ATLS practices and survival at rural level III trauma hospitals, 1995-1999

Effect of trauma quality improvement initiatives on outcomes and costs at community hospitals: A scoping review

BACKGROUND

Due to complex geography and resource constraints, trauma patients are often initially transported to community or rural facilities rather than a larger Level I or II trauma center. The objective of this scoping review was to synthesize evidence on interventions that improved the quality of trauma care and/or reduced healthcare costs at non-Level I or II facilities.

METHODS

A scoping review was performed to identify studies implementing a Quality Improvement (QI) initiative at a non-major trauma center (i.e., non-Level I or II trauma center [or equivalent]). We searched 3 electronic databases (MEDLINE, Embase, CINAHL) and the grey literature (relevant networks, organizations/associations). Methodological quality was evaluated using NIH and JBI study quality assessment tools. Studies were included if they evaluated the effect of implementing a trauma care QI initiative on one or more of the following: 1) trauma outcomes (mortality, morbidity); 2) system outcomes (e.g., length of stay [LOS], transfer times, provider factors); 3) provider knowledge or perception; or 4) healthcare costs. Pediatric trauma, pre-hospital and tele-trauma specific studies were excluded.

RESULTS

Of 1046 data sources screened, 36 were included for full review (29 journal articles, 7 abstracts/posters without full text). Educational initiatives including the Rural Trauma Team Development Course and the Advanced Trauma Life Support course were the most common QI interventions investigated. Study outcomes included process metrics such as transfer time to tertiary care and hospital LOS, along with measures of provider perception and knowledge. Improvement in mortality was reported in a single study evaluating the impact of establishing a dedicated trauma service at a community hospital.

CONCLUSIONS

Our review captured a broad spectrum of trauma QI projects implemented at non-major trauma centers. Educational interventions did result in process outcome improvements and high rates of self-reported improvements in trauma care. Given the heterogeneous capabilities of community and rural hospitals, there is no panacea for trauma QI at these facilities. Future research should focus on patient outcomes like mortality and morbidity, and locally relevant initiatives.

Structured approach with primary and secondary survey for major trauma care: an overview of reviews

BACKGROUND

A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma.

METHODS

We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence).

CONCLUSIONS

The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.

Monthly Trauma Training and Simulation Are Associated With Improved Resident Skill and Leadership

BACKGROUND

Training for trauma procedures has been limited to infrequent courses with little data on longitudinal performance, and few address procedural and leadership skills with granular assessment. We implemented a novel training program that emphasized an assessment of trauma resuscitation and procedural skills.

OBJECTIVE

This study aimed to determine whether this program could demonstrate improvement in both skill sets in surgical trainees over time.

METHODS

This was a prospective, observational study at a Level I trauma center between November 2018 and May 2019. A procedural skill and simulation program was implemented to train and evaluate postgraduate year (PGY) 1-5 residents. All residents participated in an initial course on procedures such as tube thoracostomy and vascular access, followed by a final evaluation. Skills were assessed by the Likert scale (1-5, 5 noting mastery). PGY 3s and above were additionally evaluated on resuscitation. A paired t test was performed on repeat learners.

RESULTS

A total of 40 residents participated in the structured procedural skills and simulation program. Following completion of the program, PGY-2 scores increased from a Mdn [interquartile range, IQR] 3.0 [2.5-4.0] to 4.5 [4.2-4.5]. The PGY-3 scores increased from a Mdn [IQR] 3.95 [3.7-4.6] to 4.8 [4.6-5.0]. Eighteen residents underwent repeat simulation training, with Mdn [IQR] score increases in PGY 2s (3.7 [2.5-4.0] to end score 4.47 [4.0-4.5], p = .03) and PGY 3s (3.95 [3.7-4.6] to end score 4.81 [4.68-5.0], p = .04). Specific procedural and leadership skills also increased over time.

Impact of ATLS training on preventable and potentially preventable deaths

BACKGROUND

Multiple trauma continues to have a high incidence worldwide. Trauma is the leading cause of death among people between the ages of 10 and 40. The Advanced Trauma Life Support (ATLS) is the most widely accepted method for the initial control and treatment of multiple trauma patients. It is based on the following hypothesis: The application of the ATLS program may reduce preventable or potentially preventable deaths in trauma patients.

MATERIALS AND METHODS

The present article reports a retrospective study based on the records of prospectively evaluated trauma patients between January 2007 and December 2012. Trauma patients over the age of 18 admitted to the critical care unit or patients who died before hospital admission were included. A multidisciplinary committee looked for errors in the management of each patient and classified deaths into preventable, potentially preventable, or nonpreventable. We recorded the number of specialists at our center who had received training in the ATLS program.

RESULTS

A total of 898 trauma patients were registered. The mean injury severity score was 21 (SD 15), and the mortality rate was 10.7 % (96 cases). There were 14 cases (14.6 %) of preventable or potentially preventable death. The main errors were delay in initiating suitable treatment and performing a computed tomography scan in cases of hemodynamic instability, followed by initiation of incorrect treatment or omission of an essential procedure. As the number of ATLS-trained professionals increases, the rates of potentially preventable or preventable death fall.

CONCLUSIONS

Well-founded protocols such as the ATLS can help provide the preparation health professionals need. In our hospital environment, ATLS training has helped to reduce preventable or potentially preventable mortality among trauma patients.

Effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation

OBJECTIVES

Advanced Trauma Life Support (ATLS) has been shown to improve outcomes related to trauma resuscitation; however, omissions from this protocol persist. The objective of this study was to evaluate the effect of a trauma resuscitation checklist on performance of ATLS tasks.

METHODS

Video recordings of resuscitations of children sustaining blunt or penetrating injuries at a Level I pediatric trauma center were reviewed for completion and timeliness of ATLS primary and secondary survey tasks, with and without checklist use. Patient and resuscitation characteristics were obtained from the trauma registry. Data were collected during two 4-month periods before (n = 222) and after (n = 213) checklist implementation. The checklist contained 50 items and included four sections: prearrival, primary survey, secondary survey, and departure plan.

RESULTS

Five primary survey ATLS tasks (cervical spine immobilization, oxygen administration, palpating pulses, assessing neurologic status, and exposing the patient) and nine secondary survey ATLS tasks were performed more frequently (p ≤ 0.01 for all) and vital sign measurements were obtained faster (p ≤ 0.01 for all) after the checklist was implemented. When controlling for patient and event-specific characteristics, primary and secondary survey tasks overall were more likely to be completed (odds ratio [OR] = 2.66, primary survey; OR = 2.47, secondary survey; p < 0.001 for both) and primary survey tasks were performed faster (p < 0.001) after the checklist was implemented.

CONCLUSIONS

Implementation of a trauma checklist was associated with greater ATLS task performance and with increased frequency and speed of primary and secondary survey task completion.

Advanced trauma life support training for hospital staff

BACKGROUND

Injury is responsible for an increasing global burden of death and disability. As a result, new models of trauma care have been developed. Many of these, though initially developed in high-income countries (HICs), are now being adopted in low and middle-income countries (LMICs). One such trauma care model is advanced trauma life support (ATLS) training in hospitals, which is being promoted in LMICs as a strategy for improving outcomes for victims of trauma. The impact of this health service intervention, however, has not been rigorously tested by means of a systematic review in either HIC or LMIC settings.

OBJECTIVES

To quantify the impact of ATLS training for hospital staff on injury mortality and morbidity in hospitals with and without such a training program.

SEARCH METHODS

The search for studies was run on the 16th May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), PubMed and screened reference lists.

SELECTION CRITERIA

Randomised controlled trials, controlled trials and controlled before-and-after studies comparing the impact of ATLS-trained hospital staff versus non-ATLS trained hospital staff on injury mortality and morbidity.

DATA COLLECTION AND ANALYSIS

Three authors applied the eligibility criteria to trial reports for inclusion, and extracted data.

MAIN RESULTS

None of the studies identified by the search met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

There is no evidence from controlled trials that ATLS or similar programs impact the outcome for victims of injury, although there is some evidence that educational initiatives improve knowledge of hospital staff of available emergency interventions. Furthermore, there is no evidence that trauma management systems that incorporate ATLS training impact positively on outcome. Future research should concentrate on the evaluation of trauma systems incorporating ATLS, both within hospitals and at the health system level, by using more rigorous research designs.

Improving ATLS performance in simulated pediatric trauma resuscitation using a checklist

OBJECTIVE

To develop a checklist for use during pediatric trauma resuscitation and test its effectiveness during simulated resuscitations.

BACKGROUND

Checklists have been used to support a wide range of complex medical activities and have effectively reduced errors and improved outcomes in different medical settings. Checklists have not been evaluated in the domain of trauma resuscitation.

METHODS

A focus group of trauma specialists was organized to develop a checklist for pediatric trauma resuscitation. This checklist was then tested in simulated trauma resuscitations to evaluate its impact on team performance. Resuscitations conducted with and without the checklist were compared using the Advanced Trauma Life Support (ATLS) performance score, designed to measure adherence to ATLS protocol, and surveys of team members' subjective workload.

RESULTS

The focus group generated a checklist with 56 items divided into 5 sections corresponding to different phases of trauma resuscitation. In simulation testing, the total ATLS performance score was 4.9 points higher with a checklist than without (P < 0.001), with most of this difference related to improvement in performance of the secondary survey (+3.3 points, P < 0.001). Overall, workload scores were not affected by the addition of the checklist.

CONCLUSIONS

Implementing a checklist during simulated pediatric trauma resuscitation improves adherence to the ATLS protocol without increasing the workload of trauma team members.

A comparison of rural versus urban trauma care

Objective:

We compared the survival of trauma patients in urban versus rural settings after the implementation of a novel rural non-trauma center alternative care model called the Model Rural Trauma Project (MRTP).

Materials and Methods:

We conducted an observational cohort study of all trauma patients brought to eight rural northern California hospitals and two southern California urban trauma centers over a one-year period (1995-1996). Trauma patients with an injury severity score (ISS) of >10 were included in the study. We used logistic regression to assess disparities in odds of survival while controlling for Trauma and Injury Severity Score (TRISS) parameters.

Results:

A total of 1,122 trauma patients met criteria for this study, with 336 (30%) from the rural setting. The urban population was more seriously injured with a higher median ISS (17 urban and 14 rural) and a lower Glasgow Coma Scale (GCS) (GCS 14 urban and 15 rural). Patients in urban trauma centers were more likely to suffer penetrating trauma (25% urban versus 9% rural). After correcting for differences in patient population, the mortality associated with being treated in a rural hospital (OR 0.73; 95% CI 0.39 to 1.39) was not significantly different than an urban trauma center.

Conclusion:

This study demonstrates that rural and urban trauma patients are inherently different. The rural system utilized in this study, with low volume and high blunt trauma rates, can effectively care for its population of trauma patients with an enhanced, committed trauma system, which allows for expeditious movement of patients toward definitive care.

Is the ATLS classification of hypovolaemic shock appreciated in daily trauma care? An online-survey among 383 ATLS course directors and instructors

OBJECTIVE

For the early recognition and management of hypovolaemic shock, ATLS suggests four shock classes based upon an estimated blood loss in percent. The aim of this study was to assess the confidence and acceptance of the ATLS classification of hypovolaemic shock among ATLS course directors and instructors in daily trauma care.

METHODS

During a 2-month period, ATLS course directors and instructors from the ATLS region XV (Europe) were invited to participate in an online survey comprising 15 questions.

RESULTS

A total of 383 responses were received. Ninety-eight percent declared that they would follow the 'A, B, C, D, E' approach by ATLS in daily trauma care. However, only 48% assessed 'C-Circulation' according to the ATLS classification of hypovolaemic shock. One out of four respondents estimated that in daily clinical routine, less than 50% of all trauma patients can be classified according to the current ATLS classification of hypovolaemic shock. Additionally, only 10.9% considered the ATLS classification of hypovolaemic shock as a 'good guide' for fluid resuscitation and blood product transfusion, whereas 45.1% stated that this classification only 'may help' or has 'no impact' to guide resuscitation strategies.

CONCLUSIONS

Although the 'A, B, C, D, E' approach according to ATLS is widely implemented in daily trauma care, the use of the ATLS classification of hypovolaemic shock in daily practice is limited. Together with previous analyses, this study supports the need for a critical reassessment of the current ATLS classification of hypovolaemic shock.

ATLS adherence in the transfer of rural trauma patients to a level I facility

BACKGROUND

Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility.

METHODS

We performed a retrospective analysis of all adult major trauma patients transferred ≥50km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines.

RESULTS

646 patients were analyzed. Mean age was 40.5years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions.

CONCLUSIONS

Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.

Evolution and development of the Advanced Trauma Life Support (ATLS) protocol: a historical perspective

The Advanced Trauma Life Support (ATLS) protocol is a successful course offered by the American College of Surgeons. Once based on didactic lectures and seminars taught by experts in the field, trauma training has evolved to become a set of standardized assessment and treatment protocols based on evidence rather than expert opinion. As the ATLS expands, indices to predict outcome, morbidity, and mortality have evolved to guide management and treatment based on retrospective data. This historical, perspective article attempts to tell the story of ATLS from its inception to its evolution as an international standard for the initial assessment and management of trauma patients.

The effect of a change in the surgeon response time mandate on outcomes within Ohio level III trauma centers: it is all about commitment

BACKGROUND

The American College of Surgeons Committee on Trauma guidelines for trauma center verification stipulate that the responsible surgeon be present within 15 minutes of the arrival of a critically injured patient. Recently, these guidelines were liberalized, extending the response time to 30 minutes in level III trauma centers. This study evaluated the potential impact of this guideline change on the delivery of care at Ohio's level III trauma centers. We hypothesized that there would be no measurable difference in the emergency department (ED) length of stay (LOS), ED disposition, and facility mortality after enactment of this mandate, which extended the surgeon response time from 15 minutes to 30 minutes at level III trauma centers.

METHODS

Data were collected from the trauma registries of 13 level III trauma centers in Ohio beginning 2 years before and ending 2 years after June 30, 2004, the day the response time was extended to 30 minutes. Statistical analyses were completed comparing the two groups in terms of demographic and clinical characteristics, surgeon response time, ED disposition, ED LOS, and facility mortality.

RESULTS

A total of 1,076 patients were treated during the 4-year period. The type of trauma, age, and Injury Severity Score were similar between the two groups. The mean (+/-SD) surgeon response times before and after the rule change were 14.8 minutes (+/-19.4 minutes) and 15.5 minutes (+/-22.3 minutes), respectively. The two groups also had similar ED LOS (mean = 2.9, median = 2.5 for both groups), rates of transfer to higher level centers (34.4% vs. 32.8%; p = 0.58), and facility mortality rates (10.0% vs. 11.2%; p = 0.55).

CONCLUSION

The extension of the surgeon response time from 15 minutes to 30 minutes did not adversely affect the outcomes of trauma patients at Ohio's level III trauma centers. Furthermore, the surgeon response time was similar before and after the rule change.

Trauma systems and timing of patient transfer: are we improving?

INTRODUCTION

The regionalization of trauma services is based on the premise that injured persons presenting to nontertiary facilities will be stabilized and rapidly transported to a more definitive center. Although trauma systems seem to improve outcomes for urban patients, this same benefit has not been shown for rural patients. There are many factors associated with the decision to transfer injured patients to a regional trauma center, including referral hospital and patient age, for example. The purpose of this study is to examine factors that influence the timing of transfer of trauma patients and specifically to determine if establishing specific trauma systems has led to any changes in transfer timing over time.

METHODS

The trauma registry at the University of Wisconsin was queried for all patients admitted between July 1, 1999, and June 30, 2005. Patients were included in this study if they had been transferred to the university hospital after evaluation at an outside hospital. The registry variables that were abstracted were age, referring hospital, emergency department (ED) time at referring hospital, injury severity score (ISS), the presence of a head injury, performance of a head computed tomography (CT), mode of transport, and the date of ED evaluation.

RESULTS

There were 1656 patients with ISS higher than 9 transferred during the period. The mean ED time was 153 +/- 82 minutes. Emergency department time was significantly shorter for those with ISS higher than 25 and for those transported by helicopter. Four hundred ninety-two (30%) patients had a head CT performed at the outside hospital, of which 221 (44%) were repeated at the trauma center. The mean ED time for those in whom a CT was performed was significantly longer than those without CT (179 +/- 81 vs 142 +/- 84 minutes). The ED times were slightly longer for level III hospitals (158 +/- 82 minutes) than for level IV hospitals (137 +/- 74 minutes). Emergency department times were longer for older patients. The times in the ED showed an upward, but not statistically significant, trend. After controlling for all other variables, ED times were not significantly different over the period studied.

CONCLUSION

Development of a statewide trauma system and outreach education has not significantly affected transfer times from nontrauma centers in our system. Outreach educational efforts should focus on systematic trauma evaluation, prompt transfer, and limitation of nontherapeutic testing.

Emergency intubation for acutely ill and injured patients

BACKGROUND

Emergency intubation has been widely advocated as a life saving procedure in severe acute illness and injury associated with real or potential compromises to the patient's airway and ventilation. However, some initial data have suggested a lack of observed benefit.

OBJECTIVES

To determine in acutely ill and injured patients who have real or anticipated problems in maintaining an adequate airway whether emergency endotracheal intubation, as opposed to other airway management techniques, improves the outcome in terms of survival, degree of disability at discharge or length of stay and complications occurring in hospital.

SEARCH STRATEGY

We searched the Cochrane Injuries Group Specialised Register (December 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (1950 to November 2006), EMBASE (1980 to week 50, December 2006), National Research Register (Issue 4, 2006), CINAHL (1980 to December 2006), BIDS (to December 2006) and ICNARC (to December 2006). We also examined reference lists of articles for relevant material and contacted experts in the field. Non-English language publications were searched for and examined.

SELECTION CRITERIA

All randomised (RCTs) or controlled clinical trials involving the emergency use of endotracheal intubation in the injured or acutely ill patient were examined.

DATA COLLECTION AND ANALYSIS

The full texts of 452 studies were reviewed independently by two authors using a standard form. Where the review authors felt a study may be relevant for inclusion in the final review or disagreed, the authors examined the study and a collective decision was made regarding its inclusion or exclusion from the review. The results were not combined in a meta-analysis due to the heterogeneity of patients, practitioners and alternatives to intubation that were used.

MAIN RESULTS

We identified three eligible RCTs carried out in urban environments. Two trials involved adults with non-traumatic out-of-hospital cardiac arrest. One of these trials found a non-significant survival disadvantage in patients randomised to receive a physician-operated intubation versus a combi-tube (RR 0.44, 95% CI 0.09 to 1.99). The second trial detected a non-significant survival disadvantage in patients randomised to paramedic intubation versus an oesophageal gastric airway (RR 0.86, 95% CI 0.39 to 1.90). The third included study was a trial of children requiring airway intervention in the prehospital environment. The results indicated no difference in survival (OR 0.82, 95% CI 0.61 to 1.11) or neurologic outcome (OR 0.87, 95% CI 0.62 to 1.22) between paramedic intubation versus bag-valve-mask ventilation and later hospital intubation by emergency physicians; however, only 42% of the children randomised to paramedic endotracheal intubation actually received it.

AUTHORS' CONCLUSIONS

The efficacy of emergency intubation as currently practised has not been rigorously studied. The skill level of the operator may be key in determining efficacy. In non-traumatic cardiac arrest, it is unlikely that intubation carries the same life saving benefit as early defibrillation and bystander cardiopulmonary resuscitation (CPR). In trauma and paediatric patients, the current evidence base provides no imperative to extend the practice of prehospital intubation in urban systems. It would be ethical and pertinent to initiate a large, high quality randomised trial comparing the efficacy of competently practised emergency intubation with basic bag-valve-mask manoeuvres (BVM) in urban adult out-of-hospital non-traumatic cardiac arrest.

Pediatric pedestrian injuries: emergency care considerations

Pedestrian traffic injuries are a growing public health threat worldwide. The global economic burden of motor vehicle collisions and pedestrian injuries approximates $500 billion. In the United States, the number of pedestrian fatalities increased from 4675 in 2004 to 4881 in 2005. In addition nearly 60,000 injuries occurred during the same year. Injury patterns vary depending on the age, sex, and socioeconomic status of the individual. Children comprise one of the most vulnerable populations in pedestrian traffic injuries. Pedestrian injury remains the second leading cause of unintentional injury-related death among children aged 5 to 14 years. The burden of injury, upon the individual, families, and society, is frequently overwhelming. From recent data, pedestrian injuries and deaths are increasing in the United States and the World, and they require particular attention by emergency care providers and policy makers.

Trauma education and care in the jungle of Ecuador, where there is no advanced trauma life support

BACKGROUND

The advanced trauma life support course is not available or affordable to rural areas in low-income countries. A trauma continuing education course was created to educate physicians of rural hospitals in the jungles of Ecuador.

METHODS

A basic trauma care course was designed based on local resources and location of injury, including rudimentary health posts in the jungle, rural hospitals, and definitive referral centers. Course effectiveness was evaluated by a comparison of test scores before and after the course. A multiple choice questionnaire was given. Comparison to previous test scores was also performed. Paired Student's t test was used for statistical analysis. An objective structured clinical examination (OSCE), based on the course design, was administered.

RESULTS

Twenty-six rural physicians participated in the course. Mean test scores significantly improved from pretest to post-test (72% to 79%; p = 0.032). Knowledge deficiencies in prehospital care, extremity injury care, and patient evaluation adjuncts significantly improved from 23% to 87%, 23% to 100%, and 31% to 100%, respectively. Test results after the course showed improvements in all major categories tested. Twelve of the 26 participants were repeat test takers from a course provided 2 years earlier. These participants showed improved pretest scores compared with their highest previous test score (76.8% versus 68.5%; p = 0.0496). Compared with first-time test takers, these participants showed improved pretest (76.8% versus 68.4%) as well as post-test (81% versus 76%) scores. Twenty-five of the 26 physicians participated in the OSCE, with a pass rate of 76%. The OSCE identified various strengths and deficiencies based on patient location and available resources. In rudimentary health posts, management was adequate for hemorrhage control (65%), immobilization (77%), and early transfer to rural hospitals (92%). Prehospital communication was inadequate (53%). Rural hospital management was adequate for primary evaluation (60%) and resuscitation (74%) but poor in secondary patient evaluation (53%), adjuncts (25%), and transfer to definitive referral centers (11%). OSCE scores differed from multiple choice questionnaire test results.

DISCUSSION

Where there is no advanced trauma life support, a tailored trauma course and evaluation can be effective in educating local providers. A well-designed competency evaluation (multiple choice questionnaire and OSCE) is helpful in identifying deficient local aspects of trauma care. The course design and evaluation methods may serve as a model for continuing trauma care education in developing countries.

Trauma education of junior hospital doctors at a major Australian trauma service

BACKGROUND

Junior hospital doctors are often involved in the early management of major trauma. The present study assesses the access to trauma education and clinical trauma exposure and skills of junior doctors at a major trauma service.

METHODS

A semi-structured questionnaire was distributed to all resident medical officers (pre-registrar level) at a major trauma service. The questionnaire explored the quantity of exposure to major trauma, access to trauma education, self-perceived confidence and experience in basic trauma resuscitative procedures and future career aspirations.

RESULTS

A 70% response rate was achieved; 11% were Basic Surgical Trainees. Mean length of time post-graduation was 2.5 years. Fourteen per cent of respondents had completed the Advanced Trauma Life Support (ATLS) course; another 14% were on the waiting list for the ATLS course. Sixty-four per cent of respondents had attended fewer than five adult major trauma resuscitations in their entire career; 80% had never witnessed a major paediatric trauma resuscitation. Personal confidence in inserting a chest drain, management of cervical spine and airway was reported by 20%, 36% and 63% of respondents, respectively. The majority of respondents had never performed any of these procedures. Basic Surgical Trainees did not feel more confident in performing these procedures. Two-thirds (58%) of respondents nominated a future career aspiration which would potentially require involvement in the early management of major trauma.

CONCLUSIONS

Despite working in a major trauma service, the studied cohort of resident medical officers, including Basic Surgical Trainees, have minimal exposure to major trauma, restricted access to trauma education and limited self-perceived confidence and experience in basic trauma resuscitative procedures.

TRAUMA RECEPTION AND RESUSCITATION

The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity.

Transfer times to definitive care facilities are too long: a consequence of an immature trauma system

OBJECTIVE

The purpose of this study was to review our experience with interfacility transfers to identify problems that could be addressed in the development of a statewide trauma system.

BACKGROUND

The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. This hinges on well-defined prehospital destination criteria, interfacility transfer protocols, and education of caregivers. Patients arriving at local community hospitals (LOCs) benefit from stabilization and transfer to trauma centers (TCs) for definitive care. However, in the absence of a formalized trauma system, patients may not reach the TC in a timely fashion and may not be appropriately treated or stabilized at LOCs prior to transfer.

METHODS

Our facility is a level I TC and regional referral center for a compact geographic area without a formal trauma system. The Trauma Registry was queried for adult patients admitted to the trauma service between January 1, 2001 and March 30, 2003. Patients were divided into 2 groups: those received directly from the scene (DIR) and those transferred from another institution (TRAN). Medical records were reviewed to elucidate details of the early care. Data are presented as mean +/- SEM. Continuous data were compared using Student t test, and categorical data using chi2. Transfer times were analyzed by one-way ANOVA.

RESULTS

A total of 3507 patients were analyzed. The TRAN group had a higher Injury Severity Score (ISS) (17.5 versus 11.0, P < 0.05), lower Glasgow Coma Score (GCS) (13.3 versus 14.1, P < 0.05), lower initial systolic blood pressure (SBP) (130 versus 140, P< 0.05), and higher mortality (10% versus 79%, P < 0.05) than the DIR group. The average time spent at the LOC was 162 +/- 8 minutes. The subgroup of patients with hypotension spent an average of 134 minutes at the LOC, often receiving numerous diagnostic tests despite unavailability of surgeons to provide definitive care. Severe head injury (GCS = 3) triggered more prompt transfer, but high ISS was underappreciated and did not result in a prompt transfer in all but the most severely injured group (ISS > 40). Some therapeutic interventions were initiated at the LOCs, but many were required at the TC. A total of 23 (8%) TRAN patients required critical interventions within 15 minutes of arrival; mortality in this group was 52%. Mortality among those requiring laparotomy after transfer was 33%.

CONCLUSIONS

All but the most severely injured patients spend prolonged periods of time in LOCs, and many require critical interventions upon arrival at the TC. It is unreasonable to expect immediate availability of surgeons or operating rooms in LOCs. Thus, trauma system planning efforts should focus on 1) prehospital destination protocols that allow direct transport to the TC; and 2) education of caregivers in LOCs to enhance intervention skill sets and expedite transfer to definitive care.