[Trauma care management]

[Costs and proceeds from patients admitted via the emergency room with mild craniocerebral trauma]

The introduction of the diagnosis-related groups (DRG) in 2003 radically changed the billing of the treatment costs. From the very beginning, trauma surgeons questioned whether the introduction of the DRG could have a negative impact on the care of the severely injured. "Trauma centers in need" was the big catchword warning against shortfalls at trauma centers due to the billing via DRG. This situation was confirmed in the first publications after introduction of the DRG, showing a clearly deficient level of care of polytrauma cases. Over the years, adjustments have led to an improvement in the remuneration for polytraumatized patients. In the emergency room, polytrauma is not always the final diagnosis. A considerable proportion of patients are only slightly injured, but must be admitted via the emergency room due to the circumstances of the accident or suspected diagnosis at the scene of the accident to exclude life-threatening injuries. In this study, patients with the billing diagnosis of mild craniocerebral trauma were selected as an example. The proportion of these patients was 22% during the period of observation in 2017. For these patients, the proportional costs during treatment were calculated. It could be shown that 60.36% of the costs during a 2‑day treatment of these patients were incurred in the emergency room. Costs for material and personnel could not be considered. Despite not including these expenses, the costs were never covered for any of these patients. For patients with slight injuries after trauma management in the emergency room, the present adjustments to the DRG system by increasing the basic case value seem to be insufficient. Additional remuneration for these patients seems absolutely justified to further ensure adequate quality of care.

[Near-infrared spectroscopy for the detection of traumatic intracranial hemorrhage: Feasibility study in a German army field hospital in Afghanistan]

Traumatic brain injury (TBI) is one of the most common causes of death in ordinary accidents, natural disasters, or warfare. The gold standard for diagnosis of TBI is the CT scan; a delay of diagnostics or medical care is the strongest independent predictor of mortality of TBI patients--particularly in the case of a surgically treatable intracranial hematoma. The proper classification of these patients is of major importance in situations where a CT is not accessible. A portable screening device that uses near-infrared spectroscopy (NIRS) technology allows a preliminary estimate of an intracranial hematoma. This study assessing practicability shows that the use of the device in a military medical rescue center (Kunduz, Afghanistan) is easy to learn and can be repeatedly used even under emergency room conditions. The technique can be applied in penetrating and blunt TBIs in the absence of an immediately available CT scan in rural areas, preclinically, under mass casualty conditions (e.g., in disaster situations) as well as in humanitarian crises or war zones. Nevertheless, further studies to assess the validity of this device are necessary.

[Assessment of prehospital injury severity in children: challenge for emergency physicians]

BACKGROUND

The prognosis of polytraumatized patients is dependent on the quality of emergency room (ER) management and a smooth transition from prehospital to ER therapy is essential. The accurate assessment of prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. It also helps to ensure that medical resources are immediately available. Overestimation of injury severity wastes resources and underestimation puts patients at risk. The assessment of prehospital injury severity in adults is unreliable. In children, the assessment of injury severity seems to be even more challenging.

MATERIALS AND METHODS

For the comparison of the prehospital documented injury severity and injury severity diagnosed after the ER phase, the injury severity score (ISS) and trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the revised trauma score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the abbreviated injury scale (AIS). The concordance of the injury severity within different tolerances was evaluated. A tolerance of the prehospital documented injury severity of more than ± 25 % to the injury severity calculated after ER diagnostics was considered as overestimation or underestimation. The concordance of the prehospital documented diagnosed injury severity and the severity diagnosed after the ER phase of different body regions according to the AIS was evaluated. The documented mechanism of injury in the emergency physician protocol was judged as being detailed, satisfactory or poor.

RESULTS

The results showed that 69 % of the children reached the ER during on-call hours. Furthermore 92 % of the children reached the ER during the daytime between 08.00 h and 20.00 h. The transportation of 25 % of the children was on a private basis. The mean ER-ISS was 10 points (range 1-57). In 42 % of cases the ISS of the emergency physician protocol within a tolerance of ± 25 % was concordant with the ER-ISS. According to this criterion in 38 % of cases an overestimation of the assessment of the injury severity of the emergency physician was found and in 20 % an underestimation. Within a tolerance of ± 75 % based on the ER-ISS, the ISS of the emergency physician protocol was concordant in more than half of the cases (52 %). Using the TRISS with a tolerance of ± 25 % a concordance was observed in 46 % of the cases. Within a tolerance of ± 50 % based on the ER-ISS the ISS calculated after ER diagnostics was concordant in 50 % of the cases. A high concordance of the prehospital and hospital injury severity was found in the region of the face (75 %). The concordance in the body regions of the head, thorax, extremities and pelvis and soft tissue ranged between 43 % and 50 % of the cases. Of the children 38 % suffered a traffic accident, 52 % a fall of less than 3 m and 10 % of more than 3 m. The mechanism of injury was documented in detail in 70 % and satisfactory in 8 %.

CONCLUSIONS

The assessment of prehospital injury severity in children is unreliable. In order to evaluate injury severity the use of anatomical trauma scores alone is insufficient. The adequate documentation of the mechanism of injury implies that the mechanism of injury seems to play a relevant role in the assessment of prehospital injury severity. The unreliable assessment of the injury severity, the arrival in the ER in on-call hours and the private transport to the hospital is a challenge to the ER leader in trauma life support for children.

[The TraumaRegister DGU® as the basis of medical quality management. Ten years experience of a national trauma centre exemplified by emergency room treatment]

BACKGROUND

The trauma register of the German Society of Trauma Surgery (TraumaRegister DGU®/TR-DGU) has been proven to be a valuable tool for external assessment of quality in the treatment of patients with major trauma. This publication shows for the first time how the quality of trauma treatment in a level I trauma centre could be improved over a period of almost ten years with the help of continuous quality management, i.e. recognizing a problem, developing a solution and evaluating its effect.

MATERIALS AND METHODS

Tracer parameters and indicators of quality are presented in four periods over a total study period from 1st January 1989 to 31st March 2007. The division into four periods is due to major changes in the trauma treatment algorithms or structural changes in the trauma room. The results are displayed for all patients treated in the trauma room and for those patients with an injury severity score (ISS)≥16.

RESULTS

Over all four periods a total number of n=2,239 patients were admitted to the trauma room. Based on the results of the trauma register a number of changes were made, not only structural changes, such as the introduction of point-of-care diagnostics, initially conventional X-ray, then digital X-ray and finally multislice computed tomography (CT) scanning in the trauma room but also changes in the way personnel participating in the trauma treatment are trained. Advanced trauma life support (ATLS®) has become the standard training for doctors and prehospital trauma life support (PHTLS®) for nurses. Time efficient treatment algorithms were introduced. All measures led to changes in several parameters which are chosen as indicators for good treatment quality. It was for instance possible to reduce the average total trauma treatment time for patients with an ISS≥16 from initially 90.9±48.6 min to 37.4±18.  min in the final study period.

CONCLUSIONS

The external quality management performed by the TR-DGU has proved to be a constant source of inspiration. The effects of the changes made can be scientifically proven. It is to be discussed to what extent a sole external quality management can be useful.

Delays in diagnosis in early trauma care: evaluation of diagnostic efficiency and circumstances of delay

BACKGROUND

Trauma centers, trauma management concepts, damage control surgery and the integration of whole-body CT scanning into early trauma care have reduced mortality in traumatized patients significantly. However, some injuries are still initially missed. In this study, the diagnostic efficiency of early trauma care and the circumstances of delays in diagnosis were evaluated.

MATERIALS AND METHODS

Initially missed diagnoses in 111 traumatized patients were recorded retrospectively. "Primary diagnoses" after the emergency room (ER) phase including CT scanning with immediate data evaluation were compared to "secondary diagnoses" after a secondary survey of the CT data, as well as to discharge diagnoses. Circumstances of delay were assessed according to injury severity score (ISS), hospital admission, mechanism of injury, diagnostics, treatment, time in the intensive care unit, hospitalization and mortality.

RESULTS

73% of the patients arrived at the ER during on-call hours. In 23% of all patients, diagnoses were missed after the ER phase, while in 12% of the patients diagnoses were missed after the secondary survey of the CT data. One half of the missed diagnoses were almost impossible to detect; the other half were judged to be acceptable. During on-call hours, 9% more patients with delays in diagnosis were observed. Injury severity in patients with delays in diagnosis was significantly higher than in patients without.

CONCLUSIONS

Although diagnostic quality in early trauma care has improved, some diagnoses are initially missed. Severely injured patients with life-threatening or potentially life-threatening injuries arriving at the ER during on-call hours were at higher risk for delays in diagnosis. A secondary evaluation of acquired CT data and repetitive examinations are essential.

[Quality circle in a trauma network of the German Association for Trauma Surgery. Upgrading patient care]

In industry, especially in the automobile industry, improvements in efficiency could be demonstrated by quality management and quality circles. There is no doubt that in medicine, major trauma is also a very complex challenge.The German Association for Trauma Surgery published the White Paper on the Management of the Seriously Injured in 2006. The White Paper specifies the demand for quality of care, sets the level of structural requirements for trauma care and postulates the cooperation of regional hospitals within a network of dedicated trauma centres. The Trauma Network Eastern Bavaria (TNO) was the first certified trauma network in Germany. One of the reasons for this success is the fact that cooperation between trauma surgeons has already had a long tradition in this geographic area. The key factor is communication which is supported by all technical and organisational means. The formal installation of quality circles on each level of trauma care, e.g. within and across institutions, was accepted by all partners within the network. The goal is the improvement of patient care in trauma above and beyond the guidelines of the White Paper. This paper shows the instruments used to enhance the quality of trauma care within a network.

[Preclinical prediction of prehospital injury severity by emergency physicians : approach to evaluate validity]

BACKGROUND

The prognosis of polytraumatized patients is basically dependent on the quality of emergency room (ER) management and a smooth transition from prehospital emergency therapy to ER therapy is essential. The accurate prediction of the prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. Furthermore it helps to provide medical resources on time. Overestimation of injury severity wastes resources, underestimation puts patients at risk. Prehospital misjudgement of injury severity is common. The aim of this study was to evaluate reliability of the injury severity estimated by emergency physicians.

MATERIALS AND METHODS

For comparison of the prehospital and hospital injury severity the Injury Severity Score (ISS) and Trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the Revised Trauma Score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the Abbreviated Injury Scale (AIS). The concordance of prehospital and hospital injury severity at different ranges and according to different body regions was evaluated. A difference of more than 25% between the prehospital injury severity and the injury severity calculated after ER diagnostics was considered as being relevant and judged as overestimation or underestimation. The documented injury severity in the emergency physician protocol was judged as detailed, satisfactory and poor.

RESULTS

Of the patients 73% reached the ER during on-call hours. The mean ER-ISS was 19 (1-50). At a range of ±25% referring to the ER-ISS, 30% overestimation and 36% underestimation of the prehospital injury severity was observed. A concordance of 34% was found. At a range of ±50% the concordance between the prehospital injury severity and the injury severity calculated after ER diagnostics was 57%, at a range of ±75% the concordance was 73%. The mean ER-TRISS was 6.9 points (0.3-98.6) and the mean ER-RTS was 7.569 points (0-7.841). Using the TRISS with a range of ±25% a concordance of 28% was observed. A high concordance of the prehospital and hospital injury severity was found in the region of the face (70%) and external soft tissue injuries (80%). The concordance in the body region of the abdomen was 55%, of the thorax 40%, of the extremities and pelvis 37% and of the head 33%. Underestimation in the region of the abdomen was 32%, of the head 37%, of the thorax 42% and of the extremities and pelvis 47%. Missed injuries were the reason for underestimation in the body region of extremities and pelvis in half of the cases. Of the patients 61% suffered a traffic accident, 25% a fall of less than 3 m and 8% of more than 3 m. In 5% of the cases other mechanisms of injury were observed. Injury severity was documented in a detailed manner in 61% and satisfactory in 26%.

CONCLUSIONS

The prediction of prehospital injury severity is difficult and less reliable. Relevant underestimation of injury severity was observed in visceral cavities. In order to evaluate injury severity the use of anatomical trauma scores alone might be not sufficient. In addition, the mechanism of injury and the deduced consequences, such as prehospital therapy, the choice of destination hospital and the need of ER treatment should be taken into account.

[Development of an emergency room algorithm for treatment of multiple trauma. Wolfsburg model]

Within the framework of restructuring for the certification to a regional trauma centre of the DGU (German Society for Casualty Surgery), a uniform algorithm for multiple trauma was developed in the medical centre of Wolfsburg. The Wolfsburg multiple trauma algorithm is based on ATLS (advanced trauma life support) with integration of FAST (focused assessment with sonography for trauma), as well as the white paper of the DGU and regional-specific features. Thus structural, instrumental, organizational and personnel conditions were created to improve the care of multiply traumatized patients even further. The conditions for transition to a regional trauma centre of the DGU were confirmed by a successful audit.

[Modern imaging techniques for liver trauma]

Involvement of the liver is one of the most common injuries in addition to those of the pancreas following blunt force abdominal trauma. Due to the even now high mortality radiological imaging must provide a rapid, definitive and exact assessment of the extent of the damage. Despite conflicting study results ultrasound has become established as a rapid and relatively simple method in emergency room treatment and is irreplaceable for initial orientation diagnostics. The use of contrast medium-assisted examinations promises to be an advantage for diagnostics in the secondary phase. Due to the high sensitivity and specificity modern multidetector computed tomography is the most effective examination modality for the detection of liver damage and hepatobiliary complications and plays a central role in non-operative management following abdominal trauma. Shorter and shorter scan times even allow the examination of metastable patients and a rapid assessment even of large body volumes.