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Fawaz R, Schmitt M, Robert P, Beucler N, Delmas JM, Desse N, Sellier A, Dagain A. Neurosurgical management of penetrating brain injury during World War I: A historical cohort. Neurochirurgie 2023; 69:101439. [PMID: 37084531 DOI: 10.1016/j.neuchi.2023.101439] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/23/2023] [Indexed: 04/23/2023]
Abstract
During World War I, 25% of penetrating injuries were in the cephalic region. Major Henri Brodier described his surgical techniques in a book in which he reported every consecutive penetrating brain injury (PBI) that he operated on from August 1914 to July 1916. The aim was to collate his data and discuss significant differences in management between soldiers who survived and those who died. We conducted a retrospective survey that included every consecutive PBI patient operated on by Henri Brodier from August 1914 to April 1916 and recorded in his book. We reported medical and surgical management. Seventy-seven patients underwent trepanation by Henri Brodier for PBI. Regarding injury mechanism, 66 procedures (86%) were for shrapnel injury. Regarding location, 21 (30%) involved the whole convexity. Intracranial venous sinus wound was diagnosed intraoperatively in 11 patients (14%). Postoperatively, 7 patients (9%) had seizures, 5 (6%) had cerebral herniation, 3 (4%) had cerebral abscess, and 5 (6%) had meningitis. No patients with abscess or meningitis survived. No significant intergroup differences were found for injury mechanism or wound location, including the venous sinus. Extensive initial surgery with debridement must be prioritized. Infectious complications must not be neglected. We should not forget the lessons of the past when managing casualties in present-day and future conflicts.
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Affiliation(s)
- Rayan Fawaz
- Department of Neurosurgery, Percy Military Teaching Hospital, 2, rue Lieutenant-Raoul-Batany, 92140 Clamart cedex, France; École du Val-de-Grâce, French Health Service Military Academy, 1, place Alphonse-Laveran, 75230 Paris cedex 5, France.
| | - Mathilde Schmitt
- École du Val-de-Grâce, French Health Service Military Academy, 1, place Alphonse-Laveran, 75230 Paris cedex 5, France; Department of Infectious Disease, Begin Military Teaching Hospital, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - Philémon Robert
- Department of Neurosurgery, Percy Military Teaching Hospital, 2, rue Lieutenant-Raoul-Batany, 92140 Clamart cedex, France; École du Val-de-Grâce, French Health Service Military Academy, 1, place Alphonse-Laveran, 75230 Paris cedex 5, France
| | - Nathan Beucler
- École du Val-de-Grâce, French Health Service Military Academy, 1, place Alphonse-Laveran, 75230 Paris cedex 5, France; Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, 2, boulevard Sainte-Anne, 83000 Toulon cedex, France
| | - Jean-Marc Delmas
- Department of Neurosurgery, Percy Military Teaching Hospital, 2, rue Lieutenant-Raoul-Batany, 92140 Clamart cedex, France
| | - Nicolas Desse
- Department of Neurosurgery, Percy Military Teaching Hospital, 2, rue Lieutenant-Raoul-Batany, 92140 Clamart cedex, France
| | - Aurore Sellier
- École du Val-de-Grâce, French Health Service Military Academy, 1, place Alphonse-Laveran, 75230 Paris cedex 5, France; Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, 2, boulevard Sainte-Anne, 83000 Toulon cedex, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, 2, boulevard Sainte-Anne, 83000 Toulon cedex, France; Val-de-Grâce Military Academy, 1, place Alphonse-Laveran, 75230 Paris cedex 5, France
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Kanakaris NK, Bouamra O, Lecky F, Giannoudis PV. Severe trauma with associated pelvic fractures: The impact of regional trauma networks on clinical outcome. Injury 2023:S0020-1383(23)00348-0. [PMID: 37085351 DOI: 10.1016/j.injury.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32 (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.
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Affiliation(s)
- Nikolaos K Kanakaris
- LEEDS Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
| | - Omar Bouamra
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Fiona Lecky
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, United Kingdom; Centre for Urgent and Emergency Care REsearch (CURE), Health Services Research Section, School of Health and Related Research, University of Sheffield, United Kingdom
| | - Peter V Giannoudis
- LEEDS Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom.
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Jadhakhan F, Evans D, Falla D. Early interventions for post-traumatic stress following musculoskeletal trauma: protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e065590. [PMID: 36153010 PMCID: PMC9511568 DOI: 10.1136/bmjopen-2022-065590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Post-traumatic stress symptoms (PTSS) can be triggered following exposure to a traumatic event, such as violence, disasters, serious accidents and injury. Little is known about which interventions provide the greatest benefit for PTSS. This systematic review aims to estimate the effects of early interventions on PTSS following musculoskeletal trauma. METHODS/ANALYSIS Development of this review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols checklist. This review will include randomised controlled trials and non-randomised controlled studies evaluating the effect of early (within 3 months of a traumatic event) non-pharmacological and non-surgical interventions on PTSS in adults (aged ≥18 years). MEDLINE, PsycINFO, Embase, CINAHL, Zetoc, PROSPERO, Web of Science, PubMed and Google Scholar, as well as key journals/grey literature, will be searched from inception to 31 July 2022. Only articles published in English will be considered. Two independent reviewers will search, screen studies, extract data and assess risk of bias using the Cochrane Risk of Bias tool V.2 (RoB 2) and the Risk Of Bias in Non-randomised Studies of Interventions (ROBINS-I), respectively. Mean difference or standardised mean difference (SMD) will be extracted with accompanying 95% CIs and p values where these are reported. Group effect size will be extracted and reported. Symptoms of PTSS will be ascertained using SMDs (continuous) and diagnosis of PTSS using risk ratio (dichotomous). If possible, study results will be pooled into a meta-analysis. A narrative synthesis of the results will be presented if heterogeneity is high. The overall quality of evidence and risk of bias will be assessed using the Grading of Recommendations Assessment, Development and Evaluation, RoB 2 and ROBINS-I guidelines, respectively. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review since data from published studies will be used. This review is expected to provide a better understanding of the effect of early intervention for PTSS following musculoskeletal trauma. Findings of this review will be disseminated in peer-reviewed publications and through national and international conferences. PROSPERO REGISTRATION NUMBER CRD42022333905.
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Affiliation(s)
- Ferozkhan Jadhakhan
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - David Evans
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
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Moyer JD, Lee P, Bernard C, Henry L, Lang E, Cook F, Planquart F, Boutonnet M, Harrois A, Gauss T. Machine learning-based prediction of emergency neurosurgery within 24 h after moderate to severe traumatic brain injury. World J Emerg Surg 2022; 17:42. [PMID: 35922831 PMCID: PMC9351267 DOI: 10.1186/s13017-022-00449-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
Background Rapid referral of traumatic brain injury (TBI) patients requiring emergency neurosurgery to a specialized trauma center can significantly reduce morbidity and mortality. Currently, no model has been reported to predict the need for acute neurosurgery in severe to moderate TBI patients. This study aims to evaluate the performance of Machine Learning-based models to establish to predict the need for neurosurgery procedure within 24 h after moderate to severe TBI. Methods Retrospective multicenter cohort study using data from a national trauma registry (Traumabase®) from November 2011 to December 2020. Inclusion criteria correspond to patients over 18 years old with moderate or severe TBI (Glasgow coma score ≤ 12) during prehospital assessment. Patients who died within the first 24 h after hospital admission and secondary transfers were excluded. The population was divided into a train set (80% of patients) and a test set (20% of patients). Several approaches were used to define the best prognostic model (linear nearest neighbor or ensemble model). The Shapley Value was used to identify the most relevant pre-hospital variables for prediction. Results 2159 patients were included in the study. 914 patients (42%) required neurosurgical intervention within 24 h. The population was predominantly male (77%), young (median age 35 years [IQR 24–52]) with severe head injury (median GCS 6 [3–9]). Based on the evaluation of the predictive model on the test set, the logistic regression model had an AUC of 0.76. The best predictive model was obtained with the CatBoost technique (AUC 0.81). According to the Shapley values method, the most predictive variables in the CatBoost were a low initial Glasgow coma score, the regression of pupillary abnormality after osmotherapy, a high blood pressure and a low heart rate. Conclusion Machine learning-based models could predict the need for emergency neurosurgery within 24 h after moderate and severe head injury. Potential clinical benefits of such models as a decision-making tool deserve further assessment. The performance in real-life setting and the impact on clinical decision-making of the model requires workflow integration and prospective assessment. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00449-5.
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Affiliation(s)
- Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
| | - Patrick Lee
- Capgemini Invent, Insight Driven Enterprise, Focused on Data and Artificial Intelligence Services, Paris, France
| | - Charles Bernard
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Lois Henry
- Department of Anesthesiology and Critical Care, Lille, France
| | - Elodie Lang
- Department of Anesthesiology and Critical Care, Hôpital Européen Georges Pompidou, Paris, France
| | - Fabrice Cook
- Department of Anesthesiology and Critical Care, Hôpital Henri Mondor, Créteil, France
| | - Fanny Planquart
- Department of Anesthesiology and Critical Care, Strasbourg, France
| | - Mathieu Boutonnet
- Intensive Care Unit, Percy Military Teaching Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France.,Val de Grace Academy, Place Alphonse Laveran, 75005, Paris, France
| | - Anatole Harrois
- Department of Anesthesiology and Critical Care, APH-HP, Bicêtre Hôpitaux Universitaires Paris-Sud, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Tobias Gauss
- Déchocage- Bloc des urgences, Pole Anesthésie- Réanimation, CHU Grenoble Alpes, La Tronche, France
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Pasquier P, Saleten M, Laitselart P, Martinez T, Descamps C, Debien B, Boutonnet M. Who's who in the trauma bay? Association between wearing of identification jackets and trauma teamwork performance: A simulation study. J Emerg Trauma Shock 2022; 15:139-145. [DOI: 10.4103/jets.jets_168_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/05/2022] [Accepted: 05/20/2022] [Indexed: 11/04/2022] Open
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Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. Guidelines for the acute care of severe limb trauma patients. Anaesth Crit Care Pain Med 2021; 40:100862. [PMID: 34059492 DOI: 10.1016/j.accpm.2021.100862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
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Affiliation(s)
- Julien Pottecher
- Service d'Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg Cedex, France; Université de Strasbourg, FMTS, France.
| | - Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, BP 9000, 57077 Metz Cédex 03, France
| | - Philippe Adam
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte Anne, 2 boulevard Sainte Anne, 83000 Toulon, France; Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
| | - Jonathan Charbit
- Soins critiques DAR Lapeyronie, CHU Montpellier, France; Réseau OcciTRAUMA, Réseau Régional Occitanie de prise en charge des traumatisés sévères, France
| | - Michel Galinski
- Pôle urgences adultes - SAMU 33, Hôpital Pellegrin, CHU de Bordeaux 3300 Bordeaux, France; INSERM U1219, ISPED, Bordeaux Population Health Research Center INSERM U1219-"Injury Epidemiology Transport Occupation" Team, F-33076 Bordeaux Cedex, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHU Lille, F-59000 Lille, France
| | - Tobias Gauss
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Université de Paris, Paris, France
| | - Yannick Georg
- Service de Chirurgie Vasculaire et Transplantation Rénale, Hôpitaux Universitaire de Strasbourg, Strasbourg, France
| | - Sophie Hamada
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Anatole Harrois
- Département d'anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Romain Kedzierewicz
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Bureau de Médecine d'Urgence, Division Santé, Brigade de Sapeurs-Pompiers de Paris, 1 place Jules Renard, 75017 Paris, France
| | - Pierre Pasquier
- Département anesthésie-réanimation, Hôpital d'instruction des armées Percy, Clamart, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Bertrand Prunet
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Claire Roger
- Service de Réanimation Chirurgicale, Pôle Anesthésie Réanimation Douleur Urgence, CHU Carémeau, 30000 Nîmes, France
| | - Karim Tazarourte
- Service SAMU-Urgences, CHU Edouard Herriot, Hospices civils de Lyon, Lyon, France; Université Lyon 1 Hesper EA 7425, Lyon, France
| | - Stéphane Travers
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; 1ère Chefferie du Service de Santé, Villacoublay, France
| | - Lionel Velly
- Service d'Anesthésie Réanimation, CHU Timone Adultes, 264 rue St Pierre 13005 Marseille, France; MeCA, Institut de Neurosciences de la Timone - UMR 7289, Aix Marseille Université, Marseille, France
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux, Bordeaux Population Health - INSERM U1219 Université de Bordeaux, Equipe IETO, Bordeaux, France
| | - Hervé Quintard
- Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
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Huh Y, Kwon J, Moon J, Kang BH, Kim S, Yoo J, Song S, Jung K. An Evaluation of the Effect of Performance Improvement and Patient Safety Program Implemented in a New Regional Trauma Center of Korea. J Korean Med Sci 2021; 36:e149. [PMID: 34100561 PMCID: PMC8185120 DOI: 10.3346/jkms.2021.36.e149] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/28/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea. METHODS The PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015-2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs. RESULTS Human resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008). CONCLUSION Implementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.
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Affiliation(s)
- Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Sora Kim
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Jayoung Yoo
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Seoyoung Song
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea.
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Griffiths A, Dixon J, Egglestone A, Edwards A, Handley R, Trompeter A, Eardley WGP. Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:937-945. [PMID: 33825953 DOI: 10.1007/s00590-021-02954-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/21/2021] [Indexed: 11/25/2022]
Abstract
In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.
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Affiliation(s)
- A Griffiths
- Department of Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, TS4 3BW, UK.
| | - J Dixon
- Darlington Memorial Hospital, Hollyhurst Rd, Darlington, DL3 6HX, UK
| | - A Egglestone
- Department of Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, TS4 3BW, UK
| | - A Edwards
- Trauma Audit Research Network, Summerfield House, 544 Eccles New Road, Salford, M5 5AP, UK
| | - R Handley
- British Orthopaedic Association, 35-43 Lincoln's Inn Fields, Holborn, WC2A 3PE, London, UK
| | - A Trompeter
- St George's University Hospital, Blackshaw Rd, Tooting, SW17 0QT, London, UK
| | - W G P Eardley
- Department of Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, TS4 3BW, UK
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Holmes S. Primary Orbital Fracture Repair. Atlas Oral Maxillofac Surg Clin North Am 2021; 29:51-77. [PMID: 33516540 DOI: 10.1016/j.cxom.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Simon Holmes
- Department of Oral and Maxillofacial Surgery, Royal London Hospital, London, UK.
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10
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Kwon J, Lee JH, Hwang K, Heo Y, Cho HJ, Lee JCJ, Jung K. Systematic Preventable Trauma Death Rate Survey to Establish the Region-based Inclusive Trauma System in a Representative Province of Korea. J Korean Med Sci 2020; 35:e417. [PMID: 33372420 PMCID: PMC7769700 DOI: 10.3346/jkms.2020.35.e417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/15/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. METHODS From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. RESULTS Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within "1-3 hours" than those who arrived within "1 hour." When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. CONCLUSION The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.
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Affiliation(s)
- Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Jin Hee Lee
- National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Kyungjin Hwang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Yunjung Heo
- The Health Insurance Review & Assessment Service, Wonju, Korea
| | - Hang Joo Cho
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - John Cook Jong Lee
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
- Southern Gyeonggi Trauma Center, Ajou University Hospital, Suwon, Korea.
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11
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Beaumont O, Lecky F, Bouamra O, Surendra Kumar D, Coats T, Lockey D, Willett K. Helicopter and ground emergency medical services transportation to hospital after major trauma in England: a comparative cohort study. Trauma Surg Acute Care Open 2020; 5:e000508. [PMID: 32704546 PMCID: PMC7368476 DOI: 10.1136/tsaco-2020-000508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Abstract
Background The utilization of helicopter emergency medical services (HEMS) in modern trauma systems has been a source of debate for many years. This study set to establish the true impact of HEMS in England on survival for patients with major trauma. Methods A comparative cohort design using prospectively recorded data from the UK Trauma Audit and Research Network registry. 279 107 patients were identified between January 2012 and March 2017. The primary outcome measure was risk adjusted in-hospital mortality within propensity score matched cohorts using logistic regression analysis. Subset analyses were performed for subjects with prehospital Glasgow Coma Scale <8, respiratory rate <10 or >29 and systolic blood pressure <90. Results The analysis was based on 61 733 adult patients directly admitted to major trauma centers: 54 185 ground emergency medical services (GEMS) and 7548 HEMS. HEMS patients were more likely male, younger, more severely injured, more likely to be victims of road traffic collisions and intubated at scene. Crude mortality was higher for HEMS patients. Logistic regression demonstrated a 15% reduction in the risk adjusted odds of death (OR=0.846; 95% CI 0.684 to 1.046) in favor of HEMS. When analyzed for patients previously noted to benefit most from HEMS, the odds of death were reduced further but remained statistically consistent with no effect. Sensitivity analysis on 5685 patients attended by a doctor on scene but transported by GEMS demonstrated a protective effect on mortality versus the standard GEMS response (OR 0.77; 95% CI 0.62 to 0.95). Discussion This prospective, level 3 cohort analysis demonstrates a non-significant survival advantage for patients transported by HEMS versus GEMS. Despite the large size of the cohort, the intrinsic mismatch in patient demographics limits the ability to statistically assess HEMS true benefit. It does, however, demonstrate an improved survival for patients attended by doctors on scene in addition to the GEMS response. Improvements in prehospital data and increased trauma unit reporting are required to accurately assess HEMS clinical and cost-effectiveness.
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Affiliation(s)
- Oliver Beaumont
- Clinical Academic Graduate School, Oxford University, Oxford, Oxfordshire, UK.,Department of Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, UK
| | - Fiona Lecky
- Trauma Audit Research Network, University of Manchester, Manchester, UK.,Care for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Omar Bouamra
- Trauma Audit Research Network, University of Manchester, Manchester, UK
| | - Dhushy Surendra Kumar
- Department of Critical Care, Anaesthesia and Pre-hospital Emergency Medicine, University Hospital Coventry, Coventry, UK
| | - Tim Coats
- Emergency Medicine Academic Group, University of Leicester, Leicester, UK
| | - David Lockey
- Department of Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Keith Willett
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
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12
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Barmparas G, Singer M, Ley E, Chung R, Malinoski D, Margulies D, Salim A, Bukur M. Decreased Intracranial Pressure Monitor Use at Level II Trauma Centers is Associated with Increased Mortality. Am Surg 2020. [DOI: 10.1177/000313481207801034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Previous investigations suggest outcome differences at Level I and Level II trauma centers. We examined use of intracranial pressure (ICP) monitors at Level I and Level II trauma centers after traumatic brain injury (TBI) and its effect on mortality. The 2007 to 2008 National Trauma Databank was reviewed for patients with an indication for ICP monitoring based on Brain Trauma Foundation (BTF) guidelines. Demographic and clinical outcomes at Level I and Level II centers were compared by regression modeling. Overall, 15,921 patients met inclusion criteria; 11,017 were admitted to a Level I and 4,904 to a Level II trauma center. Patients with TBI admitted to a Level II trauma center had a lower rate of Injury Severity Score greater than 16 (80 vs 82%, P < 0.01) and lower frequency of head Abbreviated Injury Score greater than 3 (80 vs 82%, P < 0.01). After regression modeling, patients with TBI admitted to a Level II trauma center were 31 per cent less likely to receive an ICP monitor (adjusted odds ratio [AOR], 0.69; P < 0.01) and had a significantly higher mortality (AOR, 1.12; P < 0.01). Admission to a Level II trauma center after severe TBI is associated with a decreased use of ICP monitoring in patients who meet BTF criteria as well as an increased mortality. These differences should be validated prospectively to narrow these discrepancies in care and outcomes between Level I and Level II centers.
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Affiliation(s)
- Galinos Barmparas
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew Singer
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Ley
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rex Chung
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Darren Malinoski
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel Margulies
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ali Salim
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marko Bukur
- From the Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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13
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French J, Agius LM, Sandiford NA. Managing the multiply injured patient: the impact of multidisciplinary teams. Br J Hosp Med (Lond) 2020; 80:703-706. [PMID: 31822166 DOI: 10.12968/hmed.2019.80.12.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Management of trauma has been tackled at a national level to improve patient care and mortality. Decision making through a multidisciplinary team approach has resulted in improved patient outcomes through a complex combination of changes. While the focus of trauma care delivery has been towards establishing an effective multidisciplinary trauma service, there are still improvements which can be made. This article reviews the history of trauma care in the UK, and the impact that multidisciplinary teams have had on the management of the multiply injured patient.
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Affiliation(s)
- Jonathan French
- Registrar, Joint Reconstruction Unit, Southland Teaching Hospital, Southern District Health Board, Invercargill, New Zealand
| | - Lewis M Agius
- Registrar, Joint Reconstruction Unit, Southland Teaching Hospital, Southern District Health Board, Invercargill, New Zealand
| | - Nemandra A Sandiford
- Consultant, Joint Reconstruction Unit, Southland Teaching Hospital, Southern District Health Board, Invercargill, New Zealand
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14
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Abstract
Major trauma in the UK has changed and can now be thought of as two different diseases: the traditional type of high energy transfer major trauma occurring in younger patients, and low energy transfer major trauma (usually an older person falling on one level). The current NHS trauma system is not well set up to treat low energy transfer major trauma - adapting to the changing disease is the next big challenge.
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Affiliation(s)
- Timothy Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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15
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Trauma research in the Nordic countries, 1995-2018 - a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:20. [PMID: 32164776 PMCID: PMC7069175 DOI: 10.1186/s13049-020-0703-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/15/2020] [Indexed: 11/14/2022] Open
Abstract
Background Trauma is a major cause of mortality and reduced quality of life. Most trauma-related research originates from trauma centres, and there are limited available data regarding the treatment of trauma patients throughout the Nordic countries. These countries differ from economically similar countries due to their cold climate, mix of rural and urban areas, and the long distances separating many residents from a trauma centre. Research funders and the general public expect trauma research to focus on all links in the treatment chain. Here we conducted a systematic review to assess the amount of trauma-related research from the Nordic countries between January 1995 and April 2018, and the distribution of this research among different countries and different parts of the trauma treatment chain. Methods A systematic literature search was conducted in Medline, Embase, the Cochrane Library, Web of Science, and Scopus. We included studies concerning the trauma population from Nordic countries, and published between January 1995 and April 2018. Two independent reviewers screened titles and abstracts, and performed data extraction from full-text articles. Results The literature search yielded 5117 titles and abstracts, of which 844 full-text articles were included in our analysis. During this period, the annual number of publications increased. Publications were equally distributed among Norway, Sweden, and Denmark in terms of numbers; however, Norway had more publications relative to inhabitants. There were fewer overall publications from Finland and Iceland. We identified mostly cohort studies and very few randomized controlled trials. Studies focused on the level of care were predominantly epidemiological studies. Research at the pre-hospital level was three-fold more frequent than research on other elements of the trauma treatment chain. Conclusion The rate of publications in the field of trauma care in the Nordic countries has increased over recent years. However, several parts of the trauma treatment chain are still unexplored and most of the available studies are observational studies with low research evidence.
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16
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Pearce AP, Marsden MER, Newell N, Hancorn K, Lecky F, Brohi K, Tai N. Trends in admission timing and mechanism of injury can be used to improve general surgical trauma training. Ann R Coll Surg Engl 2020; 102:36-42. [PMID: 31660752 PMCID: PMC6937604 DOI: 10.1308/rcsann.2019.0135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2019] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- AP Pearce
- Department of General Surgery, Royal London Hospital, Barts’ Health NHS Trust, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - MER Marsden
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Centre for Trauma Sciences, Queen Mary University of London, UK
| | - N Newell
- Department of Mechanical Engineering, Imperial College, London, UK
| | - K Hancorn
- Department of General Surgery, Royal London Hospital, Barts’ Health NHS Trust, London, UK
| | - F Lecky
- Trauma and Audit Research Network, University of Manchester, UK
| | - K Brohi
- Department of General Surgery, Royal London Hospital, Barts’ Health NHS Trust, London, UK
- Centre for Trauma Sciences, Queen Mary University of London, UK
| | - N Tai
- Department of General Surgery, Royal London Hospital, Barts’ Health NHS Trust, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Centre for Trauma Sciences, Queen Mary University of London, UK
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17
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Kulnik ST, Wulf AK, Brunker C. Experiences of long-distance visitors to intensive care units at a regional major trauma centre in the United Kingdom: A cross-sectional survey. Intensive Crit Care Nurs 2019; 55:102754. [PMID: 31515005 DOI: 10.1016/j.iccn.2019.102754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 07/23/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study aimed to investigate the experiences of long-distance visitors of major trauma patients admitted to intensive care units at a regional major trauma centre. RESEARCH METHODOLOGY/DESIGN Postal survey. SETTING Survey participants (n = 103) at a regional major trauma centre in England, United Kingdom, were identified from hospital records. Included were adult visitors (next of kin) of major trauma patients admitted to intensive care at the study site between January 2016 and July 2018, with ordinary residence located more than one hour's drive from the major trauma centre. FINDINGS Response rate was 45.6%. Median (range) driving distance between respondents' residence and the major trauma centre was 57.8 km (28.8-331.5). Median (range) number of days respondents visited at the major trauma centre was 18 (1-200). The quality of care at the centre was rated highly. Visitors described their often-challenging circumstances, negotiating the emotional, psychological, physical and financial impact of the situation. Suggested areas for improvement included car parking, signposting on and around the site, information provision, waiting areas and accommodation at or nearby the major trauma centre. CONCLUSIONS This study has described experiences of long-distance visitors at one regional major trauma centre in England and identified opportunities to ameliorate visitors' stress points locally. Replication at other regional centres may be warranted.
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Affiliation(s)
- Stefan Tino Kulnik
- Faculty of Health, Social Care and Education, Kingston University and St Georges, University of London, United Kingdom.
| | - Anna-Karynka Wulf
- Neuro-Therapies Department, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Christopher Brunker
- Neuro Intensive Care Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
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18
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Bokhari S, Aslam-Pervez N, Riaz O, Sadozai Z, Bhamra M, Harwood P. What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units? Eur J Trauma Emerg Surg 2019; 47:171-177. [PMID: 31451862 DOI: 10.1007/s00068-019-01206-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 08/10/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The Trauma network was established in April 2012 in England to improve the care of patients with trauma. The care of major trauma was centralised to major trauma centres. This article aims to survey trauma team members (TTM) to compare perceptions of trauma care delivery in major trauma centres (MTC) and trauma units (TU) from where major trauma care has been diverted. METHODS Trauma team members (TTM) from six hospitals were interviewed between June and July 2016. This included three MTCs and their neighbouring TU. Data were also gathered to determine appropriate trauma qualifications of TTMs. RESULTS TTMs in MTCs perceived the standard of trauma service improved (90% increased, 10% same) since April 2012 in comparison to TUs (10% increased, 63% same, 27% decreased) (p ≤ 0.001). In MTCs, TTMs felt their skills improved more (66% improved, 34% unchanged) compared to TU's (24% improved, 64% unchanged, 12% regressed) (p ≤ 0.001). TTM's in MTCs were more satisfied with their trauma teams training (p ≤ 0.001), leader's communication (p ≤ 0.001) and handover process (p ≤ 0.01) in comparison to TTMs in TUs. 69% of doctors in MTCs held valid trauma qualifications as compared to only 37% in TUs (p ≤ 0.001). CONCLUSION The centralisation of major trauma care to MTCs allows care for severely injured patients in specialised hospitals with allocated resources. This survey shows the effect of this reorganisation where diversion of major trauma from TUs may have led to their TTMs perceiving their standard of care to be less than TTMs in MTCs. This study recommends training support for TUs using modalities such as simulation-based training and regular audits to ensure improved perceptions and adequate qualifications. Multidisciplinary meetings between MTCs and TUs can allow information to be exchanged and shared to ensure reciprocal support and engagement to improve perception of trauma care delivery.
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Affiliation(s)
| | | | - Osman Riaz
- Pindersfields General Hospital, Wakefield, UK.
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19
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Quinn P, Walton B, Lockey D. An observational study evaluating the demand of major trauma on different surgical specialities in a UK Major Trauma Centre. Eur J Trauma Emerg Surg 2019; 46:1137-1142. [PMID: 30661136 DOI: 10.1007/s00068-019-01075-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/03/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Major Trauma Centres (MTCs) should ideally have all key surgical specialities on site. This may not always be the case since trauma is only one factor influencing speciality location. The implications of this can only be understood when the demands on specific specialities are established and this is not well documented. We investigated surgical speciality demand by quantifying the frequency and urgency of surgical trauma interventions. PATIENTS AND METHODS Data on adult trauma admissions for a UK MTC were retrieved from the UK Trauma Audit and Research Network for a 2-year period and analysed to establish the frequency and urgency of surgical interventions. RESULTS Of 1285 trauma patients with an ISS > 15 presenting in the study year period 713 (55.5%) required surgery. Neurosurgical (59.9%) and orthopaedic (55.1%) operations were most frequent. Cardiothoracic, general surgery, plastic surgery and maxillofacial operations were required infrequently. General surgery was commonly needed urgently, 45% within 4 h of MTC arrival. Urgency was also common in interventional radiology and vascular surgery. Cardiothoracic interventions were mainly urgent interventions (thoracotomy 1/3) and less urgent (rib fixation 2/3). DISCUSSION Neurosurgery and orthopaedic surgery are key on-site trauma specialities and required frequently. General surgery, interventional radiology and cardiothoracic interventions are required less frequently but often urgently. This confirms a need for MTC on-site capability and possibly training to maintain competency in occasional trauma operators, particularly in general surgery. Maxillofacial surgery, ENT and urology are required neither frequently nor urgently and on-site presence may be less critical. CONCLUSION Demand for specific surgical specialities was reported in a cohort of UK trauma patients. This confirmed the need for rapid on-site capability in key specialities and highlights possible training requirements for occasional trauma operators in specialities with low frequency but high urgency.
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Affiliation(s)
| | | | - David Lockey
- University of Bristol, Bristol, UK.
- North Bristol NHS Trust, Bristol, UK.
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20
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Stowell A, Bobbia X, Cheret J, Genre Grandpierre R, Moreau A, Pommet S, Lefrant JY, de La Coussaye JE, Markarian T, Claret PG. Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients. Air Med J 2019; 38:100-105. [PMID: 30898280 DOI: 10.1016/j.amj.2018.11.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/25/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Minimizing out-of-hospital time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome, or acute stroke. Our objective was to compare out-of-hospital times by helicopter versus ground services when the estimated time of arrival on the scene was over 20 minutes. METHODS We proposed a retrospective observational monocentric study following 2 cohorts. The helicopter group and the ground group included patients with severe trauma, acute coronary syndrome, or acute stroke transported by helicopter or ground services. RESULTS Two hundred thirty-nine patients were included; 118 were in the ground group, and 121 were in the helicopter group. Distances for the helicopter group were higher (62.1 ± 22.5 km vs. 27.6 ± 10.4 km, P < .001). When distances were over 35 km, the helicopter group was faster. We identified distance, need for surgery, and intensive care hospitalization as 3 predicting factors for choosing helicopters over ground modes of transport. CONCLUSION In cases of severe trauma, acute coronary syndrome, or acute stroke, emergency medical helicopter transport can be chosen over ground transport when patients are in a severe state and when the distance is further than 35 km from the hospital.
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Affiliation(s)
- Andrew Stowell
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
| | - Xavier Bobbia
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France; Emergency Department, Timone 2 Hospital, Aix-Marseille University, Marseille, France.
| | - Julien Cheret
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
| | - Romain Genre Grandpierre
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
| | - Alexandre Moreau
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
| | - Stéphane Pommet
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
| | - Jean-Yves Lefrant
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
| | - Jean Emmanuel de La Coussaye
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
| | - Thibaut Markarian
- Emergency Department, Timone 2 Hospital, Aix-Marseille University, Marseille, France
| | - Pierre-Géraud Claret
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, Nîmes, France
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21
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Hong ZJ, Chen CJ, Chan DC, Chen TW, Yu JC, Hsu SD. Experienced trauma team leaders save the lives of multiple-trauma patients with severe head injuries. Surg Today 2018; 49:261-267. [PMID: 30302552 DOI: 10.1007/s00595-018-1723-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 09/29/2018] [Indexed: 11/25/2022]
Abstract
The trauma team leader is a professional who receives and treats trauma patients. We aimed to evaluate whether or not the seniority of a qualified trauma team leader was a prognostic factor for multiple-trauma patients managed by a trauma team. This was a retrospective cohort study conducted at a Level I Trauma Center in North Taiwan. From January 2009 to December 2013, 284 patients were randomly assigned to one of two trauma team leaders (junior and senior leaders) on duty, irrespective of the seniority of the qualified trauma team leader. All parameters were collected and compared between these two groups. In the subgroup of multiple-trauma patients with Glasgow Coma Scale (GCS) ≤ 8, there were significant differences in the injury severity score, revised trauma score, and seniority of the leader between the alive and dead groups. A multivariate logistic regression analysis showed that the seniority of the trauma team leader was an important mortality risk factor [odds ratio (OR): 14.529, 95% confidence interval (CI) 1.683-125.429, p = 0.015] in patients with GCS ≤ 8. However, in patients with GCS > 8, age was the only independent risk factor [OR: 1.055, 95% CI 1.023-1.087, p = 0.001]. The seniority of the qualified trauma leader is important for teamwork, organization, and efficiency, all of which play an important role in improving the survival outcome of patients with GCS ≤ 8.
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Affiliation(s)
- Zhi-Jie Hong
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,Division of Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Cheng-Jueng Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.,Division of Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - De-Chuan Chan
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Teng-Wei Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Jyh-Cherng Yu
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Sheng-Der Hsu
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC. .,Division of Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC. .,Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Sec 2, Chen-Kung Rd, Neihu 114, Taipei, Taiwan, ROC.
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Grant A, Stuttard M, Mitchell T. Brief teaching sessions change behaviour in A&E. CLINICAL TEACHER 2018; 16:458-462. [PMID: 30298982 DOI: 10.1111/tct.12943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Accident and Emergency Department (A&E) is a busy environment that requires time- and resource-efficient teaching. Managing cervical spine (c-spine) trauma is often an unfamiliar skill for new doctors starting work in A&E. This study investigated the efficacy of brief teaching interventions in changing clinician behaviour within A&E. The Accident and Emergency Department is a busy environment that requires time- and resource-efficient teaching METHODS: Data for 482 patients receiving c-spine computed tomography (CT) imaging in two Gloucestershire A&Es before and after multimodal departmental teaching were compared. Time taken to CT, indication for CT scan and presence of bony injury were manually recorded from patient management software. RESULTS Following the provision of teaching, the proportion of CT scans performed within 1 hour did not significantly change, from 31% before teaching to 37.6% after teaching (p = 0.133); however, the mean number of c-spine CT scans performed per week rose from 14.50 to 23.25 (p = 0.0001), and the mean number of CT scans performed per week within 1 hour rose from 4.50 to 8.75 (p ≤ 0.001). There was no reduction in the quality of these scans, with the proportion detecting bony injury remaining constant, and there was no increase in the proportion of scans not indicated by National Institute for Health and Care Excellence guidelines. CONCLUSIONS This study demonstrates that brief, low-resource teaching can be associated with a positive change in clinician behaviour. This intervention was straightforward to implement and is likely to be transferable to other guideline-driven investigations. Limitations include the patient cohort being proportionately older than that found in major trauma centres, and a lack of data on patients in whom CT scans were indicated but not performed.
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Affiliation(s)
- Alexander Grant
- Weston General Hospital, Weston Area Health Trust, Weston-Super-Mare, Somerset, UK.,Gloucestershire Hospitals NHS Foundation Trust
| | - Matthew Stuttard
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Mapping the continuum of care to surgery following traumatic spinal cord injury. Injury 2018; 49:1552-1557. [PMID: 29934095 DOI: 10.1016/j.injury.2018.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is a devastating injury, frequently resulting in paralysis and a lifetime of medical and social problems. Reducing time to surgery may improve patient outcomes. A vital first step to reduce times is to map current pathways of care from injury to surgery, identify rapid care pathways and factors associated with rapid care pathway times. METHODS A retrospective review of the Alfred Trauma Service records was undertaken for all cases of spinal injury recorded in the Alfred Trauma Registry over a three year period. Patients with an Abbreviated Injury Scale (AIS) code matching 148 codes for spinal injury were included in the study. Information extracted from the Alfred Trauma Registry included demographic, clinical and key care timelines. RESULTS Of the 342 cases identified, 119 had SCI. The average age of SCI patients was 52 years, with 84% male. The vast majority of SCI patients experienced multiple concurrent injuries (87%). Median time from injury to surgery was 17 h r 28 min for SCI patients in comparison to 28 h r 23 min for non-SCI patients. Three pathways to surgery were identified following Trauma Centre presentation- transfer to surgery direct from trauma unit (median time to surgery was 4 h 17 min.), via Intensive Care (median time to surgery was 24 h 33 min) and via the ward (median time to surgery 28 h r 35 min.) SCI was independently associated with the fastest pathway - direct transfer from trauma unit to surgery - with 41% of SCI cases transferred directly to surgery from the trauma unit. CONCLUSION Notwithstanding that the vast majority of SCI patients presented with other traumatic injuries, half of all SCI cases reached surgery within 18 h of injury, with 25% within 9 h. SCI was independently associated with direct transfer to surgery from the trauma unit. SCI patients achieve rapid times to surgery within a complex trauma service. Furthermore, the trauma system is well positioned to implement further time reductions to surgery for SCI patients.
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Bruce D, Kocialkowski C, Bintcliffe F, Monsell F, Barnes J, Brown R. Analysis of a paediatric orthopaedic network: a six-year experience in the South West of the United Kingdom. J Child Orthop 2017; 11:404-413. [PMID: 29081857 PMCID: PMC5643936 DOI: 10.1302/1863-2548.11.170076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE We report our experience of a paediatric orthopaedic network, based on a 'hub and spoke' model, covering the South West of the United Kingdom. We identify the areas of most clinical concern, the effect of the network on stream-lining patient management and the benefits of the network to the clinician. METHODS Prospective data were collected from the minutes of the bi-annual meetings of the South West Paediatric Network (UK) between November 2006 and May 2012. Data collected included details of the condition, previous treatment, problems, complications and advice given. Cases continue to be followed up in subsequent meetings. RESULTS In total 131 cases were included and hip conditions were discussed most frequently (35.1%). The most common indication for discussion was to support and confirm the local management plan. In total, a mean average of 8.75 cases in total were presented per consultant during the study period, with those within ten to 12 years of starting independent practice presenting the majority. The clinical outcome for patients discussed in this forum was local provision of care in 74%, with transfer to the regional centre in 15.7%. Following advice, 14% of direct referrals were given appropriate advice and avoided a journey to the tertiary centre. CONCLUSION The network has enabled local provision of care, reduced the burden of travel on patients and prevented unnecessary referrals to the tertiary centre. Additionally, it provides a mechanism to reassure and educate clinicians.
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Affiliation(s)
- D. Bruce
- Royal United Hospital, Bath BA1 3NG, UK,Correspondence should be sent to: D. Bruce, Orthopaedic Trauma Department, Southmead hospital, Southmead Road, Bristol, BS10 5NB, United Kingdom. E-mail:
| | | | - F. Bintcliffe
- Eastbourne District General Hospital, Eastbourne BN21 2UD, UK
| | - F. Monsell
- Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
| | - J. Barnes
- Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
| | - R. Brown
- Cheltenham General Hospital, Cheltenham GL53 7AN, UK
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Time and place of death from automobile crashes: Research endpoint implications. J Trauma Acute Care Surg 2017; 81:420-6. [PMID: 27257691 DOI: 10.1097/ta.0000000000001124] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vehicle crashes are a leading cause of US injury and death. Early death, however, has almost entirely been studied in-hospital. The US Department of Transportation Fatality Analysis Reporting System (FARS) database captures both prehospital and in-hospital mortality. METHODS FARS location (prehospital, in-hospital) and time of death were reviewed (1978-2013), and a 2003-2005 subgroup of 55,537 early deaths (i.e., between 5 minutes and 4 hours after injury) was analyzed to quantify risk of death over time. RESULTS There has been an overall decrease in 1978-2013 US vehicle-related deaths (from 3.3 deaths per 100 million vehicle miles traveled to 1.1 and from 22.6 per 100,000 population to 10.4). Snapshots of the death data reveal an overall downward trend of total in-hospital and prehospital deaths. The proportion of hospital deaths decreased by 58%, whereas the proportion of deaths in the prehospital period increased to 56%. Subgroup analysis revealed a rate of mortality risk of 0.4% per minute for the first 30 minutes, 1% per minute for the next 60 minutes, and 0.2% per minute and plateauing thereafter. CONCLUSIONS Analysis of census FARS data of motor vehicle crash-related deaths showed an overall 35% decrease in mortality over a period of 36 years. The disproportionate reduction in in-hospital deaths is perhaps a testament to the effectiveness of trauma centers. However, there is a demonstrable need to focus on prehospital deaths with resuscitative and adjuvant therapy research and trauma system design. Quantifying risk of death over time should help focus emergency medical services, trauma system, and resuscitation goals. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Oliver GJ, Walter DP, Redmond AD. Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades. Injury 2017; 48:978-984. [PMID: 28363752 DOI: 10.1016/j.injury.2017.01.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 12/26/2016] [Accepted: 01/20/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND & OBJECTIVES In 1994, Hussain and Redmond revealed that up to 39% of prehospital deaths from accidental injury might have been preventable had basic first aid care been given. Since then there have been significant advances in trauma systems and care. The exclusion of prehospital deaths from the analysis of trauma registries, giv en the high rate of those, is a major limitation in prehospital research on preventable death. We have repeated the 1994 study to identify any changes over the years and potential developments to improve patient outcomes. METHODS We examined the full Coroner's inquest files for prehospital deaths from trauma and accidental injury over a three-year period in Cheshire. Injuries were scored using the Abbreviated-Injury-Scale (AIS-1990) and Injury Severity Score (ISS), and probability of survival estimated using Bull's probits to match the original protocol. RESULTS One hundred and thirty-four deaths met our inclusion criteria; 79% were male, average age at death was 53.6 years. Sixty-two were found dead (FD), fifty-eight died at scene (DAS) and fourteen were dead on arrival at hospital (DOA). The predominant mechanism of injury was fall (39%). The median ISS was 29 with 58 deaths (43%) having probability of survival of >50%. Post-mortem evidence of head injury was present in 102 (76%) deaths. A bystander was on scene or present immediately after injury in 45% of cases and prior to the Emergency Medical Services (EMS) in 96%. In 93% of cases a bystander made the call for assistance, in those DAS or DOA, bystander intervention of any kind was 43%. CONCLUSIONS The number of potentially preventable prehospital deaths remains high and unchanged. First aid intervention of any kind is infrequent. There is a potentially missed window of opportunity for bystander intervention prior to the arrival of the ambulance service, with simple first-aid manoeuvres to open the airway, preventing hypoxic brain injury and cardiac arrest.
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Affiliation(s)
- G J Oliver
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK.
| | - D P Walter
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK
| | - A D Redmond
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK
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Abstract
Noncompressible torso hemorrhage (NCTH) constitutes a leading cause of potentially preventable trauma mortality. NCTH is defined by high-grade injury present in one or more of the following anatomic domains: pulmonary, solid abdominal organ, major vascular or pelvic trauma; plus hemodynamic instability or the need for immediate hemorrhage control. Rapid operative management, as part of a damage control resuscitation strategy, remains the mainstay of treatment. However, endovascular techniques are evolving and may become more mainstream with the advent of hybrid rooms that can deliver concurrent open and radiologic/endovascular management of traumatic hemorrhage.
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Affiliation(s)
- Jonathan J Morrison
- Department of Vascular Surgery, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, UK.
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Haq J, Gately F, Bentley R. Implementation of an oral and maxillofacial surgery trauma team in a major trauma centre. Br J Oral Maxillofac Surg 2017; 55:396-399. [PMID: 28117114 DOI: 10.1016/j.bjoms.2016.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 12/31/2016] [Indexed: 11/30/2022]
Abstract
In 2010, King's College Hospital in London was designated as a major trauma centre. To deal with the increasing number of patients, an integrated oral and maxillofacial team of the week was established in 2012 to provide a consultant-led, emergency service dedicated to acute care, and it was anticipated that this would reduce the duration of stay by 0.3 bed-days. To assess the effect of the new system, we compared the duration of stay between 1 October and 31 January 2011-2012 with the same period in 2012-2013. We also assessed the activity and training of registrars, and the department's perception of the post of trauma registrar. The mean total duration of stay had decreased significantly by 0.84 days (p=0.03), the mean delay to operation had decreased by 0.3 days, and the mean postoperative stay had decreased by 0.5 days. During one week, the trauma registrar did 12 operations at various sites in the hospital. The new system was a cost-effective way of improving emergency OMFS care and it can be recommended to other centres with similar profiles.
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Affiliation(s)
- J Haq
- Oral & Maxillofacial Surgery, King's College Hospital, Denmark Hill, London SE5 9RS.
| | - F Gately
- Oral & Maxillofacial Surgery, King's College Hospital, Denmark Hill, London SE5 9RS.
| | - R Bentley
- Oral & Maxillofacial Surgery, King's College Hospital, Denmark Hill, London SE5 9RS.
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Nizamoglu M, O'Connor EF, Bache S, Theodorakopoulou E, Sen S, Sherren P, Barnes D, Dziewulski P. The impact of major trauma network triage systems on patients with major burns. Burns 2016; 42:1662-1670. [PMID: 27810131 DOI: 10.1016/j.burns.2016.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/23/2016] [Accepted: 08/25/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Trauma is a leading cause of death and disability worldwide. Patients presenting with severe trauma and burns benefit from specifically trained multidisciplinary teams. Regional trauma systems have shown improved outcomes for trauma patients. The aim of this study is to determine whether the development of major trauma systems have improved the management of patients with major burns. METHODS A retrospective study was performed over a four-year period reviewing all major burns in adults and children received at a regional burns centre in the UK before and after the implementation of the regional trauma systems and major trauma centres (MTC). Comparisons were drawn between three areas: (1) Patients presenting before the introduction of MTC and after the introduction of MTC. (2) Patients referred from MTC and non-MTC within the region, following the introduction of MTC. (3) Patients referred using the urban trauma protocol and the rural trauma protocol. RESULTS Following the introduction of regional trauma systems and major trauma centres (MTC), isolated burn patients seen at our regional burns centre did not show any significant improvement in transfer times, admission resuscitation parameters, organ dysfunction or survival when referred from a MTC compared to a non-MTC emergency department. There was also no significant difference in survival when comparing referrals from all hospitals pre and post establishment of the major trauma network. CONCLUSION No significant outcome benefit was demonstrated for burns patients referred via MTCs compared to non-MTCs. We suggest further research is needed to ascertain whether burns patients benefit from prolonged transfer times to a MTC compared to those seen at their local hospitals prior to transfer to a regional burns unit for further specialist care.
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Affiliation(s)
- Metin Nizamoglu
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom.
| | | | - Sarah Bache
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom.
| | | | - Sankhya Sen
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom.
| | - Peter Sherren
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom.
| | - David Barnes
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom.
| | - Peter Dziewulski
- St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, Essex, United Kingdom; St Andrew's Anglia Ruskin (StAR), Chelmsford, Essex, United Kingdom.
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Trauma care in Scotland: The role of major trauma centres, trauma units, and local emergency hospitals. Surgeon 2016; 14:241-4. [DOI: 10.1016/j.surge.2016.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/28/2016] [Accepted: 03/08/2016] [Indexed: 11/21/2022]
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Roberts N, Lorencatto F, Manson J, Brundage SI, Jansen JO. What helps or hinders the transformation from a major tertiary center to a major trauma center? Identifying barriers and enablers using the Theoretical Domains Framework. Scand J Trauma Resusc Emerg Med 2016; 24:30. [PMID: 26968161 PMCID: PMC4788933 DOI: 10.1186/s13049-016-0226-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 03/10/2016] [Indexed: 02/03/2023] Open
Abstract
Background Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations. Methods The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base. Results and discussion 1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes. Conclusions This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0226-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Neil Roberts
- Departments of Critical Care and Anaesthesia, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Fabiana Lorencatto
- Division of Health Services Research and Management, School of Health Sciences, City University London, London, UK
| | - Joanna Manson
- Barts Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Susan I Brundage
- Barts Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jan O Jansen
- Departments of Surgery and Intensive Care Medicine, Aberdeen Royal Infirmary & Health Services Research Unit, University of Aberdeen, Ward 505, Aberdeen, UK.
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Metcalfe D, Gabbe BJ, Perry DC, Harris MB, Ekegren CL, Zogg CK, Salim A, Costa ML. Quality of care for patients with a fracture of the hip in major trauma centres. Bone Joint J 2016; 98-B:414-9. [DOI: 10.1302/0301-620x.98b3.36904] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip. Patients and Methods All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days. Results There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals. Conclusion These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip. Take home message: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip. Cite this article: Bone Joint J 2016;98-B:414–19.
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Affiliation(s)
| | - B. J. Gabbe
- Monash University, 99
Commercial Road, Melbourne, Vic
3004, Australia
| | - D. C. Perry
- University of Liverpool, Liverpool, L12
2AP, UK
| | - M. B. Harris
- Brigham Women’s Hospital, 75
Francis Street, Boston, MA
02115, USA
| | - C. L. Ekegren
- Monash University, 99
Commercial Road, Melbourne, Vic
3004, Australia
| | - C. K. Zogg
- Harvard Medical School, One
Brigham Circle, Boston, MA
02115, USA
| | - A. Salim
- Harvard Medical School, One
Brigham Circle, Boston, MA
02115, USA
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Battle CE, Lecky FE, Stacey T, Edwards A, Evans PA. Management of the anticoagulated trauma patient in the emergency department: a survey of current practice in England and Wales. Emerg Med J 2016; 33:403-7. [PMID: 26727974 DOI: 10.1136/emermed-2015-205120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/13/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim of this study was to investigate current management of the anticoagulated trauma patient in the emergency departments (EDs) in England and Wales. METHODS A survey exploring management strategies for anticoagulated trauma patients presenting to the ED was developed with two patient scenarios concerning assessment of coagulation status, reversal of international normalised ratio (INR), management of hypotension and management strategies for each patient. Numerical data are presented as percentages of total respondents to that particular question. RESULTS 106 respondents from 166 hospitals replied to the survey, with 24% of respondents working in a major trauma unit with a specialist neurosurgical unit. Variation was reported in the assessment and management strategies of the elderly anticoagulated poly-trauma patient described in scenario one. Variation was also evident in the responses between the neurosurgical and non-neurosurgical units for the head-injured, anticoagulated trauma patient in scenario two. CONCLUSION The results of this study highlight the similarities and variation in the management strategies used in the EDs in England and Wales for the elderly, anticoagulated trauma patient. The variations in practice reported may be due to the differences evident in the available guidelines for these patients.
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Affiliation(s)
- Ceri E Battle
- NISCHR Haemostasis Biomedical Research Unit Epidemiology Division, Morriston Hospital, Swansea, UK
| | - Fiona E Lecky
- The Trauma Audit and Research Network, University of Manchester, University of Sheffield/University of Manchester/Salford Royal Hospital NHS Foundation Trust. Emergency Medicine Research in Sheffield (EMRiS), Health Services Research, School of Health and Related Research, Sheffield, UK
| | - Tom Stacey
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Antoinette Edwards
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Phillip A Evans
- NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK
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Stoica B, Paun S, Tanase I, Negoi I, Beuran M. Trauma pattern in a level I east-European trauma center. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Zacher MT, Kanz K, Hanschen M, Häberle S, van Griensven M, Lefering R, Bühren V, Biberthaler P, Huber‐Wagner S. Association between volume of severely injured patients and mortality in German trauma hospitals. Br J Surg 2015; 102:1213-9. [PMID: 26148791 PMCID: PMC4758415 DOI: 10.1002/bjs.9866] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/16/2014] [Accepted: 05/01/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The issue of patient volume related to trauma outcomes is still under debate. This study aimed to investigate the relationship between number of severely injured patients treated and mortality in German trauma hospitals. METHODS This was a retrospective analysis of the TraumaRegister DGU® (2009-2013). The inclusion criteria were patients in Germany with a severe trauma injury (defined as Injury Severity Score (ISS) of at least 16), and with data available for calculation of Revised Injury Severity Classification (RISC) II score. Patients transferred early were excluded. Outcome analysis (observed versus expected mortality obtained by RISC-II score) was performed by logistic regression. RESULTS A total of 39,289 patients were included. Mean(s.d.) age was 49.9(21.8) years, 27,824 (71.3 per cent) were male, mean(s.d.) ISS was 27.2(11.6) and 10,826 (29.2 per cent) had a Glasgow Coma Scale score below 8. Of 587 hospitals, 98 were level I, 235 level II and 254 level III trauma centres. There was no significant difference between observed and expected mortality in volume subgroups with 40-59, 60-79 or 80-99 patients treated per year. In the subgroups with 1-19 and 20-39 patients per year, the observed mortality was significantly greater than the predicted mortality (P < 0.050). High-volume hospitals had an absolute difference between observed and predicted mortality, suggesting a survival benefit of about 1 per cent compared with low-volume hospitals. Adjusted logistic regression analysis (including hospital level) identified patient volume as an independent positive predictor of survival (odds ratio 1.001 per patient per year; P = 0.038). CONCLUSION The hospital volume of severely injured patients was identified as an independent predictor of survival. A clear cut-off value for volume could not be established, but at least 40 patients per year per hospital appeared beneficial for survival.
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Affiliation(s)
- M. T. Zacher
- Klinikum rechts der Isar, Technical University Munich, Department of Trauma SurgeryMunichGermany
| | - K.‐G. Kanz
- Klinikum rechts der Isar, Technical University Munich, Department of Trauma SurgeryMunichGermany
| | - M. Hanschen
- Klinikum rechts der Isar, Technical University Munich, Department of Trauma SurgeryMunichGermany
| | - S. Häberle
- Klinikum rechts der Isar, Technical University Munich, Department of Trauma SurgeryMunichGermany
| | - M. van Griensven
- Klinikum rechts der Isar, Technical University Munich, Department of Trauma SurgeryMunichGermany
| | - R. Lefering
- IFOM – Institute for Research in Operative Medicine, University Witten/Herdecke, Faculty of HealthCologneGermany
| | - V. Bühren
- Berufsgenossenschaftliche Unfallklinik MurnauMurnauGermany
| | - P. Biberthaler
- Klinikum rechts der Isar, Technical University Munich, Department of Trauma SurgeryMunichGermany
| | - S. Huber‐Wagner
- Klinikum rechts der Isar, Technical University Munich, Department of Trauma SurgeryMunichGermany
| | - the TraumaRegister DGU®
- Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Section NIS)BerlinGermany
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McQueen C, Smyth M, Fisher J, Perkins G. Does the use of dedicated dispatch criteria by Emergency Medical Services optimise appropriate allocation of advanced care resources in cases of high severity trauma? A systematic review. Injury 2015; 46:1197-206. [PMID: 25863418 DOI: 10.1016/j.injury.2015.03.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES The deployment of Enhanced Care Teams (ECTs) capable of delivering advanced clinical interventions for patients at the scene of incidents is commonplace by Emergency Medical Services in most developed countries. It is unclear whether primary dispatch models for ECT resources are more efficient at targeting deployment to patients with severe trauma than secondary dispatch, following requests from EMS personnel at scene. The objective of this study was to review the evidence for primary and secondary models in the targeted dispatch of ECT resources to patients with severe traumatic injury. METHODS This review was completed in accordance with a protocol developed using the PRISMA guidelines. We conducted a search of the MEDLINE, EmBase, Web of Knowledge/Science databases and the Cochrane library, focussed on subject headings and keywords involving the dispatch of ECT resources by Emergency Medical Services. Design and results of each study were described. Heterogeneity in the design of the included studies precluded the completion of a meta-analysis. A narrative synthesis of the results therefore was performed. RESULTS Five hundred and forty-eight articles were screened, and 16 were included. Only one study compared the performance of the different models of dispatch. A non-statistically significant reduction in the length of time for HEMS resources to reach incident scenes of 4min was found when primary dispatch protocols were utilised compared to requests from EMS personnel at scene. No effect on mortality; severity of injury or proportion of patients admitted to intensive care was observed. The remaining studies examined the processes utilised within current primary dispatch models but did not perform any comparative analysis with existing secondary dispatch models. CONCLUSIONS This review identifies a lack of evidence supporting the role of primary dispatch models in targeting the deployment of Enhanced Care Teams to patients with severe injuries. It is therefore not possible to identify a model for ECT dispatch within pre-hospital systems that optimises resource utilisation. Further studies are required to assess the efficiency of systems utilised at each stage of the process used to dispatch Enhanced Care Team resources to incidents within regionalised pre-hospital trauma systems.
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Affiliation(s)
- Carl McQueen
- Clinical Trials Unit, University of Warwick Gibbet Hill, CV4 7AL Coventry, UK.
| | - Mike Smyth
- Clinical Trials Unit, University of Warwick Gibbet Hill, CV4 7AL Coventry, UK.
| | - Joanne Fisher
- University of Warwick, Gibbet Hill, CV4 7AL Coventry, UK.
| | - Gavin Perkins
- Clinical Trials Unit, University of Warwick Gibbet Hill, CV4 7AL Coventry, UK.
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Jansen JO, Morrison JJ, Smyth L, Campbell MK. Using population-based critical care data to evaluate trauma outcomes. Surgeon 2015; 14:7-12. [PMID: 25921799 DOI: 10.1016/j.surge.2015.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/26/2015] [Accepted: 03/27/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The analysis of mortality is an integral part of the evaluation of trauma care. When specific data are not available, general prediction models can be used to adjust for case mix. The aim of this study was to evaluate the feasibility of conducting a population-based analysis of trends in trauma mortality, using critical care audit data, and to investigate whether such data could provide a benchmark for the assessment of service reconfiguration. METHODS Retrospective cohort study of adult trauma patients, requiring admission to a critical care unit in Scotland, 2002-2011, using nationally collected data. Results are presented as standardised mortality ratios of observed mortality divided by APACHE II predicted mortality. Tests for trends in numbers and ratios over time were performed using linear regression. FINDINGS 4503 patients were identified. There was a significant increase in the number of trauma patients admitted per year (p = 0.011). The median predicted probability of in-hospital death was 7% (interquartile range 1-13%), against an actual mortality was 11.6%. There was no significant change in the standardised mortality ratios of trauma patients (p = 0.1224). CONCLUSIONS This study demonstrated the feasibility of utilising critical care unit audit data for analysing outcomes from trauma care. It also showed the potential of such an approach to establish a baseline against which to compare the impact of future service reconfiguration. In contrast to healthcare systems with regionalised trauma care, there appears to have been little change in the mortality of trauma patients requiring critical care unit admission in Scotland.
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Affiliation(s)
- Jan O Jansen
- Department of Surgery and Intensive Care Medicine, Aberdeen Royal Infirmary, United Kingdom; Health Services Research Unit, University of Aberdeen, United Kingdom.
| | - Jonathan J Morrison
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Lorraine Smyth
- Scottish Intensive Care Society Audit Group, NHS National Services Scotland, Edinburgh, United Kingdom
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, United Kingdom
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Morrison JJ, Yapp LZ, Beattie A, Devlin E, Samarage M, McCaffer C, Jansen JO. The epidemiology of Scottish trauma: A comparison of pre-hospital and in-hospital deaths, 2000 to 2011. Surgeon 2015; 14:1-6. [PMID: 25779672 DOI: 10.1016/j.surge.2015.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/01/2015] [Accepted: 02/11/2015] [Indexed: 10/23/2022]
Abstract
AIMS To characterise the temporal trends and urban-rural distribution of fatal injuries in Scotland through the analysis of mortality data collected by the National Records of Scotland. METHODS The prospectively collected NRS database was queried using ICD-10 codes for all Scottish trauma deaths during the period 2000 to 2011. Patients were divided into pre-hospital and in-hospital groups depending on the location of death. Incidence was plotted against time and linear regression was used to identify temporal trends. RESULTS A total of 13,100 deaths were analysed. There were 4755 (36.3%) patients in the pre-hospital group with a median age (IQR) of 42 (28-58) years. The predominant cause of pre-hospital death related to vehicular injury (27.8%), which had a decreasing trend over the study period (p = 0.004). In-hospital, patients had a median age of 80 (58-88) years and the majority (67.0%) of deaths occurred following a fall on the level. This trend was shown to increase over the decade of study (p = 0.020). In addition, the incidence of urban incidents remained static, but the rate of rural fatal trauma decreased (p < 0.001). CONCLUSIONS Around a third of Scottish trauma patients die prior to hospital admission and the predominant mechanism of injury is due to road traffic accidents. This contrasts with in-hospital deaths, which are mainly observed in elderly patients following a fall from standing height. Further research is required to determine the preventability of fatal traumatic injury in Scotland.
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Affiliation(s)
- Jonathan J Morrison
- Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow, UK; The Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | | | | | | | | | | | - Jan O Jansen
- Aberdeen Royal Infirmary, Aberdeen, UK; Health Services Research Unit, University of Aberdeen, UK.
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O’Reilly DA, Bouamra O, Kausar A, Dickson EJ, Lecky F. The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989-2013. Ann R Coll Surg Engl 2015; 97:125-30. [PMID: 25723689 PMCID: PMC4473389 DOI: 10.1308/003588414x14055925060712] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2014] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989-2013. METHODS The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both. RESULTS Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14-35) for blunt trauma and 14 (IQR: 9-18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation. CONCLUSIONS Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.
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Affiliation(s)
- DA O’Reilly
- Department of HPB Surgery, North Manchester General Hospital, Manchester, UK
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - O Bouamra
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- EMRiS, Health Service Research, School of Health and Related Research, University of Sheffield
| | - A Kausar
- Department of HPB Surgery, North Manchester General Hospital, Manchester, UK
| | - EJ Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, UK
| | - F Lecky
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- EMRiS, Health Service Research, School of Health and Related Research, University of Sheffield
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The effect of preinjury warfarin use on mortality rates in trauma patients: a European multicentre study. Emerg Med J 2015; 32:916-20. [DOI: 10.1136/emermed-2014-203959] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
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Duranteau J, Asehnoune K, Pierre S, Ozier Y, Leone M, Lefrant JY. Recommandations sur la réanimation du choc hémorragique. ANESTHESIE & REANIMATION 2015. [DOI: 10.1016/j.anrea.2014.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Kaneria AM. The history and development of trauma and emergency care in England. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614552514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the last decade, trauma care has become its own speciality. The creation of major trauma centres across the UK highlighted a clear clinical need to advance services for multiple injury patients who are known to have poor prognostic outcome. The story of trauma care development goes back well before the creation of the National Health Service (NHS). Although originally grouped with emergency medicine, the two have developed into their own distinct branches. This paper highlights key milestones and relationships in the development of trauma medicine alongside emergency medicine, from ancient times to present day, as well as the factors that have made them distinct. Reviewing the past can help medicine move forward.
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Affiliation(s)
- Anshuni M Kaneria
- King’s College Hospital, London, UK
- Trust SHO Royal National Orthopaedic Hospital, London, UK
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Trauma system development in low- and middle-income countries: a review. J Surg Res 2014; 193:300-7. [PMID: 25450600 DOI: 10.1016/j.jss.2014.09.040] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 08/12/2014] [Accepted: 09/25/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Trauma systems in resource-rich countries have decreased mortality for trauma patients through centralizing resources and standardizing treatment. Rapid industrialization and urbanization have increased the demand for formalized emergency medical services and trauma services (EMS and TS) in low- and middle-income countries (LMICs). This systematic review examines initiatives to develop EMS and TS systems in LMICs to inform the development of comprehensive prehospital care systems in resource-poor settings. MATERIALS AND METHODS EMS and TS system development publications were identified using MEDLINE, PubMed, and Scopus databases. Articles addressing subspecialty skill sets, public policy, or physicians were excluded. Two independent reviewers assessed titles, abstracts, and full texts in a hierarchical manner. RESULTS A total of 12 publications met inclusion criteria, and 10 unique LMIC EMS and TS programs were identified. Common initiatives included the integration of existing EMS and TS services and provision of standardized training and formalized certification processes for prehospital care providers, as well as the construction of a conceptual framework for system development through the public health model. CONCLUSIONS There is no single model of EMS and TS systems, and successful programs are heterogeneous across regions. Successful EMS and TS systems share common characteristics. A predevelopment needs assessment is critical in identifying existing EMS and TS resources as a foundation for further development. Implementation requires coordination of preexisting resources with cost-effective initiatives that involve local stakeholders. High-impact priority areas are identified to focus improvements. Financial stresses and mismatching of resources in LMICs are common and are more commonly encountered when implementing a high-income model EMS and TS in an LMIC. Preimplementation and postimplementation evaluations can determine the efficacy of initiatives to strengthen EMS and TS systems.
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Søreide K. Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres (Br J Surg 2014; 101: 959–964). Br J Surg 2014; 101:964-5. [DOI: 10.1002/bjs.9500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway
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Evaluation of trauma care in a mature level I trauma center in the Netherlands: outcomes in a Dutch mature level I trauma center. World J Surg 2014; 37:2353-9. [PMID: 23708318 DOI: 10.1007/s00268-013-2103-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trauma centers are associated with improved survival rates and outcomes in trauma patients. In 2000 our hospital officially became a level I trauma center. The implementation of the trauma center model showed a significant reduction in mortality and hospital length of stay in our hospital and throughout the trauma region. The aim of the present prospective database study was to present the outcomes of patients treated during the course of further maturation of a level I trauma center. METHODS We performed the prospective database study and included and analyzed outcome data for all adult trauma patients admitted to our trauma center during the years 2003 through 2006 (period 1) and 2007 through 2010 (period 2). RESULTS A total of 5,299 patients were included; 2,419 in period 1 and 2,880 in period 2. Mean Injury Severity Score (ISS) increased from 12.6 to 13.8 (p < 0.001). Mean Revised Trauma Score decreased from 7.4 to 7.2 (p < 0.001). Penetrating injuries increased from 111 (4.6 %) to 192 (6.7 %) (p < 0.001). More head injuries (+7.2 %) and spine injuries (+3.1 %), and fewer injuries to extremities (-6.5 %) were seen in the second period. Mortality, adjusted for age and ISS, was lower in period 2 (odds ratio [OR]: 0.736, p = 0.010). Adjusted for age, ISS, and survival, both the hospital stay and the intensive care unit stay were shortened (OR: 1.068, p < 0.018; OR: 1.188, p = 0.007). Mean probability of survival was significantly higher in the second period. Moreover, more unexpected survivors were seen in the second period (Z-score of 3.4 and W-value of 1.46). CONCLUSIONS Maturation of the trauma center and the trauma system resulted in improved patient outcomes. A significant increase in unexpected survivors was noted, and shorter hospital stay and ICU stay were achieved. Of note, population-based studies on trauma system and trauma center performance with statistical analysis by logistic regression are considered strong class III evidence.
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Hardcastle TC, Reeds MG, Muckart DJJ. Utilisation of a Level 1 Trauma Centre in KwaZulu-Natal: appropriateness of referral determines trauma patient access. World J Surg 2014; 37:1544-9. [PMID: 23254948 DOI: 10.1007/s00268-012-1890-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Appropriate referral of major trauma patients to an accredited Level 1 Trauma facility is associated with improved outcome. A new Level 1 Trauma Centre was opened at Inkosi Albert Luthuli Central Hospital in March 2007. This study sought to audit the referral pattern of external consults to the trauma unit and ascertain whether the unit was receiving appropriate referrals and has adequate capacity. METHODS An audit was performed of the referral proformas used in the unit to record admission decisions and of the computerised trauma database. The audit examined referral source (scene vs. interhospital), regional distribution, and final decision regarding admission of the injured patients. The study was approved by the UKZN Ethics Committee (BE207/09 and 011/010). RESULTS Of the 1,212 external consults, 540 were accepted for admission while the rest were not accepted for various reasons. These included 206 cases where no bed was available, 233 did not meet admission criteria (minor injury or futile situation), and 115 were for subspecialty management of a single-system injury. Finally, 115 were initially refused pending stabilisation for transfer at a regional facility. Twenty-six percent of the cases were referrals from the scene, with an acceptance rate of 96 %. Most patients (59 %) were from the local eThekwini region. CONCLUSION Major multiorgan system trauma remains a significant public health burden in KwaZulu-Natal. A Level 1 Trauma Service is used appropriately in most circumstances. However, the additional need for more hospital facilities that provide such services across the whole province to enable effective geographical coverage for those trauma patients requiring such specialised trauma care is essential.
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Affiliation(s)
- Timothy Craig Hardcastle
- Department of Surgery, UKZN, Trauma Unit, Inkosi Albert Luthuli Central Hospital (IALCH), 800 Bellair Road, Mayville, Postnet Suite 27, Private Bag X05, Malvern, Durban 4055, South Africa.
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An assessment of the hospital disease burden and the facilities for the in-hospital care of trauma in KwaZulu-Natal, South Africa. World J Surg 2014; 37:1550-61. [PMID: 23250389 DOI: 10.1007/s00268-012-1889-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Trauma is a significant cause of morbidity and mortality in South Africa. The present study was designed to review the hospital trauma disease burden in light of the facilities available for the care of the injured in KwaZulu-Natal (KZN), South Africa's most populous province. The primary outcomes were the annual hospital burden of trauma in KZN, determined through data extrapolation, and evaluation of the data in light of available hospital facilities within the province of KZN, a developing province. The data were obtained through review of the trauma load in relation to all emergency cases at all levels of hospitals. METHODS Hospital administrators in KZN were requested to submit trauma caseloads for the months of March and September 2010. Caseloads were reviewed to determine the trauma load for the province per category using two extrapolation methods to determine the predicted range of annual incidence of trauma, intentional versus non-intentional trauma ratios and population-related incidence of trauma. The results were GIS mapped to demonstrate variations across districts. Hospital data were obtained from assessments of structure, process, and personnel undertaken prior to a major sporting event. These were compared to the ideal facilities required for accreditation of trauma care facilities of the Trauma Society of South Africa and other established documents. RESULTS Data were obtained from 36 of the 47 public hospitals in KZN that manage acute emergency cases. The predicted annual trauma incidence in KZN ranges from 124,000 to 125,000, or 12.9 per 1,000 population. This would imply a national public hospital trauma load on the order of at least 750,000 cases per year. Most hospitals are required to treat trauma; however, within KZN many hospitals do not have adequate personnel, medical equipment, or structural integrity to be formally accredited as trauma care facilities in terms of existing criteria. CONCLUSIONS There is a significant trauma load that consumes vital emergency center resources. Most hospitals will need extensive upgrading to provide appropriate care for trauma. An inclusive trauma system needs to be formalized and funded, especially in light of the planned National Health Insurance for South Africa.
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Trauma care in Scotland: effect of rurality on ambulance travel times and level of destination healthcare facility. Eur J Trauma Emerg Surg 2014; 40:295-302. [DOI: 10.1007/s00068-014-0383-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 01/21/2014] [Indexed: 10/25/2022]
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Di Saverio S, Gambale G, Coccolini F, Catena F, Giorgini E, Ansaloni L, Amadori N, Coniglio C, Giugni A, Biscardi A, Magnone S, Filicori F, Cavallo P, Villani S, Cinquantini F, Annicchiarico M, Gordini G, Tugnoli G. Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996-2010). A population cross-sectional survey study. Langenbecks Arch Surg 2013; 399:109-26. [PMID: 24292078 DOI: 10.1007/s00423-013-1143-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 11/06/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma. INTRODUCTION The evaluation of their influence on mortality during the last 15 years can lead to further improvements. METHODS In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS >16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996-2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value. RESULTS Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p < 0.01). Mean GCS (10.2) increased during the period (test trend p < 0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p < 0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p < 0.05). Significant predictors of mortality in the whole group were year of admission (p < 0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p < 0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused (p < 0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality (p = 0.06). CONCLUSION Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS.
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Affiliation(s)
- Salomone Di Saverio
- Trauma Surgery Unit, Department of Emergency, Maggiore Hospital Trauma Center, AUSL Bologna Local Health District, Bologna, Italy,
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