Evaluation of a Mature Trauma System

Durham, Rodney M.; Pracht, Etienne E.; Orban, Barbara; Lottenburg, Larry; Tepas, Joseph J.; Flint, Lewis M.

doi:10.1097/01.sla.0000219644.52926.f1

Cited by 127 publications

(85 citation statements)

References 29 publications

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“…Naturally, countries seek to reduce the cost of trauma and 4 evidence shows that despite the high costs the presence of a trauma system or trauma care can reduce long term morbidity of survivors and improve functional outcomes (Sasser, Varghese, Joshipura, & Kellermann, 2006). Mature trauma systems have been shown to be cost effective (MacKenzie et al, 2010), and there is evidence of a 5-to 15-fold return on investment for each patient returning to work (Durham et al, 2006). This emphasizes the importance of establishing the effect of trauma system care on quality of functional outcome .…”

Section: Prehospital Trauma Care Systemsmentioning

confidence: 99%

26 Evaluating access to prehospital care for traumatic brain injury patients in a resource limited setting: focus on prehospital transport

2015

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Prehospital factors recorded include time, distance and cost. Multivariable regression analyses evaluated the effect of prehospital factors on unfavourable patient TBI outcome, in-hospital factors and demographics were controlled for. Unfavourable outcome was defined as Glasgow Outcome Score<5 on discharge or death.RESULTS: Road traffic injuries were the most common mechanism of injury (67.1%). The majority of patients were referred from other facilities in and around the region (62.3%), with 23% from the local public hospital. There was no evidence of prehospital care available in this region. Average prehospital duration was more than 1 hour, a third of this was spent in prehospital transit for a majority of the patients. A minority usedAmbulances. Predictors of unfavourable outcome (GOS<5) were: prehospital time greater than 60 minutes, multiple physical transfers during the prehospital course and being referred from another hospital.v CONCLUSION: The lack of prehospital care calls for further research into prehospital interventions for this setting. Further analysis should be conducted with a larger sample size to increase accuracy of the findings.vi

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Section: Prehospital Trauma Care Systemsmentioning

confidence: 99%

26 Evaluating access to prehospital care for traumatic brain injury patients in a resource limited setting: focus on prehospital transport

2015

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“…[115][116][117] These studies compared patients treated in trauma centres (bypassed, directly admitted and transferred in) to untransferred patients cared for in non-specialist hospitals. As they do not examine counterfactual outcomes for patients treated with or without bypass, they have little relevance to the HITS-NS decision problem.…”

Section: Hits-ns Stream Bmentioning

confidence: 99%

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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BackgroundReconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence – with regard to ‘early neurosurgery’ in this cohort – which we sought to address.MethodsPilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). Primary outcomes: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. ‘Open-label’ secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.ResultsOverall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%;p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.ConclusionsCurrent NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating ‘early neurosurgery through bypass’ and address the challenge of reliable TBI diagnosis at the scene of injury.Trial registrationCurrent Controlled Trials ISRCTN68087745.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

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“…And the following prerequisites are required to decide whether they are preventable [2]. 1) Injury should be trauma related, and the complications should be survivable, 2) treatment applied is standard or suboptimal, and 3) the confirmed error during treatment should be directly or indirectly related to the outcome.…”

Section: Discussionmentioning

confidence: 99%

“…Especially, amongst individuals aged 45 or less, who are the core of economic activity, trauma is the 1st leading cause of death, resulting in high socio-economical loss. Therefore, establishing a good trauma system in Korea is of utmost importance [1,2]. Based on these facts, Korea government has set a project of reducing preventable trauma death rate (PTDR) to 20% until 2020, which is a level compatible with developed country.…”

Section: Introductionmentioning

confidence: 99%

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PARK Index and S-score Can Be Good Quality Indicators for the Preventable Mortality in a Single Trauma Center

Park

Lee

et al. 2017

Journal of Trauma and Injury

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Purpose: Preventable Trauma Death Rate (PTDR) using Trauma and Injury Severity Score (TRISS) has been most widely used as a quality indicator in South Korea. However, this method has a small number of deaths corresponding to the denominator. Therefore, it is difficult to check the change of quality improvement for annual mortality, and there is a disadvantage that variation is severe. Therefore, we attempted to improve the quality of the mortality evaluation by reducing the variation by applying the PARK Index (preventable major trauma death rate, PMTDR) which can increase the number of denominator significantly. And the Save score (S-score) was also examined as another quality indicator. Methods: In the PARK Index, the denominator is number of all patients who have survival probability (Ps) larger than 0.25. Numerator is the number of deaths among these. The PARK Index includes only patients with ISS >15. The S-score is calculated in the same way as the W-score, but the S-score includes only patients with ISS >15, which is a difference from the W-score. Results: PARK Index decreased annually and was 12.9 (37/287) in 2014, 9.6 (33/343) in 2015, and 7.3 (52/709) in 2016. S-score increased annually and was -0.29 in 2014, 4.21 in 2015, and 8.75 in 2016. Conclusions: PARK Index and S-score improved annually. This shows that both quality indicators are improving year by year. PARK Index (PMTDR) has 9.5-fold increase in denominator overall compared to PTDR by TRISS. The S-score used only ISS >15 patients as a denominator. Therefore, there is an advantage that the numerical value change is larger than the W-score. In addition, S-score is not affected by the ratio of major trauma patients to minor trauma patients.

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Evaluation of a Mature Trauma System

Cited by 127 publications

References 29 publications

26 Evaluating access to prehospital care for traumatic brain injury patients in a resource limited setting: focus on prehospital transport

26 Evaluating access to prehospital care for traumatic brain injury patients in a resource limited setting: focus on prehospital transport

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

PARK Index and S-score Can Be Good Quality Indicators for the Preventable Mortality in a Single Trauma Center

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