[Optimization of criteria for activation of trauma teams : Avoidance of overtriage and undertriage]

No trauma-related diagnosis in emergency trauma room whole-body computer tomography of patients with inconspicuous primary survey

PURPOSE

Whole-body computer tomographic examinations (WBCT) are essential in diagnosing the severely injured. The structured clinical evaluation in the emergency trauma room, according to ATLS® and guidelines, helps to indicate the correct radiological imaging to avoid overtriage and undertriage. This retrospective, single-center study aimed to evaluate the value of WBCT in patients with an inconspicuous primary survey and whether there is any evidence for this investigation in this group of patients.

METHODS

This retrospective, single-center study was conducted with patients admitted to a maximum-care hospital and supraregional trauma center in Germany and part of the TraumaNetwork DGU® in southwest Germany between January 2012 and November 2017. Hospital files were used for evaluation, and WBCT was carried out using a 32-row MSCT device from Siemens Healthineers, Volume Zoom, Erlangen, Germany. For evaluation, non-parametric procedures such as the chi-square test, U test, Fisher test, and Wilcoxon rank sum test were used to test for significance (p < 0.05).

RESULTS

From 3976 patients treated with WBCT, 120 patients (3.02%) showed an inconspicuous primary survey. This examination did not reveal any trauma sequelae in any of this group. Additionally, 198 patients (4.98%) showed minor clinical symptoms in the primary survey, but no morphological trauma sequence could be diagnosed in WBCT diagnostics. Three hundred forty-two patients were not admitted as inpatients after WBCT and discharged to further outpatient treatment because there were no objectifiable reasons for inpatient treatment. Four hundred fifteen patients did not receive WBCT for, e.g., isolated extremity trauma, child, pregnancy, or death.

CONCLUSION

Not one of the clinically asymptomatic patients had an imageable injury after WBCT diagnostics in this study. WBCT should only be performed in severely injured patients after clinical assessment regardless of "trauma mechanism." According to guidelines and ATLS®, the clinical examination seems to be a safe and reliable method for reasonable and responsible decision-making regarding the realization of WBCT with all well-known risk factors.

[Analysis of a differentiated resuscitation room activation at a national trauma center]

BACKGROUND

In order to continue to efficiently provide both personnel-intensive and resource-intensive care to severely injured patients, some hospitals have introduced individually differentiated systems for resuscitation room treatment. The aim of this study was to evaluate the concept of the A and B classifications in terms of practicability, indications, and potential complications at a national trauma center in Bavaria.

METHODS

In a retrospective study, data from resuscitation room trauma patients in the year 2020 were collected. The assignment to A and B was made by the prehospital emergency physician. Parameters such as the injury severity score (ISS), Glasgow outcome scale (GOS), upgrade rate, and the indication criteria according to the S3 guidelines were recorded. Statistical data comparisons were made using t‑tests, χ2-tests, or Mann-Whitney U‑tests.

RESULTS

A total of 879 resuscitation room treatments (A 473, B 406) met the inclusion criteria. It was found that 94.5% of resuscitation room A cases had physician accompaniment, compared to 48% in resuscitation room B assignments. In addition to significantly lower ISS scores (4.1 vs. 13.9), 29.8% of B patients did not meet the treatment criteria defined in the S3 guidelines. With a low upgrade rate of 4.9%, 98% of B patients had a GOS score of 4 or 5.

CONCLUSION

The presented categorization is an effective and safe way to manage the increasing number of resuscitation room alerts in a resource-optimized manner.

[Patient safety in differentiated (in-hospital) activation of the resuscitation room for severely injured patients]

BACKGROUND AND OBJECTIVE

Providing trauma services demands high personnel resources and structural costs. The goal of this study was to show if the assignment of trauma patients to a defined A or B resuscitation room treatment as a modified management concept is safe and feasible.

MATERIAL AND METHODS

Between May 2020 and January 2021, all resuscitation room trauma patients were included in this single center prospective observational study. All patients admitted to the resuscitation room underwent a classification according to the German S3 guidelines grade of recommendation GoR A and GoR B in polytrauma and the status of the ABCDE sequence to an A and B resuscitation room. The classification was performed by the senior consultant on call via telephone after consultation and discussion of clinical findings.

RESULTS

All 135 resuscitation room patients were included in the study of whom 42 trauma patients were assigned to the A resuscitation room (A-SR) and 93 were assigned to the B resuscitation room (B-SR). The comparison of the two groups showed that patients in the A‑SR group are more likely to be accompanied by a prehospital emergency physician (80.5%) than patients in the B‑SR group (55.5%). Patients in the B‑SR group showed a significantly higher Glasgow coma scale (GCS). Using the eFAST emergency ultrasound protocol, 2.4% of the A‑SR and 4.3% of the B‑SR patients had trauma-associated pathologies, 26% of the A‑SR and only 3.2% of the B‑SR patients had to be admitted to the ICU, 21.4% of the A‑SR and 1% of the B‑SR patients died within 30 days after trauma. The injury severity scores (ISS) of the A‑SR patients were significantly higher than in the B‑SR group (ISS 28.3 vs. 6.8).

CONCLUSION

The study confirmed that the assignment by the emergency department consultant according to the German S3 guideline in combination with the ABCDE sequence into resuscitation room A or B treatment is feasible, does not compromise the quality of care and is efficient in the use of the personnel resources.

[Trauma team activation-Who should be alerted for which patients?]

INTRODUCTION

It is estimated that in total almost 10 million people are injured in accidents in Germany every year, most of which are in the household milieu and leisure sector. It is estimated that of these more than 32,000 seriously injured patients are admitted to the emergency room every year. It is recommended that the decision of the prehospital treatment team or the first examiner in the hospital as to whether a potentially severely injured patient should be admitted via the emergency room of the hospital should be based on a catalogue of criteria.

MATERIAL AND METHOD

Against the background of the update of the S3 guidelines on the treatment of multiple trauma/severely injured patients and on the basis of the current literature, an overview with respect to the composition of the team and the criteria for which an emergency room team is or should be activated is given.

RESULTS

Alerting the emergency room team is still recommended if a certain injury pattern is present or if a prehospital intervention is necessary. The B‑criteria based on the course of the accident or mechanism, which have recently been the subject of increasing criticism, have been adapted. Recommendations for geriatric patients could also be formulated.

DISCUSSION

Compared to the S3 guidelines from 2016 the emergency room alarm criteria could be revised on the basis of new literature and have been included in the revised guidelines. There is no doubt that further optimization. e.g., based on prehospital algorithms or using point of care diagnostics, are possible and desirable in the future.

Evaluation der Aufnahmekriterien von Patienten nach Verkehrsunfall in den Schockraum

Hintergrund

Die aktuelle S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung der Deutschen Gesellschaft für Unfallchirurgie (DGU) empfiehlt bei einem Pkw-Unfall mit einer Geschwindigkeitsveränderung von delta >30 km/h die Versorgung in einem Schockraum ohne Berücksichtigung der Verletzungen des Patienten. Ziel dieser Studie war es zu untersuchen, ob Patienten, die ausschließlich aufgrund dieses Kriteriums über einen Schockraum aufgenommen wurden, relevante Verletzungen aufwiesen, die intensivmedizinische Behandlungen oder (Not‑)Operationen benötigten.

Methode

Nach einem Pkw-Unfall wurden Patienten ohne spezifische Verletzung, bei denen ausschließlich eine Geschwindigkeitsveränderung von delta >30 km/h vorlag (Empfehlungsgrad B der S3-Leitlinie), der Studiengruppe, Patienten mit Verletzungen gem. Empfehlungsgrad A der Leitlinie der Vergleichsgruppe zugeordnet. Ein schockraumrelevantes Trauma wurde als Injury Severity Score (ISS) ≥16, operative Versorgung innerhalb 24 h, intensivmedizinische Überwachung >24 h, Versterben während des Krankenhausaufenthalts sowie DGU-Basiskollektiv (MAIS3+ oder MAIS2 mit Intensivverweildauer >24 h bzw. Versterben während des Krankenhausaufenthalts) definiert.

Ergebnisse

Der Vergleich zeigte einen hochsignifikanten Unterschied in Bezug auf den mittleren ISS (p ≤ 0,001), ein schockraumrelevantes Trauma (ISS ≥16; p ≤ 0,001), eine intensivmedizinische Versorgung >24 h (p ≤ 0,001), Operation innerhalb von 24 h nach Krankenhausaufnahme (p ≤ 0,001), Letalität (p ≤ 0,001) sowie DGU-Basiskollektiv (p ≤ 0,001). Anhand dieser Ergebnisse konnte gezeigt werden, dass innerhalb der Studiengruppe (Geschwindigkeitsveränderung von delta >30 km/h; Empfehlungsgrad B der S3-Leitlinie) lediglich ein Patient eine Traumafolge aufwies, die eine intensivmedizinische Behandlung >24 h oder eine Operation nötig machte. Studien- und Vergleichsgruppen waren in Bezug auf das mittlere Alter (p = 1,778), das männliche Geschlecht (p = 0,1728) sowie die durchschnittliche Unfallgeschwindigkeit (p = 0,4606) vergleichbar.

Diskussion

Ein alleiniges Vorliegen eines Pkw-Unfalls mit einer Geschwindigkeitsveränderung von delta >30 km/h kann nicht als adäquater Prädiktor für ein schockraumrelevantes Trauma gesehen werden. Weitere Studien könnten durch eine Leitlinienanpassung eine weiterhin sichere und hochwertige Patientenversorgung bei Reduktion von personellen und finanziellen Belastungen ermöglichen.

Der Schockraum als Nahtstelle zwischen Präklinik und Klinik

Die ständige Vorhaltung und Verfügbarkeit eines Schockraums zur Versorgung von kritisch kranken und schwer verletzten Patienten ist eine wesentliche und für die transsektorale Notfallversorgung wichtige klinische Ressource. In diesem Artikel sollen die derzeitigen Entwicklungen der Schockraumbereitstellung in Deutschland aufgezeigt werden.

Survey on worldwide trauma team activation requirement

Purpose

Trauma team activation (TTA) is thought to be essential for advanced and specialized care of very severely injured patients. However, non-specific TTA criteria may result in overtriage that consumes valuable resources or endanger patients in need of TTA secondary to undertriage. Consequently, criterion standard definitions to calculate the accuracy of the various TTA protocols are required for research and quality assurance purposes. Recently, several groups suggested a list of conditions when a trauma team is considered to be essential in the initial care in the emergency room. The objective of the survey was to post hoc identify trauma-related conditions that are thought to require a specialized trauma team that may be widely accepted, independent from the country’s income level.

Methods

A set of questions was developed, centered around the level of agreement with the proposed post hoc criteria to define adequate trauma team activation. The participants gave feedback before they answered the survey to improve the quality of the questions. The finalized survey was conducted using an online tool and a word form. The income per capita of a country was rated according to the World Bank Country and Lending groups.

Results

The return rate was 76% with a total of 37 countries participating. The agreement with the proposed criteria to define post hoc correct requirements for trauma team activation was more than 75% for 12 of the 20 criteria. The rate of disagreement was low and varied between zero and 13%. The level of agreement was independent from the country’s level of income.

Conclusions

The agreement on criteria to post hoc define correct requirements for trauma team activation appears high and it may be concluded that the proposed criteria could be useful for most countries, independent from their level of income. Nevertheless, more discussions on an international level appear to be warranted to achieve a full consensus to define a universal set of criteria that will allow for quality assessment of over- and undertriage of trauma team activation as well as for the validation of field triage criteria for the most severely injured patients worldwide.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01334-z) contains supplementary material, which is available to authorized users.