Oddvar Uleberg

Overtriage in trauma – what are the causes?

Background:  Different criteria are employed to activate trauma teams. Because of a growing concern about overtriage, the objective of this study was to investigate the performance of our trauma team’s activation protocol.

The acute sick and injured patients: an overview of the emergency department patient population at a Norwegian University Hospital Emergency Department.

Objectives There is a lack of knowledge of the emergency department (ED) population in Norway; hence, the aim of this study was to describe the ED patient population at a Norwegian University Hospital. Materials and methods Prospective data of all ED patients admitted to the main ED over a period of 2 months were collected. The patients’ presenting complaint was registered using the International Classification of Primary Care-2 (ICPC-2). Results A total of 3163 patients arrived in the ED during the study period. The majority (71%) of patients presented with a complaint that was defined as a symptom in ICPC-2. The most common symptoms were abdominal pain (13%), chest pain (13%), and dyspnea (9%). The complaints of the remaining patients (29%) were primarily traumas, infections, and other diagnoses. Conclusion ED patients have a diverse spectrum of presenting complaints and the majority of patients present with symptoms rather than a defined medical diagnosis.

Norwegian trauma care: a national cross-sectional survey of all hospitals involved in the management of major trauma patients

BackgroundApproximately 10% of the Norwegian population is injured every year, with injuries ranging from minor injuries treated by general practitioners to major and complex injuries requiring specialist in-hospital care. There is a lack of knowledge concerning the caseload of potentially severely injured patients in Norwegian hospitals. Aim of the study was to describe the current status of the Norwegian trauma system by identifying the number and the distribution of contributing hospitals and the caseload of potentially severely injured trauma patients within these hospitals.MethodsA cross-sectional survey with a structured questionnaire was sent in the summer of 2012 to all Norwegian hospitals that receive trauma patients. These were defined by number of trauma team activations in the included hospitals. A literature review was performed to assess over time the development of hospitals receiving trauma patients.ResultsForty-one hospitals responded and were included in the study. In 2011, four trauma centres and 37 acute care hospitals received a total of 6,570 trauma patients. Trauma centres received 2,175 (33%) patients and other hospitals received 4,395 (67%) patients. There were significant regional differences between health care regions in the distribution of trauma patients between trauma centres and acute care hospitals. More than half (52.5%) of the hospitals received fewer than 100 patients annually. The national rate of hospital admission via trauma teams was 13 per 10,000 inhabitants. There was a 37% (from 65 to 41) reduction in the number of hospitals receiving trauma patients between 1988 and 2011.ConclusionsIn 2011, hospital acute trauma care in Norway was delivered by four trauma centres and 37 acute care hospitals. Many hospitals still receive a small number of potentially severely injured patients and only a few hospitals have an electronic trauma registry. Future development of the Norwegian trauma system needs to address the challenge posed by a scattered population and long geographical distances. The implementation of a trauma system, carefully balanced between centres with adequate caseloads against time from injury to hospital care, is needed and has been shown to have a beneficial effect in countries with comparable challenges.

Patient visits to the emergency department at a Norwegian university hospital: variations in patient gender and age, timing of visits, and patient acuity

Background The patient visits to Norwegian emergency departments (EDs) have increased significantly over the last few years. A national evaluation revealed a lack of systematic activity control, resource management and quality improvement. This paper describes some variables in patient visits to an urban Norwegian university hospital. Methods The retrospective data were collected from a database (Akuttdatabasen) and included all patients admitted to the main ED at the St. Olavs University Hospital between 1 December 2010 and 1 December 2011. Results ED visits have increased by 44% over the last decade and show considerable timely variations. Almost 50% of the patients are older than 65 years of age. The rate of patients triaged with the highest acuity level was 11%, but only 1.3% of the patients were admitted to the Intensive Care Unit (ICU). The total admission rate was 89%. Conclusions The increase in ED visits to the St. Olavs Hospital in recent years follows the same trend as in other countries. The authors see a slightly higher percentage of high level acuity patients compared with international studies due the general practitioners intended ‘gatekeeper’ function. The authors also found a high total admission rate and a low ICU admission rate compared with other countries. These differences cannot be explained solely by differences in the healthcare system in Norway. The cultural and traditional organisation of the Norwegian Health Care System needs to change and this creates an excellent opportunity to improve the competence by establishing emergency medicine as a specialty in Norway.

Trauma care in a combined rural and urban region: an observational study

The available information on trauma care in mixed rural‐urban areas with scattered populations is limited. The aim of this study is to describe epidemiology, resource use, transfers and outcomes for trauma care within such an area, prior to implementation of a formal trauma system.

Physician-provided prehospital critical care, effect on patient physiology dynamics and on-scene time

Introduction Improved physiologic status can be seen as a surrogate measure of improved outcome and a field-friendly prognostic model such as the Mainz Emergency Evaluation Score (MEES) could quantify the effect on physiological response. We aim to examine the dynamic physiological profile as measured by this score on patients managed by physician-manned helicopter emergency medical services and how this profile was related to on-scene time expenditure and critical care interventions. Materials and methods Data including patient characteristics, physiological data, and description of diagnostic and therapeutic interventions were prospectively collected over two 14-day periods, summer and winter, at six participating Norwegian bases. The MEES score was utilized to examine the difference between a score measured at first patient contact (MEES 1) and end-of-care (MEES 2), (MEES 2–MEES 1=[INCREMENT]MEES). Results A total of 240 primary missions with patient-on-scene form the basis of the study. In total, 43% were considered severely ill or injured, of whom 59% were medical patients. Twenty-nine percent were severely deranged physiologically. The most common advanced procedure performed was advanced airway management (15%), followed by defibrillation (8.8%). Using [INCREMENT]MEES as an indicator, 1% deteriorated under care, whereas 66% remained unchanged and 33% showed an improvement in their physiological status. With increasing on-scene time, fewer patients deteriorated and a greater proportion of patients improved. Conclusion Restoring deranged physiology remains a mantra for all critical care practitioners. We have shown that this is also possible in the prehospital context, even when prolonging on-scene time, and after initiating advanced procedures.

Quality measurement in physician-staffed emergency medical services: a systematic literature review

Abstract Purpose Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS. Data sources The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus. Study selection The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool. Data extraction The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well. Results of data synthesis In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were ‘Adherence to medical protocols’, ‘Provision of advanced interventions’, ‘Response time’ and ‘Adverse events’. Conclusion The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.

Impact of 2015 Earthquakes on a local hospital in Nepal: A Prospective Hospital-based Study

Introduction Natural disasters pose a great challenge to the health systems and individual health facilities. In low-resource settings, disaster preparedness systems are often limited and not been well described. Two devastating earthquakes hit Nepal within a 17-days period in 2015. This study aims to describe the burden and distribution of emergency cases to a local hospital. Methods This is a prospective observational study of patients presenting to a local hospital for a period of 21 days following the earthquake on April 25, 2015. Demographic and clinical information was prospectively registered for all patients in the systematic emergency registry. Systematic telephone interviews were conducted in a random sample of the patients 90 days after admission to the hospital. Results A total of 2,003 emergency patients were registered during the period. The average daily number of emergency patients during the first five days was almost five times higher (n = 150) than the pre-incident daily average (n = 35). The majority of injuries were fractures (58%), 348 (56%) in the lower extremities. A total of 345 surgical procedures were performed and the hospital treated 111 patients with severe injuries related to the earthquake (compartment syndrome, crush injury, and internal injury). Among those with follow-up interviews, over 90% reported that they had been severely affected by the earthquakes; complete house damage, living in temporary shelter, or loss of close family member. Conclusion The hospital experienced a very high caseload during the first days, and the majority of patients needed orthopaedic services. The proportion of severely injured and in-hospital deaths were relatively low, probably indicating that the most severely injured did not reach the hospital in time. The experiences underline the need for robust and easily available local health services that can respond to disasters.

Population‐based analysis of the impact of trauma on longer‐term functional outcomes

Functional outcome measures are important as most patients survive trauma. The aim of this study was to describe the long‐term impact of trauma within a healthcare region from a social perspective.

When do trauma patients lose temperature? - a prospective observational study

The prevalence of hypothermia in trauma patients is high and rapid recognition is important to prevent further heat loss. Hypothermia is associated with poor patient outcomes and is an independent predictor of increased mortality. The aim of this study was to analyze the changes in core body temperature of trauma patients during different treatment phases in the pre‐hospital and early in‐hospital settings.