Koen W. W. Lansink

Do designated trauma systems improve outcome

Purpose of reviewTrauma systems are introduced world wide with the goal to improve survival and outcome of the injured patient. This review is focused on the influence of trauma systems on the survival and outcome of injured patients. Recent findingsLarge population-based studies have been published over the last 2 years strengthening the hypothesis that trauma systems indeed improve survival rates in injured patients. Mortality was reduced by 15–25% when severely injured patients were treated at a trauma center. Although ‘inclusive’ trauma systems have been advocated since 1991 only recently did the first population-based study prove that ‘inclusive’ trauma systems do better than ‘exclusive’ trauma systems. Because further improvements in survival in mature trauma systems are likely to be small, more focus should be given to quality of life studies, rather than to survival in trauma system evaluation. SummaryTrauma systems indeed improve survival rates in injured patients. Inclusive trauma systems do better than exclusive trauma systems. More attention should be given to quality of outcome.

Accuracy of the field triage protocol in selecting severely injured patients after high energy trauma

BACKGROUND For optimal treatment of trauma patients it is of great importance to identify patients who are at risk for severe injuries. The Dutch field triage protocol for trauma patients, the LPA (National Protocol of Ambulance Services), is designed to get the right patient, in the right time, to the right hospital. Purpose of this study was to determine diagnostic accuracy and compliance of this triage protocol. STUDY DESIGN Triage criteria were categorised into physiological condition (P), mechanism of trauma (M) and injury type (I). A retrospective analysis of prospectively collected data of all high-energy trauma patients from 2008 to 2011 in the region Central Netherlands is performed. Diagnostic parameters (sensitivity, specificity, negative predictive value, positive predictive value) of the field triage protocol for selecting severely injured patients were calculated including rates of under- and overtriage. Undertriage was defined as the proportion of severely injured patients (Injury Severity Score (ISS)≥16) who were transported to a level two or three trauma care centre. Overtriage was defined as the proportion of non-severely injured patients (ISS<16) who were transported to a level one trauma care centre. RESULTS Overall sensitivity and specificity of the field triage protocol was 89.1% (95% confidence interval (CI) 84.4-92.6) and 60.5% (95% CI 57.9-63.1), respectively. The overall rate of undertriage was 10.9% (95%CI 7.4-15.7) and the overall rate of overtriage was 39.5% (95%CI 36.9-42.1). These rates were 16.5% and 37.7%, respectively for patients with M+I-P-. Compliance to the triage protocol for patients with M+I-P- was 78.7%. Furthermore, compliance in patients with either a positive I+ or positive P+ was 91.2%. CONCLUSION The overall rate of undertriage (10.8%) was mainly influenced by a high rate of undertriage in the group of patients with only a positive mechanism criterion, therefore showing low diagnostic accuracy in selecting severely injured patients. As a consequence these patients with severe injury are undetected using the current triage protocol. As it has been shown that severely injured patients have better outcome in level one trauma care centres further optimisation of this protocol aiming at lowering undertriage is therefore essential, preferably without incrementing overtriage too much.

History, development and future of trauma care for multiple injured patients in the Netherlands

IntroductionThe development of trauma systems all over the world resulted in improved outcome for a broad range of trauma victims. In this review, we demonstrate the developments of an inclusive regionalised trauma system in the Netherlands and the subsequent developments in our level one trauma centre and trauma region in comparison.Comparison with other trauma systemsWith the seasoning of the trauma system, further improvements in outcome could be demonstrated, in the region an OR of 0.84 and in the trauma centre an OR of 0.61, in a later comparison over the years another OR 0.74 was noted. In addition, a further diversification of the trauma populations was seen in the various hospitals with different levels, based on a pre-hospital triage system. Torso and multiple injured patients were more seen in the trauma centre and increased to more than 350 patients with an ISS of >15, whereas monotrauma was almost exclusively seen in the level two and three hospitals. The further development of the trauma system is discussed, in which the minimum requirements of the individual trauma surgeon and institution are taken as a guideline.Future, discussion and conclusionBased on these considerations, a further concentration of the most severely injured patients is proposed in a small country as the Netherlands culminating in one trauma centre for the most severely injured patients, combined with an integrated pre-hospital helicopter system, on top of the current good functioning inclusive trauma system. These developments could be a template for further developments of trauma systems in Europe.

Performance of the modified TRISS for evaluating trauma care in subpopulations: A cohort study

INTRODUCTION Previous research showed that there is no agreement on a practically applicable model to use in the evaluation of trauma care. A modification of the Trauma and Injury Severity Score (modified TRISS) is used to evaluate trauma care in the Netherlands. The aim of this study was to evaluate the prognostic ability of the modified TRISS and to determine where this model needs improvement for better survival predictions. METHODS Patients were included if they were registered in the Brabant Trauma Registry from 2010 through 2015. Missing values were imputed according to multiple imputation. Subsets were created based on age, length of stay, type of injury and injury severity. Probability of survival was calculated with the modified TRISS. Discrimination was assessed with the Area Under the Receiver Operating Curve (AUROC). Calibration was studied graphically. RESULTS The AUROC was 0.84 (95% CI: 0.83, 0.85) for the total cohort (N = 69 747) but only 0.53 (95% CI: 0.51, 0.56) for elderly patients with hip fracture. Overall, calibration of the modified TRISS was adequate for the total cohort, with an overestimation for elderly patients and an underestimation for patients without brain injury. CONCLUSIONS Outcome comparison conducted with TRISS-based predictions should be interpreted with care. If possible, future research should develop a simple prediction model that has accurate survival prediction in the aging overall trauma population (preferable with patients with hip fracture), with readily available predictors.

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

Purpose Severely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers. Methods All trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data. Results For adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region. Conclusion The compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.

Validation study of 3D-printed anatomical models using 2 PLA printers for preoperative planning in trauma surgery, a human cadaver study

Introduction3D printing contributes to a better understanding of the surgical approach, reduction and fixation of complex fractures. It is unclear how a 3D-printed model relates to a human bone. The accuracy of 3D-printed models is important to pre-bend plates and fit of surgical guides. We conduct a validation study in which we compare human cadavers with 3D-printed models to test the accuracy of 3D printing.MethodsNine specimens were scanned, volume rendered into 3D reconstructions and saved as STL data. All models were in a ratio of 1:1 printed on the Ultimaker 3 and Makerbot Replicator Z18. Two independent observers measured all distances between the K-wires on the human cadavers, 2DCT, 3D reconstruction, Meshlab and both printers. A paired Samples T test was used to compare the measurements between the different modalities.ResultsThe least decrease in average distance in millimetres was seen in “the 3D printed pelvis 1”, − 0.3 and − 0.8% on respectively the Ultimaker and Makerbot when compared with cadaver Pelvis (1) The 3D model of “Hand 2” showed the most decrease, − 2.5 and − 3.2% on the Ultimaker and Makerbot when compared with cadaver hand (2) Most significant differences in measurements were found in the conversion from 3D file into a 3D print and between the cadaver and 3D-printed model from the Makerbot.ConclusionOur 3D printing process results in accurate models suitable for preoperative workup. The Ultimaker 3 is slightly more accurate than the Makerbot Replicator Z18. We advise that medical professionals should perform a study that tests the accuracy of their 3D printing process before using the 3D-printed models in medical practice.