Improved Functional Outcomes for Major Trauma Patients in a Regionalized, Inclusive Trauma System

IntroductionAn increasing proportion of the major trauma population are older persons. The pattern of injury is different in this age group and serious chest injuries represent a significant subgroup, with implications for trauma system design. The aim of this study was to examine trends in thoracic injuries among major trauma patients in an inclusive trauma system.MethodsThis was a retrospective review of all adult cases of major trauma with thoracic injuries of Abbreviated Injury Scale score of 3 or more, using data from the Victorian State Trauma Registry from 2007 to 2016. Prevalence and pattern of thoracic injury was compared between patients with multitrauma and patients with isolated thoracic injury. Poisson regression was used to determine whether population-based incidence had changed over the study period.ResultsThere were 8805 cases of hospitalised major trauma with serious thoracic injuries. Over a 10-year period, the population-adjusted incidence of thoracic injury increased by 8% per year (incidence rate ratio [IRR] 1.08, 95% CI 1.07 to 1.09). This trend was observed across all age groups and mechanisms of injury. The greatest increase in incidence of thoracic injuries, 14% per year, was observed in people aged 85 years and older (IRR 1.14, 95% CI 1.09 to 1.18).ConclusionsAdmissions for thoracic injuries in the major trauma population are increasing. Older patients are contributing to an increase in major thoracic trauma. This is likely to have important implications for trauma system design, as well as morbidity, mortality and use of healthcare resources.

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Age and the distribution of major injury across a national trauma system

Age and Ageing ◽

10.1093/ageing/afz151 ◽

2019 ◽

Vol 49 (2) ◽

pp. 218-226

Author(s):

Jan Robert Dixon ◽

Fiona Lecky ◽

Omar Bouamra ◽

Paul Dixon ◽

Faye Wilson ◽

...

Keyword(s):

Older Patients ◽

Major Trauma ◽

National Level ◽

Trauma System ◽

Injured Patient ◽

Healthcare Services ◽

Research Network ◽

Trauma Patients ◽

Significant Burden ◽

Trauma Networks

Abstract Background Trauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution. Objectives There is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between. Methods The TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England. Results About 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs. Conclusions Within adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.

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Helicopter emergency medical service dispatch in older trauma: time to reconsider the trigger?

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-021-00877-3 ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

J. E. Griggs ◽

◽

J. W. Barrett ◽

E. ter Avest ◽

R. de Coverly ◽

...

Keyword(s):

Critical Care ◽

Major Trauma ◽

Road Traffic ◽

Trauma System ◽

Trauma Centre ◽

Trauma Patients ◽

Emergency Medical ◽

Major Trauma Centre ◽

Head Injured ◽

Injured Patients

Abstract Background Helicopter Emergency Medical Services (HEMS) respond to serious trauma and medical emergencies. Geographical disparity and the regionalisation of trauma systems can complicate accurate HEMS dispatch. We sought to evaluate HEMS dispatch sensitivity in older trauma patients by analysing critical care interventions and conveyance in a well-established trauma system. Methods All trauma patients aged ≥65 years that were attended by the Air Ambulance Kent Surrey Sussex over a 6-year period from 1 July 2013 to 30 June 2019 were included. Patient characteristics, critical care interventions and hospital disposition were stratified by dispatch type (immediate, interrogate and crew request). Results 1321 trauma patients aged ≥65 were included. Median age was 75 years [IQR 69–89]. HEMS dispatch was by immediate (32.0%), interrogation (43.5%) and at the request of ambulance clinicians (24.5%). Older age was associated with a longer dispatch interval and was significantly longer in the crew request category (37 min [34–39]) compared to immediate dispatch (6 min [5–6] (p = .001). Dispatch by crew request was common in patients with falls < 2 m, whereas pedestrian road traffic collisions and falls > 2 m more often resulted in immediate dispatch (p = .001). Immediate dispatch to isolated head injured patients often resulted in pre-hospital emergency anaesthesia (PHEA) (39%). However, over a third of head injured patients attended after dispatch by crew request received PHEA (36%) and a large proportion were triaged to major trauma centres (69%). Conclusions Many patients who do not fulfil the criteria for immediate HEMS dispatch need advanced clinical interventions and subsequent tertiary level care at a major trauma centre. Further studies should evaluate if HEMS activation criteria, nuanced by age-dependant triggers for mechanism and physiological parameters, optimise dispatch sensitivity and HEMS utilisation.

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Predictors of Undertriage after Major Trauma in a Physician-led Prehospital System: Insights of a French Registry

10.21203/rs.3.rs-135822/v1 ◽

2020 ◽

Author(s):

Axel BENHAMED ◽

Laurie FRATICELLI ◽

Clément CLAUSTRE ◽

Marion DOUPLAT ◽

Guillaume MARCOTTE ◽

...

Keyword(s):

Trauma Center ◽

Major Trauma ◽

Injury Severity ◽

Ultrasound Examination ◽

Trauma System ◽

Trauma Patients ◽

Medical Systems ◽

Aged Patients ◽

Increased Risk ◽

French Registry

Abstract BackgroundThe proper prehospital triage and transportation of patients suffering major trauma to lever 1 trauma centers is associated with better outcomes. Hence, emergency medical systems (EMS) aim is to avoid undertriage in these patients. The main objective of this study was to assess the rate and predictors of undertriage in a physician-led prehospital system.MethodsWe conducted an observational multicentric, region-wide, retrospective study based on the RESUVal Trauma-System registry, Rhône-Alpes region, France. All adults assessed by physician-led EMS units, from January 2011 to December 2017 with major trauma (Injury Severity Score (ISS) ≥ 16) were included. We defined the correct-triage group as major trauma patients admitted to a level I trauma center. We performed univariate then multivariate logistic regressions with undertriage as outcome.ResultsA total of 7,110 patients were included in the registry, of whom 2,591 patients with an ISS≥ 16. Among these patients, 320 (12.35%) were undertriaged. Median ISS was 25. In-hospital mortality was 16.45% (n=351/2134). Mid-aged patients (51-65 years old) were associated with a higher risk of undertriage than the others (OR=1.62, 95%CI 1.15-2.28, p=0.01). Factors associated with a lower risk of undertriage were: mechanism (fall or gunshot/stabbing wounds, 0.62, [0.45-0.86], p=0.01 and 0.44, [0.22-0.9], p=0.02, respectively), time on-scene (over 60 minutes, 0.61, [0.38-0.95], p=0.03), prehospital need for endotracheal intubation and ultrasound examination (0.53, [0.39-0.72], p<0.001 and 0.15, [0.08-0.29], p<0.001 respectively). After adjusting for severity, undertriage showed a non-significant tendency toward an increased risk of mortality (1.22, [0.8-1.89], p=0.36).ConclusionsIn our region-wide, physician-led prehospital system, undertriage of major trauma was not rare. The typical profile of undertriaged patients was a mid-aged male suffering from a blunt trauma, without respiratory distress or neurologic impairment, not benefiting from prehospital ultrasound examination and located close to a non-trauma center hospital.

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Predictors of Undertriage after Major Trauma in a Physician-led Prehospital System: Insights of a French Registry

10.21203/rs.3.rs-122488/v1 ◽

2020 ◽

Author(s):

Axel BENHAMED ◽

Laurie FRATICELLI ◽

Clément CLAUSTRE ◽

Marion DOUPLAT ◽

Guillaume MARCOTTE ◽

...

Keyword(s):

Trauma Center ◽

Major Trauma ◽

Injury Severity ◽

Ultrasound Examination ◽

Trauma System ◽

Trauma Patients ◽

Medical Systems ◽

Aged Patients ◽

Increased Risk ◽

French Registry

Abstract BackgroundThe proper prehospital triage and transportation of patients suffering major trauma to lever 1 trauma centers is associated with better outcomes. Hence, emergency medical systems (EMS) aim is to avoid undertriage in these patients. The main objective of this study was to assess the rate and predictors of undertriage in a physician-led prehospital system.MethodsWe conducted an observational multicentric, region-wide, retrospective study based on the RESUVal Trauma-System registry, Rhône-Alpes region, France. All adults assessed by physician-led EMS units, from January 2011 to December 2017 with major trauma (Injury Severity Score (ISS) ≥ 16) were included. We defined the correct-triage group as major trauma patients admitted to a level I trauma center. We performed univariate then multivariate logistic regressions with undertriage as outcome.ResultsA total of 7,110 patients were included in the registry, of whom 2,591 patients with an ISS≥ 16. Among these patients, 320 (12.35%) were undertriaged. Median ISS was 25. In-hospital mortality was 16.45% (n=351/2134). Mid-aged patients (51-65 years old) were associated with a higher risk of undertriage than the others (OR=1.62, 95%CI 1.15-2.28, p=0.01). Factors associated with a lower risk of undertriage were: mechanism (fall or gunshot/stabbing wounds, 0.62, [0.45-0.86], p=0.01 and 0.44, [0.22-0.9], p=0.02, respectively), time on-scene (over 60 minutes, 0.61, [0.38-0.95], p=0.03), prehospital need for endotracheal intubation and ultrasound examination (0.53, [0.39-0.72], p<0.001 and 0.15, [0.08-0.29], p<0.001 respectively). After adjusting for severity, undertriage showed a non-significant tendency toward an increased risk of mortality (1.22, [0.8-1.89], p=0.36).ConclusionsIn our region-wide, physician-led prehospital system, undertriage of major trauma was not rare. The typical profile of undertriaged patients was a mid-aged male suffering from a blunt trauma, without respiratory distress or neurologic impairment, not benefiting from prehospital ultrasound examination and located close to a non-trauma center hospital.

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Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study

BMC Emergency Medicine ◽

10.1186/s12873-021-00543-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Chih-Jung Wang ◽

Tsung-Han Yang ◽

Kuo-Shu Hung ◽

Chun-Hsien Wu ◽

Shu-Ting Yen ◽

...

Keyword(s):

Cohort Study ◽

Blood Transfusion ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Major Trauma ◽

Trauma System ◽

Trauma Patients ◽

Feedback Group ◽

Hospital Transfer

Abstract Background Undertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes. Method This retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed. Results A total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p < 0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076). Conclusion This study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.

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Identifying Homogeneous Patterns of Injury in Paediatric Trauma Patients to Improve Risk-Adjusted Models of Mortality and Functional Outcomes

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17030892 ◽

2020 ◽

Vol 17 (3) ◽

pp. 892

Author(s):

Joanna F. Dipnall ◽

Belinda J. Gabbe ◽

Warwick J. Teague ◽

Ben Beck

Keyword(s):

Functional Outcomes ◽

Goodness Of Fit ◽

Latent Class ◽

Injury Severity ◽

System Development ◽

Trauma System ◽

Paediatric Population ◽

Trauma Patients ◽

Homogeneous Groups ◽

Paediatric Trauma

Injury is a leading cause of morbidity and mortality in the paediatric population and exhibits complex injury patterns. This study aimed to identify homogeneous groups of paediatric major trauma patients based on their profile of injury for use in mortality and functional outcomes risk-adjusted models. Data were extracted from the population-based Victorian State Trauma Registry for patients aged 0–15 years, injured 2006–2016. Four Latent Class Analysis (LCA) models with/without covariates of age/sex tested up to six possible latent classes. Five risk-adjusted models of in-hospital mortality and 6-month functional outcomes incorporated a combination of Injury Severity Score (ISS), New ISS (NISS), and LCA classes. LCA models replicated the best log-likelihood and entropy > 0.8 for all models (N = 1281). Four latent injury classes were identified: isolated head; isolated abdominal organ; multi-trauma injuries, and other injuries. The best models, in terms of goodness of fit statistics and model diagnostics, included the LCA classes and NISS. The identification of isolated head, isolated abdominal, multi-trauma and other injuries as key latent paediatric injury classes highlights areas for emphasis in planning prevention initiatives and paediatric trauma system development. Future risk-adjusted paediatric injury models that include these injury classes with the NISS when evaluating mortality and functional outcomes is recommended.

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