TraumaRegister DGU® der Deutschen Gesellschaft für Unfallchirurgie

[Registry-based research in ophthalmology]

Medical registries and registry studies are frequently used for health services research as they represent a valuable means of capturing real-life data. Registry studies are particularly suitable for rare diseases for which epidemiological population-based or randomized controlled clinical studies are difficult. The are many examples of successful medical registries that have not only contributed to both epidemiological and clinical research, but which have also improved health service delivery. Only few ophthalmological medical registries are currently available. For non-infectious uveitis in children and adolescents with juvenile idiopathic arthritis (JIA), a rare disease entity, there is a need for data on, e.g., treatment, long-term outcomes, and risk factors for progression. The advantages for this disease of a registry with uveitis module from which numerous scientific publications and guidelines have been derived has been proven. Thus, we use the example of non-infectious uveitis to discuss the benefits of registries for other areas of ophthalmology.

Improvement of polytrauma management-quality inspection of a newly introduced course concept

RATIONALE, AIMS, AND OBJECTIVES

A systematic literature search for training course concepts for care of severely injured and severely ill patients respecting improvement of process and outcome yielded little data. For several years, the University Hospital of Bonn has hosted a shock-room management course which, on the one hand, communicates human factor aspects and, on the other hand, pursues interdisciplinary and interprofessional team training. The Bonn shock-room management course (BSM-course®) differs from other courses in both format and principles. The aim of this study was to evaluate the quality of the structure of the course based on course evaluations of participants and its impact on the quality of the process and results for polytrauma care.

METHODS

Single-center retrospective evaluation study (2011 to 2014). It was based on data from simulator training and records from the German Trauma Registry (DGU)®.

RESULTS

Subjective evaluation of participants (n = 188) of the structure quality of Bonn's shock-room management course was overall positive. Objective measures of course participant performance also improved during simulation training (P = 0.012). An increasing number of trained employees also had a positive influence in reducing process time for shock-room care. Further, the course likewise had a positive impact on documentation quality (degree of completion), with regard to 4 relevant predictive parameters. Early mortality during the first 24 hours remained constant at 6.0-6.5% between 2011 and 2013, yet it decreased to 3.1% in 2014.

CONCLUSION

The BSM-course® represents a symbiosis of horizontal team approach of trauma care and human factor training. The course format is able to ensure interdisciplinary and interprofessional team training with a high degree of efficiency. Furthermore, the presented work shows that a modern course concept can improve the quality of trauma care.

[Treatment of severely injured patients : Impact of the German Trauma Registry DGU®]

The German Trauma Registry DGU® started in 1993 as an initiative of five dedicated trauma centers and has evolved significantly since then. Data were obtained at four points of time from the site of the accident until discharge from hospital. In the first year (1993), the registry collected data of 260 patients from 5 hospitals. In 2015 more than 38.000 were included from 640 hospitals.This paper focusses on the impact of the trauma registry on the treatment of severely injured patients. Several authors could show that the data can be used by hospitals for benchmarking. This can help to detect problems in individual hospitals and to find solutions that can be implemented into the process of care and its subsequent reevaluation. Due to structural and process-related changes, the time necessary for the management in the emergency room could be reduced significantly. Various scientific analyses of the Trauma Registry DGU® data were implemented in the treatment of severely injured patients. In the prehospital treatment, this changed the criteria for intubation and led to a reduction of volume replacement. In the hospital setting, the analysis influenced the radiologic work-up and the treatment of coagulopathy of severely injured patients. Moreover, the risk-adjusted mortality of severely injured patients in Germany could be continuously reduced over the past 20 years.

Patterns of early resuscitation associated with mortality after penetrating injuries

BACKGROUND

Penetrating injuries are rare in European populations so their management represents a particular challenge. The aim was to assess early therapeutic aspects that are associated with favourable outcomes in patients with penetrating trauma.

METHODS

Patients with penetrating injuries documented from 2009 to 2013 in the TraumaRegister DGU® were analysed. Patients with a primary admission and an Injury Severity Score (ISS) of at least 9 were included. The Revised Injury Severity Classification (RISC) II score was used for mortality prediction, and a standardized mortality ratio (SMR) calculated per hospital. Hospitals with favourable outcome (SMR below 1) were compared with those with poor outcome (SMR 1 or more).

RESULTS

A total of 50 centres had favourable outcome (1242 patients; observed mortality rate 15.7 per cent) and 34 centres had poor outcome (918 patients; observed mortality rate 24.4 per cent). Predicted mortality rates according to RISC-II were 20.4 and 20.5 per cent respectively. Mean(s.d.) ISS values were 22(14) versus 21(14) (P = 0.121). Patients in the favourable outcome group had a significantly shorter time before admission to hospital and a lower intubation rate. They received smaller quantities of intravenous fluids on admission to the emergency room, but larger amounts of fresh frozen plasma, and were more likely to receive haemostatic agents. A higher proportion of patients in the favourable outcome group were treated in a level I trauma centre. Independent risk factors for hospital death following penetrating trauma identified by multivariable analysis included gunshot injury mechanism and treatment in non-level I centres.

CONCLUSION

Among penetrating traumas, gunshot injuries pose an independent risk of death. Treatment of penetrating trauma in a level I trauma centre was significantly and independently associated with lower hospital mortality.

[The TraumaRegister DGU® as data source for monitoring severe injuries]

BACKGROUND

The TraumaRegister DGU® of the German Society for Trauma Surgery (TR-DGU) has collected data on the treatment of severely injured accident victims in Germany since 1993. Due to the current number of more than 600 participating clinics which regularly receive quality comparison reports, these register data are becoming an increasingly more valuable source for healthcare research.

OBJECTIVES

The aims of this article are to describe the potential of the TR-DGU for dealing with epidemiological questions and for describing the quality of the process and results for treatment of severely injured patients.

MATERIAL AND METHODS

The TR-DGU includes approximately 100 details per patient on the person, the circumstances of the accident, the injury pattern, the preclinical and hospital treatment, the condition of the patient and the outcome. Using comparative analyses the observed mortality is adjusted by considering prognostically relevant findings. Some key features of the register are reported for patients who were treated in German hospitals between 2002 and 2012 with an injury severity score (ISS) of  ≥9 points.

RESULTS

Since 1993 more than 122,000 patients have been included in the register. The majority are traffic accident victims (57 %), followed by patients with falls from low heights (< 3 m, 17 %) or greater heights (> 3 m, 16 %). Among the traffic accident victims approximately one half are car drivers or passengers (46 %), one quarter are motorbike drivers (25 %) and the rest are cyclists (14 %) and pedestrians (13 %). The mortality of patients with an ISS ³ 9 is 12.8 %. This value is approximately 1-2 % below the expected prognosis based on data from the 1990s.

DISCUSSION

The TR-DGU is not only a successful instrument for external quality assurance of the treatment of severely injured patients but also an increasingly more valuable source for scientific evaluation within the framework of healthcare research. The introduction of regional trauma networks by the DGU has made a substantial contribution to the comprehensive compilation of severely injured patients and allows increasingly more detailed information on the epidemiology of severe injuries in Germany to be compiled.

[On-scene times for helicopter services. Influence of central dispatch center strategy]

BACKGROUND

Previous studies have suggested that when using several emergency systems and air rescue prehospital and on-scene times are extended, depending on the dispatch strategy. Emergency medical services (EMS) in Germany are delivered by ambulances (AMB) staffed by paramedics alone or with physicians (EMD) and by helicopter emergency medical services (HEMS) always staffed by both. The advantages of HEMS in countries with short transport distances and high hospital density are controversial. The best dispatching strategy for HEMS has not been determined

OBJECTIVE

The BoLuS study in the German state of Hessen was designed to evaluate the influence of dispatch strategy on prehospital times for responses involving both HEMS and EMS.

METHODS

Rescue responses involving HEMS were prospectively evaluated in 12 regions of Hessen from July 2010 to September 2011. Although all regions had access to HEMS, only one had its own service. Data from both central dispatch centers and helicopter services were collected and combined to calculate the on-scene time (OST) and correlate it with dispatch strategy.

RESULTS

A total of 2111 emergency interventions were evaluated. Internal medicine emergencies accounted for 42.9 % of cases and trauma for 36.7 %. Just one patient was involved in 87.9 % of rescues. Two services were involved in 65.3 % of rescues and three or more in 31.5 %. The most common dispatch categories were initial dispatch of EMS and HEMS (50.6 %), initial dispatch of EMS with later request for HEMS (19.7 %) and initial dispatch of both EMS and EMD with later request for HEMS (17.4 %). The OST for these categories were 31.0 ± 13.7 min, 43.7 ± 16.2 min and 54.6 ± 21.3 min (p < 0.01), respectively.

CONCLUSION

OST varies significantly depending on the number of EMS involved and the dispatch strategy. Sequential dispatching of ground and later HEMS wastes time. Getting an emergency physician to the scene as quickly as possible, reducing transport time to an appropriate hospital and caring for more complex emergencies are the main indications for HEMS. If HEMS appears likely to be needed, it should be dispatched immediately.

[Emergency room management of multiple trauma : ATLS® and S3 guidelines]

Trauma management in the emergency room is an important part of the treatment chain of the severely injured. Important decisions with respect to diagnostics and treatment must be made under time pressure. Successful trauma management in the emergency room requires a hospital tailored treatment protocol. This written protocol needs consent from all participating disciplines and must be known by all members of the resuscitation team. The ATLS® and the recently published clinical practice guidelines on multiple trauma can be of help in order to establish or update such protocols. In order to continuously evaluate and improve performance in the emergency room local quality circles are needed that truly follow that aim. Important factors are reliability of agreement between the different disciplines and continuous communication of results to the team members. In order to be successful such quality circles need people that care.