Application of standard operating procedures accelerates the process of trauma care in patients with multiple injuries:

TraumaFlow-development of a workflow-based clinical decision support system for the management of severe trauma cases

PURPOSE

The treatment of severely injured patients in the resuscitation room of an emergency department requires numerous critical decisions, often under immense time pressure, which places very high demands on the facility and the interdisciplinary team. Computer-based cognitive aids are a valuable tool, especially in education and training of medical professionals. For the management of polytrauma cases, TraumaFlow, a workflow management-based clinical decision support system, was developed. The system supports the registration and coordination of activities in the resuscitation room and actively recommends diagnosis and treatment actions.

METHODS

Based on medical guidelines, a resuscitation room algorithm was developed according to the cABCDE scheme. The algorithm was then modeled using the process description language BPMN 2.0 and implemented in a workflow management system. In addition, a web-based user interface that provides assistance functions was developed. An evaluation study was conducted with 11 final-year medical students and three residents to assess the applicability of TraumaFlow in a case-based training scenario.

RESULTS

TraumaFlow significantly improved guideline-based decision-making, provided more complete therapy, and reduced treatment errors. The system was shown to be beneficial not only for the education of low- and medium-experienced users but also for the training of highly experienced physicians. 92% of the participants felt more confident with computer-aided decision support and considered TraumaFlow useful for the training of polytrauma treatment. In addition, 62% acknowledged a higher training effect.

CONCLUSION

TraumaFlow enables real-time decision support for the treatment of polytrauma patients. It improves guideline-based decision-making in complex and critical situations and reduces treatment errors. Supporting functions, such as the automatic treatment documentation and the calculation of medical scores, enable the trauma team to focus on the primary task. TraumaFlow was developed to support the training of medical students and experienced professionals. Each training session is documented and can be objectively and qualitatively evaluated.

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.

The pelvic vascular injury score (P-VIS): a prehospital instrument to detect significant vascular injury in pelvic fractures

PURPOSE

The purpose of this study was to identify predictive factors for peri-pelvic vascular injury in patients with pelvic fractures and to incorporate these factors into a pelvic vascular injury score (P-VIS) to detect severe bleeding during the prehospital trauma management.

METHODS

To identify potential predictive factors, data were taken (1) of a Level I Trauma Centre with 467 patients (ISS ≥ 16 and AISPelvis ≥ 3). Analysis including patient's charts and digital recordings, radiographical diagnostics, mechanism and pattern of injury as well as the vascular bleeding source was performed. Statistical analysis was performed descriptively and through inference statistical calculation. To further analyse the predictive factors and finally develop the score, a 10-year time period (2012-2021) of (2) the TraumaRegister DGU® (TR-DGU) was used in a second step. Relevant peri-pelvic bleeding in patients with AISPelvis ≥ 3 (N = 9227) was defined as a combination of the following entities (target group PVITR-DGU N = 2090; 22.7%): pelvic fracture with significant bleeding (> 20% of blood volume), Injury of the iliac or femoral artery or blood transfusion of ≥ 6 units (pRBC) prior to ICU admission. The multivariate analysis revealed nine items that constitute the pelvic vascular injury score (P-VIS).

RESULTS

In study (1), 467 blunt pelvic trauma patients were included of which 24 (PVI) were presented with significant vascular injury (PVI, N = 24; control (C, N = 443). Patients with pelvic fractures and vascular injury showed a higher ISS, lower haemoglobin at admission and lower blood pressure. Their mortality rate was higher (PVI: 17.4%, C: 10.3%). In the defining and validating process of the score within the TR-DGU, 9227 patients met the inclusion criteria. 2090 patients showed significant peripelvic vascular injury (PVITR-DGU), the remaining 7137 formed the control group (CTR-DGU). Nine predictive parameters for peripelvic vascular injury constituted the peripelvic vascular injury score (P-VIS): age ≥ 70 years, high-energy-trauma, penetrating trauma/open pelvic injury, shock index ≥ 1, cardio-pulmonary-resuscitation (CPR), substitution of > 1 l fluid, intubation, necessity of catecholamine substitution, remaining shock (≤ 90 mmHg) under therapy. The multi-dimensional scoring system leads to an ordinal scaled rating according to the probability of the presence of a vascular injury. A score of ≥ 3 points described the peripelvic vascular injury as probable, a result of ≥ 6 points identified a most likely vascular injury and a score of 9 points identified an apparent peripelvic vascular injury. Reapplying this score to the study population a median score of 5 points (range 3-8) (PVI) and a median score of 2 points (range 0-3) (C) (p < 0.001). The OR for peripelvic vascular injury was 24.3 for the patients who scored > 3 points vs. ≤ 2 points. The TR-DGU data set verified these findings (median of 2 points in CTR-DGU vs. median of 3 points with in PVITR-DGU).

CONCLUSION

The pelvic vascular injury score (P-VIS) allows an initial risk assessment for the presence of a vascular injury in patients with unstable pelvic injury. Thus, the management of these patients can be positively influenced at a very early stage, prehospital resuscitation performed safely targeted and further resources can be activated in the final treating Trauma Centre.

Design and Development of an Objective Evaluation System for a Web-Based Simulator for Trauma Management

BACKGROUND

Trauma injuries are one of the main leading causes of death in the world. Training with guidelines and protocols is adequate to provide a fast and efficient treatment to patients that suffer a trauma injury.

OBJECTIVES

This study aimed to evaluate deviations from a set protocol, a new set of metrics has been proposed and tested in a pilot study.

METHODS

The participants were final-year students from the Universidad Autónoma de Madrid and first-year medical residents from the Hospital Universitario La Paz. They were asked to train four trauma scenarios with a web-based simulator for 2 weeks. A test was performed pre-training and another one post-training to evaluate the evolution of the treatment to those four trauma scenarios considering a predefined trauma protocol and based on the new set of metrics. The scenarios were pelvic and lower limb traumas in a hospital and in a prehospital setting, which allow them to learn and assess different trauma protocols.

RESULTS

The results show that, in general, there is an improvement of the new metrics after training with the simulator.

CONCLUSION

These new metrics provide comprehensive information for both trainers and trainees. For trainers, the evaluation of the simulation is automated and contains all relevant information to assess the performance of the trainee. And for trainees, it provides valuable real-time information that could support the trauma management learning process.

Simultaneous treatment of trauma patients in a dual room trauma suite with integrated movable sliding gantry CT system: an observational study

The trauma center of the University Hospital Wuerzburg has developed an advanced trauma pathway based on a dual-room trauma suite with an integrated movable sliding gantry CT-system. This enables simultaneous CT-diagnostics and treatment of two trauma patients. The focus of this study was to investigate the quality of the concept based on defined outcome criteria in this specific setting (time from arrival to initiation of CT scan: tCT; time from arrival to initiation of emergency surgery: tES). We analyzed all trauma patients admitted to the hospital’s trauma suite from 1st May 2019 through 29th April 2020. Two subgroups were defined: trauma patients, who were treated without a second trauma patient present (group 1) and patients, who were treated simultaneously with another trauma patient (group 2). Simultaneous treatment was defined as parallel arrival within a period of 20 min. Of 423 included trauma patients, 46 patients (10.9%) were treated simultaneously. Car accidents were the predominant trauma mechanism in this group (19.6% vs. 47.8%, p < 0.05). Prehospital life-saving procedures were performed with comparable frequency in both groups (intubation 43.5% vs. 39%, p = 0.572); pleural drainage 3.2% vs. 2.2%, p = 0.708; cardiopulmonary resuscitation 5% vs. 2.2%, p = 0.387). At hospital admission, patients in group 2 suffered significantly more pain (E-problem according to Advanced Trauma Life Support principles^©; 29.2% vs. 45.7%, p < 0.05). There were no significant differences in the clinical treatment (emergency procedures, vasopressor and coagulant therapy, and transfusion of red blood cells). tCT was 6 (4–10) minutes (median and IQR) in group 1 and 8 (5–15.5) minutes in group 2 (p = 0.280). tES was 90 (78–106) minutes in group 1 and 99 (97–108) minutes in group 2 (p = 0.081). The simultaneous treatment of two trauma patients in a dual-room trauma suite with an integrated movable sliding gantry CT-system requires a medical, organizational, and technical concept adapted to this special setting. Despite the oftentimes serious and life-threatening injuries, optimal diagnostic and therapeutic procedures can be guaranteed for two simultaneous trauma patients at an individual medical level in consistent quality.

Trauma burden, patient demographics and care-process in major hospitals in Tanzania: A needs assessment for improving healthcare resource management

Background

Appropriate referrals of injured patients could improve clinical outcomes and management of healthcare resources. To gain insights for system development, we interrogated the current situation by assessing burden, patient demography, causes of injury, trauma mortality and the care-process.

Methods

We used an observational, cross-sectional study design and convenience sampling to review patient charts from 3 major hospitals and the death registry in Tanzania.

Results

Injury constitutes 9–13% of the Emergency Centre census. Inpatient trauma-deaths were 8%; however, the trauma death registry figures exceeded the ‘inpatient deaths’ and recorded up to 16%. Most patients arrive through a hospital referral system (82%) and use a hospital transport network (76%). Only 8% of the trauma admissions possessed National Health Insurance. Road traffic collision (RTC) (69%), assault (20%) and falls (9%) were the leading causes of injury. The care process revealed a normal primary-survey rate of 73–90%. Deficiencies in recording were in the assessment of: Airway and breathing (67%), circulation (40%) and disability (80%). Most patients had non-operative management (42–57%) or surgery for wound care or skeletal injuries (43%). Laparotomies were performed in 26%, while craniotomy and chest drain-insertion were each performed in 10%.

Conclusion

The burden of trauma is high, and the leading causes are: RTC, assault, and falls. Deaths recorded in the death registries outweigh in-hospital deaths for up to twofold. There are challenges in the care process, funding and recording. We found a functional hospital referral-network, transport system, and death registry.

Pediatric Drowning: A Standard Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion

OBJECTIVES

Drowning is one of the leading causes of death in children. Resuscitating a child following submersion is a high-pressure situation, and standard operating procedures can reduce error. Currently, the Resuscitation Council UK guidance does not include a standard operating procedure on pediatric drowning. The objective of this project was to design a standard operating procedure to improve outcomes of drowned children.

METHODS

A literature review on the management of pediatric drowning was conducted. Relevant publications were used to develop a standard operating procedure for management of pediatric drowning.

RESULTS

A concise standard operating procedure was developed for resuscitation following pediatric submersion. Specific recommendations include the following: the Heimlich maneuver should not be used in this context; however, prolonged resuscitation and therapeutic hypothermia are recommended.

CONCLUSIONS

This standard operating procedure is a potentially useful adjunct to the Resuscitation Council UK guidance and should be considered for incorporation into its next iteration.

Time to computed tomography: does this affect trauma patient outcomes? A retrospective analysis at an Australian major trauma centre

BACKGROUND

Computed tomography (CT) is an essential diagnostic tool for severe multi-trauma patients. International guidelines recommend an optimal time of 1 h from arrival. The aim of this study was to determine the time interval from arrival at the emergency department to CT for all trauma patients and the effects on in-hospital mortality and hospital length of stay.

METHODS

Retrospective study of all patients who triggered a trauma call and underwent CT scanning at the Gold Coast University Hospital from January 2016 to December 2017. Exclusion criteria were scans performed at peripheral hospitals or performed more than 5 h after arrival to emergency department.

RESULTS

One thousand six hundred and nineteen eligible trauma patients were admitted over the study period and underwent CT scanning. Median time to CT was found to be 43 min. CTs done within 1 h compared to those done after 1 h from emergency department arrival were found to have a higher mean injury severity score (11 ± 10 versus 9 ± 9, P = 0.003), a longer mean hospital length of stay (9 ± 21 versus 7 ± 13 days, P = 0.012) and no difference in mortality rates (2.2% versus 2.1%, P = 1.000). Age, injury severity score and intubation status were identified as independent predictors for longer hospital length of stay and higher mortality while time to CT did not. Injury severity score was shown to be an independent predictor of time to CT.

CONCLUSION

Our time to CT scanning is well within the timeframe recommended by international guidelines. Early CT scanning may also improve outcomes in severely injured trauma patients.

Non-randomized comparative study on the efficacy of a trauma protocol in the emergency department

PURPOSE

Trauma is a major health problem in developing countries and worldwide which requires many resources and much time in an emergency department (ED). Although Advanced Trauma Life Support (ATLS) is the gold standard, operator dependence can affect the quality of care. The objective was to identify differences in numbers and time to lifesaving interventions, investigation, ED length of stay, and mortality between an in-house protocol and conventional practice.

METHODS

This was a single-center prospective non-randomized study for adult trauma patients in the ED. The trauma protocol was developed from the recent ATLS guideline.

RESULTS

Thirty-two and 41 cases were in the in-house protocol group and conventional practice group, respectively. Endotracheal intubation was done more frequently in the in-house protocol group (84% vs. 59%, p = 0.03). Intercostal drainage tube insertion was done faster (6-26 min, median 11 min vs. 15-84 min, median 35 min, p = 0.02) and pre-arrival notification by emergency medical service increased in the in-house protocol group (66% vs. 30%, p = 0.01). Hypothermia in the operating room was found only in the conventional practice group (62% vs. 0, p = 0.007) and a warm blanket was used significantly more often in the in-house protocol group (25% vs. 0, p < 0.001). A directed acyclic graph with multivariate analysis was used to identify confounders. Time to Focused Assessment Sonography in Trauma was significantly shorter in the in-house protocol group (6.5-15.6 min, median 11 min, p = 0.019).

CONCLUSION

In addition to the ATLS guideline, the trauma protocol could improve trauma care by reduced time to investigation, early notification of the trauma team in pre-hospital situations, reduced incidence of hypothermia in the operating room, and increased use of a warm blanket.

Clinical implications of fracture-associated vascular damage in extremity and pelvic trauma

BACKGROUND

Vascular damage in polytrauma patients is associated with high mortality and morbidity. Therefore, specific clinical implications of vascular damage with fractures in major trauma patients are reassessed.

METHODS

This comprehensive nine-year retrospective single center cohort study analyzed demography, laboratory, treatment and outcome data from 3689 patients, 64 patients with fracture-associated vascular injuries were identified and were compared to a control group.

RESULTS

Vascular damage occurred in 7% of patients with upper and lower limb and pelvic fractures admitted to the trauma room. Overall survival was 80% in pelvic fracture and 97% in extremity fracture patients and comparable to non-vascular trauma patients. Additional arterial damage required substantial fluid administration and was visible as significantly anemia and disturbed coagulation tests upon admission. Open procedures were done in over 80% of peripheral extremity vascular damage. Endovascular procedures were predominant (87%) in pelvic injury.

CONCLUSION

Vascular damage is associated with high mortality rates especially in combination with pelvic fractures. Initial anemia, disturbed coagulation tests and the need for extensive pre-clinical fluid substitution were observed in the cohort with vascular damage. Therefore, fast diagnosis and early interventional and surgical procedures are necessary to optimize patient-specific outcome.

Mapping the continuum of care to surgery following traumatic spinal cord injury

BACKGROUND

Traumatic spinal cord injury (SCI) is a devastating injury, frequently resulting in paralysis and a lifetime of medical and social problems. Reducing time to surgery may improve patient outcomes. A vital first step to reduce times is to map current pathways of care from injury to surgery, identify rapid care pathways and factors associated with rapid care pathway times.

METHODS

A retrospective review of the Alfred Trauma Service records was undertaken for all cases of spinal injury recorded in the Alfred Trauma Registry over a three year period. Patients with an Abbreviated Injury Scale (AIS) code matching 148 codes for spinal injury were included in the study. Information extracted from the Alfred Trauma Registry included demographic, clinical and key care timelines.

RESULTS

Of the 342 cases identified, 119 had SCI. The average age of SCI patients was 52 years, with 84% male. The vast majority of SCI patients experienced multiple concurrent injuries (87%). Median time from injury to surgery was 17 h r 28 min for SCI patients in comparison to 28 h r 23 min for non-SCI patients. Three pathways to surgery were identified following Trauma Centre presentation- transfer to surgery direct from trauma unit (median time to surgery was 4 h 17 min.), via Intensive Care (median time to surgery was 24 h 33 min) and via the ward (median time to surgery 28 h r 35 min.) SCI was independently associated with the fastest pathway - direct transfer from trauma unit to surgery - with 41% of SCI cases transferred directly to surgery from the trauma unit.

CONCLUSION

Notwithstanding that the vast majority of SCI patients presented with other traumatic injuries, half of all SCI cases reached surgery within 18 h of injury, with 25% within 9 h. SCI was independently associated with direct transfer to surgery from the trauma unit. SCI patients achieve rapid times to surgery within a complex trauma service. Furthermore, the trauma system is well positioned to implement further time reductions to surgery for SCI patients.

Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review

OBJECTIVES

This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome.

METHODS

An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes.

RESULTS

The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients.

CONCLUSIONS

The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.

Coma of unknown origin in the emergency department: implementation of an in-house management routine

BACKGROUND

Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines.

METHODS

We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in-house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed "coma alarm"). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP.

RESULTS

During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1-4), then fluctuated between 84 and 94 % (months 5-24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period. We achieved a median door-to-CT time of 20 minutes. 85 % of patients needed subsequent ICU treatment, 40 % of which required specialised neuro-ICUs.

DISCUSSION

Our results indicate that our new simple in-house triage criteria may be sufficient to identify eligible patients before arrival. We aimed at ensuring the fastest possible proceedings given high portions of underlying time-sensitive neurological and medical pathologies while using all available resources as purposefully as possible.

CONCLUSIONS

Our SOP may provide an appropriate tool for efficient management of patients with non-traumatic coma. Our results justify the assignment of the initial diagnostic workup to neurologists and internal specialists in collaboration with anaesthesiologists.

Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill

INTRODUCTION

Rapid sequence induction (RSI) of critically ill patients outside of theatres is associated with a higher risk of hypoxia, cardiovascular collapse and death. In the prehospital and military environments, there is an increasing awareness of the benefits of standardised practice and checklists.

METHODS

We conducted a non-systematic review of literature pertaining to key components of RSI preparation and management. A standard operating procedure (SOP) for in-hospital RSI was developed based on this and experience from large teaching hospital anaesthesia and critical care departments.

RESULTS

The SOP consists of a RSI equipment set-up sheet, pre-RSI checklist and failed airway algorithm. The SOP should improve RSI preparation, crew resource management and first pass intubation success while minimising adverse events.

CONCLUSION

Based on the presented literature, we believe the evidence is sufficient to recommend adoption of the core components in the suggested SOP. This standardised approach to RSI in the critically ill may reduce the current high incidence of adverse events and hopefully improve patient outcomes.

Adherence to ATLS primary and secondary surveys during pediatric trauma resuscitation

STUDY AIM

Adherence to Advanced Trauma Life Support (ATLS) protocol has been associated with improved management of injured patients. The objective of this study is to determine factors associated with delayed and omitted ATLS primary and secondary survey tasks at a level 1 pediatric trauma center.

METHODS

Video recorded resuscitations of 237 injured patients <18 years old obtained over a four month period at our hospital were evaluated to assess completeness and timeliness of essential tasks in the primary and secondary survey of ATLS. Multivariate analyses were performed to identify features associated with decreased ATLS performance.

RESULTS

Primary survey findings were stated less often in patients with burn injuries compared to those with blunt injuries (RR=1.72; 95% CI: 1.26-2.35) and less often during the overnight shift [11 PM-7 AM] (RR=1.22; 95% CI: 1.02-1.46). Secondary survey findings were verbalized less often in patients with penetrating injures (RR=2.30; 95% CI: 1.06-5.00). Time to statement of primary surveys findings was delayed in patients with burn injuries (HR=0.69; 95% CI: 0.48-0.98) and among those transferred from another hospital. Completeness and timeliness of ATLS task performance were not associated with age or injury severity score.

CONCLUSIONS

Mechanism of injury and hospital factors are associated with incomplete and delayed primary and secondary surveys. Interventions that address deficient ATLS adherence related to these factors may lead to a reduction in errors during this critical period of patient care.

[The White Paper on treating medical emergencies preclinically and at hospital : how can it be implemented?]

Up-to-date management of medical emergencies implies primarily that definitive diagnoses and treatment are performed in a timely manner. These claims have been reconfirmed in 2007 by the leading German language medical associations in their "White Paper on Emergency Treatment". To actually realize the demands described in this paper a timely, transsectoral and close collaboration of all involved organizations is mandatory. To illustrate this race against cell death the phrase relay of survival is proposed and launched to replace the hitherto used but rigid concept of chain of survival. The tasks of each member of this relay of survival are critically scrutinized one after the other from a patient perspective. The paper presents tangible recommendations for improving the respective individual performance as well as, in particular, the cooperation and coordination between the team members which is comparable to handing over the baton in a relay race.

[Advanced Trauma Life Support (ATLS) in the emergency room. Is it suitable as an SOP?]

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

Impact of a care pathway in acute pancreatitis

BACKGROUND

Previous studies have shown that accurate process of care predicts quality of care. Few examples currently exist for process of care for the acute surgical patient. A recent region wide audit had identified good outcomes for patients with acute pancreatitis at our institution but aspects of care that could be improved.

METHODS

For this re-audit, a simple written care pathway for the management of those presenting with acute pancreatitis was introduced in our institution from February to July 2009. The audit standards were set against the British Society of Gastroenterology (BSG) guidelines for management of acute pancreatitis and were compared with the previous region wide audit.

RESULTS

Marked improvements were noted in the rates of abdominal imaging achieved within 24 h of diagnosis (35.2% vs 47.7%), severity stratification within 48 h of diagnosis (28.7% vs 75%), critical care admission for those classified as severe (39.3% vs 63.6%) and definitive treatment during index admission (22.2% vs 38.5%). Survival rates were 100% for this audit cycle and 95% for all patients within the region wide audit. Despite these improvements, care still does not reach the standards set out by BSG.

CONCLUSION

Predefined processes of care may help to recognise those developing or likely to develop severe pancreatitis, ensure accurate documentation of severity, expedite critical care review and/or admission, and help to encourage the timely management of those with a treatable underlying cause of their pancreatitis.

[Different case fatality rates at German trauma centres : Critical analysis]

OBJECTIVE

The level of trauma care in Germany belongs to one of the best worldwide. Nevertheless, previous studies have shown significant differences in the case fatality rates of multiple trauma patients in German trauma centres. The objective of this study was to indentify the reasons for the different outcomes based on data of the trauma registry of the German Society of Orthopaedic Surgery and Traumatology.

METHODS

Due to the inadequacy of comparing only the case fataltiy rates in the different trauma centres, the data recorded in the trauma registry were analyzed in a retrospective, multicentre study to calculate the probability of survival, revised injury severity classification (RISC) and, additionally, the standardized mortality ratio (SMR) for ranking of the participating trauma centres. As a criterion for inclusion in the study, a minimum of 100 trauma patients admitted directly from the scene within a 4 year period was set. The ranking was carried out using the SMR (observed mortality divided by probability of survival). With the help of data from the trauma registry an attempt was made to find the differences in trauma management between the top 10 centres (lowest SMR), the 10 middle and the last 10 centres (highest SMR) in the ranking.

RESULTS

The data of 6,522 patients were included in the study. There were significant differences in the pre-hospital time, the time spent in the emergency room (ER) and time until a CT scan had been performed. Pre-hospital time was longer in patients admitted to the top centres, whereas time in the ER was longer in the last centres of the ranking. Comparing the sum of pre-hospital time and time in the ER, there were no differences between the top and the last centres. At the scene of accident overall intubation rate and intubation rate in patients with traumatic brain injury were higher in patients admitted to the top centres. Regarding the transport modality, significantly more patients were transported by helicopter in the group of the top centres. In top centres CT scans, in particular whole-body CTs, were initiated sooner and used much more frequently so that the rate of missed injuries was much lower. The amount of fluid given at the scene of accident did not differ between the centres but the amount of fluid given in ER and the operating room until admission to the intensive care unit was significantly higher in the top centres.

CONCLUSION

There are significant differences in the pre-hospital and clinical care of patients admitted to German trauma centres. Under clinical conditions a tight time management, an immediate and complete diagnostic approach, particularly by means of whole-body CT and a liberal fluid resuscitation seem to be favorable factors.

Impact of a multifunctional image-guided therapy suite on emergency multiple trauma care

Background

The multifunctional image-guided therapy suite (MIGTS), a combined diagnostic and operating theatre, is currently the subject of considerable interest. This study investigated the effect of instituting a MIGTS on the emergency treatment of multiply injured patients.

Methods

This prospective controlled intervention study (MIGTS versus conventional treatment) included consecutive multiply injured trauma patients (Injury Severity Score of 16 or more) admitted between February 2003 and April 2005 to a university hospital. Main outcome measures were time to computed tomography (CT) and number of in-hospital transfers.

Results

A total of 168 patients were enrolled, 87 in the MIGTS and 81 in the control group. On average, CT was started at least 13 min sooner in the MIGTS group (P &lt; 0·001), and these patients underwent fewer within-hospital transfers before arrival in the intensive care unit (median 2 versus 4 for controls; odds ratio −2·92, P &lt; 0·001). Team members indicated increased satisfaction with the quality of the MIGTS procedure over the course of the study (P = 0·009). Thirty-day mortality rate (17 per cent for MIGTS versus 22 per cent for controls; P = 0·420) and long-term outcome did not differ between the two groups.

Conclusion

Implementation of a MIGTS in the emergency treatment of multiple trauma significantly accelerated the procedure and reduced the number of in-hospital transports. Registration number: NCT0072213 (http://www.clinicaltrials.gov).