Abstract
Few studies have evaluated intrainstitutional improvement of trauma care. We hypothesized that the formalization of a dedicated multidisciplinary trauma service in a major Scandinavian trauma center in 2005 would result in improved outcome. Institutional trauma registry data for 7,243 consecutive patients from the years 2002-2008 were retrospectively evaluated using variable life-adjusted display (VLAD) as one of several performance indicators. VLAD is a refinement of the cumulative sum method that adjusts death and survival by each patient's risk status (probability of survival) and provides a graphical display of performance over time. Probability of survival was calculated according to Trauma and Injury Severity Score (TRISS) methodology with National Trauma Data Bank 2005 coefficients. VLAD demonstrated a sharp increase in cumulative survival starting at the beginning of 2005 and continuing linearly throughout the study period, amounting to 68 additional saved lives. The increase was mainly caused by improved survival among the critically injured (injury severity score 25-75). A cutoff point t0 for analysis of differences between time periods was set at January 1, 2005, coinciding with the formalization of a dedicated trauma service. Mortality in the whole trauma population showed a 33% decrease after t0. W-statistics confirmed the increased survival to be significant. There were no significant changes in age, gender, or injury mechanism. Injury severity score decreased, but differences in case mix were adjusted for in the survival prediction model. We have shown that the start of the long-lasting performance improvement coincided with formalization of a dedicated trauma service, providing increased multidisciplinary focus on all aspects of trauma care.
Highlights
Damage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries
A very limited number of hospitals had treated more than one trauma patient with temporary abdominal closure (TAC) (5%) or one patient with abdominal compartment syndrome (ACS) (14%) on average per year
Due to increasing non-operative management (NOM), an increasing number of patients with abdominal injuries was not accompanied by an increase in number of laparotomies
Summary
Damage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries. This study was undertaken to assess the institutional patient volume and performance over the period 2002-2009 for patients with abdominal injuries including the use of variable lifeadjusted display (VLAD) in order to describe risk-adjusted survival trends throughout the period. The trauma room at Oslo University Hospital- Ulleval is fully equipped for major damage control procedures, in order to minimize delay to surgery. In spite of the risk of increasing time to surgery, a change in protocol was made in 2006, mandating patients in need of trauma laparotomy to be transferred to the dedicated trauma operating room (OR) one floor above the ED, when deemed possible. Damage control techniques as well as prevention and treatment of abdominal compartment syndrome (ACS) includes the use of temporary abdominal closure (TAC), resulting in the clinical challenges of open abdomenrelated morbidity.
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