Hans Morten Lossius

The Utstein template for uniform reporting of data following major trauma: A joint revision by SCANTEM, TARN, DGU-TR and RITG

BackgroundIn 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases.MethodsOver a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique.ResultsThe expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping.ConclusionThrough a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.

Epidemiology and Contemporary Patterns of Trauma Deaths: Changing Place, Similar Pace, Older Face

AbstractBackgroundThe epidemiology of trauma deaths in Europe is less than well investigated. Thus, our goal was to study the contemporary patterns of trauma deaths within a defined population with an exceptionally high trauma autopsy rate.MethodsThis was a retrospective evaluation of 260 consecutive trauma autopsies for which we collected demographic, pre-hospital and in-hospital data. Patients were analyzed for injury severity by standard scoring systems (Abbreviated Injury Scale [AIS], Revised Trauma Score [RTS], and Injury Severity Score [ISS]), and the Trauma and Injury Severity Scale [TRISS] methodology.ResultsThe fatal trauma incidence was 10.0 per 100,000 inhabitants (17.4 per 100,000 age-adjusted ≥ 55 years). Blunt mechanism (87%), male gender (75%), and pre-hospital deaths (52%) predominated. Median ISS was 38 (range: 4–75). Younger patients (<55 years) who died in the hospital were more often hypotensive (SBP < 90 mmHg; p = 0.001), in respiratory distress (RR < 10/min, or > 29/min; p < 0.0001), and had deranged neurology on admission (Glasgow Coma Score [GCS] ≤ 8; p < 0.0001), compared to those ≥ 55 years. Causes of death were central nervous system (CNS) injuries (67%), exsanguination (25%), and multiorgan failure (8%). The temporal death distribution is model-dependent and can be visualized in unimodal, bimodal, or trimodal patterns. Age increased (r = 0.43) and ISS decreased (r = –0.52) with longer time from injury to death (p < 0.001). Mean age of the trauma patients who died increased by almost a decade during the study period (from mean 41.7 ± 24.2 years to mean 50.5 ± 25.4 years; p = 0.04). The pre-hospital:in-hospital death ratio shifted from 1.5 to 0.75 (p < 0.007).ConclusionsWhile pre-hospital and early deaths still predominate, an increasing proportion succumb after arrival in hospital. Focus on injury prevention is imperative, particularly for brain injuries. Although hemorrhage and multiorgan failure deaths have decreased, they do still occur. Redirected attention and focus on the geriatric trauma population is mandated.

Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers

IntroductionPre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.MethodsWe conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.ResultsFrom 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).ConclusionsThis comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.

Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region.

AIM OF THE STUDY Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates. METHODS We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001-2005 vs. 2006-2008). RESULTS We found no significant differences between the two time periods for mean age (71 and 70 years (p=0.309)), sex distribution (males 70% and 71% (p=0.708)), location of the OHCA (home 64% and 63% (p=0.732)), proportion of shockable rhythms (44% and 47% (p=0.261)) and rate of return of spontaneous circulation (38% and 43% (p=0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p<0.0001), as did the overall rate of survival to discharge from 18% to 25% (p=0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p=0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p=0.0105). CONCLUSION Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival.

Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained?

Background:  The benefit of prehospital advanced life support (ALS) is disputed, as is the prehospital use of specially trained, hospital‐based physicians. The purpose of the study was to assess the health benefit from an anesthesiologist‐manned prehospital emergency medical service (EMS), and to separate the benefit of the anesthesiologist from that of rapid transport.

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.

The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration

BackgroundPhysician-manned emergency medical teams supplement other emergency medical services in some countries. These teams are often selectively deployed to patients who are considered likely to require critical care treatment in the pre-hospital phase. The evidence base for guidelines for pre-hospital triage and immediate medical care is often poor. We used a recognised consensus methodology to define key priority areas for research within the subfield of physician-provided pre-hospital critical care.MethodsA European expert panel participated in a consensus process based upon a four-stage modified nominal group technique that included a consensus meeting.ResultsThe expert panel concluded that the five most important areas for further research in the field of physician-based pre-hospital critical care were the following: Appropriate staffing and training in pre-hospital critical care and the effect on outcomes, advanced airway management in pre-hospital care, definition of time windows for key critical interventions which are indicated in the pre-hospital phase of care, the role of pre-hospital ultrasound and dispatch criteria for pre-hospital critical care services.ConclusionA modified nominal group technique was successfully used by a European expert group to reach consensus on the most important research priorities in physician-provided pre-hospital critical care.

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.

A consensus-based template for uniform reporting of data from pre-hospital advanced airway management

BackgroundAdvanced airway management is a critical intervention that can harm the patient if performed poorly. The available literature on this subject is rich, but it is difficult to interpret due to a huge variability and poor definitions. Several initiatives from large organisations concerned with airway management have recently propagated the need for guidelines and standards in pre-hospital airway management. Following the path of other initiatives to establish templates for uniform data reporting, like the many Utstein-style templates, we initiated and carried out a structured consensus process with international experts to establish a set of core data points to be documented and reported in cases of advanced pre-hospital airway management.MethodsA four-step modified nominal group technique process was employed.ResultsThe inclusion criterion for the template was defined as any patient for whom the insertion of an advanced airway device or ventilation was attempted. The data points were divided into three groups based on their relationship to the intervention, including system-, patient-, and post-intervention variables, and the expert group agreed on a total of 23 core data points. Additionally, the group defined 19 optional variables for which a consensus could not be achieved or the data were considered as valuable but not essential.ConclusionWe successfully developed an Utstein-style template for documenting and reporting pre-hospital airway management. The core dataset for this template should be included in future studies on pre-hospital airway management to produce comparable data across systems and patient populations and will be implemented in systems that are influenced by the expert panel.

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.