Establishment Of Trauma Centers Research Articles

Mortality Trends in Chest-Abdominal Trauma Patients Before and After the Establishment of Trauma Centers in South Korea

Purpose: We sought to assess mortality trends in chest-abdominal trauma patients, before and after the implementation of the Project Supporting Establishment of Trauma Centers (PSETC) in the Republic of Korea.Methods: Data from the National Health Insurance Service claims database between 2009 to 2017 were analyzed. Patients with chest-abdominal trauma were defined as those with relevant main diagnosis codes and claims for emergency medical management fees. Mortality and cumulative data were analyzed for each year to compare mortality before and after the establishment of regional trauma centers across Korea (2014).Results: In total, 29,127 patients were included in the analysis. While the annual incidence of trauma-related chest-abdominal injuries increased, mortalities decreased. In particular, the trauma incidence rate among patients over 50 years increased during the study period. Mortalities at trauma centers did not change year by year after the PSETC. Before and after 2014, when trauma centers operated under the PSETC, mortalities decreased [trauma cases before the PSETC; <i>n</i> = 14,321 (mortality 5.61), after the PSETC; <i>n</i> = 14,806 (mortality 4.96)].Conclusion: The number of patients treated for chest-abdominal injuries increased from 2009 to 2017 in Korea, whereas mortalities decreased over the same period.

Assessment of critical resource gaps in pediatric injury care in Mozambique's four largest Hospitals.

Hospitals from resource-scarce countries encounter significant barriers to the provision of injury care, particularly for children. Shortages in material and human resources are seldom documented, not least in African settings. This study analyzed pediatric injury care resources in Mozambique hospital settings. We undertook a cross-sectional study, encompassing the country's four largest hospitals. Data was collected in November 2020 at the pediatric emergency units. Assessment of the resources available was made with standardized WHO emergency equipment and medication checklists, and direct observation of premises and procedures. The potential impact of unavailable equipment and medications in pediatric wards was assessed considering the provisions of injury care. There were significant amounts of not available equipment and medications in all hospitals (ranging from 20% to 49%) and two central hospitals stood out in that regard. The top categories of not available equipment pertained to diagnosis and monitoring, safety for health care personnel, and airway management. Medications to treat infections and poisonings were those most frequently not available. There were several noteworthy and life-threatening shortcomings in how well the facilities were equipped for treating pediatric patients. The staff regarded lack of equipment and skills as the main obstacles to delivering quality injury care. Further, they prioritized the implementation of trauma courses and the establishment of trauma centers to strengthen pediatric injury care. The country's four largest hospitals had substantial quality-care threatening shortages due to lack of equipment and medications for pediatric injury care. All four hospitals face issues that put at risk staff safety and impede the implementation of essential care interventions for injured children. Staff wishes for better training, working environments adequately equipped and well-organized. The room for improvement is considerable, the study results may help to set priorities, to benefit better outcomes in child injuries.

Epidemiology of skeletal trauma and skull fractures in children younger than 1 year in Shenzhen: a retrospective study of 664 patients

BackgroundUnintentional injury is one of the top three causes of death for infants. However, the epidemiological studies of skeletal trauma and skull fractures in infants younger than 1 year were poorly understood in China. Therefore, our study aimed to examine accidental and emergency attendance in infants under 1 year. It also tried to determine the prevalence and severity of accident types in infants.MethodsA retrospective analysis was performed on the demographic characteristics of infants younger than 1 year with skeletal trauma and skull fractures who visited the Shenzhen Children’s Hospital from January 1, 2016 to December 31, 2019. Age, gender, fracture site and type, mechanism of injury, length of visit, length of hospital stay, hospitalization cost, and treatment methods were analyzed.ResultsA total number of 675 fractures in 664 infants were included, the median age was 187days (IQR,90-273days), including 394 males and 270 females. The top three fracture sites were the skull (430 sites, 63.70 %), long bones of the limbs (168 sites, 24.89 %), and clavicle (53 sites, 7.85 %). The top three causes of injury were locomotion injuries (256 cases, 38.55 %), falls or trips from low height (from beds, tables, chairs, etc.) (130 cases, 19.58 %), and birth injuries (97 cases, 14.61 %). The greatest amount of fractures occurred in children 1–28 days of life (d) reached a top of 101 cases, followed by 331–365 days, accounting for 15.21 and 10.24 %, respectively. The number of fractures reached a trough of 29 cases in the 29-60d group (4.37 %). And increased again to 65 cases in the 151-180d group (9.79 %). The proportion remained relatively constant at 9 % in the 181-210d group (9.19 %) and 211-240d group (9.64 %). The interval between injury and visiting our hospital was ≤ 72 h in 554 cases.ConclusionsSpecial attention should be given to the demographic characteristics of fractures in infants under 1 year of age, and appropriate outreach should be implemented. For example, health education should be provided to aid in the prevention especially for frequently occurring locomotion injuries, and prompt access to specialist medical care should be recommended for skull fractures, which are prone to delayed treatment. In addition, multidisciplinary collaboration should be implemented in trauma care, while also promoting the establishment of trauma centers in specialist children’s hospitals with a stronger capacity to treat pediatric trauma, and a regional system for pediatric trauma treatment.

Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center.

Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80min, p = 0.022), time from admission to operation (125 vs. 112min, p = 0.010), time from admission to first treatment (119 vs. 99min, p = 0.004), and time from admission to first transfusion (70 vs. 52min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.

Early experience of a regional trauma center in Gangwon province: First step toward organizing a regional trauma system

Background: The Korean Ministry of Health and Welfare decided to establish a trauma medical service system to reduce preventable deaths. OO hospital in Gangwon Province was selected as a regional trauma center and was inaugurated in 2015. Objectives: This study examines the impact of this center, comparing mortality and other variables before and after inaugurating the center. Methods: Severely injured patients (injury severity score > 15) presenting to OO hospital between January 2014 and December 2016 were enrolled and categorized into two groups: before trauma center (n = 365) and after trauma center (n = 904). Patient characteristics, variables, and patient outcomes (including mortality rate) before and after the establishment of trauma centers were compared accordingly for both groups. Risk factors for in-hospital mortality were also identified. Results: Probability of survival using trauma and injury severity score (%) method was significantly lower in the after trauma center group (81.3 ± 26.1) than in the before trauma center group (84.7 ± 21.0) (p = 0.014). In-hospital mortality rates were similar in both groups (before vs after trauma center group: 13.2% vs 14.2%; p = 0.638). The Z and W statistics revealed higher scores in the after trauma center group than in the before trauma center group (Z statistic, 4.69 vs 1.37; W statistic, 4.52 vs 2.10); 2.42 more patients (per 100 patients) survived after trauma center establishment. Conclusion: Although the mortality rates of trauma patients remained unchanged after the trauma center establishment, the Z and W statistics revealed improvements in the quality of care.

Distribution and epidemiological characteristics of disease spectrum in patients with pre-hospital care in Hohhot in 2016: a case analysis in 28 325 patients

To analyze the distribution and epidemiological characteristics of patients in pre-hospital emergency in Hohhot. The data of 28 325 pre-hospital emergency patients in 7 first-aid stations in Hohhot from January 1st to December 31st in 2016 were analyzed retrospectively. The gender, age, call time, disease spectrum of patients served as investigation elements, the data were collected into Excel 2010 form, and statistical analysis was carried out. Among 28 325 pre-hospital emergency patients, there were 15 973 male (56.39%) and 12 352 female (43.61%), with the ratio of male to female of 1.29:1. The age of patients were 1 day-108 years, with the majority of patients aged 51-60 years, which accounting for 16.08% (4 554/28 325). The top 6 of diseases were trauma [33.10% (9 376/28 325)], neurological system diseases [16.81% (4 762/28 325)], circulatory system diseases [12.31% (3 486/28 325)], respiratory system diseases [7.62% (2 159/28 325)], digestive system diseases [5.68% (1 609/28 325)], acute poisoning [5.02% (1 422/28 325)]. The peak period of call for help was 09:00-11:00 (12.55%, 3 554/28 325), and 1 small peak occurred at 15:00-17:00 (11.22%, 3 179/28 325). The highest number of patients with pre-hospital care happened in summer (26.22%, 7 428/28 325), followed by autumn (24.94%, 7 065/28 325) and winter (24.83, 7 032/28 325), and the lowest in spring (24.01%, 6 800/28 325). The peak incidence of traumatic patients was in November (11.13%, 1 044/9 376), the most patients with nervous system diseases were found in October (9.97%, 475/4 762), and the most patients with circulatory system diseases were found in July (11.16%, 389/3 486). The first aid patients in Hohhot were mainly suffered from diseases of trauma, nervous system and circulatory system, more men than women, most in 51-60 years old patients, and the summer was the peak season. Therefore, the establishment of trauma center in emergency department, strengthening the health education of high-risk groups and the primary prevention of patients with cardiovascular and cerebrovascular diseases, scientific and effective use of medical resources can improve the success rate of pre-hospital rescue.

Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center

Despite using a multidisciplinary treatment approach, the mortality rate of patients with hemodynamic instability from severe pelvic fractures is still 40-60%. We evaluated the improvement of outcomes in this patient population after the establishment of a regional trauma center in Korea. We retrospectively reviewed the medical charts of 50 patients with hemodynamic instability due to pelvic fractures between March 2011 and November 2016. Patients were divided into two groups: the pre-trauma center (PTC) group (n = 23) and trauma center (TC) group (n = 27). Sixteen (32.0%) patients died of exsanguination. Patients in the TC group had shorter trauma resuscitation room stay (101 vs 273min, p < 0.001) and underwent preperitoneal pelvic packing (PPP) more frequently (88.9 vs 8.7%, p < 0.001) than those in the PTC group. During the TC period, emergent procedures such as PPP and pelvic angiography were performed more frequently (92.6 vs 39.1%, p < 0.001). Although there was no statistical difference in the overall mortality rate between groups, patients in the TC group had less mortality due to hemorrhage (18.5 vs 47.8%, p = 0.027). Logistic regression analysis demonstrated that initial systolic blood pressure and establishment of trauma center were independent protective factors of mortality from hemorrhage [odds ratio (OR) 0.957, 95% confidence interval (CI) 0.926-0.988, p = 0.007; OR 0.134, 95% CI 0.028-0.633, p = 0.011]. Since the regional trauma center was established, emergent procedures such as pelvic angiography and PPP were performed more frequently, and mortality due to exsanguination was significantly decreased.

Organization of trauma care.

The organization of trauma care and the study of trauma systems is an evolving and dynamic endeavor. Historically, trauma has centered on the clinical care of specific injuries and wounds. In ancient times, for those who survived the initial insult, treatment would have centered on superficial soft tissue injuries and fractures. Prayers, incantations, topical salves and dressings would have been the primary modalities of treatment. Careful observation and trial and error would lead to improved treatments and increased capabilities to care for more extensive injuries. As early as 6000 B. C., the Egyptians are reported to have performed amputations, extraction of foreign bodies and lithotomies (1). The opportunity for such learning has almost always been provided by conflict and war. Military surgeons have led the way in both the clinical and the systematic care of the injured patient. Dominique Larrey, during the Napoleonic Wars, developed the concepts of rapid evacuation and early treatment of the injured. Towards this goal he created the ambulance volante or “flying hospital” to evacuate soldiers from the battlefield to the hospital for treatment. Moreover, he established hospitals near the battlefield to decrease the distance and time for evacuation. Prior to these simple concepts, the injured soldiers would often lay on the battlefield for hours to days before any treatment was given (2). A further development in the creation of trauma systems came during the American Civil War. The military recognized that for both issues of mobility and economics, it was not feasible to provide definitive care at every battle being fought. Instead, military hospitals were established along the same Army organization as line units and progression up the hierarchy led to hospitals with increasing levels of care (3). By World War I, the systematic treatment of the wounded through progressive echelons of care was standard protocol (4). Army medics and Navy corpsmen had the dangerous task of evacuating the wounded from the battlefield to the Battalion Aid Station where the injured were treated and returned to combat or quickly stabilized and triaged to a higher level of care at hospitals in the rear. In World War II, motorized ambulances had decreased the evacuation time to 4–6 hours (3). Research in shock and the extensive use of blood transfusions to treat it decreased mortality and morbidity due to acute renal failure from under-resuscitation. Antisepsis and the advent of antibiotics further contributed to the decreased mortality. The U.S. Army had been keeping detailed medical reports of the wounded since the Civil War and these precursors to present day trauma registries allowed development of protocols regarding the best treatment of specific wounds. As an example, during WW II, it was a court martial offense not to treat a colon injury with a colostomy (5). With the advent of helicopters by the Korean War and the Vietnam Conflict, evacuation times were now less than one hour from the battlefield to a fully equipped hospital. Wounded soldiers were expeditiously triaged and cared for by well-trained personnel in a system that provided for definitive care in the shortest time possible. This led to a 97.5 % survival among those soldiers who arrived to a surgical hospital alive (6). These principles were adopted in West Germany in 1970 with the establishment of trauma centers along the autobahns. Helicopters and ambulances ensured rapid prehospital transport of injured persons to definitive care. This contributed, in part, to a 25 percent reduction in motor vehicle crash mortality after system implementation (2).

Advances in the management of pediatric trauma

Background: Numerous important advances have been made in the management of trauma in childhood in prevention, prehospitalization and intrahospital care, postoperative management, and rehabilitation. As with adult trauma care, the development of trauma systems has impacted greatly on morbidity and mortality in injured children. Data sources: Recent literature was searched for information regarding selected aspects of pediatric trauma care where significant improvements in outcome have occurred. The specific areas selected because of their contribution to improved outcomes include changes in the organization of care including the establishment of trauma centers and trauma systems, understanding trauma physiology as a basis for care, selective management of blunt trauma, management of burn injury, and prevention. Conclusion: Because of the various advances in the understanding of the effects of injury that have been translated to improved approaches to treatment, overall treatment mortality in childhood has dropped 45% over the last 20 years and mortality with burn injury has been reduced by half in patients with over 60% of body surface burn and almost eliminated below that level unless there are additional circumstances. Nonetheless, trauma is still the leading cause of death in childhood, so continuing commitment by pediatric surgeons to advancing trauma care for children is in order as well as providing education for adult surgeons willing to commit themselves to care of the injured child.

Traumatic death in urban children, revisited.

Trauma is the leading cause of death in children older than 1 year in the United States. We performed an analysis of the causes of death due to trauma in children in a large urban community to suggest means of prevention in such communities. We also examined data obtained before and after the designation of pediatric trauma centers to determine whether this has made a difference. Records of the Medical Examiner, Cook County, Illinois, from 1983 through 1988. The admitting log was reviewed for all children before their 16th birthday. During the 6-year study period, 3121 autopsies were performed on children, 36.1% of whom died due to traumatic injuries. We reviewed the records of those children who died secondary to these injuries. Record review on pediatric trauma deaths as to cause of death, time of death, age, sex, and any other pertinent information. Of all trauma deaths, fire was the most common cause of death, followed by motor vehicle-related injuries, homicides, drownings, and falls. These findings differ from national statistics. Improvement in outcome was seen following the designation of general trauma centers, with further improvement seen following the designation of specific pediatric trauma centers. Identification of causes of pediatric trauma death enables us to suggest methods of prevention. The centralized care of seriously injured children through the establishment of trauma centers and, specifically, pediatric trauma centers might help to prevent these deaths. Further study of pediatric trauma deaths, including hospital and ambulance records, is needed to improve medical care.