Closing the knowledge–performance gap: An audit of medical management for severe paediatric trauma in Flanders (Belgium)

Abstract

Considerable variability in (paediatric) trauma care has been reported. We wanted to audit current practice in Flanders (Belgium). The PENTA network prospectively collected data on paediatric trauma patients in a representative sample of Flemish hospitals during 2005. All cases with an ISS>or=13 and sufficient data availability were withheld for panel evaluation (n=92). Two trained experts reviewed the medical care provided in the first hours after trauma, based on available evidence and existing universal guidelines. 'Defaults' were only withheld as such if there was 100% consensus. At random, about 25% of cases were also reviewed by two other experts in order to assess interobserver variability. In the 92 cases, 264 defaults were recognised. 25.4% of all defaults were thought to have a direct impact on the individual patient's outcome. Specific difficulties were observed with, e.g. cervical spine management (18/82 relevant cases), pCO2 and global respiratory management (38/92), fluid management (29/92) and analgesia (27/89). The agreement between the two panels was good for defaults identified (crude agreement 74.8%), yet only fair for the presumed impact on outcome (crude agreement 58.3%). We audited paediatric trauma care in Flanders and identified several problem areas (often in basic areas of paediatric life support). The inherent degree of interobserver variability does not diminish the importance of these findings. More performance-based teaching and timely recertification may have a positive impact on the quality of the care delivered.