Are severely injured trauma victims in Norway offered advanced pre-hospital care? National, retrospective, observational cohort

Exploring the competencies of Chinese critical care nurses in mobile medical teams based on the onion model: A qualitative study

BACKGROUND

With frequent conflicts, natural disasters, and public health emergencies globally, mobile medical teams (MMTs) are becoming increasingly critical. Importantly, the competency of critical care nurses in MMTs can substantially affect the effectiveness and quality of its rescue efforts. Yet, these nurses' competencies are not well understood.

AIM

This study examined the competencies of critical care nurses in MMTs using the Onion Model.

DESIGN

A qualitative descriptive method was used to describe the competencies of Chinese MMT critical care nurses.

METHODS

From April to May 2022, a convenience sample of 18 participants (14 critical care nurses and 4 surgeons) from 10 MMTs was recruited for semi-structured interviews. Deductive and inductive coding methods were combined for content analysis.

RESULTS

In total, 29 competencies were identified, which were grouped into four major domains using the Onion Model. From the outer to inner layers, these domains were knowledge and skills, professional abilities, professional quality, and personal traits. Several novel competencies emerged, including field medical equipment operation skills, on-site hazard identification and safety prevention skills, triage knowledge, and field survival skills.

CONCLUSIONS

Using the Onion Model, this study furthers the understanding of the competency of critical care nurses in MMTs, especially by revealing the novel competencies. Further, the results can be used to recruit, evaluate, and train critical care nurses for MMTs.

RELEVANCE TO CLINICAL PRACTICE

Understanding MMT critical care nurses' competencies can help managers plan and provide relevant training and education before deployment, which can improve nurses' performance, and especially reduce the mortalities and disabilities from trauma.

Dispatch accuracy of physician-staffed emergency medical services in trauma care in south-east Norway: a retrospective observational study

Background

Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement.

Methods

Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times.

Results

Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74–80% and the range of undertriage was 20–32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was “Police/fire brigade request immediate response” recorded in 4321 (22.7%) of the incidents. Criteria from the groups “Accidents” and “Road traffic accidents” were recorded in 10,875 (57.2%) incidents, and criteria from the groups “Transport reservations” and “Unidentified problem” in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records.

Conclusions

Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00982-3.

Teams managing civilian and military complex trauma: What are the competencies required in austere environments and the potential of simulation technology to address them?

Surgical training in civilian hospitals may not be sufficient for managing complex trauma in a setting where such care is not commonly practiced. Understanding the challenges that civilian teams face when moving to austere environments can inform the competencies that need to be trained. The aim of this study was to explore the competencies required in austere environments for teams managing complex trauma, and how they can be trained with simulation technologies. Ethnographic field observations were conducted, and field notes were synthesized. The field notes were structured with the elements of Activity Theory to generate the teams' competencies that need to be trained. A literature review was conducted to verify the results and identify examples of relevant simulation modalities. The analysis resulted in a structured list of competencies for civilian teams to manage complex trauma in an austere environment and recommendations which simulation technologies could be used in training of those competencies based on published studies. Our study contributes to understanding the challenges that civilian teams face when operating in an austere environment. A systematized list of competencies with suggested simulation technologies directs future research to improve quality of complex trauma training in civilian and military collaboration.

Geographical risk of fatal and non-fatal injuries among adults in Norway

INTRODUCTION

A rural gradient in trauma mortality disfavoring remote inhabitants is well known. Previous studies have shown higher risk of traumatic deaths in rural areas in Norway, combined with a paradoxically decreased prevalence of non-fatal injuries. We investigated the risk of fatal and severe non-fatal injuries among all adults in Norway during 2002-2016.

METHODS

All traumatic injuries and deaths among persons with a residential address in Norway from 2002-2016 were included. Data were collected from the Norwegian National Cause of Death Registry and the Norwegian Patient Registry. All cases were stratified into six groups of centrality based on Statistics Norway's classification system, from most urban (group one) to least urban/most rural (group six). Mortality and injury rates were calculated per 100,000 inhabitants per year.

RESULTS

The mortality rate differed significantly among the centrality groups (p<0.05). The rate was 64.2 per 100,000 inhabitants/year in the most urban group and 78.6 per 100,000 inhabitants/year in the most rural group. The lowest mortality rate was found in centrality group 2 (57.9 per 100,000 inhabitants/year). For centrality group 6 versus group 2, the risk of death was increased (relative risk, 1.36; 95%CI: 1.11-1.66; p<0.01). The most common causes of death were transport injury, self-harm, falls, and other external causes. The steepest urban-rural gradient was seen for transport injuries, with a relative risk of 3.32 (95%CI: 1.81-6.10; p<0.001) for group 6 compared with group 1. There was a significantly increasing risk for severe non-fatal injuries from urban to rural areas. Group 2 had the lowest risk for non-fatal injuries (1531 per 100,000 inhabitants/year) and group 6 the highest (1803 per 100,000 inhabitants/year). The risk for non-fatal injuries increased with increasing rurality, with a relative risk of 1.07 (95%CI: 1.02-1.11; p<0.01) for group 6 versus group 1.

CONCLUSIONS

Fatal and non-fatal injury risks increased in parallel with increasing rurality. The lowest risk was in the second most urban region, followed by the most urban (capital) region, yielding a J-shaped risk curve. Transport injuries had the steepest urban-rural gradient.

Disaster preparedness should represent an augmentation of the everyday trauma system, but are we prepared?

Background

The increased frequency, geographical spread and the heterogenicity in mass casualty incidents (MCIs) challenge healthcare systems worldwide. Trauma systems constitute the base for disaster preparedness. Norway is sparsely populated, with four regional trauma centers (TCs) and 35 hospitals treating trauma (non-trauma centers (NTCs)). We wanted to assess whether hospitals fill the national trauma system requirements for competence and the degree of awareness of MCI plans.

Methods

We conducted a cross-sectional survey of on-call trauma teams in all 39 hospitals during two time periods: July–August (holiday season (HS)) and September–June (non-holiday season (NHS)). A standardized questionnaire was used to evaluate the MCI preparedness.

Results

A total of 347 trauma team members participated (HS: 173 and NHS: 174). Over 95% of the team members were aware of the MCI plan; half had read the plan during the last 6 months, whereas 63% at the TCs and 74% at NTCs were confident with their MCI role. Trauma team exercises were conducted regularly and 86% had ever participated. Only 63% at the TCs and 53% at the NTCs had participated in an MCI exercise. The proportion of resident surgeons and anesthetists with >4 years’ clinical experience was significantly higher in TCs (88% and 63%) than in NTCs (27% and 17%). All the on-call consultant surgeons were at home, leaving interns in charge at several of the hospitals. All resident surgeons at the TCs were ATLS providers compared with 64% at the NTCs, and almost 90% of the consultant surgeons had participated in advanced trauma surgical courses.

Discussion

Despite increased national focus on disaster preparedness, we identified limited compliance with trauma system requirements concerning competency and training. Strict guidelines to secure immediate notification and early presence of consultants whenever a situation that might turn into an MCI occurs should be a prerequisite.

Level of evidence

Level IV. Study type: cross- sectional.

The advanced machine learner XGBoost did not reduce prehospital trauma mistriage compared with logistic regression: a simulation study

Background

Accurate prehospital trauma triage is crucial for identifying critically injured patients and determining the level of care. In the prehospital setting, time and data are often scarce, limiting the complexity of triage models. The aim of this study was to assess whether, compared with logistic regression, the advanced machine learner XGBoost (eXtreme Gradient Boosting) is associated with reduced prehospital trauma mistriage.

Methods

We conducted a simulation study based on data from the US National Trauma Data Bank (NTDB) and the Swedish Trauma Registry (SweTrau). We used categorized systolic blood pressure, respiratory rate, Glasgow Coma Scale and age as our predictors. The outcome was the difference in under- and overtriage rates between the models for different training dataset sizes.

Results

We used data from 813,567 patients in the NTDB and 30,577 patients in SweTrau. In SweTrau, the smallest training set of 10 events per free parameter was sufficient for model development. XGBoost achieved undertriage rates in the range of 0.314–0.324 with corresponding overtriage rates of 0.319–0.322. Logistic regression achieved undertriage rates ranging from 0.312 to 0.321 with associated overtriage rates ranging from 0.321 to 0.323. In NTDB, XGBoost required the largest training set size of 1000 events per free parameter to achieve robust results, whereas logistic regression achieved stable performance from a training set size of 25 events per free parameter. For the training set size of 1000 events per free parameter, XGBoost obtained an undertriage rate of 0.406 with an overtriage of 0.463. For logistic regression, the corresponding undertriage was 0.395 with an overtriage of 0.468.

Conclusion

The under- and overtriage rates associated with the advanced machine learner XGBoost were similar to the rates associated with logistic regression regardless of sample size, but XGBoost required larger training sets to obtain robust results. We do not recommend using XGBoost over logistic regression in this context when predictors are few and categorical.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01558-y.

Helicopter Transportation of Brazilian Trauma Patients: A Comparison of Times to Care

OBJECTIVE

The purpose of this study was to analyze helicopter emergency medical service (HEMS) transport with secondary land ambulance transfer, comparing landings performed inside and outside the hospital complex to the emergency department.

METHODS

This was a cross-sectional observational study of HEMS transports of trauma patients between 2016 and 2018 in southern Brazil. Patients were attended by the HEMS team at the trauma site or stabilized in hospitals nearby and subsequently referred to trauma centers. In this region, no trauma centers have their own helipads so helicopters land in remote areas close to the hospital, which may be inside or outside the hospital complex. Both landings require ground emergency medical service transport, with off-site landings necessitating ground emergency medical service transport via public access roads to reach the hospital. Data were analyzed using descriptive statistics, and on-site and off-site transport times were compared using a t-test for independent samples.

RESULTS

Of 176 transports, 28.5% resulted in on-site landings, whereas 71.5% occurred off-site. The ground transport time when the landing zone was off-site was 5 minutes longer than on-site (P < .001).

CONCLUSION

Off-site landings result in longer transports to the emergency room. The construction of helipads in trauma centers can reduce transport time, in addition to reducing the costs and sequelae of trauma.

Undertriage in trauma: an ignored quality indicator?

BACKGROUND

Early identification of life-threatening injuries is essential to reduce morbidity and mortality in trauma patients. Failure to detect severe injury may cause delayed diagnosis and therapeutic interventions and is associated with increased morbidity. A national trauma system will contribute to ensure the optimal care for seriously injured patients throughout the treatment chain by, among other things, defining a sensitive triage tool for identifying severe injury and contribute to correct treatment destination. In 2017, a National trauma plan was implemented in Norway and several quality indicators were recommended to ensure an evaluation of potential gaps between achieved and desired quality, and thereby highlighting areas with potential for quality improvement. With this commentary, we want to draw attention to, what we believe is, an ignoring of an important quality indicator: undertriage in trauma.

MAIN BODY

Severely injured patients not met by a trauma team is commonly referred to as undertriage. An undertriage rate below 5 % is an internationally recognized quality indicator in trauma care and is emphasized in the Norwegian national trauma plan. However, whether hospitals measure and report data about undertriage, have received little attention. Therefore, a national survey was performed among Norwegian hospitals, where thirty-seven of forty trauma receiving hospitals contributed. The results of the survey showed that only half of Norwegian trauma hospitals were capable of providing these data. The results of this survey show that currently the national trauma system is not equipped to obtain important data on an important and specific quality indicator. An ongoing discussion at a national level is how to define severe injury, which may alter future definitions on undertriage.

CONCLUSIONS

Knowledge of undertriage in trauma is important to enhance patient safety, increase the precision of the triage tool and provide valuable learning information to individual hospitals and prehospital services. Currently only half of Norwegian hospitals who receive trauma patients report undertriage rates and unfortunately, only few hospital administrators request these data.

Characteristics of patients treated by the Danish Helicopter Emergency Medical Service from 2014-2018: a nationwide population-based study

Background

A national Helicopter Emergency Medical Service (HEMS) was introduced in Denmark in 2014 to ensure the availability of physician-led critical care for all patients regardless of location.

Appropriate dispatch of HEMS is known to be complex, and resource utilisation is a highly relevant topic. Population-based studies on patient characteristics are fundamental when evaluating and optimising a system. The aim of this study was to describe the patient population treated by the Danish HEMS in terms of demographics, pre-hospital diagnostics, severity of illness or injury, and the critical care interventions performed.

Method

The study is a retrospective nationwide population-based study based on data gathered from the Danish HEMS database. We included primary missions resulting in a patient encounter registered between October 1^st 2014 and April 30^th 2018.

Results

Of 13.391 dispatches registered in the study period we included 7133 (53%) primary missions with patient encounter: 4639 patients were air lifted to hospital, 174 patients were escorted to hospital by the HEMS physician in an ambulance, and in 2320 cases HEMS assisted the ground crew on scene but did not escort the patient to hospital. Patient age ranged from 0-99 years and 64% of the population were men. The median age was 60 years.

The main diagnostic groups were cardio-vascular emergencies (41%), trauma (23%) and neurological emergencies (16%). In 61% of the cases, the patient was critically ill/injured corresponding to a NACA (National Advisory Committee for Aeronautics) score between 4 and 7 (both included). In more than one third of the missions a critical care intervention was performed. Ultrasound examination and endo-tracheal intubation were the critical care interventions most frequently performed (21% and 20%, respectively).

Conclusion

The national Danish HEMS primarily attends severely ill or injured patients and often perform critical care interventions. In addition, the Danish HEMS provides rapid transport to highly specialised treatment for patients in the more rural parts of the country.

Patients with cardio-vascular emergencies, trauma and neurological emergencies are among those patient groups most commonly seen.

We conclude that the overall dispatch profile appears appropriate but emphasise that continuous development and refinement is essential.

Comparing population and incident data for optimal air ambulance base locations in Norway

Background

Helicopter emergency medical services are important in many health care systems. Norway has a nationwide physician manned air ambulance service servicing a country with large geographical variations in population density and incident frequencies. The aim of the study was to compare optimal air ambulance base locations using both population and incident data.

Methods

We used municipality population and incident data for Norway from 2015. The 428 municipalities had a median (5–95 percentile) of 4675 (940–36,264) inhabitants and 10 (2–38) incidents. Optimal helicopter base locations were estimated using the Maximal Covering Location Problem (MCLP) optimization model, exploring the number and location of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, in green field scenarios and conditioned on the existing base structure.

Results

The existing bases covered 96.90% of the population and 91.86% of the incidents for time threshold 45 min. Correlation between municipality population and incident frequencies was −0.0027, and optimal base locations varied markedly between the two data types, particularly when lowering the target time. The optimal solution using population density data put focus on the greater Oslo area, where one third of Norwegians live, while using incident data put focus on low population high incident areas, such as northern Norway and winter sport resorts.

Conclusion

Using population density data as a proxy for incident frequency is not recommended, as the two data types lead to different optimal base locations. Lowering the target time increases the sensitivity to choice of data.

Are severely injured trauma victims in Norway offered advanced pre-hospital care? National, retrospective, observational cohort

Background

Studies of severely injured patients suggest that advanced pre‐hospital care and/or rapid transportation provides a survival benefit. This benefit depends on the disposition of resources to patients with the greatest need. Norway has 19 Emergency Helicopters (HEMS) staffed by anaesthesiologists on duty 24/7/365. National regulations describe indications for their use, and the use of the national emergency medical dispatch guideline is recommended. We assessed whether severely injured patients had been treated or transported by advanced resources on a national scale.

Methods

A national survey was conducted collecting data for 2013 from local trauma registries at all hospitals caring for severely injured patients. Patients were analysed according to hospital level; trauma centres or acute care hospitals with trauma functions. Patients with an Injury Severity Score (ISS) > 15 were considered severely injured.

Results

Three trauma centres (75%) and 17 acute care hospitals (53%) had data for trauma patients from 2013, a total of 3535 trauma registry entries (primary admissions only), including 604 victims with an ISS > 15. Of these 604 victims, advanced resources were treating and/or transporting 51%. Sixty percent of the severely injured admitted directly to trauma centres received advanced services, while only 37% of the severely injured admitted primarily to acute care hospitals received these services.

Conclusion

A highly developed and widely distributed HEMS system reached only half of severely injured trauma victims in Norway in 2013.