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Havermans RJM, de Jongh MAC, van der Veen AH, Edwards M, Lansink KWW. Recovery to normal vital functions and acid-base status after a severe trauma in Level I versus Level II Trauma Centres. Eur J Trauma Emerg Surg 2024; 50:513-522. [PMID: 38093136 DOI: 10.1007/s00068-023-02390-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/02/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE In the Netherlands, approximately 70% of severely injured patients (ISS ≥ 16) are transported directly to a Level I trauma center. This study compared the time needed to return to normal vital parameters and normal acid-base status in severely injured patients and some in-hospital processes in Level I versus Level II trauma centers. METHODS This retrospective cohort study included all adult severely injured patients or adult trauma patients admitted to the intensive care unit between 2015 and 2020 in a Dutch trauma region. The primary endpoint was time until normal vital parameters and acid-base status. Secondary endpoints were complication rate, hospital length of stay, emergency department length of stay, and time until a computed tomography (CT) scan. RESULTS A total of 2345 patients were included. Patients admitted to a Level I trauma center had a significantly higher rate of normalization of vital parameters over time (HR 1.51). There was no significant difference in normalization rate of the acid-base status over time (HR 1.10). In Level I trauma centers, time spent at the emergency department and time until the CT scan was significantly shorter (respectively, β - 38 min and β - 77 min), and the complication rate was significantly lower (OR 0.35). CONCLUSION Severely injured patients admitted to a Level I trauma center require less time to normalize their vital functions. Level I centers are better equipped, resulting in better in-hospital processes with shorter time at the emergency department and shorter time until a CT scan.
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Affiliation(s)
- Roos J M Havermans
- Department of Surgery, ETZ Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands.
| | - Mariska A C de Jongh
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands
| | | | - Michael Edwards
- Department of Trauma Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Koen W W Lansink
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands
- Department of Trauma Surgery, ETZ Hospital, Tilburg, The Netherlands
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Renberg M, Dahlberg M, Gellerfors M, Rostami A, Günther M, Rostami E. Prehospital transportation of severe penetrating trauma victims in Sweden during the past decade: a police business? Scand J Trauma Resusc Emerg Med 2023; 31:45. [PMID: 37684674 PMCID: PMC10492387 DOI: 10.1186/s13049-023-01112-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION Sweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome. METHOD This was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality. RESULT A total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS. CONCLUSION Non-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.
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Affiliation(s)
- Mattias Renberg
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Surgery, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Gellerfors
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Rapid Response Car, Capio, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Swedish Air Ambulance (SLA), Mora, Sweden
| | - Amir Rostami
- Department for Social Work and Criminology, University of Gävle, Gävle, Sweden
| | - Mattias Günther
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden.
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Department of Clinical Science and Education, Section for Anesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden.
| | - Elham Rostami
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital , Uppsala, Sweden
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Benhamed A, Fraticelli L, Claustre C, Gossiome A, Cesareo E, Heidet M, Emond M, Mercier E, Boucher V, David JS, El Khoury C, Tazarourte K. Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study. Eur J Trauma Emerg Surg 2023; 49:1707-1715. [PMID: 36508023 DOI: 10.1007/s00068-022-02186-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To assess the incidence of undertriage in major trauma, its determinant, and association with mortality. METHODS A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011-2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage. RESULTS A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51-65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36). CONCLUSIONS In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France.
| | | | - Clément Claustre
- RESUVal and RESCUe Network, Lucien Hussel Hospital, Vienne, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
| | - Eric Cesareo
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
| | - Matthieu Heidet
- SAMU 94 and Emergency Department, Assistance Publique-Hôpitaux de Paris (AP-HP) University Hospital Henri Mondor, Créteil, France
- Université Paris-Est Créteil (UPEC), EA-3956 (CIR), Créteil, France
| | - Marcel Emond
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Valérie Boucher
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jean-Stéphane David
- Trauma Centre and Critical Care, Centre Hospitalier Universitaire Lyon Sud, Pierre-Bénite, France
| | - Carlos El Khoury
- RESUVal and RESCUe Network, Lucien Hussel Hospital, Vienne, France
- Emergency Department, Médipôle Hôpital Mutualiste, Villeurbanne, France
| | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
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Costa FF, de Campos Vieira Abib S. Direct transport versus inter-hospital transfer of trauma victims in the Brazilian Emergency Medical System. Trauma Case Rep 2022; 45:100743. [DOI: 10.1016/j.tcr.2022.100743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/22/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
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Tiruneh A, Bodas M, Radomislensky I, Goldman S, Acker A, Aviran N, Bahouth H, Bar A, Becker A, Ben Ely M, Fadeev D, Grevtsev I, Jeroukhimov I, Kedar A, Korin A, Lerner A, Qarawany M, Schwarz AD, Shomar W, Soffer D, Stein M, Venturero M, Weiss M, Yaslowitz O, Zoarets I, Bala M, ITG-Israel Trauma Group. Do direct admissions to trauma centers have a survival benefit compared to inter-hospital transfers in severe trauma? Eur J Trauma Emerg Surg 2022. [PMID: 36451025 DOI: 10.1007/s00068-022-02182-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE To compare mortality among severe and critically injured patients who were directly admitted (DA) to level I trauma center (TCI) or level II trauma center (TCII) with those who were transferred to a TCI after being initially admitted to a TCII. METHODS A cohort study of severe and critically injured patients (Injury Severity Score 16-75) hospitalized between 2010 and 2019 using data from the National Program for Trauma Registration. Multivariate logistic regression models estimated mortality risk, including stratified analyses. RESULTS Of the 27,131 hospitalizations, 9.5% were transfers, 60.1% were DA to TCI and 30.4% were DA to TCII. Children ages ≤ 17 years, Non-Jews (minority), critical injuries (ISS 25-75), head injuries (AIS ≥ 3) and fall injuries were significantly more frequent among transfers, compared with the DA groups. Evacuation by emergency medical services was less frequent among transfers. After accounting for possible confounders, transfers had a greater risk of in-hospital mortality [DA to TCI vs transfer, OR (95% CI) 0.61 (0.52-0.72); DA to TCII vs transfer, OR (95% CI) 0.78 (0.65-0.94)]. In stratified analyses, these mortality differences persisted among the sub-group of patients who sustained critical injuries, among the patients with non-penetrating injuries, among the elderly ages ≥ 65 year and during the first 2 weeks of hospitalization. CONCLUSION This study has intervention implications that should be directed primarily at prehospital triage and the inter-hospital transfer processes. In addition, there may be a need to optimize the capabilities of regional trauma systems along with continuous performance evaluations and actions as required.
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French WJ, Gunderson M, Travis D, Bieniarz M, Zegre‐Hemsey J, Goyal A, Jacobs AK. Emergency Interhospital Transfer of Patients With ST‐Segment–Elevation Myocardial Infarction: Call 9‐1‐1—The American Heart Association Mission: Lifeline Program. J Am Heart Assoc 2022; 11:e026700. [DOI: 10.1161/jaha.122.026700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ABSTRACT: The American Heart Association Mission: Lifeline program objectives are to improve the quality of care and outcomes for patients with ST‐segment–elevation myocardial infarction. Every minute of delay in treatment adversely affects 1‐year mortality. Transfer of patients safely and timely to hospitals with primary percutaneous coronary intervention capability is needed to improve outcomes. But treatment times continue to show delays, especially during interhospital transfers. A simple 3‐step process of an interhospital “Call 9‐1‐1” protocol may expedite this process. This STAT TRANSFER process uses a systems approach that considers diverse ways in which patients access care, how EMS responds and determines destinations, how referring hospital transfers are performed, urban and rural differences, and how receiving hospitals prepare for an incoming patient with ST‐segment–elevation myocardial infarction. This initiative suggests a strategy to reduce variability in interhospital transfer times using a STAT TRANSFER and a Call 9‐1‐1 process in a system of care that involves all stakeholders.
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Affiliation(s)
- William J. French
- Geffen School of Medicine at UCLA, Cardiac Catheterization Laboratory, Harbor‐UCLA Medical Center Torrance CA
| | - Mic Gunderson
- Center for Systems Improvement, Cambridge Consulting Group; Emergency Health Services University of Maryland Baltimore County MD
| | - David Travis
- EMS Programs Hillsborough Community College Tampa FL
| | - Mark Bieniarz
- New Mexico Heart Institute Lovelace Medical Center Albuquerque NM
| | - Jessica Zegre‐Hemsey
- School of Nursing; Department of Emergency Medicine The University of North Carolina at Chapel Hill NC
| | - Abhinav Goyal
- Emory Heart and Vascular Center, Emory Healthcare; Medicine (Cardiology) Emory School of Medicine; Emory Rollins School of Public Health Atlanta GA
| | - Alice K. Jacobs
- Department of Medicine Boston University School of Medicine and Boston Medical Center Boston MA
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Bansal V, Patil P, Faria I, Khajanchi M, Garba D, Raykar NP, Jhunjhunwala R, Sharma MR, Chatterjee S, Wärnberg MG, Roy N. Mortality and Risk Factors in Isolated Traumatic Brain Injury Patients: A Prospective Cohort Study. J Surg Res 2022; 279:480-90. [PMID: 35842973 DOI: 10.1016/j.jss.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/17/2022] [Accepted: 05/21/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Outcomes in patients with isolated traumatic brain injury (iTBI) have not been evaluated comprehensively in low-income and middle-income countries. We aimed to study the in-hospital iTBI mortality and its associated risk factors in a prospective multicenter Indian trauma registry. METHODS Patients with iTBI (head and neck Abbreviated Injury Score ≥2 and other region Abbreviated Injury Score ≤2) were included. Study variables comprised age, gender, mechanism of injury, systolic blood pressure (SBP) at arrival, Glasgow Coma Scale (GCS) score - classified as mild (13-15), moderate (9-12), and severe (3-8), transfer status, and time to presentation at any participating hospital. A multivariable logistic regression was performed to assess the impact of these factors on 24-h and 30-d mortality following iTBI. RESULTS Among 5042 included patients, 24-h and 30-d in-hospital mortalities were 5.9% and 22.4%. On a regression analysis, 30-d mortality was associated with age ≥45 y (odds ratio [OR] = 2.1 [1.6-2.7]), railway injury mechanisms (OR = 2.1 [1.3-3.5]), SBP <90 mmHg (OR = 2.6 [1.6-4.1]), and moderate (OR = 3.8 [3.0-5.0]) to severe (OR = 21.1 [16.8-26.7]) iTBI based on GCS scores. 24-h mortality showed similar trends. Patients transferred to the participating hospitals from other centers had higher odds of 30-d mortality (OR = 1.4 [1.2-1.8]) compared to those arriving directly. Those who received neurosurgical intervention had lower odds of 24-h mortality (0.3 [0.2-0.4]). CONCLUSIONS Age ≥45 y, GCS score ≤12, and SBP <90 mmHg at arrival increased the risk of in-hospital mortality from iTBI.
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Alqurashi N, Alotaibi A, Bell S, Lecky F, Body R. The diagnostic accuracy of prehospital triage tools in identifying patients with traumatic brain injury: A systematic review. Injury 2022; 53:2060-2068. [PMID: 35190184 DOI: 10.1016/j.injury.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/04/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prehospital care providers are usually the first responders for patients with traumatic brain injury (TBI). Early identification of patients with TBI enables them to receive trauma centre care, which improves outcomes. Two recent systematic reviews concluded that prehospital triage tools for undifferentiated major trauma have low accuracy. However, neither review focused specifically on patients with suspected TBI. Therefore, we aimed to systematically review the existing evidence on the diagnostic performance of prehospital triage tools for patients with suspected TBI. METHODS A comprehensive search of the current literature was conducted using Medline, EMBASE, CINAHL Plus and the Cochrane library (inception to 1st June 2021). We also searched Google Scholar, OpenGrey, pre-prints (MedRxiv) and dissertation databases. We included all studies published in English language evaluating the accuracy of prehospital triage tools for TBI. We assessed methodological quality and risk of bias using a modified Quality Assessment of Diagnostic Studies (QUADAS-2) tool. Two reviewers independently performed searches, screened titles and abstracts and undertook methodological quality assessments. Due to the heterogeneity in the population of interest and prehospital triage tools used, a narrative synthesis was undertaken. RESULTS The initial search identified 1787 articles, of which 8 unique eligible studies met the inclusion criteria (5 retrospective, 2 prospective, 1 mixed). Overall, sensitivity of triage tools studied ranged from 19.8% to 87.9% for TBI identification. Specificity ranged from 41.4% to 94.4%. Two decision tools have been validated more than once: HITS-NS (2 studies, sensitivity 28.3-32.6%, specificity 89.1-94.4%) and the Field Triage Decision Scheme (4 studies, sensitivity 19.8-64.5%, specificity 77.4%-93.1%). Existing tools appear to systematically under-triage older patients. CONCLUSION Further efforts are needed to improve and optimise prehospital triage tools. Consideration of additional predictors (e.g., biomarkers, clinical decision aids and paramedic judgement) may be required to improve diagnostic accuracy.
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Affiliation(s)
- Naif Alqurashi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK; Department of Accidents and Trauma, Prince Sultan bin Abdelaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia.
| | - Ahmed Alotaibi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Trust, Bolton, BL1 5DD, UK.
| | - Fiona Lecky
- University of Sheffield, School of Health and Related Research, Sheffield, UK.
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK; Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK.
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Alharbi RJ, Shrestha S, Lewis V, Miller C. The effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis. World J Emerg Surg 2021; 16:38. [PMID: 34256793 PMCID: PMC8278750 DOI: 10.1186/s13017-021-00381-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/23/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Traumatic injury remains the leading cause of death, with more than five million deaths every year. Little is known about the comparative effectiveness in reducing mortality of trauma care systems at different stages of development. The objective of this study was to review the literature and examine differences in mortality associated with different stages of trauma system development. METHOD A systematic review of peer-reviewed population-based studies retrieved from MEDLINE, EMBASE, and CINAHL. Additional studies were identified from references of articles, through database searching, and author lists. Articles written in English and published between 2000 and 2020 were included. Selection of studies, data extraction, and quality assessment of the included studies were performed by two independent reviewers. The results were reported as odds ratio (OR) with 95 % confidence intervals (CI). RESULTS A total of 52 studies with a combined 1,106,431 traumatic injury patients were included for quantitative analysis. The overall mortality rate was 6.77% (n = 74,930). When patients were treated in a non-trauma centre compared to a trauma centre, the pooled statistical odds of mortality were reduced (OR 0.74 [95% CI 0.69-0.79]; p < 0.001). When patients were treated in a non-trauma system compared to a trauma system the odds of mortality rates increased (OR 1.17 [95% CI 1.10-1.24]; p < 0.001). When patients were treated in a post-implementation/initial system compared to a mature system, odds of mortality were significantly higher (OR 1.46 [95% CI 1.37-1.55]; p < 0.001). CONCLUSION The present study highlights that the survival of traumatic injured patients varies according to the stage of trauma system development in which the patient was treated. The analysis indicates a significant reduction in mortality following the introduction of the trauma system which is further enhanced as the system matures. These results provide evidence to support efforts to, firstly, implement trauma systems in countries currently without and, secondly, to enhance existing systems by investing in system development. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019142842 .
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Affiliation(s)
- Rayan Jafnan Alharbi
- School of Nursing & Midwifery, La Trobe University, 1st floor, HSB 1, La Trobe University, Bundoora, VIC, 3086, Australia. .,Department of Emergency Medical Service, Jazan University, Jazan, Saudi Arabia.
| | - Sumina Shrestha
- Australian Institute for Primary Care and Ageing, School of Nursing & Midwifery, La Trobe University, Bundoora, VIC, Australia.,Community Development and Environment Conservation Forum, Chautara, Nepal
| | - Virginia Lewis
- Australian Institute for Primary Care and Ageing, School of Nursing & Midwifery, La Trobe University, Bundoora, VIC, Australia
| | - Charne Miller
- School of Nursing & Midwifery, La Trobe University, 1st floor, HSB 1, La Trobe University, Bundoora, VIC, 3086, Australia
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Sturms LM, Driessen MLS, van Klaveren D, Ten Duis HJ, Kommer GJ, Bloemers FW, den Hartog D, Edwards MJ, Leenhouts PA, van Zutphen S, Schipper IB, Spanjersberg R, Wendt KW, de Wit RJ, Poeze M, Leenen LP, de Jongh M. Dutch trauma system performance: Are injured patients treated at the right place? Injury 2021; 52:1688-1696. [PMID: 34045042 DOI: 10.1016/j.injury.2021.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/09/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS). METHODS Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC. RESULTS Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times. CONCLUSIONS Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.
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Affiliation(s)
| | | | - David van Klaveren
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Henk-Jan Ten Duis
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Geert Jan Kommer
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, location VU, Amsterdam, the Netherlands
| | - Dennis den Hartog
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Michael J Edwards
- Department of Trauma surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter A Leenhouts
- Department of Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - S van Zutphen
- Department of Surgery, ETZ Two Cities Hospital, Tilburg, The Netherlands
| | - Inger B Schipper
- Department of Trauma surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen
| | - Ralph J de Wit
- Department of Trauma Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luke P Leenen
- Department of Trauma surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mariska de Jongh
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, the Netherlands
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Andrews R, Wynn MT, Vallmuur K, Elcock M, Rashford S, Bosley E, Ter Hofstede AH. Trauma by-pass guideline: A data-driven conformance analysis for road trauma cases in Queensland. Emerg Med Australas 2021; 33:1059-1065. [PMID: 34060229 DOI: 10.1111/1742-6723.13807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 02/02/2021] [Accepted: 04/27/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Study objectives were to (i) develop and test a whole-of-system method for identifying patients who meet a major trauma by-pass guideline definition; (ii) apply this method to assess conformance to the current 2006 guideline for a road trauma cohort; and (iii) leverage relevant findings to propose improvements to the guideline. METHODS Retrospective analysis of existing, routinely collected data relating to Queensland road trauma patients July 2015 to June 2017. Data from ambulance, aero-medical retrievals, ED, hospital and death registers were linked and used for analysis. Processes of care measured included: frequency of pre-hospital triage criteria, distribution of destination (trauma service level), compliance with guideline (recommended vs actual destination), trauma service level by threat to life (injury severity) (all modes of transport and aero-medical in particular), proportion of patients requiring only ED, transport pathway (direct vs inter-hospital transfer). RESULTS 3847 cases were identified from data as meeting criteria for major trauma by-pass. The top five most frequently used criteria for qualifying patients as meeting the major trauma by-pass guideline were pulse rate, vehicle rollover, possible spinal cord injury, respiration rate and entrapment. The study demonstrates a 65% conformance to the clinical guideline. Overtriaged patients (transported to higher trauma service than recommended) generally reveal International Classification of Disease Injury Severity Score representing a high threat to life. CONCLUSION Overall, the present study found good conformance, with overtriage rate as expected by clinicians. It is recommended to include data values to capture paramedics assessment of trauma level to enable more accurate assessment of conformance to guideline and future revision of the thresholds.
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Affiliation(s)
- Robert Andrews
- School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Moe T Wynn
- School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kirsten Vallmuur
- Centre for Healthcare Transformation, Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Jamieson Trauma Institute, Metro North Hospital and Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Mark Elcock
- Retrieval Services Queensland, Queensland Health, Brisbane, Queensland, Australia
| | | | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Arthur Hm Ter Hofstede
- School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia
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12
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Lavanchy JL, Dubuis JB, Osterwalder A, Winterhalder S, Haltmeier T, Candinas D, Schnüriger B. Impact of Inter-Hospital Transfer on Outcomes in Patients Undergoing Emergency Abdominal Surgery: A Tertiary Referral Center's Perspective. World J Surg 2021; 45:2703-11. [PMID: 34059929 DOI: 10.1007/s00268-021-06174-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND In trauma patients, the impact of inter-hospital transfer has been widely studied. However, for patients undergoing emergency abdominal surgery (EAS), the effect of inter-hospital transfer on outcomes is largely unknown. METHODS This is a single-center, retrospective observational study. Outcomes of transferred patients undergoing EAS were compared to patients primarily admitted to a tertiary care hospital from 01/2016 to 12/2018 using univariable and multivariable analyses. The primary outcome was in-hospital mortality. RESULTS Some 973 patients with a median (IQR) age of 58.1 (39.4-72.2) years and a median body mass index of 25.8 (22.5-29.3) kg/m2 were included. The transfer group comprised 258 (26.3%) individuals and the non-transfer group 715 (72.7%). The population was stratified in three subgroups: (1) patients with low surgical stress (n = 483, 49.6%), (2) with hollow viscus perforation (n = 188, 19.3%) and (3) with potential bowel ischemia (n = 302, 31.1%). Neither in the low surgical stress nor in the hollow viscus perforation group was the transfer status associated with mortality. However, in the potential bowel ischemia group inter-hospital transfer was a predictor for mortality (OR 3.54, 95%CI 1.03-12.12, p = 0.045). Moreover, in the hollow viscus perforation group inter-hospital transfer was a predictor for reduced hospital length of stay (RC -10.02, 95%CI -18.14/-1.90, p = 0.016) and reduced severe complications (OR 0.38, 95%CI 0.18-0.77, p = 0.008). CONCLUSION Other than in patients with low surgical stress or hollow viscus perforation, in patients with potential bowel ischemia inter-hospital transfer was an independent predictor for higher mortality. Taking into account the time sensitiveness of bowel ischemia, efforts should be made to avoid inter-hospital transfer in this vulnerable subgroup of patients.
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13
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Van Ditshuizen JC, Sewalt CA, Palmer CS, Van Lieshout EMM, Verhofstad MHJ, Den Hartog D. The definition of major trauma using different revisions of the abbreviated injury scale. Scand J Trauma Resusc Emerg Med 2021; 29:71. [PMID: 34044857 PMCID: PMC8162011 DOI: 10.1186/s13049-021-00873-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/01/2021] [Indexed: 11/19/2022] Open
Abstract
Background A threshold Injury Severity Score (ISS) ≥ 16 is common in classifying major trauma (MT), although the Abbreviated Injury Scale (AIS) has been extensively revised over time. The aim of this study was to determine effects of different AIS revisions (1998, 2008 and 2015) on clinical outcome measures. Methods A retrospective observational cohort study including all primary admitted trauma patients was performed (in 2013–2014 AIS98 was used, in 2015–2016 AIS08, AIS08 mapped to AIS15). Different ISS thresholds for MT and their corresponding observed mortality and intensive care (ICU) admission rates were compared between AIS98, AIS08, and AIS15 with Chi-square tests and logistic regression models. Results Thirty-nine thousand three hundred seventeen patients were included. Thresholds ISS08 ≥ 11 and ISS15 ≥ 12 were similar to a threshold ISS98 ≥ 16 for in-hospital mortality (12.9, 12.9, 13.1% respectively) and ICU admission (46.7, 46.2, 46.8% respectively). AIS98 and AIS08 differed significantly for in-hospital mortality in ISS 4–8 (χ2 = 9.926, p = 0.007), ISS 9–11 (χ2 = 13.541, p = 0.001), ISS 25–40 (χ2 = 13.905, p = 0.001) and ISS 41–75 (χ2 = 7.217, p = 0.027). Mortality risks did not differ significantly between AIS08 and AIS15. Conclusion ISS08 ≥ 11 and ISS15 ≥ 12 perform similarly to a threshold ISS98 ≥ 16 for in-hospital mortality and ICU admission. This confirms studies evaluating mapped datasets, and is the first to present an evaluation of implementation of AIS15 on registry datasets. Defining MT using appropriate ISS thresholds is important for quality indicators, comparing datasets and adjusting for injury severity. Level of evidence Prognostic and epidemiological, level III. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00873-7.
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Affiliation(s)
- Jan C Van Ditshuizen
- Department of Surgery, Trauma Research Unit, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Charlie A Sewalt
- Department of Surgery, Trauma Research Unit, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.,Department of Public Health, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Cameron S Palmer
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia.,Trauma Service, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Esther M M Van Lieshout
- Department of Surgery, Trauma Research Unit, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Michiel H J Verhofstad
- Department of Surgery, Trauma Research Unit, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Department of Surgery, Trauma Research Unit, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
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14
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Odland ML, Whitaker J, Nepogodiev D, Aling' CA, Bagahirwa I, Dushime T, Erlangga D, Mpirimbanyi C, Muneza S, Nkeshimana M, Nyundo M, Umuhoza C, Uwitonze E, Steans J, Rushton A, Belli A, Byiringiro JC, Bekele A, Davies J. Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi-disciplinary Stakeholder Exercise. World J Surg 2021; 44:2903-2918. [PMID: 32440950 PMCID: PMC7385009 DOI: 10.1007/s00268-020-05571-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. Methods A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem.
Results Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “Training and retention of specialist staff”, “Health education/awareness of injury severity”, “Geographical coverage of referral trauma centres”, and “Lack of protocol for bypass to referral centres”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map.
Conclusion Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.
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Affiliation(s)
- Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - John Whitaker
- Faculty of Life Sciences and Medicine, King's Centre for Global Health and Health Partnerships, King's College London, Room 2.13, Global Health Offices, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK. .,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Dmitri Nepogodiev
- National Institute for Health Research, Global Health Research Unit on Global Surgery, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | | | | | | | - Darius Erlangga
- Warwick Medical School, Population Evidence and Technologies, University of Warwick, Coventry, UK
| | | | | | | | - Martin Nyundo
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Christian Umuhoza
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | | | - Jill Steans
- Department of Political Science and International Studies, School of Government and Society, University of Birmingham, Birmingham, UK
| | - Alison Rushton
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Antonio Belli
- College of Medicine and Dental Sciences, NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - Jean Claude Byiringiro
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Faculty of Life Sciences and Medicine, King's Centre for Global Health and Health Partnerships, King's College London, Room 2.13, Global Health Offices, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK.,Faculty of Health Sciences, Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, University of Witwatersrand, Johannesburg, Gauteng, South Africa
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15
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Haslam NR, Bouamra O, Lawrence T, Moran CG, Lockey DJ. Time to definitive care within major trauma networks in England. BJS Open 2020; 4:963-969. [PMID: 32644299 PMCID: PMC7528529 DOI: 10.1002/bjs5.50316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 05/26/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016. METHODS An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death. RESULTS Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001). CONCLUSION Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.
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Affiliation(s)
- N. R. Haslam
- Barts and The London School of Anaesthesia, Barts Health NHS TrustLondonUK
| | - O. Bouamra
- Trauma Research and Audit NetworkUniversity of ManchesterSalfordUK
| | - T. Lawrence
- Trauma Research and Audit NetworkUniversity of ManchesterSalfordUK
| | - C. G. Moran
- Trauma and Orthopaedic SurgeryQueen's Medical CentreNottinghamUK
| | - D. J. Lockey
- Centre for Trauma Sciences, Blizard InstituteQueen Mary University of LondonLondonUK
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16
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Edwards KH, Franklin RC, Aitken P, Elcock M, Edwards MT. A Program Profile of Air Medical Transport in Regional Central Queensland, Australia. Air Med J 2019; 38:431-436. [PMID: 31843155 DOI: 10.1016/j.amj.2019.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the epidemiology of air medical patients and referral patterns in Central Queensland Hospital and Health Service (CQHHS). METHODS Analysis of air medical transport from January 2010 to December 2014. Air medical tasks within the local health service boundary were included. All patients transported on rotor or fixed wing aircraft for medical purposes were included. Patterns of air medical tasks in and out of the region by referring and receiving location, aircraft type, flight priority, time of day, month, sex, age, illness, and referral indexes were analyzed. RESULTS There were 11,456 air ambulance tasks in CQHHS region during the study period, an average of 2,291 retrievals per annum or 191 per month. Frequent referrals were to a tertiary facility, located 800 km across economic and political boundaries. Referral pattern indexes highlight a net patient flow of 1.2 to 1. Cardiology was the largest illness category (24%). Males represented 59% overall as well as patients 66 years and older (33%). Fixed wing aircraft carried out 87% of the tasks with a frequent response time of 6 to 24 hours. CONCLUSION Air medical transports are an integral part of the health system in Central Queensland communities with vast geographic distances. Identifying regional referral pattern rates and ratios aid in the planning of resource allocation.
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Affiliation(s)
| | | | - Peter Aitken
- James Cook University, Townsville, Queensland, Australia; Queensland Department of Health, Aeromedical Retrieval and Disaster Management Branch Queensland, Brisbane, Australia
| | - Mark Elcock
- Queensland Department of Health, Aeromedical Retrieval and Disaster Management Branch Queensland, Brisbane, Australia
| | - Mark Terrell Edwards
- James Cook University, Townsville, Queensland, Australia; LifeFlight Retrieval Medicine Australia, Brisbane, Australia; Queensland Health, Emergency Medicine Department, Rockhampton, Queensland, Australia
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17
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Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. A comparison of major trauma patient transport destination in metropolitan Perth, Western Australia. Australas Emerg Care 2019; 23:90-96. [PMID: 31668941 DOI: 10.1016/j.auec.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/25/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite evidence of a lower risk of death, major trauma patients are not always transported to Trauma Centres. This study examines the characteristics and outcomes of major trauma patients between transport destinations. METHODS A retrospective cohort study of major trauma patients (Injury Severity Score >15) transported by ambulance was undertaken. Cases were divided into transport destination groups: (1) Direct, those transported to the Trauma Centre directly from the scene; (2) Indirect, those transported to another hospital prior to Trauma Centre transfer and (3) Non-transfers, those transported to a non-Trauma Centre and never subsequently transferred. Median and interquartile range (IQR) were used to describe the groups and differences were assessed using the Kruskal-Wallis test for continuous variables and Pearson chi-square for categorical. RESULTS A total of 1625 patients were included. The median age was oldest in the non-transfers cohort (72 years IQR 46-84). This group had the highest proportion of falls from standing and head injuries (n = 298/400, 75%, p < 0.001). The non-transfers had the highest proportion of 30-day mortality (n = 134/400, 34%). CONCLUSIONS There were significant differences between the groups with older adults, falls and head injuries over-represented in the non-transfer group. Considering the ageing population, trauma systems will need to adapt.
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Affiliation(s)
- Elizabeth Brown
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia.
| | - Paul Bailey
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Daniel Fatovich
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Emergency Medicine, Royal Perth Hospital, University of Western Australia, Bentley, WA, Australia; Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, WA, Australia.
| | - Gavin Pereira
- School of Public Health, Curtin University, Bentley, WA, Australia; Telethon Kids Institute, WA, Australia.
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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18
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Voskens FJ, van Rein EAJ, van der Sluijs R, Houwert RM, Lichtveld RA, Verleisdonk EJ, Segers M, van Olden G, Dijkgraaf M, Leenen LPH, van Heijl M. Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients. JAMA Surg 2019; 153:322-327. [PMID: 29094144 DOI: 10.1001/jamasurg.2017.4472] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Importance A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system. Objective To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients. Design, Setting, and Participants Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury. Main Outcomes and Measures The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol. Results A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication. Conclusions and Relevance More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol.
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Affiliation(s)
- Frank J Voskens
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eveline A J van Rein
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Utrecht Trauma Center, Utrecht, the Netherlands
| | - Robert Anton Lichtveld
- Regional Ambulance Facility Utrecht, Regionale Ambulance Voorziening Utrecht, Utrecht, the Netherlands
| | - Egbert J Verleisdonk
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, the Netherlands
| | - Michiel Segers
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ger van Olden
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - Marcel Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, the Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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19
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Lerner EB, Studnek JR, Fumo N, Banerjee A, Arapi I, Browne LR, Ostermayer DG, Reynolds S, Shah MI. Multicenter Analysis of Transport Destinations for Pediatric Prehospital Patients. Acad Emerg Med 2019; 26:510-516. [PMID: 30343530 DOI: 10.1111/acem.13641] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/12/2018] [Accepted: 10/14/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although all emergency departments (EDs) should be ready to treat children, some may have illnesses or injuries that require higher-level pediatric resources that are not available at all hospitals. There are no national guidelines for emergency medical services (EMS) providers about when to directly transport children to hospitals with higher-level pediatric resources, with the exception of severe trauma. Variability exists in EMS protocols about when children warrant transport to hospitals with higher-level pediatric care. OBJECTIVE The objective was to determine how frequently pediatric patients are transported by EMS to hospitals with higher-level pediatric resources and to evaluate distribution patterns based on illness and injury severity. METHODS We conducted a retrospective analysis of all pediatric (age 0-18 years) transports in three large EMS systems between November 2014 and November 2016. Each community had a hospital with higher-level pediatric resources that was within a 30-minute transport time from any location. Patients were included if they were transported by ground ambulance and the request originated in the 9-1-1 system. We assessed the frequency of transports to a hospital with higher-level pediatric resources. Data were stratified by chief complaint of illness or injury and severity. Potential risk for severe injury was defined as meeting the physiologic step of the field triage guidelines and potential risk for severe illness was defined as having an abnormal vital sign after adjusting for patient age. RESULTS A total of 41,345 pediatric patients were transported by a participating EMS agency to an ED and had complete destination data. A total of 55% of all EMS-transported pediatric patients were transported to a hospital with higher-level pediatric resources. There was variation by site (range = 45%-71%) in the percentage of children who went to a hospital with higher-level pediatric resources. Patients over 15 years of age went to general EDs (57%) more often than younger patients. When stratified by severity, 60% of those with potentially severe illness and 74% of those with potentially severe trauma were transported to a hospital with higher-level pediatric resources. CONCLUSIONS EMS providers commonly transport children to hospitals with higher-level pediatric resources. However, more than one-quarter of children with potentially severe injuries and illnesses are transported to general EDs.
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Affiliation(s)
- E. Brooke Lerner
- Department of Emergency Medicine Medical College of Wisconsin Milwaukee WI
- Department of Pediatrics Section of Emergency Medicine Medical College of Wisconsin Milwaukee WI
| | | | - Nicole Fumo
- Department of Emergency Medicine Medical College of Wisconsin Milwaukee WI
| | - Anjishnu Banerjee
- Department of Emergency Medicine Medical College of Wisconsin Milwaukee WI
| | - Igli Arapi
- Department of Emergency Medicine Medical College of Wisconsin Milwaukee WI
| | - Lorin R. Browne
- Department of Pediatrics Section of Emergency Medicine Medical College of Wisconsin Milwaukee WI
| | | | | | - Manish I. Shah
- Department of Pediatrics Section of Emergency Medicine Baylor College of Medicine Houston TX
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20
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van Rein EAJ, Jochems D, Lokerman RD, van der Sluijs R, Houwert RM, Lichtveld RA, van Es MA, Leenen LPH, van Heijl M. Diagnostic value of emergency medical services provider judgement in the identification of head injuries among trauma patients. Eur J Neurol 2018; 26:274-280. [DOI: 10.1111/ene.13804] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- E. A. J. van Rein
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - D. Jochems
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. D. Lokerman
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. van der Sluijs
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. M. Houwert
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
- Trauma Centre Utrecht; Utrecht
| | | | - M. A. van Es
- Department of Neurology; University Medical Centre Utrecht; Utrecht
| | - L. P. H. Leenen
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - M. van Heijl
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
- Department of Surgery; Diakonessenhuis Utrecht/Zeist/Doorn; Utrecht The Netherlands
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21
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Maissan IM, Verbaan LA, van den Berg M, Houmes RJ, Stolker RJ, den Hartog D. Helicopter Transportation Increases Intracranial Pressure: a Proof-of-Principle Study. Air Med J 2018; 37:249-52. [PMID: 29935704 DOI: 10.1016/j.amj.2018.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/28/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE After severe (primary) brain injury, Dutch physician-based helicopter emergency medical services start therapy to lower the intracranial pressure (ICP) on scene to stop or delay secondary brain injury. In some cases, helicopter transportation to the nearest level 1 trauma center is indicated. During transportation, the head-down position may counteract the ICP-lowering strategies because of venous blood pooling in the head. To examine this theory, we measured the optic nerve sheath diameter (ONSD) during helicopter transport in healthy volunteers. METHODS The ONSD was measured by ultrasound in healthy volunteers during helicopter liftoff and acceleration in the supine position or with a raised headrest. RESULTS In this proof-of-principle study, the ONSD increased during helicopter acceleration (-9° Trendelenburg, mean = 5.6 ± .3 mm) from baseline (0° supine position, mean = 5.0 ± .4 mm). After headrest elevation (20°-25°), the ONSD did not increase during helicopter acceleration (mean ONSD = 5.0 ± .5 mm). CONCLUSION ONSD and ICP seem to increase during helicopter transportation in -9° head-down (Trendelenburg) position. By raising the headrest of the gurney before liftoff, these effects can be prevented.
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Schwindling L, Ragoschke-Schumm A, Kettner M, Helwig S, Manitz M, Roumia S, Lesmeister M, Grunwald IQ, Fassbender K. Prehospital Imaging-Based Triage of Head Trauma with a Mobile Stroke Unit: First Evidence and Literature Review. J Neuroimaging 2016; 26:489-93. [PMID: 27159772 DOI: 10.1111/jon.12355] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/29/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND An ambulance equipped with a computed tomography (CT) scanner, point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit [MSU]) has been shown to enable delivery of thrombolysis to stroke patients at the emergency site, thereby significantly decreasing time to treatment. However, the MSU frequently assesses patients with cerebral disorders other than stroke. For some of these disorders, prehospital CT scanning may also be beneficial. METHODS Our institution manages a program investigating prehospital stroke treatment of patients with neurological emergencies. We assessed a patient with head trauma for whom prehospital CT scanning and laboratory tests allowed cause-based triage to the most appropriate hospital. We examined implications of this case for clinical practice in light of a literature review. RESULTS The MSU was dispatched to assess a 74-year-old woman with suspected head trauma or stroke, found lying on the floor with a left frontal laceration. Her Glasgow Coma Scale score was 13, apart from drowsiness she exhibited no neurologic deficit. A CT scan ruled out intracranial hemorrhage and skull fracture. On the basis of these prehospital diagnostic findings, the patient was taken to the nearest primary care hospital rather than to a trauma center with neurosurgery facilities. CONCLUSION Patients with neurologic disorders other than stroke, such as traumatic brain injury, may also benefit from prehospital CT studies. This case report and the results of our analysis of the literature support the potential benefit of prehospital imaging in correctly triaging patients with suspected traumatic brain injury to the appropriate target hospital.
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Affiliation(s)
- L Schwindling
- Department of Neurology, Saarland University, Homburg, Germany
| | | | - M Kettner
- Department of Neurology, Saarland University, Homburg, Germany
| | - S Helwig
- Department of Neurology, Saarland University, Homburg, Germany
| | - M Manitz
- Department of Neurology, Saarland University, Homburg, Germany
| | - S Roumia
- Institute of Neuroradiology, Saarland University, Homburg, Germany
| | - M Lesmeister
- Department of Neurology, Saarland University, Homburg, Germany
| | - I Q Grunwald
- Neuroscience Department, Anglia Ruskin University, Chelmsford, Essex, UK
| | - K Fassbender
- Department of Neurology, Saarland University, Homburg, Germany
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Rubenson Wahlin R, Ponzer S, Skrifvars MB, Lossius HM, Castrén M. Effect of an organizational change in a prehospital trauma care protocol and trauma transport directive in a large urban city: a before and after study. Scand J Trauma Resusc Emerg Med 2016; 24:26. [PMID: 26956015 PMCID: PMC4784308 DOI: 10.1186/s13049-016-0218-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/01/2016] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Trauma systems and regionalized trauma care have been shown to improve outcome in severely injured trauma patients. The aim of this study was to evaluate the implementation of a prehospital trauma care protocol and transport directive, and to determine its effects on the number of primary admissions and secondary trauma transfers in a large Scandinavian city. METHODS We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County; patients > 15 years of age with an Injury Severity Score (ISS) > 15 transported to any emergency care hospitals in the Stockholm area were included for the years 2006 and 2008. We also included secondary transferred patients to the regional trauma center during 2006, 2008, and 2013. RESULTS A total of 693 primarily admitted trauma patients were included for the years 2006 and 2008. For the years 2006, 2008 and 2013, we included 114 secondarily transported trauma patients. The number of primary patient transports to the trauma center increased during the years by 20.2%, (p < 0.001); patients primarily transported to the trauma center had a significantly higher Injury Severity Score in 2008 than in 2006, and the number of patients transported secondarily to the trauma center in 2006 was higher compared to 2008 and to 2013 (p < 0.001, all 3 years). DISCUSSION Our data indicate that implementation of a prehospital trauma care protocol may have an effect on transportation of severely injured trauma patients. A decrease in secondarily transported trauma patients to the regional trauma center was noted after 1 year and persisted at 7 years after the organizational change. Patients primarily admitted to the trauma center after the change had more severe injuries than patients transported to other emergency hospitals in the area even if 20 % of patients were not admitted primarily to a trauma center. This does not imply that the transport directives or the criteria were not followed but rather reveals the difficulties and uncertainties of field triage. CONCLUSIONS With the introduction of a prehospital trauma transport directive in a large urban city, an increase in patients transported to the regional trauma center and a decrease in secondary transfers were detected, but a considerable number of severely injured patients were still transported to local hospitals.
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Affiliation(s)
- Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden. .,Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, SE-118 83, Sweden.
| | - Sari Ponzer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, FI-00029 HUS, Finland
| | - Hans Morten Lossius
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden.,Field of Prehospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, Stavanger, NO, 4036, Norway
| | - Maaret Castrén
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden.,Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, FI-00029 HUS, Finland
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