Major trauma care in Hong Kong and Germany: a trauma registry data benchmark study

BACKGROUND

Trauma remains a leading cause of death and effective trauma management within a well-developed trauma system has been shown to reduce morbidity and mortality. A trauma registry, as an integral part of a mature trauma system, can be used to monitor the quality of trauma care and to provide a means to compare local versus international standards. Hong Kong and Germany both have highly developed health care services. We compared the performance of trauma systems including outcomes among major trauma victims (ISS > 15) over a 3-year period (2013-2015) in both settings using trauma registry data.

METHODS

This study was a retrospective analysis of prospectively collected data from trauma registries in Hong Kong and Germany. Data from 01/2013 to 12/2015 were extracted from the trauma registries of the five trauma centers in Hong Kong and the TraumaRegister DGU^® (TR-DGU). The study cohort included adults (≥ 18 years) with major trauma (ISS > 15). Data related to patient characteristics, nature of the injury, prognostic parameters to calculate the RISC II score, outcomes and clinical management were collected and compared.

RESULTS

Datasets from 1,864 Hong Kong and 10,952 German trauma victims were retrieved from respective trauma registries. The unadjusted mortality in Hong Kong (22.4%) was higher compared to Germany (19.2%); the difference between observed and expected mortality was higher in Hong Kong (+ 2.7%) than in Germany (- 0.5%). The standardized mortality ratio (SMR) in Hong Kong and Germany were 1.138 (95% CI 1.033-1.252) and 0.974 (95% CI 0.933-1.016), respectively, and the adjusted death rate in Hong Kong was significantly higher compared to the calculated RISC II data. However, patients in Hong Kong were significantly older, had more pre-trauma co-morbidities, more head injuries, shorter hospital and ICU stays and lower ICU admission rates.

CONCLUSION

Hong Kong had a higher mortality rate and a statistically significantly higher standardized mortality ratio (SMR) after RISC II adjustment. However, multiple differences existed between trauma systems and patient characteristics.

Prevalence and Predictors of Under-Diversion in the Primary Trauma Diversion System in Hong Kong

Introduction

Primary trauma diversion (PTD) enables direct transfer of major trauma patients to trauma centres for definitive care. This study aimed to evaluate the performance of PTD in the New Territories West Cluster (NTWC) of Hospital Authority and to identify the predictors for under-diversion.

Methods

A cross-sectional study based on local trauma registry. All major trauma patients (defined as ISS>15 or requiring trauma team activation) in the catchment area of the local hospital from September 2007 to December 2011 were included. The appropriateness of diversion decision was independently evaluated by an expert team (a trauma nurse coordinator and an emergency medicine practitioner). The sensitivity, specificity, predictive values, agreement, over-diversion and under-diversion rates were calculated. Potential predictors for under-diversion including age, Glasgow Coma Scale, mechanism of injury, injured body part, and the distance from scene to the trauma centre/local hospital were employed for logistic regression analysis.

Results

There were 141 eligible cases identified. The sensitivity and specificity for PTD were 59.5% and 96.5% respectively. The over-diversion rate was 3.5% and the under-diversion rate was 40.5%. The overall accuracy was around 74.5%. Non-motor vehicle accident (OR 13, 95% confidence interval [CI]=3.5-48.0, p<0.01) and isolated head injury (OR 5.35, 95% CI=1.5-19.5, p=0.01) were 2 independent predictors for under-diversion in PTD.

Conclusions

The overall field triage compliance by the paramedics is satisfactory. Under-diversion rate in NTWC is high. Non-motor vehicle accident mechanism and isolated head injury are 2 significant predictors for under-diversion. Reinforcement in training to avoid potential pitfalls would improve the paramedics' trauma triage performance.

Over-Triage in Casevac Categorisation is Common in Hong Kong

Objective

To review the categorisation of patients who were transferred out from out-lying islands to urban hospitals utilising casualty evacuation (CASEVAC), and to search for possible patient characteristics which might have contributed to mis-categorisation during the ‘non-flying’ hours.

Methods

The medical records of 459 patients, who were transferred out in the year 2009 were reviewed. Correctness of categorisation was determined by 2 independent assessors according to the CASEVAC guidelines. The rates of mis-categorisation between ‘clinic hours’ and ‘AED hours’, and that between the ‘flying’ and ‘non-flying’ hours, were compared. The patients' demographic data and their presenting symptoms were collected and analysed using logistic regression models to identify factors contributing to mis-categorisation.

Results

The mis-categorisation rate was 60.1%. Among them, all were over-categorised. The over-categorisation rates between ‘clinic hours’ and ‘AED hours’, and between ‘flying’ and ‘non-flying’ hours, were not significantly different (p=0.07 and 0.09, respectively). Abnormal pulse rate was significantly associated with over-categorisation (p<0.01). Patients at extremes of age and psychiatric/drunk patients were significantly less likely to be over-categorised (p<0.05 and p<0.01, respectively). There was 20% disagreement between the two assessors when applying the existing CASEVACs guidelines (kappa score 0.58 or ‘moderate agreement’).

Conclusions

Over-triage in CASEVAC categorisation is common irrespective of the time of day. Revision of the current CASEVAC guidelines is recommended. (Hong Kong j.emerg.med. 2013; 20:327-336)

Clinical Outcomes of Trauma Patients after Implementation of a Standardised Diversion Protocol for Trauma Patients in Two Regional Hospitals in Hong Kong

Introduction

Despite recent advance in prehospital trauma diversion, patients are triaged to the nearest medical facility before transferred to designated trauma centre. A new standardised diversion protocol for trauma patients was implemented on 1st April 2011 to facilitate trauma care. Severely-injured patients were transferred to designated trauma centre directly from emergency department of the regional hospital after initial resuscitation.

Objective

This study was undertaken to examine clinical outcomes of trauma patients after implementation of the new standardised diversion protocol for trauma patients in the emergency department.

Method

This was a before-and-after interventional study on trauma patients presenting to the emergency department in critical or emergency conditions during the study period from 1st April 2011 to 31st March 2012. Patients presented in the two-year period before implementation of the trauma protocol were used as historical control. Medical records of eligible cases were reviewed. Main outcome measures were 30-day mortality, length of hospital stay and time to definitive care. Mortality data was compared with oversea standard by TRISS methodology.

Results

There were 153 eligible patients in the study group and 355 in the historical control group. After new arrangement of trauma diversion, W-statistics improves from -1.26 to 0.09. Z-statistics was -2.03 before and 0.09 after implementation. M-statistics were 0.91 before and 0.88 after the new protocol. Mean time to definitive care was shortened by 33.4 minutes in the subgroup who were transferred to trauma centre after trauma team activation (p=0.005).

Conclusion

A trend of improved outcomes and shorter time to definitive care are observed after implementation of the new trauma diversion protocol. (Hong Kong j.emerg.med. 2015;22:201-209)

Performance of a prehospital trauma diversion system in Hong Kong, China

PURPOSE

To evaluate the performance of a prehospital trauma diversion system in Hong Kong, China.

METHODS

A retrospective analysis of prospectively collected data in the trauma registry of Queen Mary Hospital, Hong Kong from 1 January 2009 to 31 December 2013 was done. All adult patients aged 18 years or above, either primarily or secondarily diverted to Queen Mary Hospital according to the trauma patient diversion protocol, were recruited. Need for trauma center level of care was based on a consensus-based criterion standard published in 2014. Performance of the protocol in terms of over- diversion and under-diversion was determined.

RESULTS

A total of 209 patients were included for analysis. About 30% of the patients required trauma center level of care. The most common reason was the need for vascular, neurologic, abdominal, thoracic, pelvic, spine or limb-conserving surgery within 24 h of presentation. The over-diversion rate and under- diversion rate were 69.6% and 19.7% respectively.

CONCLUSION

The trauma patient diversion protocol currently in use in Hong Kong is not accurate enough. Further revision and refinement is needed.

Traumatic Brain Injury Rehabilitation in Hong Kong: A Review of Practice and Research

Background. The rising public health concern regarding traumatic brain injury (TBI) implies a growing need for rehabilitation services for patients surviving TBI. Methods. To this end, this paper reviews the practices and research on TBI rehabilitation in Hong Kong so as to inform future developments in this area. This paper begins by introducing the general situation of TBI patients in Hong Kong and the need for rehabilitation. Next, the trauma system in Hong Kong is introduced. Following that is a detailed description of the rehabilitation services for TBI patients in Hong Kong, as exemplified by a rehabilitation hospital in Hong Kong. This paper will also review intervention studies on rehabilitating brain-injured populations in Hong Kong with respect to various rehabilitation goals. Lastly, the implications of culture-related issues will be discussed in relation to TBI. Results/Conclusions. The intervention studies conducted in Hong Kong are generally successful in achieving various rehabilitative outcomes. Additionally, certain cultural-related issues, such as the stigma associated with TBI, may impede the rehabilitative process and lead to various psychosocial problems.