Trauma Care Systems Research Articles

A Geographic Simulation Model for the Treatment of Trauma Patients in Disasters.

Though the US civilian trauma care system plays a critical role in disaster response, there is currently no systems-based strategy that enables hospital emergency management and local and regional emergency planners to quantify, and potentially prepare for, surges in trauma care demand that accompany mass-casualty disasters. A proof-of-concept model that estimates the geographic distributions of patients, trauma center resource usage, and mortality rates for varying disaster sizes, in and around the 25 largest US cities, is presented. The model was designed to be scalable, and its inputs can be modified depending on the planning assumptions of different locales and for different types of mass-casualty events. To demonstrate the model's potential application to real-life planning scenarios, sample disaster responses for 25 major US cities were investigated using a hybrid of geographic information systems and dynamic simulation-optimization. In each city, a simulated, fast-onset disaster epicenter, such as might occur with a bombing, was located randomly within one mile of its population center. Patients then were assigned and transported, in simulation, via the new model to Level 1, 2, and 3 trauma centers, in and around each city, over a 48-hour period for disaster scenario sizes of 100, 500, 5000, and 10,000 casualties. Across all 25 cities, total mean mortality rates ranged from 26.3% in the smallest disaster scenario to 41.9% in the largest. Out-of-hospital mortality rates increased (from 21.3% to 38.5%) while in-hospital mortality rates decreased (from 5.0% to 3.4%) as disaster scenario sizes increased. The mean number of trauma centers involved ranged from 3.0 in the smallest disaster scenario to 63.4 in the largest. Cities that were less geographically isolated with more concentrated trauma centers in their surrounding regions had lower total and out-of-hospital mortality rates. The nine US cities listed as being the most likely targets of terrorist attacks involved, on average, more trauma centers and had lower mortality rates compared with the remaining 16 cities. The disaster response simulation model discussed here may offer insights to emergency planners and health systems in more realistically planning for mass-casualty events. Longer wait and transport times needed to distribute high numbers of patients to distant trauma centers in fast-onset disasters may create predictable increases in mortality and trauma center resource consumption. The results of the modeled scenarios indicate the need for a systems-based approach to trauma care management during disasters, since the local trauma center network was often too small to provide adequate care for the projected patient surge. Simulation of out-of-hospital resources that might be called upon during disasters, as well as guidance in the appropriate execution of mutual aid agreements and prevention of over-response, could be of value to preparedness planners and emergency response leaders. Study assumptions and limitations are discussed. Carr BG , Walsh L , Williams JC , Pryor JP , Branas CC . A geographic simulation model for the treatment of trauma patients in disasters. Prehosp Disaster Med. 2016;31(4):413-421.

The impact of major trauma centre implementation on the pathways and outcome of traumatic intracranial extradural haematoma in a regional centre

Introduction: A new trauma care system with regional major trauma centres (MTC) was implemented on 1st April 2012 across England. We aimed to assess whether this has affected the referral pathways and mortality of patients undergoing emergency craniotomy for extradural haematoma (EDH), where clinical outcome is correlated with the time to intervention.Materials and methods: This was a retrospective cohort comparison study. All patients who had undergone evacuation of EDH from January 2011 to December 2013 were identified. Only those in whom a decision for emergency craniotomy had been made at the time of referral to the on-call neurosurgeon were included. The CRASH predicted risk of mortality was calculated for individual patients. Mortality was assessed at 14 days in order to compute standardised mortality ratios (SMR).Results: Overall, 65 patients underwent EDH evacuation during the study period (21 pre-MTC and 44 post-MTC). Of those, 43 emergency procedures according to the aforementioned definition were included for further analysis (13 pre-MTC, 30 post-MTC). The mean CRASH predicted risk of mortality was 0.21 for the pre-MTC cohort (95% CI: 0.07–0.34) and 0.094 for the post-MTC cohort (95% CI: 0.039–0.15; p = 0.052). There was no significant difference in the rate of secondary transfers before and after MTC implementation (9/13 vs. 23/30, p = 0.71). The mean interval from referral to operation was 198 min for the pre-MTC cohort (95% CI: 123–273) and 201 min for the post-MTC cohort (95% CI: 141–262; p = 0.95). The SMR was 0.37 for the pre-MTC cohort (95% CI: 0.02–1.81; 1 death) and 0.71 for the post-MTC cohort (95% CI: 0.12–2.34; 2 deaths).Conclusions: MTC implementation has not affected the time to operation or the mortality following EDH evacuation.

Uptake of the World Health Organization's trauma care guidelines: a systematic review.

ObjectiveTo understand the degree to which the trauma care guidelines released by the World Health Organization (WHO) between 2004 and 2009 have been used, and to identify priorities for the future implementation and dissemination of such guidelines.MethodsWe conducted a systematic review, across 19 databases, in which the titles of the three sets of guidelines – Guidelines for essential trauma care, Prehospital trauma care systems and Guidelines for trauma quality improvement programmes – were used as the search terms. Results were validated via citation analysis and expert consultation. Two authors independently reviewed each record of the guidelines’ implementation.FindingsWe identified 578 records that provided evidence of dissemination of WHO trauma care guidelines and 101 information sources that together described 140 implementation events. Implementation evidence could be found for 51 countries – 14 (40%) of the 35 low-income countries, 15 (32%) of the 47 lower-middle income, 15 (28%) of the 53 upper-middle-income and 7 (12%) of the 59 high-income. Of the 140 implementations, 63 (45%) could be categorized as needs assessments, 38 (27%) as endorsements by stakeholders, 20 (14%) as incorporations into policy and 19 (14%) as educational interventions.ConclusionAlthough WHO’s trauma care guidelines have been widely implemented, no evidence was identified of their implementation in 143 countries. More serial needs assessments for the ongoing monitoring of capacity for trauma care in health systems and more incorporation of the guidelines into both the formal education of health-care providers and health policy are needed.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: protocol for a mixed methods cohort study.

BackgroundInjury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear. The objective of this study is to review the processes of care and describe the impacts of a regionalised trauma system on the outcomes of severely injured children.MethodsThis article describes the design of a mixed methods cohort study evaluating the paediatric trauma system in New South Wales (NSW), the most populous state in Australia. Recommendations and an implementation strategy will be developed for aspects of the paediatric trauma care system that require change.All injured children (aged <16 years) requiring intensive care, or with an Injury Severity Score (ISS) ≥ 9 treated in NSW, or who died following injury in NSW in the 2015–16 financial year, will be eligible for participation. Injury treatment and processes will be examined via retrospective medical record review. Quality of care will be measured via peer review and staff interviews, utilising a human factors framework. Health service and cost outcomes will be calculated using activity based funding data provided by the Ministry of Health. Health-related quality of life (HRQoL) proxy measures will occur at baseline, 6 and 12 months to measure child HRQoL and functional outcomes.DiscussionThis will be the first comprehensive analysis undertaken in Australia of the processes and systems of care for severe paediatric injury. The collaborative research method will encourage clinician, consumer and clinical networks to lead the clinical reform process and will ultimately enable policy makers and service providers to ensure that children seriously injured in Australia have the best opportunity for survival, improved functional outcome and long-term quality of life.

Diagnosis and treatment of rare complications of pelvic fractures

PurposeTo enhance the awareness of rare complications of pelvic fracture and describe the correct diagnosis and effective treatment. MethodsA total of 188 cases of pelvic fractures were retrospectively reviewed, and four patients who suffered from four types of rare pelvic fracture complications were described, namely ureteral obstruction caused by retroperitoneal hematoma-induced abdominal compartment syndrome (ACS), bowel entrapment, external iliac artery injury, and open scrotal sac injury. ResultsWe demonstrated that combined measures should be employed to prevent the occurrence of ACS following major pelvic fractures. Ureteral catheter support may be a good option at an early stage when ACS occurred. Contrasted computed tomography examination and sufficient awareness are keys to a correct diagnosis of bowel entrapment following pelvic fractures. Recognition of risk factors, early diagnosis, and prompt treatment of suspected injury of the external iliac artery are keys to patient survival and to avoid limb loss. Scrotal and/or testicular injury complicated by pelvic fractures should be carefully treated to maintain normal gonad function. Additionally, establishment of a sophisticated trauma care system and multi-disciplinary coordination are important for correct diagnosis and treatment of rare complications in pelvic fractures. ConclusionsRare complications of pelvic fractures are difficult to diagnose and negatively impact outcome. Recognition of risk factors and sufficient awareness are essential for correct diagnosis and prompt treatment.

Diagnosis and treatment of rare complications of pelvic fractures

PurposeTo enhance the awareness of rare complications of pelvic fracture and describe the correct diagnosis and effective treatment. MethodsA total of 188 cases of pelvic fractures were retrospectively reviewed, and four patients who suffered from four types of rare pelvic fracture complications were described, namely ureteral obstruction caused by retroperitoneal hematoma-induced abdominal compartment syndrome (ACS), bowel entrapment, external iliac artery injury, and open scrotal sac injury. ResultsWe demonstrated that combined measures should be employed to prevent the occurrence of ACS following major pelvic fractures. Ureteral catheter support may be a good option at an early stage when ACS occurred. Contrasted computed tomography examination and sufficient awareness are keys to a correct diagnosis of bowel entrapment following pelvic fractures. Recognition of risk factors, early diagnosis, and prompt treatment of suspected injury of the external iliac artery are keys to patient survival and to avoid limb loss. Scrotal and/or testicular injury complicated by pelvic fractures should be carefully treated to maintain normal gonad function. Additionally, establishment of a sophisticated trauma care system and multi-disciplinary coordination are important for correct diagnosis and treatment of rare complications in pelvic fractures. ConclusionsRare complications of pelvic fractures are difficult to diagnose and negatively impact outcome. Recognition of risk factors and sufficient awareness are essential for correct diagnosis and prompt treatment.

Surveillance and Data Capture to Assess Trauma Care Capacity in Low- and Middle-Income Countries.

WecommendStewartetal1on their article regarding their longitudinal capacity assessment of the progress in trauma service availability during the last decade inGhana and their recognition of the need for expanding the evidence base for trauma care capacity in lowand middle-income countries. The successes in improving in-hospital capacity such as infrastructure (eg, blood bank), equipment (eg, chest tubes,ventilator), andservices (eg, skin grafting, neurosurgery) are part of broader needed efforts for capacity development of a complex, multicomponent, interconnected, and evolving trauma care delivery system. Remaining gaps in process evaluation (eg, prevention, prehospital triage,mobile emergency services, definitivehospital care, workforce distribution, long-term rehabilitation, transfer protocols and criteria, communication, and workflow) as well as injury and outcome surveillance present ongoing opportunities for collaboration and building to overcome present barriers in the delivery of trauma care. These summative factors arenecessary components for accurate and reliable appraisal of a country’s trauma care capacity. Moreover, the implementation of a formal injury surveillance mechanismwould enable the collectionof reliable injurydata for problem assessment and determination of whether advances have been made regarding quality and process improvement. Establishing monitoring mechanisms that provide country-specific injury andoutcomedatawill enable the accurate characterization of persistent deficits in trauma care capacity that may then more effectively inform policy making. Therefore, adoption of a systems-based approach and a broadening of the context-specific knowledgebase are essential to trauma care capacity development. In short, we need timely, accurate, and available data on the occurrence of injuries and related deaths; once these data have been collected and outcomes have been reviewed, steps can bemade toward applied data2—targeted, sustainable, and costeffective strengthening of trauma care services in already resource-poor settings. A recent study demonstrating a largely unchanged preponderance of prehospital deaths (76%) in Ghana compared with adecadeearlier (80%)3 seems tounderscore the conceivable impact that prioritizationof strategic interventions at the level of prehospital triage and transport could have. As other sectors such as maternal and child health recognize the need for such monitoring and evaluation, even as part of the MillenniumDevelopment Goal Acceleration Framework,4 hopefully lessons learned can be transferred and applied to Ghana’s trauma care system.

Serial Assessment of Trauma Care Capacity in Ghana in 2004 and 2014

Trauma care capacity assessments in developing countries have generated evidence to support advocacy, detailed baseline capabilities, and informed targeted interventions. However, serial assessments to determine the effect of capacity improvements or changes over time have rarely been performed. To compare the availability of trauma care resources in Ghana between 2004 and 2014 to assess the effects of a decade of change in the trauma care landscape and derive recommendations for improvements. Capacity assessments were performed using direct inspection and structured interviews derived from the World Health Organization's Guidelines for Essential Trauma Care. In Ghana, 10 hospitals in 2004 and 32 hospitals in 2014 were purposively sampled to represent those most likely to care for injuries. Clinical staff, administrators, logistic/procurement officers, and technicians/biomedical engineers who interacted, directly or indirectly, with trauma care resources were interviewed at each hospital. Availability of items for trauma care was rated from 0 (complete absence) to 3 (fully available). Factors contributing to deficiency in 2014 were determined for items rated lower than 3. Each item rated lower than 3 at a specific hospital was defined as a hospital-item deficiency. Scores for total number of hospital-item deficiencies were derived for each contributing factor. There were significant improvements in mean ratings for trauma care resources: district-level (smaller) hospitals had a mean rating of 0.8 for all items in 2004 vs 1.3 in 2014 (P = .002); regional (larger) hospitals had a mean rating of 1.1 in 2004 vs 1.4 in 2014 (P = .01). However, a number of critical deficiencies remain (eg, chest tubes, diagnostics, and orthopedic and neurosurgical care; mean ratings ≤ 2). Leading contributing factors were item absence (503 hospital-item deficiencies), lack of training (335 hospital-item deficiencies), and stockout of consumables (137 hospital-item deficiencies). There has been significant improvement in trauma care capacity during the past decade in Ghana; however, critical deficiencies remain and require urgent redress to avert preventable death and disability. Serial capacity assessment is a valuable tool for monitoring efforts to strengthen trauma care systems, identifying what has been successful, and highlighting needs.

Proposal for stabilization of regional trauma centers in Korea

From 2011 to 2016, 16 regional trauma centers were designated throughout the country and 9 of the 16 centers have been operating their own trauma facilities. At present, there are some differences in treatment experiences and levels according to the type and size of the trauma centers. Treating the trauma system as a part of emergency medical service, while the field of severe trauma is clearly different from the rest of emergency medical service in particular, has become a serious problem in Korea. First of all, the role of trauma centers should have been established before they are added to the trauma care system. Beyond that, manpower is the most important factor in building a trauma center. Pusan National University Hospital offers the ideal environment for a study on the relationship between trauma centers and emergency centers. Pusan National University Hospital has 2 independent emergency rooms: one each in the trauma center and emergency center. Therefore, it is possible to compare the outcomes of 2 different emergency rooms and identify the proportion of the trauma population who is transferred from the emergency center to the trauma center due to trauma severity index. Ultimately, the government and individual hospitals must support personnel in each trauma centers administratively and financially to sustain trauma centers over the long term. The purpose of this proposal is to suggest some resolutions to the problems associated with the trauma care system in Korea.

The study of abdominal trauma: non operative and operative intervention and their outcome

Background: The aim was to study the cases of abdominal trauma in context of surgical intervention and criteria for non-operative and operative management, post-operative morbidity, mortality and final outcome. Methods: The study of 50 cases of abdominal trauma, including blunt as well as penetrating trauma was conducted prospectively during the period of 23 months (January 2010 to November 2011). Patients of all age and sex who were admitted in our department after abdominal trauma were potential candidate for enrolment in this study and study was done in context to fulfill our aim. Results: In our study, 4 (8%) patients had undergone conservative management while 46 (92%) patients were managed by operative intervention. Amongst the surgical procedures drainage of haemoperitoneum and haemostasis (n = 20, 43.47%) is commonly done procedure for abdominal trauma involving solid organs especially liver. However some splenic injury may warrant removal of spleen (n = 10, 21.79%). In small bowel perforation primary repair (n = 8, 17.39%) is the choice of procedure however resection anastomosis (n = 4, 08.69%) is necessary if multiple perforations are present in small segment. Post-operative recovery in this study was generally good with rate of complication as 8% (n = 4) and most of the complications were wound related (n = 04, 08%). we have observed mortality rate of 8% (n = 04) and persistent shock and haemorrhage (n = 3, 75%) is the most common cause of death in our study. The reason was extensive polytrauma involving massive injuries of spleen, liver, pancreas and kidney associated with thoracic injuries, orthopaedic injuries and cranio-cerebral injuries. The average hospital stay in our study was 9.26 days. Out of 50 abdominal trauma patients 46 (92%) has survived and shown good prognosis on follow ups. These data suggests that good outcome can be achieved if proper evaluation done and timely definitive treatment is given to the trauma victims. Conclusions: From our study we can conclude that for “optimum outcome” of abdominal trauma through timely definitive treatment is of prime importance. Establishment of dedicated and efficient trauma care system is mandatory to achieve these goals in abdominal trauma management.

Abdominal injuries in communal crises: The Jos experience.

Background:Abdominal injuries contribute significantly to battlefield trauma morbidity and mortality. This study sought to determine the incidence, demographics, clinical features, spectrum, severity, management, and outcome of abdominal trauma during a civilian conflict.Materials and Methods:A prospective analysis of patients treated for abdominal trauma during the Jos civil crises between December 2010 and May 2012 at the Jos University Teaching Hospital.Results:A total of 109 victims of communal conflicts with abdominal injuries were managed during the study period with 89 (81.7%) males and 20 (18.3%) females representing about 12.2% of the total 897 combat related injuries. The peak age incidence was between 21 and 40 years (range: 3–71 years). The most frequently injured intra-abdominal organs were the small intestine 69 (63.3%), colon 48 (44%), and liver 41 (37.6%). Forty-four (40.4%) patients had extra-abdominal injuries involving the chest in 17 (15.6%), musculoskeletal 12 (11%), and the head in 9 (8.3%). The most prevalent weapon injuries were gunshot 76 (69.7%), explosives 12 (11%), stab injuries 11 (10.1%), and blunt abdominal trauma 10 (9.2%). The injury severity score varied from 8 to 52 (mean: 20.8) with a fatality rate of 11 (10.1%) and morbidity rate of 29 (26.6%). Presence of irreversible shock, 3 or more injured intra-abdominal organs, severe head injuries, and delayed presentation were the main factors associated with mortality.Conclusion:Abdominal trauma is major life-threatening injuries during conflicts. Substantial mortality occurred with loss of nearly one in every 10 hospitalized victims despite aggressive emergency room resuscitation. The resources expenditure, propensity for death and expediency of timing reinforce the need for early access to the wounded in a concerted trauma care systems.

The Influence of How the Trauma Care System Is Applied at the Trauma Center: The Initial Experience at Single Trauma Center

The Influence of How the Trauma Care System Is Applied at the Trauma Center: The Initial Experience at Single Trauma Center

Fall Injuries in Nepal: A Countrywide Population-based Survey

BackgroundAn estimated 424,000 fatal falls occur globally each year, making falls the second leading cause of unintentional injury-related deaths after road traffic injuries. More than 80% of fall-related fatalities occur in low- and middle-income countries. Data from low-income South Asian countries like Nepal are lacking, particularly at the population level. The aim of this study was to provide an estimate of fall-injury prevalence and the number of fall injury-related deaths countrywide in Nepal and to describe the epidemiology of fall injuries in Nepal at the community level. MethodsA countrywide cross-sectional study was performed in 15 of the 75 districts in Nepal using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool. The SOSAS survey gathers data in 2 sections: demographic data, including the household’s access to health care and recent deaths in the household, and assessment of a representative spectrum of surgical conditions, including injuries. Data was collected regarding an individuals’ experience of injury including road traffic injuries, falls, penetrating trauma, and burns. Data included anatomic location, timing of injury, and whether health care was sought. If health care was not sought, the reason for barrier to care was included. Descriptive statistics were used to analyze the data. ResultsOf 2695 individuals from 1350 households interviewed, 141 reported injuries secondary to falls (5.2%; 95% confidence interval [CI], 4.4%–6.1%), with a mean age of 30.7 years; 58% were male. Falls represented 37.2% of total injuries (n = 379) reported (95% CI, 32.3%–42.3%). Twelve individuals who suffered from a fall injury were unable to access surgical care (8.5%; 95% CI, 4.5%–14.4%). Reasons for barrier to care included no money for health care (n = 3), facility/personnel not available (n = 7), and fear/no trust (n = 2).Of the 80 recent deaths reported, 7 were due to fall injury (8.8%; 95% CI, 3.6%–17.2%), and patients had a mean age of 46 years (SD 22.8). Surgical care was not delivered to those who died for the following reasons: no time (n = 4), facility/personnel not available (n = 1), fear/no trust (n = 1), and no need (n = 1). ConclusionThe Nepal SOSAS study provides countrywide, population-based data on fall-injury prevalence in Nepal and has identified falls as a crucial public health concern. These data highlight persistent barriers to access to care for the injured and the need to improve trauma care systems in developing countries such as Nepal.

Practice of primary trauma care training system for undergraduate teaching reform in anes-the-siology

The teaching team of undergraduates of anesthesiology in Anhui Medical University applied the primary trauma care system of encourage, heuristic teaching and practical teaching to further deepen the educational reform and improve teaching quality for undergraduate education. They designed the diversified section such as drills, discussion, teaching, questions, feedback and so on, implemented the simulation training of anesthesia crisis management skills and completed the feedback evaluation of comprehensive ability before and after the teaching, and then achieved the effect of improving the actual operation ability and clinical thinking capacity of students. So it is a good method and worth extending. Key words: Teaching reform; Teaching quality; Primary trauma care; Heuristic teaching

Reported traffic injuries during a pilot of injury surveillance system in Kingdom of Saudi Arabia

Road traffic injuries are second leading cause of mortality in hospitals of Ministry of Health (MOH) – Kingdom of Saudi Arabia (KSA) (1), costing billions of Saudi Riyals annually (2). The Injury &amp; Accidents Prevention Program in MOH, realizing the dearth of data about injuries, designed a uniform Injury Surveillance System in 2013, with assistance of the World Health Organization (WHO) and in collaboration with Ministry of Interior and Red Crescent. The Injury Surveillance System aimed to gather regular ongoing information for prevention and control of injuries and efficient use of resources. The pilot phase involved a multistage stratified random sample, where half of 20 health regions were selected in first stage and 14 health facilities from each region in second stage stratified by type and level of facility. A minimum of two physicians from each selected health facility were trained on the predesigned tool, adopted and modified from WHO-CDC Guidelines (3), before the start of data collection. The data on the prescribed form was collected at the healthcare facilities and communicated through Regional Coordinator to the Injury &amp; Accident Prevention Program in MOH on regularly basis for entry and analysis. Injuries were third highest cases (15%) after falls (31%) and blunt force (20%) among the 10,008 reported cases. About 32% of drivers were reported to be over-speeding; in 13.7%, condition of vehicle was flawed; and some 13 % crashes seemingly occurred due to bad weather. The pilot identified that data from health facilities is very useful for decision making. Surveillance system is efficient and has the capacity to capture injury cases reporting to health facilities, but necessitates the inclusion of nurses and paramedics besides the attending physicians, to distribute the work load. Robust functioning of the system would require more ownership of the regional offices, besides continuous commitment of senior management at MOH.

Designing trauma registry system using a logical framework approach

While trauma registries provide the mechanisms to collect comprehensive, timely and accurate data related to the injuries and evaluate trauma care systems, they have not been established in most developing countries. On the other hand, in complex projects that have large aims, a logical framework approach (LFA) can help summarize and describe the multiple branches of the project systematically, and elucidate the main goals, extensive objectives, activities and expected outcomes. Therefore a LFA can be used to design and guide trauma registry project management, to integrate the cultural, clinical and capacity variations among countries; and to ensure early alignment of the project’s design and evaluation.

Trauma research in Qatar: a literature review and discussion of progress after establishment of a trauma research centre.

A structured research programme is one of the main pillars of a trauma care system. Despite the high rate of injury-related mortalities, especially road traffic accidents, in Qatar, little consideration has been given to research in trauma. This review aimed to analyse research publications on the subject of trauma published from Qatar and to discuss the progress of clinical research in Qatar and the Gulf Cooperation Council countries with special emphasis on trauma research. A literature search using PubMed and Google Scholar search engines located 757 English-language articles within the fields of internal medicine, surgery and trauma originating from Qatar between the years 1993 and 2013. A steep increase in the number of trauma publications since 2010 could be linked to the setting up of a trauma research centre in Qatar in 2011. We believe that establishing a research unit has made a major impact on research productivity, which ultimately benefits health care.

Preventable transfers in pediatric trauma: A 10-year experience at a level I pediatric trauma center

BackgroundInjured children are often treated at one facility then transferred to another that specializes in pediatric trauma care. The purpose of this study was to identify and characterize potentially preventable transfers (PT) to a freestanding level-I pediatric trauma center. MethodsChildren with traumatic injuries transferred between 2003 and 2013 were retrospectively analyzed. A PT was defined as a child who was discharged within 36hours of arrival without surgical intervention or advanced imaging studies. ResultsDuring this period, 6380 children were transferred, with head injury being the most common injury. 61% had CT imaging performed before transfer. The mean age was 6.9years, mean injury severity score (ISS) 10.4, and median transfer distance 37miles. 27% of these transfers were classified as PT. Air transport was used in 15% at mean charge of $18,574. 29% were discharged from the emergency department. When compared, PTs were younger (6.0 vs. 7.2years, p<0.001), with lower median ISS (5 vs. 9, p<0.001), shorter median LOS (15 vs. 43.6hours, p<0.001), and less PICU admissions (6% vs. 34%, p<0.001). ConclusionA significant number of pediatric trauma transfers can be classified as preventable. Reducing preventable transfers could offer opportunities for improving value in a trauma care system.

Mortality after acute trauma: Progressive decreasing rather than a trimodal distribution

ObjectiveTo characterize the pattern of mortality for major trauma patients. MethodsRetrospective study of major trauma patients admitted in a Level I trauma center, during the latest 5 years was conducted. Selection criteria included (1) injury severity score (ISS) > 16 and (2) in-hospital death. ResultsThere were 47 patients, with a mean age of 37.2 ± 19.9 years. The mean ISS was 37.6 ± 12.7 and the mean revised trauma score was 4.5 ± 2.2. Computed tomography scan on admission was done in 18 (38%) patients, 20% being hemodynamically unstable (P = 0.001). The diagnostic peritoneal lavage was performed in 10 (22%) cases, 23.3% being hemodynamically unstable (P > 0.05). The mean number of intraabdominal injuries was 3. The need for transfusion was 8.2 ± 6.7 units. The mean time to death was 4.9 days. Early death was secondary to hemorrhagic shock (HS) (ISS = 35.2 ± 15.9, P > 0.05, revised trauma score = 3.74 ± 2.70, P = 0.008) and multiple organ failure (ISS = 36.6 ± 14.1, P > 0.05, revised trauma score = 5.94 ± 1.34, P = 0.008) was the cause for later mortality. Combined liver and splenic injuries were found in 13 cases, with secondary death through HS in 5 and multiple system organ failure (MSOF) in 8 cases. Combined liver, splenic and kidney injuries were found in 5 cases (cause of death: HS 2 cases, MSOF 3 cases). A total of 14 patients had associated head, thorax, abdomen and extremity trauma (cause of death: cerebral trauma 6 cases, MSOF 5 cases, HS 2 cases); 5 patients had thorax and abdomen trauma (cause of death: HS 5 cases); 8 patients had thorax, abdomen and extremity trauma (cause of death: MSOF 5 cases, HS 3 cases); 3 patients had abdomen and extremity trauma (HS 2 cases). We did not find a trimodal time distribution for mortality. ConclusionsThe trimodal time distribution of mortality remains a milestone in trauma education and research. Nevertheless, it must be questioned in the modern and very efficient trauma systems, but still very actual for developing trauma care systems. In conclusion, the pattern of mortality due to major trauma seems decreasing continuously with time rather than presenting high peaks of frequency at some moments.

An interview of trauma registry custodians to determine lessons learnt.

The international burden of injury is an increasing concern in global healthcare. Developed trauma care systems have reduced death and disability following injury. The ideal platform for surveillance and clinical governance in trauma care quality improvement is the trauma registry. There is a great disparity in the prevalence of active trauma registries between developed and developing countries. More detailed information on lessons learnt would guide those settings, hospitals and regions looking to establish a sustainable trauma registry. The aim of this study was to explore the experiences and perceptions of trauma registry custodians regarding the development of successful and sustainable trauma registries. This was a qualitative study using semi-structured interviews of trauma registry custodians. Trauma registries were selected from a wide range of jurisdictions, including single hospital and multi-hospital registries, based in developed and developing countries. Interview transcripts were analysed using thematic analysis; recurrent themes were identified, and a coding frame developed. Quotes were identified to illustrate the themes in the participants' own words. Twenty-seven interviews, representing 29 registries, were completed. Fourteen of the source registries were based in developed countries (6 single hospital, 8 multi-hospital) and 15 were based in developing countries (9 single hospital, 6 multi-hospital). The analysis generated 15 themes covering resources, data and strategies. The themes dealing with resources were: funding, staffing, information technology and tools for guidance. The themes dealing with data were: data quality, simplicity, injury coding and data utilisation. The themes dealing with strategies were: having a local champion and a clear purpose, stakeholder buy-in, governance, integration, getting started and persistence. For developing countries, the need for a local champion, dealing with data quality through prospective data collection, integration into local resources and keeping it simple were considered particularly important. The general consensus was that, for a trauma registry to be successful, in addition to adequate funding and trained staff, it needs to be led by a local champion with engagement of key local stakeholders. It should have a clear purpose, pay close attention to data quality and ensure that the data is well used.