Andreas J. Krüger

Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines

BackgroundField triage is important for regional trauma systems providing high sensitivity to avoid that severely injured are deprived access to trauma team resuscitation (undertriage), yet high specificity to avoid resource over-utilization (overtriage). Previous informal trauma team activation (TTA) at Ulleval University Hospital (UUH) caused imprecise triage. We have analyzed triage precision after introduction of TTA guidelines.MethodsRetrospective analysis of 7 years (2001–07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity).ResultsOf the 4 659 patients included in the study, 2 221 (48%) were severely injured. TTA occurred 4 440 times, only 2 002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1 508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics.Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6–3.4, p < 0.001) compared to those correctly triaged to TTA.ConclusionTriage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased risk of dying.

Trauma systems and early management of severe injuries in Scandinavia: Review of the current state

INTRODUCTION Scandinavian countries face common challenges in trauma care. It has been suggested that Scandinavian trauma system development is immature compared to that of other regions. We wanted to assess the current status of Scandinavian trauma management and system development. METHODS An extensive search of the Medline/Pubmed, EMBASE and SweMed+ databases was conducted. Wide coverage was prioritized over systematic search strategies. Scandinavian publications from the last decade pertaining to trauma epidemiology, trauma systems and early trauma management were included. RESULTS The incidence of severe injury ranged from 30 to 52 per 100,000 inhabitants annually, with about 90% due to blunt trauma. Parts of Scandinavia are sparsely populated with long pre-hospital distances. In accordance with other European countries, pre-hospital physicians are widely employed and studies indicate that this practice imparts a survival benefit to trauma patients. More than 200 Scandinavian hospitals receive injured patients, increasingly via multidisciplinary trauma teams. Challenges remain concerning pre-hospital identification of the severely injured. Improved triage allows for a better match between patient needs and the level of resources available. Trauma management is threatened by the increasing sub-specialisation of professions and institutions. Scandinavian research is leading the development of team- and simulation-based trauma training. Several pan-Scandinavian efforts have facilitated research and provided guidelines for clinical management. CONCLUSION Scandinavian trauma research is characterised by an active collaboration across countries. The current challenges require a focus on the role of traumatology within an increasingly fragmented health care system. Regional networks of predictable and accountable pre- and in-hospital resources are needed for efficient trauma systems. Successful development requires both novel research and scientific assessment of imported principles of trauma care.

Scandinavian pre-hospital physician-manned Emergency Medical Services—Same concept across borders?

BACKGROUND In Scandinavia, scattered populations and challenging geographical and climatic conditions necessitate highly advanced medical treatment by qualified pre-hospital services. Just like every other part of the health care system, the specialized pre-hospital EMS should aim to optimize its resource use, and critically review as well as continuously assess the quality of its practices. This study aims to provide a comprehensive profile of the pre-hospital, physician-manned EMS in the Scandinavian countries. METHODS The study was designed as a web-based cross-sectional survey. All specialized pre-hospital, physician-manned services in Scandinavia were invited, and data concerning organization, qualification and medical activity in 2007 were mapped. RESULTS Of the 41 invited services, 37 responded, which corresponds to a response rate of 90% (Finland 86%, Sweden 83%, Denmark 92%, Norway 94%). Organization and education are basically identical. All services provide advanced life support and have short response intervals. Services take care of a variety of patient groups, and skills are needed not only in procedures, but also in diagnostics, logistics, intensive care, and mass-casualty management. Consistent and detailed medical documentation was often lacking, however. Differences are mainly related to time variables, patient volume, and service area. The Danish and Swedish services have higher volumes of patient care encounters while the Finnish and Norwegian ones provide a wider variety of medical services. CONCLUSIONS This survey documented several significant similarities among pre-hospital physician-staffed EMS systems in Scandinavia. Although medical data registration is currently under-developed, Scandinavian physician-manned EMS is a feasible arena for future multi-centre research.

Abbreviated Injury Scale: Not a reliable basis for summation of injury severity in trauma facilities?

BACKGROUND Injury severity is most frequently classified using the Abbreviated Injury Scale (AIS) as a basis for the Injury Severity Score (ISS) and the New Injury Severity Score (NISS), which are used for assessment of overall injury severity in the multiply injured patient and in outcome prediction. European trauma registries recommended the AIS 2008 edition, but the levels of inter-rater agreement and reliability of ISS and NISS, associated with its use, have not been reported. METHODS Nineteen Norwegian AIS-certified trauma registry coders were invited to score 50 real, anonymised patient medical records using AIS 2008. Rater agreements for ISS and NISS were analysed using Bland-Altman plots with 95% limits of agreement (LoA). A clinically acceptable LoA range was set at ± 9 units. Reliability was analysed using a two-way mixed model intraclass correlation coefficient (ICC) statistics with corresponding 95% confidence intervals (CI) and hierarchical agglomerative clustering. RESULTS Ten coders submitted their coding results. Of their AIS codes, 2189 (61.5%) agreed with a reference standard, 1187 (31.1%) real injuries were missed, and 392 non-existing injuries were recorded. All LoAs were wider than the predefined, clinically acceptable limit of ± 9, for both ISS and NISS. The joint ICC (range) between each rater and the reference standard was 0.51 (0.29,0.86) for ISS and 0.51 (0.27,0.78) for NISS. The joint ICC (range) for inter-rater reliability was 0.49 (0.19,0.85) for ISS and 0.49 (0.16,0.82) for NISS. Univariate linear regression analyses indicated a significant relationship between the number of correctly AIS-coded injuries and total number of cases coded during the raters career, but no significant relationship between the rater-against-reference ISS and NISS ICC values and total number of cases coded during the raters career. CONCLUSIONS Based on AIS 2008, ISS and NISS were not reliable for summarising anatomic injury severity in this study. This result indicates a limitation in their use as benchmarking tools for trauma system performance.

Pre-hospital critical care by anaesthesiologist-staffed pre-hospital services in Scandinavia: a prospective population-based study

All Scandinavian countries provide anaesthesiologist‐staffed pre‐hospital services. Little is known of the incidence of critical illness or injury attended by these services. We aimed to investigate anaesthesiologist‐staffed pre‐hospital services in Scandinavia with special emphasis on incidence and severity.

Outcome following physician supervised prehospital resuscitation: a retrospective study

Background Prehospital care provided by specially trained, physician-based emergency services (P-EMS) is an integrated part of the emergency medical systems in many developed countries. To what extent P-EMS increases survival and favourable outcomes is still unclear. The aim of the study was thus to investigate ambulance runs initially assigned ‘life-saving missions’ with emphasis on long-term outcome in patients treated by the Mobile Emergency Care Unit (MECU) in Odense, Denmark Methods All MECU runs are registered in a database by the attending physician, stating, among other parameters, the treatment given, outcome of the treatment and the patients diagnosis. Over a period of 80 months from May 1 2006 to December 31 2012, all missions in which the outcome of the treatment was registered as ‘life saving’ were scrutinised. Initial outcome, level of competence of the caretaker and diagnosis of each patient were manually established in each case in a combined audit of the prehospital database, the discharge summary of the MECU and the medical records from the hospital. Outcome parameters were final outcome, the aetiology of the life-threatening condition and the level of competences necessary to treat the patient. Results Of 25 647 patients treated by the MECU, 701 (2.7%) received prehospital ‘life saving treatment’. In 596 (2.3%) patients this treatment exceeded the competences of the attending emergency medical technician or paramedic. Of these patients, 225 (0.9%) were ultimately discharged to their own home. Conclusions The present study demonstrates that anaesthesiologist administrated prehospital therapy increases the level of treatment modalities leading to an increased survival in relation to a prehospital system consisting of emergency medical technicians and paramedics alone and thus supports the concept of applying specialists in anaesthesiology in the prehospital setting especially when treating patients with cardiac arrest, patients in need of respiratory support and trauma patients.

Noninvasive assessment of hemodynamic variables using near-infrared spectroscopy in patients experiencing cardiogenic shock and individuals undergoing venoarterial extracorporeal membrane oxygenation☆

PURPOSE The relationship between near-infrared spectroscopy cerebral oximetry (CrSO2), peripheral oximetry (PrSO2) and hemodynamic variables is not fully understood. METHODS The relationship between CrSO2/PrSO2 and cardiac index (CI), systemic vascular resistance index (SVRI) and mean arterial pressure (MAP) in patients experiencing cardiogenic shock and those undergoing venoarterial extracorporeal membrane oxygenation (ECMO) was retrospectively analyzed; in patients on ECMO, total circulatory index (TCI) was calculated from the sum of CI and extracorporeal blood flow index. RESULTS In patients experiencing cardiogenic shock (n=10), significant correlations between PrSO2 values and CI (Spearman r=0.81; P<.0001), SVRI (r=-0.45; P<.0001), and MAP (r=0.58; P<.0001) were found. Significant correlations between CrSO2 and CI (r=0.55; P<.0001) and SVRI (r=-0.47; P<.0001), but not MAP, were observed. Linear regression analysis revealed that CI could be calculated using the following equation: CI=PrSO2/24.0. In patients on VA ECMO (n=12), significant correlations were found between PrSO2 and TCI (r=0.68; P<.0001), SVRI (r=-0.47; P<.0001), and MAP (r=0.27; P=.025). Significant correlations were also found between CrSO2 and TCI (r=0.68; P<.0001) and SVRI (r=-0.51; P<.0001), but not MAP. CONCLUSIONS Results of the present study suggest that CrSO2 and PrSO2 in particular can be used for noninvasive estimation and monitoring of global circulatory status in patients experiencing cardiogenic shock and individuals undergoing ECMO.

Developing templates for uniform data documentation and reporting in critical care using a modified nominal group technique

BackgroundClinical practice in trauma and critical care is predominantly derived from quantitative observational cohort studies based on data retrospectively collected from medical records. Such data create uncontrolled bias and influence external and internal validity, thereby hindering systematic reviews. Templates or standards for uniform documenting and scientific reporting may result in high quality and internationally standardised data being collected on a regular basis, enhance large international multi-centre studies, and increase the quality of evidence. Templates or standards may be developed using multidisciplinary expert panel consensus methods.We present three consensus processes aimed at developing templates for documenting and scientific reporting. We discuss the advantages, limitations, and possible future improvements of our method.MethodsThe template preparation was based on expert panel consensus derived through a modified nominal group technique (NGT) method that combined the traditional Delphi method with the traditional NGT method in a four-step process.ResultsStandard templates for documenting and scientific reporting were developed for major trauma, pre-hospital advanced airway handling, and physician-staffed pre-hospital EMS. All templates were published in scientific journals.ConclusionOur modified NGT consensus method can successfully be used to establish templates for reporting trauma and critical care data. When used in a structured manner, the method uses recognised experts to achieve consensus, but based on our experiences, we recommend the consensus process to be followed by feasibility, reliability, and validity testing.

Major incident preparedness and on-site work among Norwegian rescue personnel – a cross-sectional study

BackgroundA major incident has occurred when the number of live casualties, severity, type of incident or location requires extraordinary resources. Major incident management is interdisciplinary and involves triage, treatment and transport of patients. We aimed to investigate experiences within major incident preparedness and management among Norwegian rescue workers.MethodsA questionnaire was answered by 918 rescue workers across Norway. Questions rated from 1 (doesn’t work) to 7 (works excellently) are presented as median and range.ResultsHealth-care personnel constituted 34.1% of the participants, firefighters 54.1% and police 11.8%. Training for major incident response scored 5 (1, 7) among health-care workers and 4 (1, 7) among firefighters and police. Preparedness for major incident response scored 5 (1, 7) for all professions. Interdisciplinary cooperation scored 5 (3, 7) among health-care workers and police and 5 (1, 7) among firefighters. Among health-care workers, 77.5% answered that a system for major-incident triage exists; 56.3% had triage equipment available. The majority – 45.1% of health-care workers, 44.7% of firefighters and 60.4% of police – did not know how long it would take to get emergency stretchers to the scene.ConclusionsRescue personnel find major incident preparedness and on-scene multidisciplinary cooperation to function well. Some shortcomings are reported with regard to systems for major incident triage, tagging equipment for triage and knowledge about access to emergency stretchers.

Trauma systems and early management of severe injuries in scandinavia: review and current status

Scandinavian countries face common challenges in trauma care. There are suggestions that Scandinavian trauma system development is immature compared to other regions. We wanted to assess the current status of Scandinavian trauma management and system development.