Changing from a two-tiered to a one-tiered trauma team activation protocol: a before-after observational cohort study investigating the clinical impact of undertriage

Interprofessional interventions that impact collaboration and quality of care across inpatient trauma care continuum: A scoping review

INTRODUCTION

Despite the recognized importance of interprofessional collaboration (IPC) in trauma care, healthcare professionals often work in silos. Interprofessional (IP) interventions are crucial for optimizing IPC and delivering high-quality care across clinical contexts, yet their effectiveness throughout the inpatient trauma care continuum is not well understood. Thus, this review aimed to examine the literature on the effectiveness of IP interventions on collaboration processes and related outcomes in inpatient trauma care.

METHODS

We conducted a scoping review following Joanna Briggs Institute's methodology. We searched six databases for studies from the last decade on IP interventions in inpatient trauma care. Two independent reviewers categorized IP interventions (education, practice, organization) and extracted their impact on IPC processes and related outcomes (team performance, patient, organization).

RESULTS

Of the 17,397 studies screened, 148 met the inclusion criteria. Most were cohort designs (72%), conducted in level I trauma centers (57%) and emergency departments (51%), and involved surgeons (56%) and nurses (53%). Studies focused on IP organization interventions (51%), such as clinical pathways; IP practice interventions (35%), such as trauma team activation protocols; and IP education interventions (14%) including multi-method education. IP practice interventions most effectively improved team performance results, while IP education interventions primarily improved IPC processes. Positive patient outcomes were limited, with few studies examining organizational effects.

CONCLUSIONS

Significant advancements are still required in IP interventions and trauma care research. Future studies should rigorously explore the effectiveness of interventions throughout the inpatient trauma care continuum and focus on developing robust measures for patient and organizational outcomes.

Characteristics and demography of low energy fall injuries in patients > 60 years of age: a population-based analysis over a decade with focus on undertriage

BACKGROUND

An increasing group of elderly patients is admitted after low energy falls. Several studies have shown that this patient group tends to be severely injured and is often undertriaged.

METHODS

Patients > 60 years with low energy fall (< 1 m) as mechanism of injury were identified from the Stavanger University Hospital trauma registry. The study period was between 01.01.11 and 31.12.20. Patient and injury variables as well as clinical outcome were described. Undertriage was defined as patients with a major trauma, i.e., Injury Severity Score (ISS) > 15, without trauma team activation. Statistical analysis was performed using the Chi-squared test for categorical variables and the Mann-Whitney U test for continuous variables.

RESULTS

Over the 10-year study period, 388 patients > 60 years with low energy fall as mechanism of injury were identified. Median age was 78 years (IQR 68-86), and 53% were males. The location of major injury was head injury in 41% of the patients, lower extremities in 19%, and thoracic injuries in 10%. Thirty-day mortality was 13%. Fifty percent were discharged to home, 31% to nursing home, 9% in hospital mortality, and the remaining 10% were transferred to other hospitals or rehabilitation facilities. Ninety patients had major trauma, and the undertriage was 48% (95% confidence interval, 38 to 58%).

CONCLUSIONS

Patients aged > 60 years with low energy falls are dominated by head injuries, and the 30-day mortality is 13%. Patients with major trauma are undertriaged in half the cases mandating increased awareness of this patient group.

Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted, sent to the intensive care unit (ICU), and sent to the operating room (OR).  Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentage of TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

Outcomes of Injured Patients Before and After the Institution of a Third-Tier Activation at a Level 1 Trauma Center

BACKGROUND

We hypothesized that the addition of a third-level trauma activation would improve outcomes by formalizing an evaluation process for patients in need of urgent evaluation who did not meet the criteria for full or partial trauma alert activation.

METHODS

Admission records for all trauma patients admitted between 2000 and 2021 were obtained. The gamma alert trauma activation was implemented in 2011. A washout period of 6 months was used to account for adjustment to the new protocol. Propensity score matching was performed based on ISS scores, age, injury mechanism, and best-validated comorbidities to create a balanced patient distribution. Patients with missing data were excluded from this study. The association between era and outcomes was determined using logistic and linear regression analyses.

RESULTS

The matched cohort was well balanced (SMD <.1, all balanced covariates) and included 18,572 patients. Patients in the gamma alert era had decreased ED dwell time, hospital length of stay, and intensive care unit (ICU) length of stay. Readmission rates and rates of upgrade to ICU status were reduced in the gamma alert era. This era was also associated with lower rates of renal failure, UTI, and pneumonia. There was no significant difference in mortality following implementation of the gamma alert.

DISCUSSION

Implementation of the gamma alert was associated with an improvement in ED dwell times, fewer unplanned admissions to the ICU, decreased readmissions, and a reduction in other in-hospital events. We believe that this reflects improved triage of patients to the ICU and more effective care of trauma patients.

Current trauma team activation processes at Canadian trauma centres: A national survey

BACKGROUND

Trauma team activation (TTA) allows the provision of specialized and timely care to improve outcomes for severely injured patients. Limited information is available on the current state of TTA in Canadian trauma centres (TC). Study objectives were to describe TTA processes, data and reports, along with the challenges and successes from a national perspective.

METHODS

A mixed-methods, cross-sectional survey was undertaken with Canadian trauma leadership, utilizing a total population sampling strategy. The questionnaire, containing 108-items, was administered online between February-April 2022, utilizing a modified Dillman technique. Descriptive statistics and thematic analyses were performed.

RESULTS

Trauma leaders from 9 out of 10 provinces responded for a response rate of 68% (32/47). Two-thirds (67%) of respondents worked in adult TC; 63% in a level I center. A higher proportion of pediatric TC had a two-tiered TT response (60% pediatric; 35% adult). The most common criteria were neurologic compromise (100% one-level TTA) and hypotension (pediatric: 100% one-level, 100% tier 1; adult: 92% one-level, 86% tier 1). All one-level TTA included penetrating trauma criteria. One-third of respondents reported using TTA subgroup criteria for pediatric, pregnant, and/or geriatric patients. There was variability with disciplines responding to TTA, with largest, most comprehensive teams for tier 1. Two-thirds of TC review activation compliance (under/overtriage), while 55% focus on non-compliance and reasons for missed TTA. The most frequent challenges related to TTA practices were reliable data collection (60%) while successes included were the establishment of TTA guidelines to improve team compliance (33%) and RN initiated TTA.

CONCLUSIONS

Some TTA practices were similar among Canadian TC, while others showed variability. Findings provide opportunities for improvement, including a two-tier system, geriatric-specific criteria, and RN initiated TTA, and could help establish national standards and best practices. Compliance with standards has the potential to improve Canadian TTA practices and patient outcomes.

Resource Deployment in Response to Trauma Patients

Background Variance in the deployment of the trauma team to the emergency department (ED) can result in patient treatment delays and excess burden on ED personnel. Characteristics of trauma patients, including mechanism of injury, injury type, and age, have been associated with differences in trauma resource deployment. Therefore, this retrospective, single-site study aimed to examine the deployment patterns of trauma resources, the characteristics of the trauma patients associated with levels of trauma resource deployment, and the deployment impact on ED workforce utilization and non-trauma ED patients. Methodology This was an investigator-initiated, single-institution, retrospective cohort study of all patients designated as a trauma response and admitted to a community hospital's ED from July 01, 2019, through July 01, 2022. Results Resource deployment for trauma patients varied by mechanism of injury (p < 0.001), injury type (p < 0.001), and patient age groups (p < 0.001). Specifically, there was a lower average trauma activation for geriatric trauma patients with a fall as a mechanism of injury compared to all younger patient groups with any mechanism of injury (F(5) = 234.49, p < 0.001). In the subsample, there was an average of 3.35 ED registered nurses (RNs) allocated to each trauma patient. Additionally, the ED RNs were temporarily reallocated from an average of 4.09 non-trauma patients to respond to trauma patients, despite over a third of the trauma patients in the subsample being the trauma patients being discharged home from the ED. Conclusions Trauma activation responses need to be standardized with a specific plan for geriatric fall patients to ensure efficient use of trauma and ED personnel resources.

Epidemiology of abdominal trauma: An age- and sex-adjusted incidence analysis with mortality patterns

PURPOSE

Abdominal injuries may occur in up to one-third of all patients who suffer severe trauma, but little is known about epidemiological trends and characteristics in a Northern European setting. This study investigated injury demographics, and epidemiological trends in trauma patients admitted with abdominal injuries.

METHODS

This was an observational cohort study of all consecutive patients admitted to Stavanger University Hospital (SUH) with a documented abdominal injury between January 2004 and December 2018. Injury demographics, age- and sex-adjusted incidence, and mortality patterns are analyzed across three time periods.

RESULTS

Among 7202 admitted trauma patients, 449 (6.2%) suffered abdominal injuries. The median age was 31 years, and the age increased significantly over time (from a median of 25 years to a median of 38.5 years; p = 0.020). Patients with ASA 2 and 3 increased significantly over time. Men accounted for 70% (316/449). The injury mechanism was blunt in 91% (409/449). Transport-related accidents were the most frequent cause of injury in 57% (257/449). The median Injury Severity Score (ISS) was 21, and the median New Injury Severity Score (NISS) was 25. The annual adjusted incidence of all abdominal injuries was 7.2 per 100,000. Solid-organ injuries showed an annual adjusted incidence of 5.7 per 100,000. The most frequent organ injury was liver injury, found in 38% (169/449). Multiple abdominal injuries were recorded in 44% (197/449) and polytrauma in 51% (231/449) of the patients. Overall 30-day mortality was 12.5% (56/449) and 90-day mortality 13.6% (61/449).

CONCLUSION

The overall adjusted incidence rate of abdominal injuries remained stable. Age at presentation increased by over a decade, more often presenting with pre-existing comorbidities (ASA 2 and 3). The proportion of polytrauma patients was significantly reduced over time. Mortality rates were declining, although not statistically significant.

A prospective study comparing two methods of pre-hospital triage for trauma

We conducted a prospective study comparing two different pre-hospital triage tools for trauma: the American College of Surgeons Committee on Trauma (ACS-COT) field triage decision scheme and the TRENAU score. The main objective was to evaluate which triage tool was more appropriate in the setting of Lombardy's trauma system. Data were collected from the population of trauma patients admitted to Niguarda hospital in Milan from January to June 2021. RStudio and Excel were used for data analysis. For each triage tool performance measures, Receiver Operating Characteristics (ROC) curves, and overtriage and undertriage rates were obtained. A total of 1439 injured patients admitted through 118 pre-hospital Emergency Medical Services (EMS) were included in the study. The ACS-COT triage tool showed a good accuracy but an excessive overtriage rate (59%). The TRENAU triage tool had a moderately good accuracy and a low overtriage rate (23%) while maintaining an acceptable undertriage rate (3.9%). The TRENAU triage tool proved to be efficient in optimizing the use of resources dedicated to trauma care while resulting safe for the injured patient. In a modern trauma system such as Lombardy's it would be more appropriate to adopt the TRENAU score over the ACS-COT field triage decision scheme.

Characteristics, image findings and clinical outcome of moderate and severe traumatic brain injury among severely injured children: a population-based cohort study

PURPOSE

The aim of this study was to explore patient and injury characteristics, image findings, short-term clinical outcome and time trends of moderate and severe traumatic brain injury in severely injured children.

METHODS

This study is an observational cohort study based on prospectively collected data from an institutional trauma registry database covering all trauma patients in South West Norway. All paediatric patients registered in the database between 01.01.2004 and 31.12.2019 were included.

RESULTS

During the 16 years-study periods, 82 paediatric patients with moderate (n = 42) and severe (n = 40) traumatic brain injury were identified. Median age was 13.0 years, 45% were female and median Glasgow Coma Scale score at admission was 9.0. Cranial fractures were common image findings in both groups. Cerebral contusions (32%) and epidural hematomas (29%) were more commonly found in moderate traumatic brain injury; cerebral contusions (49%), diffuse axonal injury (31%) and cerebral oedema (46%) were more prominent in severe traumatic brain injury. All children with moderate traumatic brain injury survived and favourable outcome was registered in 98%. Overall mortality in the severe traumatic brain injury cohort was 38% (thereof 25% due to TBI) and only 38% had a favourable short-term outcome.

CONCLUSIONS

In this population-based study on paediatric trauma patients over a period of 16 years severe traumatic brain injury in children still had a considerably high mortality and a higher proportion of patients experienced an unfavourable clinical short-term outcome. Moderate traumatic brain injury resulted in favourable clinical outcome.

Incidence, Mechanisms of Injury and Mortality of Severe Traumatic Brain Injury: An Observational Population-Based Cohort Study from New Zealand and Norway

BACKGROUND

Comparing trauma registry data from different countries can help to identify possible differences in epidemiology, which may help to improve the care of trauma patients.

METHODS

This study directly compares the incidence, mechanisms of injuries and mortality of severe TBI based on population-based data from the two national trauma registries from New Zealand and Norway. All patients prospectively registered with severe TBI in either of the national registries for the 4-year study period were included. Patient and injury variables were described and age-adjusted incidence and mortality rates were calculated.

RESULTS

A total of 1378 trauma patients were identified of whom 751 (54.5%) from New Zealand and 627 (45.5%) from Norway. The patient cohort from New Zealand was significantly younger (median 32 versus 53 years; p < 0.001) and more patients from New Zealand were injured in road traffic crashes (37% versus 13%; p < 0.001). The age-adjusted incidence rate of severe TBI was 3.8 per 100,000 in New Zealand and 2.9 per 100,000 in Norway. The age-adjusted mortality rates were 1.5 per 100,000 in New Zealand and 1.2 per 100,000 in Norway. The fatality rates were 38.5% in New Zealand and 34.2% in Norway (p = 0.112).

CONCLUSIONS

Road traffic crashes in younger patients were more common in New Zealand whereas falls in elderly patients were the main cause for severe TBI in Norway. The age-adjusted incidence and mortality rates of severe TBI among trauma patients are similar in New Zealand and Norway. The fatality rates of severe TBI are still considerable with more than one third of patients dying.