High quality acute care for the severely injured is not consistently available in England, Wales and Northern Ireland: report of a survey by the Trauma Committee, The Royal College of Surgeons of England

Global changes in mortality rates in polytrauma patients admitted to the ICU-a systematic review

Background

Many factors of trauma care have changed in the last decades. This review investigated the effect of these changes on global all-cause and cause-specific mortality in polytrauma patients admitted to the intensive care unit (ICU). Moreover, changes in trauma mechanism over time and differences between continents were analyzed.

Main body

A systematic review of literature on all-cause mortality in polytrauma patients admitted to ICU was conducted. All-cause and cause-specific mortality rates were extracted as well as trauma mechanism of each patient. Poisson regression analysis was used to model time trends in all-cause and cause-specific mortality.

Thirty studies, which reported mortality rates for 82,272 patients, were included and showed a decrease of 1.8% (95% CI 1.6–2.0%) in all-cause mortality per year since 1966. The relative contribution of brain injury-related death has increased over the years, whereas the relative contribution of death due to multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, and sepsis decreased. MODS was the most common cause of death in North America, and brain-related death was the most common in Asia, South America, and Europe. Penetrating trauma was most often reported in North America and Asia.

Conclusions

All-cause mortality in polytrauma patients admitted to the ICU has decreased over the last decades. A shift from MODS to brain-related death was observed. Geographical differences in cause-specific mortality were present, which may provide region-specific learning possibilities resulting in improvement of global trauma care.

The Baux score is dead. Long live the Baux score: a 27-year retrospective cohort study of mortality at a regional burns service

BACKGROUND

To assess trends in mortality after burn injuries treated in a regional specialist burns service between 1982 and 2008.

METHODS

Patient and burn-specific information and mortality were collated from written admission ledgers and the hospital coding department for 11,109 patients. The data set was divided into age cohorts (0-14, 15-44, 45-64, and >65 years) and time cohorts (1982-1991, 1992-2000, and 2000-2008). Lethal area 50 (LA50) was calculated by logistic regression and probit analysis. Mortality was related to the Baux score (age + total % burned surface area) by logistic regression.

RESULTS

In the time period 2000 to 2008, the LA50 values with approximate 95% confidence intervals (CIs) were 100% (CI, 85.5-100%) in the 0 to 14 cohort (LA10, 78.3%; CI, 64.1-92.5%), 76.4% (CI, 69.1-83.8%) in the 15 to 44 cohort, 58.6% (CI, 50.8-66.5%) in the 45 to 64 cohort, and 30.8% (CI, 24.7-36.9%) in the >65 cohort. The point of futility (the Baux Score at which predicted mortality is 100%) was 160 and the Baux50 (the Baux score at which predicted mortality is 50%) was 109.6 (CI, 105.9-113.4) in the 2000 to 2008 cohort.

CONCLUSIONS

Mortality is markedly improved over earlier data from this study and other historical series and compares favorably with outcomes published from the US National Burn Repository. The Baux Score continues to provide an indication of the risk of mortality. Survival after major burn injury is increasingly common, and decisions by nonspecialist about initial triage, management, and futility of care should be made after consultation with a specialist burn service.

Improvements in the management of trauma patients with the introduction of a lower limb trauma coordinator

Mortality and morbidity from trauma continues to be a serious, ubiquitous public health problem. Our short communication reports on the benefits of a dedicated lower limb trauma coordinator (LLTC) to the trauma service of a busy inner-London Plastics unit. This is based on a retrospective case-note based audit; performed 19 months prior to the introduction of the LLTC and for 16 months after. After the introduction of a LLTC our statistical analysis demonstrated a significant improvement in trauma timings in terms of injury to referral time, time to first plastics operation and duration of inpatient stay. This suggests the use of a fully qualified nurse with an orthopaedic background as a coordinator may prove to be highly advantageous over a non-clinical administrator improving the overall journey of the lower limb trauma patient in the English National Health Service.

Patterns of mortality and causes of death in polytrauma patients--has anything changed?

INTRODUCTION

Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed.

MATERIALS AND METHODS

A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies.

RESULTS

Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death.

DISCUSSION

Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.

Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review

BACKGROUND

Quality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.

METHODS

The review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.

RESULTS

Thirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.

CONCLUSIONS

Trauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.