Anita West

A major trauma centre is a specialty hospital not a hospital of specialties

High estimates of preventable death rates have renewed the impetus for national regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance improvement programme was hypothesized to have resulted in improved outcomes for severely injured patients.

The Impact of a Pan-regional Inclusive Trauma System on Quality of Care.

Objectives: To evaluate the impact of the implementation of an inclusive pan-regional trauma system on quality of care. Background: Inclusive trauma systems ensure access to quality injury care for a designated population. The 2007 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) found quality deficits for 60% of severely injured patients. In 2010, London implemented an inclusive trauma system. This represented an opportunity to evaluate the impact of a pan-regional trauma system on quality of care. Methods: Evaluation of the London Trauma System (ELoTS) utilized the NCEPOD study core methodology. Severely injured patients were identified prospectively over a 3-month period. Data were collected from prehospital care to 72 h following admission or death. Quality, processes of care, and outcome were assessed by expert review using NCEPOD criteria. Results: Three hundred and twenty one severely injured patients were included of which 84% were taken directly to a major trauma center, in contrast to 16% in NCEPOD. Overall quality improved with the proportion of patients receiving “good overall care” increasing significantly [NCEPOD: 48% vs ALL-ELoTS: 69%, RR 1.3 (1.2 to 1.4), P < 0.01], primarily through improvements in organizational processes rather than clinical care. Improved quality was associated with increased early survival, with the greatest benefit for critically injured patients [NCEPOD: 31% vs All-ELoTS 11%, RR 0.37 (0.33 to 0.99), P = 0.04]. Conclusions: Inclusive trauma systems deliver quality and process improvements, primarily through organizational change. Most improvements were seen in major trauma centers; however, systems implementation did not automatically lead to a reduction in clinical deficits in care.

Major trauma and urban cyclists: physiological status and injury profile

Introduction Pedal cycling in cities has the potential to deliver significant health and economic benefits for individuals and society. Safety is the main concern for potential cyclists although the statistical risk of death is low. Little is known about the severity of injuries sustained by city cyclists and their outcome. Aim The aim of this study was to characterise the physiological status and injury profile of cyclists admitted to our urban major trauma centre (MTC). Methods Database analysis of cyclist casualties between 2004 and 2009. The physiological parameters examined were admission systolic blood pressure (SBP), admission base deficit and prehospital Glasgow Coma Scale. Results 265 cyclists required full trauma-team activation. 82% were injured during a collision with a motorised vehicle. The majority (73%) had collided with a car or a heavy goods vehicle (HGV). These casualties formed the cohort for further analysis. Cyclists who collided with an HGV were more severely injured and had a higher mortality rate. Low SBP and high base deficit indicate that haemorrhagic shock is a key feature of HGV casualties. Conclusion Collision with any vehicle can result in death or serious injury to a cyclist. Injury patterns vary with the type of vehicle involved. HGVs were associated with severe injuries and death as a result of uncontrollable haemorrhage. Awareness of this injury profile may aid prehospital management and expedite transfer to MTC care. Rapid haemorrhage control may salvage some, but not all, of these casualties. The need for continued collision prevention strategies and long-term outcome data collection in trauma patients is highlighted.

Can residents be effective trauma team leaders in a major trauma centre

OBJECTIVE The overall objective of this study was to compare senior Emergency Department (ED) trainees (residents) with consultant trauma team leaders, assessing their influence on trauma team performance and patient outcomes. We aimed to identify the effect of seniority of leader on time-based performance measures and clinical outcomes. METHODS This retrospective study of prospectively collected data was conducted in an urban Major Trauma Centre which has a well-established trauma team. For the period covered by this study the trauma team was led by either an ED consultant or specialist registrar having completed a local trauma team leader development programme. Data from all adult trauma team activations for seriously injured trauma patients (ISS - Injury Severity Score >15) presenting between 1st January 2008 and 31st October 2009 were included. Performance measures included time to FAST, time to CT scan and time to haemorrhage control. Patient outcomes were mortality, critical care and hospital length of stay. RESULTS There were 579 patients seriously injured in the study period. Trainees led 126 (22%) of the trauma teams. Significant differences in times to diagnostics or haemorrhage control between trainees and consultants were only seen in patients presenting with shock. Compared with trainees, consultant team leaders were significantly more likely to achieve targets for diagnostic imaging (FAST <15 min: consultants 97% vs. 33% trainees, p<0.01; CT scan <60 min: 76% vs. 50%, p<0.01) and haemorrhage control (surgery or angiography <60 min: 82% vs. 54%, p<0.001). There was no significant difference in overall mortality between consultants and trainees (consultants 25% vs. trainees 27%, p 1.00). Critical care length of stay was also the same for both (consultants median 5 days vs. trainees median 5 days). CONCLUSIONS Consultant team leaders improve team performance, resulting in shorter times to diagnostic imaging, and faster transfer to haemorrhage control. The greatest benefit seems to be for bleeding patients. Clinical outcomes were similar for trainees and consultants in our major trauma centre.

Older people and major trauma

Major traumatic injury is a leading cause of death in younger age groups, but increasingly older people are affected also. Adverse outcomes, both physical and psychological, are associated with injury in the older population. This review aims to locate and describe the evidence relating to older people and major trauma in order to inform policy, practice, research and education. The published research and systematic reviews fall into three main topics: mechanism of traumatic injury in older people, the effects of co-morbidities on older trauma patients and outcomes following serious traumatic injury in older people. The psychological impact of traumatic injury and the resulting functional alteration cannot be underestimated in this group of patients

Acute Kidney Injury in Trauma Patients Admitted to Critical Care: Development and Validation of a Diagnostic Prediction Model

Acute Kidney Injury (AKI) complicating major trauma is associated with increased mortality and morbidity. Traumatic AKI has specific risk factors and predictable time-course facilitating diagnostic modelling. In a single centre, retrospective observational study we developed risk prediction models for AKI after trauma based on data around intensive care admission. Models predicting AKI were developed using data from 830 patients, using data reduction followed by logistic regression, and were independently validated in a further 564 patients. AKI occurred in 163/830 (19.6%) with 42 (5.1%) receiving renal replacement therapy (RRT). First serum creatinine and phosphate, units of blood transfused in first 24 h, age and Charlson score discriminated need for RRT and AKI early after trauma. For RRT c-statistics were good to excellent: development: 0.92 (0.88–0.96), validation: 0.91 (0.86–0.97). Modelling AKI stage 2–3, c-statistics were also good, development: 0.81 (0.75–0.88) and validation: 0.83 (0.74–0.92). The model predicting AKI stage 1–3 performed moderately, development: c-statistic 0.77 (0.72–0.81), validation: 0.70 (0.64–0.77). Despite good discrimination of need for RRT, positive predictive values (PPV) at the optimal cut-off were only 23.0% (13.7–42.7) in development. However, PPV for the alternative endpoint of RRT and/or death improved to 41.2% (34.8–48.1) highlighting death as a clinically relevant endpoint to RRT.

The Trauma Centre: a specialty hospital, not a hospital of specialties

Background Trauma is a leading cause of death and disability in England and Wales, with 16,000 injury deaths per year. High estimates of preventable death rates have renewed the impetus for national regionalisation of major trauma to specialist centres. We hypothesized that the institution of a specialist multidisciplinary trauma service and performance improvement programme had resulted in significant improvements in outcomes in excess of any observed national changes.