An Analysis of Patients Dead on Arrival in the American College of Surgeons Trauma Quality Program Participant Use File Data Set

Background Trauma patient care begins on-scene as field triage and mode of transportation are determinants of patient outcomes. This study evaluates the US national patterns of dead on arrival (DOA) among the trauma population. Methods A cross-sectional review of the American College of Surgeons (ACS) Trauma Quality Program Participant Use File (TQP-PUF) data set (2013-2017) was performed. Trauma patients reported as DOA were stratified by ISS into low (<15), intermediate (15-24), or high (≥25) severity. Each group was then subdivided by patient demographics, mechanism, type of injury, and mode of transportation. Results Of the 4 336 816 injury cases in the TQP-PUF data set, 33 199 were DOA (.77%). 77.1% (25 604/33 199) of DOAs were male. In the low-ISS group, .36% (13 272/3 639 811) were DOA; in the intermediate-ISS group, 1.2% (4868/421 994) were DOA; and in the high-ISS group, 5.5% (15 059/275 011) were DOA. Motor vehicle collisions (MVCs) (11 262) and firearms (8894) were the most common injury types, equating to 60.7% of DOAs. Falls accounted for 9.1% of all DOAs. The most common DOA age-group was 18-64 years, followed by ≥65 years. Conclusion DOA trauma patients are predominately adult men suffering fatal blunt force injuries most frequently via MVC. DOAs are caused by all ranges of injury severity. We recommend further development of prevention programs thereby reducing the prevalence of common traumatic injuries, notably MVC, falls, and firearms to improve survival. Future studies should also investigate the access to and distribution of trauma centers and the role of helicopter, ground, and police transport modalities and transport time on and reducing DOAs and improving trauma patient outcomes.

Evaluation of a standardized instrument for post hoc analysis of trauma-team-activation-criteria in 75,613 injured patients an analysis of the TraumaRegister DGU®

Introduction To improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently. The objective was to examine whether the catalogue can identify patients that died after admission to the hospital and therefore can benefit from a specialized trauma team mostly. Materials and methods The catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum abbreviated injury score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care. Results The TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%. Discussion The consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria. Summary Our instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury.

Prehospital Response Time of the Emergency Medical Service during Mass Casualty Incidents and the Effect of Triage: A Retrospective Study

Objective: Prehospital time affects survival in trauma patients. Mass casualty incidents (MCIs) are overwhelming events where medical care exceeds available resources. This study aimed at evaluating the prehospital time during MCIs and investigating the effect of triage. Methods: A retrospective analysis was performed using Florida’s Event Medical Services Tracking and Reporting System database. All patients involved in MCIs during 2018 were accessed, and prehospital time intervals were evaluated and compared to that of non-MCIs. The effect of MCI triage and field triage (Field Triage Criteria) on prehospital time was evaluated. Results: In 2018, it was estimated that 2236 unique MCIs occurred in Florida, with a crude incidence of 10.1-10.9/100000 people. 2180 EMS units arrived at the hospital for patient disposition with a median alarm-to-hospital time of 43.74 minutes, significantly longer than non-MCIs (39.15 min; P < 0.001). MCI triage and field triage were both associated with shorter alarm-to-hospital time (39.37 min and 37.55 min, respectively). Conclusions: MCIs resulted in longer prehospital time intervals than non-MCIs. This finding suggests that additional efforts are needed to reduce the prehospital time for MCI patients. MCI triage and field triage were both associated with shorter alarm-to-hospital times. Widespread use may improve prehospital MCI care.

Evaluation of a Standardized Instrument for Post Hoc Analysis of Trauma-Team-Activation-Criteria in 75,613 Injured Patients - An Analysis of the TraumaRegister DGU®

IntroductionIn order to improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently. The objective was to examine whether the catalogue can identify patients that died after admission to hospital and therefore can benefit of a specialized trauma team mostly.Materials and MethodThe catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum Abbreviated Injury Score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care.ResultsThe TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%.DiscussionThe consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria. SummaryOur instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury.

Disaster Response to a Mass Casualty Incident in a Hospital Fire by Regional Disaster Medical Assistance Team: Characteristics of Hospital Fire

ABSTRACT Objective: A disaster in the hospital is particularly serious and quite different from other ordinary disasters. This study aimed at analyzing the activity outcomes of a disaster medical assistance team (DMAT) for a fire disaster at the hospital. Methods: The data which was documented by a DMAT and emergent medical technicians of a fire department contained information about the patient’s characteristics, medical records, triage results, and the hospital which the patient was transferred from. Patients were categorized into four groups according to results of field triage using the simple triage and rapid treatment method. Results: DMAT arrived on the scene in 37 minutes. One hundred and thirty eight (138) patients were evacuated from the disaster scene. There were 25 patients (18.1%) in the Red group, 96 patients (69.6%) in the Yellow group, and 1 patient (0.7%) in the Green group. One patient died. There were 16 (11.6%) medical staff and hospital employees. The injury of the caregiver or the medical staff was more severe compared to the family protector. Conclusions: For an effective disaster-response system in hospital disasters, it is important to secure the safety of medical staff, to utilize available medical resources, to secure patients’ medical records, and to reorganize the DMAT dispatch system.

Flipped Classroom Approach Used in the Training of Mass Casualty Triage for Medical Undergraduate Students

Objective: The aim of this study was to explore the application of the flipped classroom approach in the training of Mass Casualty Triage (MCT) to medical undergraduate students. Methods: In this study, 103 fourth-year medical students were randomly divided into a Flipped Classroom (FC) group (n = 51) and a Traditional Lecture-based Classroom (TLC) group (n = 52). A post-class quiz, simulated field triage (SFT) and feedback questionnaires were performed to assess both groups of students for their learning of the course. Results: In the post-quiz, the median (IQR) scores achieved by students from the FC and TLC groups were 42(5) and 39(5.5), respectively. Significant differences were found between the two groups. In the SFT, overall triage accuracy was 67.06% for FC, and 64.23% for TLC students. Over-triage and under-triage errors occurred in 18.43% and 14.50% of the FC group, respectively. The TLC group had a similar pattern of 20.77% over-triage and 15.0% under-triage errors. No significant differences were found regarding overall triage accuracy or triage errors between the two groups. Conclusions: The FC approach could enhance course grades reflected in the post-quiz and improve students’ satisfaction with the class. However, there was no significant difference of competency between the two groups demonstrated in the SFT exercise.

Mortality and hospitalisation in the Danish Helicopter Emergency Medical Service (HEMS) population from 2014 to 2018: a national population-based study of HEMS triage

ObjectiveTo describe characteristics and outcomes for patients where the Danish Helicopter Emergency Medical Service (HEMS) either transported the patient to hospital, treated the patient on scene but did not transport the patient or was dispatched but cancelled en route to the patient (aborted mission), and to assess the field triage by comparing these outcomes.DesignNational population-based study.Setting and participantsHEMS dispatches are undertaken from the five Danish emergency dispatch medical centres according to national guidelines. The study analysed all primary missions with helicopter take off where the patient was admitted to hospital between 1st October 2014 and 30th April 2018.Main outcome measuresMortality rates, admittance to an intensive care unit (ICU), need of mechanical ventilation and length of hospital stay (LOS).Results6931 patients were admitted to hospital; 3311 patients were air lifted, 164 patients were ground escorted by a HEMS physician, 1421 were assisted on scene by HEMS, but escorted by the ground units and 2035 missions were aborted. The mortality was highest among the airlifted and ground escorted patients, and lowest among the patients in the aborted mission group. Mortality for the airlifted patients increased from 8.2% (95% CI; 7.3 to 9.2) at day 1 to 19.5% (95% CI; 18.2 to 20.9) after 1 year. The airlifted and ground escorted patients were frequently admitted to ICU and subsequently mechanically ventilated and they also had an increased LOS compared with the patients only assisted on scene by HEMS and the patients in the aborted mission group.ConclusionPatients to whom HEMS are dispatched are often critically ill or injured and have a relatively high mortality. The patients airlifted or ground escorted to hospital by HEMS appear more critically ill or injured compared with the assisted patients and the patients in the aborted mission group. The on-scene triage seems appropriate.

Field triage of children with abdominal trauma

Objective Identify physical findings in children with abdominal trauma to inform prehospital providers regarding appropriate hospital destinations. Methods This is a secondary analysis of the Pediatric Emergency Care Applied Research Network Abdominal Trauma Public Use Dataset. Children involved in motor vehicle collisions; struck by motor vehicles at >20 mph; involved in all-terrain vehicle, motorcycle, or scooter accidents; or who fell from >10 ft ( n = 5575) were included. Stepwise multivariable multinomial logistic regression was used to compare clinical findings at presentation between children with no intra-abdominal injury, intra-abdominal injury without intervention, and intra-abdominal injury with intervention (laparoscopy/laparotomy, embolization, red blood cell transfusion, or admission >48 h on intravenous fluids). Results Compared to children with no intra-abdominal injury, children with intra-abdominal injury (with and without intervention) were more likely to have evidence of abdominal wall trauma, abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and evidence of thoracic trauma. Children with intra-abdominal injury requiring intervention were more likely to have evidence of abdominal wall trauma (OR 3.32, 95% CI 2.03–5.44) and be intubated (OR 4.93, 95% CI 3.17–7.65) when compared to children with intra-abdominal injury without intervention. Conclusions The findings of abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and thoracic trauma may be used to identify children who warrant evaluation at any trauma center because of increased risk of intra-abdominal injury, whereas intubation and evidence of abdominal wall trauma help identify children with intra-abdominal injury in need of transport to a pediatric trauma center due to risk of undergoing intervention.