Dutch trauma system performance: Are injured patients treated at the right place?

Leontien M Sturms,Mitchell L.S Driessen,David Van Klaveren,Henk-Jan Ten Duis,Geert Jan Kommer,Frank W Bloemers,Dennis Den Hartog,Michael J Edwards,Peter A Leenhouts,S Van Zutphen,Inger B Schipper,Richard Spanjersberg,Klaus W Wendt,Ralph J De Wit,Martijn Poeze,Luke P Leenen,Mariska De Jongh

doi:10.1016/j.injury.2021.05.015

Abstract

BackgroundThe 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). MethodsData 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. ResultsOf 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. ConclusionsApproximately 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.

Highlights

In the late 1980s, Dutch trauma surgeons expressed their concerns about the quality of care, especially for severely injured patients in the Netherlands [1]
In 1998, following the United States’ example, the Dutch government decided on the implementation of an organised “inclusive” trauma care system [2] composed of regional trauma networks [3]
The government designated ten highly specialised, regional, major level one trauma centres (MTCs) and instructed them to care for severely injured individuals, establish regional trauma networks, exchange knowledge and skills, and monitor the quality of trauma care by setting up a trauma registry

Summary

Introduction

In the late 1980s, Dutch trauma surgeons expressed their concerns about the quality of care, especially for severely injured patients in the Netherlands [1]. A major issue was that those severely injured patients were often directly transported from the injury scene to the closest hospital regardless of the patients’ injuries and the available resources. The government designated ten (eleven in 2008) highly specialised, regional, major level one trauma centres (MTCs) and instructed them to care for severely injured individuals, establish regional trauma networks, exchange knowledge and skills, and monitor the quality of trauma care by setting up a trauma registry. Injured patients have shown better outcomes if treated in a major trauma centre (MTC). 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)

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