The association between trauma system and trauma center components and outcome in a mature regionalized trauma system

A rapid and effective approach to building a life-saving multidisciplinary team for transferred postpartum haemorrhage patients: leveraging trauma experience-a retrospective study

BACKGROUND

Establishing an efficient multidisciplinary team for transferred postpartum haemorrhage (PPH) cases is challenging due to limited clinical exposure. We hypothesised that leveraging trauma team experience could effectively facilitate the development of such a team within a short timeframe.

METHODS

In September 2019, a multidisciplinary team was established at our tertiary care centre to provide rapid management of critical PPH cases transferred from the obstetric clinic, prioritising immediate resuscitation and haemostatic interventions. This historical cohort study (2017-2022) compared outcomes before (2017-2018, before group [BG]) and after (2019-2022, after group [AG]) team establishment. Outcomes included process-related quality indicators, clinical measures such as length of hospital stay, intensive care unit (ICU) days, presence of the lethal triad, and hysterectomy rate.

RESULTS

Of the 71 PPH patients transferred during the study period, 24 were in the BG and 47 in the AG. The AG demonstrated higher use of tranexamic acid (33.33% vs. 74.47%, P = 0.002), shorter time to the first blood transfusion (11 vs. 8 min, P = 0.029), and increased rates of arrival in the operating room within 60 min (25% vs. 80%, P = 0.014). Clinical outcomes showed reduced rates of cardiopulmonary resuscitation (16.67% vs. 0%, P = 0.011) and shorter ICU stays (4 vs. 1 day, P = 0.005) in the AG.

CONCLUSIONS

Leveraging trauma team expertise is an effective strategy for establishing a multidisciplinary PPH team, significantly improving outcomes for critically ill PPH patients transferred from obstetric clinics.

Synthesizing the Evidence Base to Enhance Coordination between Humanitarian Mine Action and Emergency Care for Casualties of Explosive Ordnance and Explosive Weapons: A Scoping Review

BACKGROUND

Humanitarian mine action (HMA) stakeholders have an organized presence with well-resourced medical capability in many conflict and post-conflict settings. Humanitarian mine action has the potential to positively augment local trauma care capacity for civilian casualties of explosive ordnance (EO) and explosive weapons (EWs). Yet at present, few strategies exist for coordinated engagement between HMA and the health sector to support emergency care system strengthening to improve outcomes among EO/EW casualties.

METHODS

A scoping literature review was conducted to identify records that described trauma care interventions pertinent to civilian casualties of EO/EW in resource-constrained settings using structured searches of indexed databases and grey literature. A 2017 World Health Organization (WHO) review on trauma systems components in low- and middle-income countries (LMICs) was updated with additional eligible reports describing trauma care interventions in LMICs or among civilian casualties of EO/EWs after 2001.

RESULTS

A total of 14,195 non-duplicative records were retrieved, of which 48 reports met eligibility criteria. Seventy-four reports from the 2017 WHO review and 16 reports identified from reference lists yielded 138 reports describing interventions in 47 countries. Intervention efficacy was assessed using heterogenous measures ranging from trainee satisfaction to patient outcomes; only 39 reported mortality differences. Interventions that could feasibly be supported by HMA stakeholders were synthesized into a bundle of opportunities for HMA engagement designated links in a Civilian Casualty Care Chain (C-CCC).

CONCLUSIONS

This review identified trauma care interventions with the potential to reduce mortality and disability among civilian EO/EW casualties that could be feasibly supported by HMA stakeholders. In partnership with local and multi-lateral health authorities, HMA can leverage their medical capabilities and expertise to strengthen emergency care capacity to improve trauma outcomes in settings affected by EO/EWs.

Impact of trauma teams on high grade liver injury care: a two-decade propensity score approach study in Taiwan

High-grade liver laceration is a common injury with bleeding as the main cause of death. Timely resuscitation and hemostasis are keys to the successful management. The impact of in-hospital trauma system on the quality of resuscitation and management in patients with traumatic high-grade liver laceration, however, was rarely reported. We retrospectively reviewed the impact of team-based approach on the quality and outcomes of high-grade traumatic liver laceration in our hospital. Patients with traumatic liver laceration between 2002 and 2020 were enrolled in this retrospective study. Inverse probability of treatment weighting (IPTW)-adjusted analysis using the propensity score were performed. Outcomes before the trauma team establishment (PTTE) and after the trauma team establishment (TTE) were compared. A total of 270 patients with liver trauma were included. After IPTW adjustment, interval between emergency department arrival and managements was shortened in the TTE group with a median of 11 min (p < 0.001) and 28 min (p < 0.001) in blood test reports and duration to CT scan, respectively. Duration to hemostatic treatments in the TTE group was also shorter by a median of 94 min in patients receiving embolization (p = 0.012) and 50 min in those undergoing surgery (p = 0.021). The TTE group had longer ICU-free days to day 28 (0.0 vs. 19.0 days, p = 0.010). In our study, trauma team approach had a survival benefit for traumatic high-grade liver injury patients with 65% reduction of risk of death within 72 h (Odds ratio (OR) = 0.35, 95% CI = 0.14-0.86) and 55% reduction of risk of in-hospital mortality (OR = 0.45, 95% CI = 0.23-0.87). A team-based approach might contribute to the survival benefit in patients with traumatic high-grade liver laceration by facilitating patient transfer from outside the hospital, through the diagnostic examination, and to the definitive hemostatic procedures.

Nationwide analysis of proximity of America College of Surgeons--verified and state-designated trauma centers to the nearest highway exit and associated prehospital motor vehicle collision fatalities

BACKGROUND

Motor vehicle collisions remain a leading cause of trauma-related deaths. We aim to investigate the relationship between the proximity of trauma centers to the nearest highway exit and prehospital motor vehicle collision fatalities at the county level nationwide.

METHODS

This was a cross-sectional study evaluating the association between the distance of trauma centers to the nearest highway exit and prehospital motor vehicle collision fatalities between the years 2014 and 2019. Prehospital motor vehicle collision fatalities were obtained from National Highway Traffic Safety Administration. Mapping software was used to determine the distance of trauma center to the nearest highway exit and transport time. Linear regression analysis was performed.

RESULTS

A total of 2,019 American College of Surgeons-verified and/or state-designated trauma centers were included (211 Level 1, 356 Level 2, 491 Level 3, and 961 Level 4 trauma centers). Prehospital motor vehicle collision fatalities were positively correlated with the distance of trauma center to the nearest highway exit for counties with trauma centers located ≤5 miles from the nearest highway exit (r = 0.328; P < .001). In the 612 counties with a 10% increase in prehospital motor vehicle collision fatalities from 2014 to 2019, prehospital motor vehicle collision fatalities were also positively correlated with distance to the nearest highway exit (r = 0.302; P < .001). The counties with more dispersed distributions of trauma centers were significantly associated with motor vehicle collision fatalities (Spearman's rank coefficient = 0.456; 95% confidence interval, 0.163-0.675; P = .003).

CONCLUSION

Shorter distances between trauma centers and the nearest highway exit are associated with fewer prehospital motor vehicle collision fatalities for counties with trauma centers ≤5 miles of the nearest highway exit. Further enhancement of existing highway infrastructure and standardization of emergency medical services transport protocols are needed to address the burden of prehospital motor vehicle collision fatalities in the United States.

International Perspectives of Prehospital and Hospital Trauma Services: A Literature Review

Background: Evidence suggests that reductions in the incidence in trauma observed in some countries are related to interventions including legislation around road and vehicle safety measures, public behaviour change campaigns, and changes in trauma response systems. This study aims to briefly review recent refereed and grey literature about prehospital and hospital trauma care services in different regions around the world and describe similarities and differences in identified systems to demonstrate the diversity of characteristics present. Methods: Articles published between 2000 and 2020 were retrieved from MEDLINE and EMBASE. Since detailed comparable information was lacking in the published literature, prehospital emergency service providers’ annual performance reports from selected example countries or regions were reviewed to obtain additional information about the performance of prehospital care. Results: The review retained 34 studies from refereed literature related to trauma systems in different regions. In the U.S. and Canada, the trauma care facilities consisted of five different levels of trauma centres ranging from Level I to Level IV and Level I to Level V, respectively. Hospital care and organisation in Japan is different from the U.S. model, with no dedicated trauma centres; however, patients with severe injury are transported to university hospitals’ emergency departments. Other similarities and differences in regional examples were observed. Conclusions: The refereed literature was dominated by research from developed countries such as Australia, Canada, and the U.S., which all have organised trauma systems. Many European countries have implemented trauma systems between the 1990s and 2000s; however, some countries, such as France and Greece, are still forming an integrated system. This review aims to encourage countries with immature trauma systems to consider the similarities and differences in approaches of other countries to implementing a trauma system.

Smartphone application alerts for early trauma team activation: Millennial technology in healthcare

BACKGROUND

Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival.

METHODS

Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges.

RESULTS

Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001).

CONCLUSION

Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

Effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis protocol

INTRODUCTION

The introduction of trauma systems that began in the 1970s resulted in improved trauma care and a decreased rate of morbidity and mortality of trauma patients. Worldwide, little is known about the effectiveness of trauma care system at different stages of development, from establishing a trauma centre, to implementing a trauma system and as trauma systems mature. The objective of this study is to extract and analyse data from research that evaluates mortality rates according to different stages of trauma system development globally.

METHODS AND ANALYSIS

The proposed review will comply with the checklist of the 'Preferred reporting items for systematic review and meta-analysis'. In this review, only peer-reviewed articles written in English, human-related studies and published between January 2000 and December 2020 will be included. Articles will be retrieved from MEDLINE, EMBASE and CINAHL. Additional articles will be identified from other sources such as references of included articles and author lists. Two independent authors will assess the eligibility of studies as well as critically appraise and assess the methodological quality of all included studies using the Cochrane Risk of Bias for Non-randomised Studies of Interventions tool. Two independent authors will extract the data to minimise errors and bias during the process of data extraction using an extraction tool developed by the authors. For analysis calculation, effect sizes will be expressed as risk ratios or ORs for dichotomous data or weighted (or standardised) mean differences and 95% CIs for continuous data in this systematic review.

ETHICS AND DISSEMINATION

This systematic review will use secondary data only, therefore, research ethics approval is not required. The results from this study will be submitted to a peer-review journal for publication and we will present our findings at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42019142842.

Systematic Preventable Trauma Death Rate Survey to Establish the Region-based Inclusive Trauma System in a Representative Province of Korea

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.

No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture

BACKGROUND

A comparison of outcomes between Level I (LI) and Level II (LII) Trauma Centers (TCs) performing surgical stabilization of rib fracture (SSRF) has not been well described. We sought to compare risk of mortality for patients undergoing SSRF between LI and LII TCs.

METHODS

The Trauma Quality Improvement Program was queried for patients presenting with rib fracture to LI or LII TCs from 2010 to 2015. A multivariable logistic regression analysis was performed.

RESULTS

14,046 (7.1%) of 199,020 patients with rib fractures underwent SSRF. SSRF increased from 1304 in 2010 to 3489 in 2015: a geometric mean annual increase of 22%. LI TCs demonstrated a mortality incidence of 1.6% while LII TCs demonstrated a mortality incidence of 1.5% (p > 0.05). There was no statistically significant difference in risk of mortality after SSRF between LI and LII TCs (odds ratio 1.12, confidence interval 0.79-1.59, p-value 0.529).

CONCLUSIONS

Patients undergoing SSRF at LI and LII TCs have no significant difference in risk of mortality. Additionally, there is an annually growing trend across all centers in SSRF performed both for flail and non-flail segments.

Variability in Current Trauma Systems and Outcomes

Background:

Complication rates may be indicative of trauma center (TC) performance. The complication rates between Level 1 and 2 TCs at the national level are unknown. Our study aimed to determine the relationship between American College of Surgeons (ACS)-verified and state-designated TCs and complications.

Study Design and Methods:

This was a cohort review of the National Sample Program (NSP) from the National Trauma Data Bank, the world's largest validated trauma database. TCs were categorized by ACS or state Level 1 or 2. TCs not categorized as Level 1 or 2 were excluded. All 22 complications provided by the NSP were analyzed. Chi-squared analysis was used with statistical significance defined as P < 0.05.

Results:

Of the 94 TCs in the NSP, 67 had ACS and 80 had state designations of Level 1 or 2. There were 38 ACS Level 1 TCs treating 87,340 patients and 29 ACS Level 2 TCs treating 35,763. There were 45 state Level 1 TCs treating 106,640 and 35 state Level 2 TCs treating 43,290. ACS Level 1 TCs had significantly higher complications compared to ACS Level 2 TCs (13.5% [11,776/87,340] vs. 10.1% [3,606/35,763], P < 0.0001). In addition, state Level 1 TCs had significantly more complications compared to state Level 2 TCs (4.4% [4,681/106,640] vs. 1.6% [673/43,290], P < 0.0001).

Conclusion:

Both ACS and state Level 2 TCs had significantly lower complication rates than ACS and state Level 1 TCs. Further investigations should look for the source and impact of this difference.

Geospatial relationship of trauma and violent crime: An analysis of violent crime and trauma center utilization

Introduction

Descriptive epidemiologic and geographic analysis utilizing geographic information science (GIS) has been used to determine the utilization of trauma systems and to spatially describe patterns of trauma and crime. We examined the relationship between spatial components of criminality and injuries in order to evaluate the optimal trauma center location and determine a correlation between reported violent crime and trauma center utilization.

Methods

All adult trauma and violent crime (VC) encounters in a defined area over a single year were included. Geospatial statistics pattern analysis tools of Median Center (MC) and the Average Nearest Neighbor analysis (ANNa) were used to determine if mapped points occurred in complete spatial randomness or were clustered in a significant pattern.

Results

ANNa of VC resulted in a z-score of –20.54 and a p-value of <0.001, indicating a <1% likelihood that violent crimes were distributed randomly. Further ANNa yielded a zscore of –5.67 and p-value of <0.001 for injuries. Our trauma center is 1.45 miles from the MC of VC and 2.28 miles from the MC for injuries. Spatial autocorrelation failed to demonstrate a direct relationship between criminality and trauma center utilization with a z-score of 0.030 and p-value of 0.98.

Conclusion

While not statistically significant, the spatial trends of violent crime and trauma center utilization demonstrated a clear pattern. GIS is a powerful tool for the trauma director, and examination of the local regional patterns of trauma should be undertaken by health systems to assist with optimizing outreach, expansion, and response times.

No Difference in Mortality Between Level I and II Trauma Centers for Combined Burn and Trauma

BACKGROUND

Trauma patients with burn injuries have higher morbidity and mortality rates compared with patients who solely experience burn or trauma injuries. There is a paucity of data regarding burn-trauma (BT) patient outcomes at level I (LI) trauma centers compared with level II (LII) centers. We hypothesized that BT patients at LI trauma centers have lower mortality rates than those at LII trauma centers.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients aged ≥18 y who had BT injuries. Patients treated at an LI were compared with those at an LII center with a primary outcome of in-hospital mortality. Secondary outcomes included hospital length of stay (LOS) and intensive care unit (ICU) LOS. A multivariable logistic regression analysis was used to identify factors associated with all-cause mortality.

RESULTS

From 1971 BT patients, 1540 (78%) were treated at an LI trauma center, and 431 (22%) at an LII center. Compared with LII centers, LI BT patients had a longer median LOS (10 versus 7 d; P < 0.001) and ICU LOS (5 versus 4 d; P < 0.001). Both LI and LII centers had similar mortality rates (8.5% versus 7.0%; P = 0.300). On multivariable analysis, receiving care at an LI trauma center was not associated with decreased mortality (odds ratio 0.79, 95% confidence interval 0.42-1.48; P = 0.456).

CONCLUSIONS

We report that LI trauma center BT patients had an increased hospital and ICU LOS compared with those at LII centers. However, there was no significant difference in mortality between patients cared for at LI and LII trauma centers in risk-adjusted models.

Improving out-of-hospital notification in traumatic cardiac arrests with novel usage of smartphone application

INTRODUCTION

Timely out-of-hospital notifications in patients with traumatic cardiac arrest are associated improvements in mortality. Details surrounding these events are often limited, and decisions to perform advanced resuscitative procedures must be made based on limited data. This study evaluated the ability of a mobile application (app) called Citizen (sp0n Inc., New York, NY) to address these issues by providing a novel, secondary source of out-of-hospital information in traumatic cardiac arrest. Citizen sends notifications to mobile devices in response to nearby detected public safety events, and we sought to evaluate its utility in prenotification for traumatic cardiac arrest.

METHODS

This was a retrospective observational study. Patients ≥ 15 years of age with traumatic cardiac arrest attributed to penetrating trauma were included. The 2 coprimary outcomes observed were the time difference between the app notification and emergency medical services notification, and the app's success rate in generating a notification for each patient in traumatic cardiac arrest.

RESULTS

From February 2, 2019 to October 10, 2019, there were 43 patients who met the criteria for this study. On average, the Citizen app notification arrived 12.9 minutes before emergency medical services radio notification (95% confidence interval, 9.2-16.6; P < 0.001). Citizen generated a notification for 36 of 43 patients (84%).

CONCLUSION

The Citizen app generates earlier notifications in traumatic cardiac arrest compared with standard radio communications. It also provides a previously unavailable secondary source of information for making rapid resuscitative decisions upon the arrival of the arresting patient to the emergency department. Further research is needed to determine how to optimally integrate the app into existing trauma systems.

Prehospital notification of injured patients presenting to a trauma centre in India: a prospective cohort study

OBJECTIVES

To assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes.

DESIGN

Longitudinal prospective cohort study with preintervention and postintervention cohorts.

SETTING

Major trauma centre in India.

PARTICIPANTS

Injured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories.

INTERVENTION

A prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality.

RESULTS

Data from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (p<0.001). After the intervention, more patients were managed with a trauma call-out (relative risk (RR) 1.30; 95% CI: 1.10 to 1.52); a trauma bay was ready for more patients (RR 1.47; 95% CI: 1.05 to 2.05) and a trauma team leader present for more patients (RR 1.50; 95% CI: 1.07 to 2.10). There was no difference in time to the initial chest X-ray (p=0.45). There was no association with mortality at hospital discharge (RR 0.94; 95% CI: 0.72 to 1.23), but the intervention was associated with significantly less risk of patients dying in the ED (RR 0.11; 95% CI: 0.03 to 0.39).

CONCLUSIONS

The prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India.

TRIAL REGISTRATION NUMBER

NCT02877342.

Managing the multiply injured patient: the impact of multidisciplinary teams

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.

Trauma team leaders in Canada: A national survey

Introduction

The availability, composition and activation criteria for trauma teams vary across different health care systems, but little is known about these features in the Canadian health system. The aim of this study is to provide a description of the current trauma team available in Level 1 and 2 centres across Canada.

Methods

In 2017, using a modified Dillman technique, a survey was sent to 210 health professionals across all Canadian trauma care facilities, including questions that focused on (1) the presence and the composition of a trauma team, (2) the established criteria to activate this team and (3) the initial patient care.

Results

Overall, 107 (57%) completed surveys were received. Only 22 (11.7%) were from Level 1 or 2 centre and considered for compilation. Seventeen respondents have a trauma team in their centre, and they all shared their criteria for activating their team (1–27 different indications). The suspected injuries, the judgment of the emergency physician, the systolic blood pressure, the Glasgow Coma Score and the respiratory rate were the most frequently mentioned items. In the presence of a pre-hospital care warning, the initial assessment of a severely injured patient is exclusively completed by a member of the trauma team for only 35.1% of the respondents. For 11.8% of respondents, trauma team coordinates airway management. For 64.7% of participants, the trauma team leader is the dedicated care provider to accompany patients until the final destination.

Conclusions

The results suggest a great variability across Canada, regarding the roles assumed by the trauma team but also regarding the activation criteria leading them to take action.

Over view of major traumatic injury in Australia--Implications for trauma system design

BACKGROUND

Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia.

METHODS

The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS).

RESULTS

There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28-68) years. Median (IQR) ISS was 17 (14-25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03-2.12) h to reach hospital and spent 7.10 (3.64-15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups.

CONCLUSION

Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.

Effect of predicted travel time to trauma care on mortality in major trauma patients in Nova Scotia

Background

Trauma is a leading contributor to the burden of disease in Canada, accounting for more than 15 000 deaths annually. Although caring for injured patients at designated trauma centres (TCs) is consistently associated with survival benefits, it is unclear how travel time to definitive care influences outcomes. Using a population-based sample of trauma patients, we studied the association between predicted travel time (PTT) to TCs and mortality for patients assigned to ground transport.

Methods

Victims of penetrating trauma or motor vehicle collisions (MVCs) in Nova Scotia between 2005 and 2014 were identified from a provincial trauma registry. We conducted cost distance analyses to quantify PTT for each injury location to the nearest TC. Adjusted associations between TC access and injury-related mortality were then estimated using logistic regression.

Results

Greater than 30 minutes of PTT to a TC was associated with a 66% increased risk of death for MVC victims (p = 0.045). This association was lost when scene deaths were excluded from the analysis. Sustaining a penetrating trauma greater than 30 minutes from a TC was associated with a 3.4-fold increase in risk of death. Following the exclusion of scene deaths, this association remained and approached significance (odds ratio 3.48, 95% confidence interval 0.98–14.5, p = 0.053).

Conclusion

Predicted travel times greater than 30 minutes were associated with worse outcomes for victims of MVCs and penetrating injuries. Improving communication across the trauma system and reducing prehospital times may help optimize outcomes for rural trauma patients.

Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients

BACKGROUND

Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS).

MATERIALS AND METHODS

We performed a retrospective cohort study at two level I pediatric trauma centers.

INCLUSION CRITERIA

<15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics.

RESULTS

We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82).

CONCLUSIONS

Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.

Impact of trauma level designation on survival of patients arriving with no signs of life to US trauma centers

BACKGROUND

Trauma level designation and verification are examples of healthcare regionalization aiming at improving patient outcomes. This study examines impact of Trauma Levels on survival of patients arriving with "no signs of life" to US trauma centers.

METHODS

This retrospective study used the US National Trauma Data Bank (NTDB) 2015 dataset. A descriptive followed by a bivariate analysis was done comparing variables by the trauma designation levels. A multivariate analysis assessed the effect of the trauma designation on survival to hospital discharge after controlling for potential confounding factors.

RESULTS

6160 patients without signs of life were included. The average age was 40.66 years (±19.96) with male predominance (77.3%). Most patients were transported using ground ambulance (83.5%) and were taken to Level I (57%) and Level II (32.4%) centers. Blunt injuries were the most common (56.9%). Motor Vehicle Collision (MVC) (38.5%) and firearm (33.8%) were the most common mechanisms of injury. Survival to hospital discharge among patients with no signs of life ranged from 13.7% at Level I to 27.9% at Level III. After adjusting for confounders, including Injury Severity Score (ISS), higher survival was noted at Level II trauma centers compared to Level I.

CONCLUSIONS

Patients presenting without signs of life to Level II trauma centers had higher survival to hospital discharge compared to Level I and Level III centers. These findings can guide future prehospital triage criteria of trauma patients in organized Emergency Medical Services (EMS) systems and highlight the need for more outcome research on trauma systems.

The impact of level of the American College of Surgeons Committee on Trauma verification and state designation status on trauma center outcomes

The American College of Surgeons (ACS) Committee on Trauma (COT) verification and State designation of trauma centers (TCs) into Level 1 or 2 establishes a distinction based on resources, trauma volume, and educational commitment. The ACS COT and individual states each verify TCs to differentiate performance levels. We aim to determine the relationship between ACS and State Level 1 versus 2, and injury-adjusted, all-cause mortality in a national sampling.TCs were identified by review of the National Sample Program (NSP) from the National Trauma Data Bank (NTDB)-the largest validated trauma database in the nation-of the year 2013. TCs were categorized by ACS or State Level 1 or 2 status, all others were excluded. Adjusted mortality was determined using observed/expected mortality (O/E) ratios, derived by trauma and injury severity score (TRISS) methodology. Chi-squared and t test analyses were used for categorical variables, with a statistical significance defined as P-value <.05.Of the 94 TCs in the NSP, 67 had ACS and 80 had State designations. There were 38 ACS Level 1 TCs and 29 ACS Level 2. For State designations, there were 45 as State Level 1 and 35 State Level 2. ACS Level 1 TCs had a similar O/E compared with ACS Level 2 verified centers (0.73 vs 0.75, chi-square, P = .36). Level 1 TCs designated by their state, had a similar O/E compared with State Level 2 centers (0.70 vs 0.74, chi-square, P = .08).Both ACS and State Level 1 and 2 trauma centers performed similarly on injury adjusted, all-cause mortality.

Trauma center need: the American College of Surgeons' definition in contrast to Swiss highly specialized medicine regulations-a Swiss trauma center perspective

PURPOSE

According to the American College of Surgeons (ACS) recommendations, the benchmark for trauma center need (TCN) is an Injury Severity Score (ISS) > 15. In contrast, Swiss highly specialized medicine (HSM) regulations set out TCN for all patients with an ISS > 19 or an Abbreviated Injury Severity (AIS) of the head ≥ 3. This investigation assessed to what extent the modification might be justified.

METHODS

Consecutive analysis of all significantly injured (new ISS, NISS ≥ 8) adults treated in a trauma center from 2010 to 2016 based on their ISS and AIS head and in respect to utilized resources and outcome.

RESULTS

Of 2171 patients (mean age 57.2 ± 21.6; ISS 15.0 ± 8.5) 40.1% fulfilled the ACS and 52.7% the HSM-definition of TCN. Comparative analysis of specified subgroups representing combinations of the ISS and the AIS head revealed that patients within the HSM but not within the ACS-definition of TCN achieved worse outcomes in mortality or on the Glasgow Outcome Score and had a higher inpatient rehabilitation rate than patients with an ISS < 15 and an AIS head < 3 compared to patients with an ISS > 15. Mortality for patients with an ISS 16-19 and AIS head < 3 (qualifying for the ACS but not the HSM-definition of TCN) was found to be twice as high for patients who were not in the ACS or the HSM group (ISS < 16 & AIS head < 3).

CONCLUSIONS

If confirmed by others, both the ACS and the Swiss-recommendations for TCN should be adapted accordingly, provided that the resultant increased workload is feasible for the trauma centers concerned.

Evaluating quality indicators of tertiary care hospitals for trauma care in Japan

Objective

This study examined the associations between trauma mortality and quality of care indicators currently used in Japan.

Design

This is a retrospective two-level discrete-time survival analysis. Quality indicators were derived from the 2012-2013 annual hospital survey conducted by the Ministry of Health, Labour and Welfare. Trauma mortality data were derived from the Japan Trauma Data Bank for the period of April 2012 to March 2013.

Setting

Tertiary care centers designated as emergency and critical care centers (ECCCs) in Japan.

Participants

The analysis included 12 378 patients aged ≥15 years with blunt trauma and an Injury Severity Score ≥9, registered to the data bank from 91 ECCCs.

Intervention

Quality of care indicators examined in the annual hospital survey.

Main Outcome Measures

Deaths within 30 days.

Results

Of the 12 378 patients, 660 (5%) died within 30 days. Higher indicator score was significantly associated with lower mortality risk (hazard ratio [HR] for the second, third and fourth quartiles vs. lowest quartile 0.61, 0.55 and 0.52, respectively). Factors significantly associated with lower mortality risk were, higher patient volume (HR for the highest vs. lowest quartile, 0.74), director's qualification as specialist (HR 0.57) or consultant (HR 0.58), review of patient arrival process (HR 0.68), triage functions (HR 0.69), availability of psychiatrists (HR 0.75) and operating room being ready 24-h (HR 0.81).

Conclusions

The study identified certain indicators associated with trauma patient mortality. Further refinement of indicators is required to specifically identify what needs changing.

Acuity Prediction Using Emergency Medical Services Prenotifications in a Pediatric Emergency Department

OBJECTIVES

Emergency medical services (EMS) prenotifications are critical, although they oftentimes inaccurately convey the arriving patient's true acuity, resulting in inappropriate preparation in the emergency department. The objectives of this study were (1) to determine interrater reliability of acuity prediction based on prenotifications among physicians and (2) to compare predicted versus actual patient acuity based on prenotifications.

METHODS

A panel of physicians reviewed recordings of EMS prenotifications and then predicted the patient's acuity using the Emergency Severity Index (ESI). The scores were analyzed for interrater reliability using the weighted κ statistic. In the prospective phase of the study, physicians predicted an ESI before patient arrival based solely on the EMS prenotification and then calculated an actual ESI upon arrival. Descriptive statistics were calculated, and comparisons between the predicted and actual ESI were performed using Wilcoxon signed rank for matched pairs.

RESULTS

Panelists reviewed a total of 23 recordings, and the interrater reliability was 0.23 overall (SE, 0.026; P < 0.001), indicating only fair agreement. One hundred patients were enrolled in the prospective analysis. There was a statistically significant difference between the predicted and actual ESI made by physicians (P = 0.0001). For 46 patients, the predicted and actual scores matched, but 13 patients were "undertriaged," and 41 patients were "overtriaged" based on predicted acuity.

CONCLUSIONS

Interpretation of acuity using EMS prenotifications among physicians was only fairly reliable, and physicians had difficulty predicting actual acuity based on prenotifications. Improper preparation based on these prenotifications can potentially impact patient care and resource allocation.

Impact of duplicate CT scan rate after implementation of transfer image repository system at a level 1 trauma center

Purpose

The regionalization of trauma in the USA results in frequent transfers of patients from a primary hospital ED to a higher level trauma facility. While many hospitals have a Picture Archive Communication System (PACS) which captures digital radiological images, these are often not available to the receiving institution resulting in duplicate imaging. The state of Arkansas instituted a trauma image repository (TIR) in July 2013. We examined whether implementation of this repository would impact CT scan duplication in the trauma system.

Methods

This was a retrospective analysis of trauma patients transferred from outlying hospitals in Arkansas and Missouri to a single level 1 trauma hospital in Missouri between July 2012 and June 2015. We compared the duplicate CT rate for patients transferred from Arkansas and Missouri hospitals before and after the repository was implemented for Arkansas.

Results

Prior to implementation (July 2012–June 2013) of Arkansas TIR, duplicate CT rates were similar for patients transferred from Arkansas (11.5% ± 2.8) or Missouri (16.3% ± 7.5). Following implementation (July 2013–June 2014), the duplicate CT rate for patients transferred from Arkansas was significantly lower (Arkansas = 10.1% vs. Missouri 16.2%; CI 95%, p = 0.02), and significance continued (Arkansas = 9.0% vs. Missouri = 17.8%; CI 95%, p = 0.02) during follow-up (July 2014–June 2015).

Conclusion

Fewer patients received duplicated scans within the Arkansas as compared with the Missouri-based trauma referral systems regardless of Injury Severity Scores (ISS). Our findings suggest that TIR adoption coupled with PACS improved transferability of radiographic studies and could improve patient care while reducing costs in trauma transfers.

The "mortality ascent": Hourly risk of death for hemodynamically unstable trauma patients at Level II versus Level I trauma centers

BACKGROUND

Severely injured trauma patients have higher in-hospital mortality at Level II versus Level I trauma centers (TCs). To better understand these differences, we sought to determine if there were any periods during which hemodynamically unstable trauma patients are at higher risk of death at Level II versus Level I TCs within the first 24 hours postadmission.

STUDY DESIGN

Trauma patients aged 18 years to 64 years, with Injury Severity Score of 15 or greater, systolic blood pressure less than 90 mm Hg at admission, and treated at Level II or Level I TCs, were identified using the 2007 to 2012 National Trauma Data Bank. Burn patients, transfers, and patients dead on arrival were excluded. Log-binomial regression models, adjusted for patient- and hospital-level confounders, were used to compare mortality at Level II versus Level I TCs over the first 24 hours postadmission.

RESULTS

Of 13,846 hemodynamically unstable patients, 4,212 (30.4%) were treated at 149 Level II TCs, and 9,634 (69.6%) at 116 Level I TCs. Within the first 24 hours, 3,059 (22.1%) patients died. In risk-adjusted models, mortality risk was significantly elevated at Level II versus Level I TCs during the 24 hours postadmission (relative risk, 1.08; 95% confidence interval, 1.01-1.16). Hourly mortality risk was significantly different between Level II and Level I TCs during 4 hours to 7 hours postadmission, with a maximal difference at 7 hours (relative risk, 1.70; 95% confidence interval, 1.23-2.36) and comparable mortality risk beyond 7 hours postadmission.

CONCLUSION

The 4-hour to 7-hour time window postadmission is critical for hemodynamically unstable trauma patients. Variations in available treatment modalities may account for higher relative mortality at Level II TCs during this time. Further investigation to elucidate specific risk factors for mortality during this period may lead to reductions in in-hospital mortality among hemodynamically unstable trauma patients.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Prehospital notification for major trauma patients requiring emergency hospital transport: A systematic review

OBJECTIVE

This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (<30 days) and early (<24 hours) mortality, hospital reception, and trauma team presence (or equivalent) on arrival, time to critical interventions, and length of hospital stay.

METHODS

Experimental and observational studies of prehospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria.

RESULTS

Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality; (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants); and the other demonstrating a nonsignificant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low.

CONCLUSION

Limited research on the topic constrains conclusive evidence on the effect of prehospital notification on patient-centered outcomes after severe trauma. Composite interventions that combine prehospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence, and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation.

Time and place of death from automobile crashes: Research endpoint implications

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.

Effect of Hospital Volume on Success of Thumb Replantation

PURPOSE

Hospital volume-outcome association has been examined for many high-risk surgical procedures. Little is known about this association for thumb replantation, a complex but essential surgical procedure to restore hand function. We aimed to determine patient and hospital characteristics that are associated with increased probability of replanted thumb survival and to examine volume-outcome association among hospitals that performed thumb replantation.

METHODS

We used data from 2008 to 2012 from the National Trauma Data Bank. Our sample included 773 patients who underwent thumb replantation procedures in 1 of 180 hospitals during the study period. We used patient-level logistic models to examine the association between a hospital's annual thumb replantation volume and the probability of survival for the replanted thumb.

RESULTS

Patients with drug/alcohol abuse record, and higher numbers of comorbid conditions had lower odds of replant success. Treatment in teaching hospitals and hospitals with a higher volume of thumb replantation increased the odds of replant survival. The risk-adjusted replantation success rate in high-volume hospitals was 12% higher than in low-volume hospitals.

CONCLUSIONS

Regionalization of digit replantation procedures to high-volume centers can achieve the highest rate of successful revascularization.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis II.

Positive correlation between regional emergency medical resources and mortality in severely injured patients: results from the Korean National Hospital Discharge In-depth Survey

OBJECTIVES

In South Korea, injury is a public health problem due to its high incidence and high mortality. To improve emergency medical systems, the government announced plans to increase the emergency medical resources for each region. This study investigated the association between regional emergency medical resources and mortality during hospitalization in severely injured inpatients.

METHODS

To analyse mortality for severely injured inpatients, we used the Korean National Hospital Discharge In-depth Survey data, consisting of 18,621 hospitalizations from 2005-2012. Generalized estimating equations were analysed to examine the association between mortality during hospitalization and both individual and regional variables.

RESULTS

Mortality during hospitalization occurred in 913 (4.9%) cases. Patients in regions with a higher number of emergency departments (odds ratio [OR]=0.94, 95% confidence interval [CI]: 0.91-0.98), a higher number of ambulances (OR=0.99, 95% CI: 0.98-0.99), and a higher number of registered nurses per emergency department (OR=0.88, 95% CI: 0.83-0.94) had a lower risk of mortality during hospitalization.

CONCLUSIONS

Our findings suggest that regional emergency medical resources are associated with a lower risk of mortality during hospitalization in severely injured patients. Thus, health care policymakers need to determine the proper distribution of emergency medical resources for each region and the function of emergency departments to provide a superior quality of emergency medical services to patients.

Accuracy of Perceived Estimated Travel Time by EMS to a Trauma Center in San Bernardino County, California

INTRODUCTION

Mobilization of trauma resources has the potential to cause ripple effects throughout hospital operations. One major factor affecting efficient utilization of trauma resources is a discrepancy between the prehospital estimated time of arrival (ETA) as communicated by emergency medical services (EMS) personnel and their actual time of arrival (TOA). The current study aimed to assess the accuracy of the perceived prehospital estimated arrival time by EMS personnel in comparison to their actual arrival time at a Level II trauma center in San Bernardino County, California.

METHODS

This retrospective study included traumas classified as alerts or activations that were transported to Arrowhead Regional Medical Center in 2013. We obtained estimated arrival time and actual arrival time for each transport from the Surgery Department Trauma Registry. The difference between the median of ETA and actual TOA by EMS crews to the trauma center was calculated for these transports. Additional variables assessed included time of day and month during which the transport took place.

RESULTS

A total of 2,454 patients classified as traumas were identified in the Surgery Department Trauma Registry. After exclusion of trauma consults, walk-ins, handoffs between agencies, downgraded traumas, traumas missing information, and traumas transported by agencies other than American Medical Response, Ontario Fire, Rialto Fire or San Bernardino County Fire, we included a final sample size of 555 alert and activation classified traumas in the final analysis. When combining all transports by the included EMS agencies, the median of the ETA was 10 minutes and the median of the actual TOA was 22 minutes (median of difference=9 minutes, p<0.0001). Furthermore, when comparing the difference between trauma alerts and activations, trauma activations demonstrated an equal or larger difference in the median of the estimated and actual time of arrival (p<0.0001). We also found month and time of day to be associated with variability in the difference between the median of the estimated and actual arrival time (p=0.0082 and p=0.0005 for month and time of the day, respectively).

CONCLUSION

EMS personnel underestimate their travel time by a median of nine minutes, which may cause the trauma team to abandon other important activities in order to respond to the emergency department prematurely. The discrepancy between ETA and TOA is unpredictable, varying by month and time of day. As such, a better method of estimating patient arrival time is needed.

Pre-Hospital Emergency in Iran: A Systematic Review

CONTEXT

Pre-hospital care plays a vital role in saving trauma patients.

OBJECTIVES

This study aims to review studies conducted on the pre-hospital emergency status in Iran.

DATA SOURCES

Data were sourced from Iranian electronic databases, including SID, IranMedex, IranDoc, Magiran, and non-Iranian electronic databases, such as Medline, Embase, Cochrane Library, Scopus, and Google Scholar. In addition, available data and statistics for the country were used.

DATA SELECTION

All Persian-language articles published in Iranian scientific journals and related English-language articles published in Iranian and non-Iranian journals indexed on valid sites for September 2005 - 2014 were systematically reviewed.

DATA EXTRACTION

To review the selected articles, a data extraction form developed by the researchers as per the study's objective was adopted. The articles were examined under two categories: structure and function of pre-hospital emergency.

RESULTS

A total of 19 articles were selected, including six descriptive studies (42%), four descriptive-analytical studies (21%), five review articles (16%), two qualitative studies (10.5%), and two interventional (experimental) studies (10.5%). In addition, of these, 14 articles (73.5%) had been published in the English language. The focus of these selected articles were experts (31.5%), bases of emergency medical services (26%), injured (16%), data reviews (16%), and employees (10.5%). A majority of the studies (68%) investigated pre-hospital emergency functions and 32% reviewed the pre-hospital emergency structure.

CONCLUSIONS

The number of studies conducted on pre-hospital emergency services in Iran is limited. To promote public health, consideration of prevention areas, processes to provide pre-hospital emergency services, policymaking, foresight, systemic view, comprehensive research programs and roadmaps, and assessments of research needs in pre-hospital emergency seem necessary.

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

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.

Role of trauma team activation in poor outcomes of elderly patients

INTRODUCTION

Elderly trauma patients suffer worse outcomes than younger patients. Trauma team activation (TTA) improves outcomes in younger patients. It is unclear whether decreased TTA effectiveness or under-activation in elderly patients could contribute to their poor outcomes.

MATERIAL AND METHODS

This retrospective registry study examined all adult trauma patients admitted to a level 1 trauma center over 2 y. Analyses tested (1) whether age modifies the effect of TTA on poor outcomes, (2) whether elderly patients with severe injury were less likely to receive TTA than younger patients, and (3) which early variables were associated with poor outcomes among elderly patients who did not receive TTA.

RESULTS

The study included 10,033 patients. The adjusted relative risk from TTA for all ages was 0.48 (95% confidence interval (CI) = 0.34-0.68, P < 0.001), and there was no effect modification by age (interaction term P value, 0.171). The adjusted odds ratio for the young was 0.49 (95% CI = 0.26-0.91, P = 0.024) and for the elderly was 0.80 (95% CI = 0.53-1.20, P = 0.282). The adjusted odds ratio for lack of TTA associated with old age was 1.37 (95% CI = 1.12-1.69, P = 0.003). The strongest associations with poor outcomes were seen with low heart rate, low minimum blood pressure, high injury severity score, and high Glasgow coma score.

CONCLUSIONS

Lack of TTA could contribute to elderly patients' poor outcomes. Clinicians should not be reassured by normal heart rates and should be wary of even transiently lower blood pressures in the elderly. A large cohort study is needed to identify which additional elderly patients could benefit from TTA.

Preparation for and organization during a major incident

Major incidents during the past 30 years have caused the NHS and other agencies to respond in a coordinated fashion and create the comprehensive Emergency Preparedness, Resilience and Response framework 2013. This along with supporting documents gives a detailed structure of the role of the NHS in any type of major incident from man-made disaster to pandemic flu. This has required preparation of communication, transport, security, military and healthcare systems. Included is also how the response is handled at a more local level and for different levels of response. The Royal Colleges have responded by including specialist training at the higher and advanced level for trainees so that victims are triaged at the scene and received by consultants with appropriate training in such work. Hospitals, ambulance services and intensive care units across the country are able to use networks to ensure not only logical and rapid access to major trauma centres but also to network highly sophisticated skills when advanced life support is required. The NHS is better able to cope with major incidents than ever before.

Triaging the right patient to the right place in the shortest time

Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.

The effect of a nurse team leader on communication and leadership in major trauma resuscitations

BACKGROUND

Effective assessment and resuscitation of trauma patients requires an organised, multidisciplinary team. Literature evaluating leadership roles of nurses in trauma resuscitation and their effect on team performance is scarce.

AIM

To assess the effect of allocating the most senior nurse as team leader of trauma patient assessment and resuscitation on communication, documentation and perceptions of leadership within an Australian emergency department.

METHODS

The study design was a pre-post-test survey of emergency nursing staff (working at resuscitation room level) perceptions of leadership, communication, and documentation before and after the implementation of a nurse leader role. Patient records were audited focussing on initial resuscitation assessment, treatment, and nursing clinical entry. Descriptive statistical analyses were performed.

RESULTS

Communication trended towards improvement. All (100%) respondents post-test stated they had a good to excellent understanding of their role, compared to 93.2% pre-study. A decrease (58.1-12.5%) in 'intimidating personality' as a negative aspect of communication. Nursing leadership had a 6.7% increase in the proportion of those who reported nursing leadership to be good to excellent. Accuracy of clinical documentation improved (P = 0.025).

CONCLUSION

Trauma nurse team leaders improve some aspects of communication and leadership. Development of trauma nurse leaders should be encouraged within trauma team training programmes.

A trauma quality improvement programme associated with improved patient outcomes: 21 years of experience at an Australian Major Trauma Centre

INTRODUCTION

Quality improvement programmes are an important part of care delivery in trauma centres. The objective was to describe the effect of a comprehensive quality improvement programme on long term patient outcome trends at a low volume major trauma centre in Australia.

METHODS

All patients aged 15 years and over with major trauma (Injury Severity Score>15) admitted to a single inner city major trauma centre between 1992 and 2012 were studied. The outcomes of interest were in-hospital mortality and transfer to rehabilitation. Time series analysis using integer valued autoregressive Poisson models was used to determine the reduction in adjusted monthly count data associated with the intervention period (2007-2012). Risk adjusted odds ratios for mortality over three yearly intervals was also obtained using multivariable logistic regression. Crude and risk adjusted mortality was compared before and after the implementation period.

RESULTS

3856 patients were analysed. Crude in-hospital mortality fell from 16% to 10% after implementation (p<0.001). The intervention period was associated with a 25% decrease in monthly mortality counts. Risk adjusted mortality remained stable from 1992 to 2006 and did not fall until the intervention period. Crude and risk adjusted transfer to in-patient rehabilitation after major trauma also declined during the intervention period.

CONCLUSION

In this low volume major trauma centre, the implementation of a comprehensive quality improvement programme was associated with a reduction in crude and risk adjusted mortality and risk adjusted discharge to rehabilitation in severely injured patients.