths. Thirty-day mortality was 10% for patients over 85 with minor trauma, which was higher than major trauma for all age groups under 65. Deprivation was not significantly associated with major trauma mortality. For minor trauma, patients older than 40 had significantly higher aORs than the 0-15 age group. Both the most and second most deprived had significantly higher aORs (1.35 and 1.28 respectively).

CONCLUSIONS

This study provides evidence of an independent relationship between SES and mortality after minor trauma, but not for major trauma. Our results identify that, for less severe trauma, older patients and patients with low SES with have an increased risk of 30-day mortality. Policy makers and service providers should consider extending the provision of 'major trauma' healthcare delivery to this at-risk population.