National trauma system establishment based on implementation of regional trauma centers improves outcomes of trauma care: A follow-up observational study in South Korea

Effects of Transport to Trauma Centers on Survival Outcomes Among Severe Trauma Patients in Korea: Nationwide Age-Stratified Analysis

BACKGROUND

Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea.

METHODS

Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19-65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted.

RESULTS

Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group.

CONCLUSION

We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.

Trauma Care Systems in Urban Areas: Our Thoughts on the Contrasting Approaches in South Korea and Japan

Trauma is a major global health issue, causing significant mortality, disability, and healthcare expenses. Since 2012, the Ajou Trauma Center in South Korea has been at the forefront, providing centralized severe trauma care for a population of 9.5 million. In 2022, the center managed 3,500 cases of severe trauma, including 500 helicopter transports, and conducted 2,800 surgeries, with 450 addressing torso trauma. Its exceptional performance has garnered global recognition, solidifying its position among the top advanced trauma centers. In Tokyo, critically ill and major trauma patients are currently transported to the nearest emergency and critical care centers, each serving a population of approximately 0.5 to 0.6 million people. Due to the low incidence of trauma per facility and an aging population, implementing a high level of trauma care and a comprehensive training framework within Japan's existing system poses significant challenges. A comparative analysis of South Korea's centralized system and Tokyo's decentralized approach indicates that the centralized system may lead to the establishment of a more advanced trauma center with ethical and equity considerations, compared to the decentralized approach. Therefore, consolidating major trauma cases in Tokyo shows promise for establishing exceptional trauma centers. This emphasizes the urgent need for Japan to take immediate steps towards a more robust future in trauma care. This assertion aligns with the global discourse on improving trauma care practices and could make a valuable contribution to the scholarly literature on trauma care systems.

Perceived trauma nursing core competency, interprofessional collaborative competency, and associated barriers among regional trauma center nurses

INTRODUCTION

As key members of interprofessional teams working in complex settings, nurses in trauma centers require trauma nursing core competency.

PURPOSE

This study sought to determine the levels and relationships of the perceived importance and performance of trauma nursing core competency, as well as the interprofessional collaborative competency and associated barriers among Korean regional trauma center nurses.

METHODS

This cross-sectional, descriptive, and correlational survey involved a convenience sample of 190 Korean trauma center nurses. Data were collected using a web-based self-reporting questionnaire about the perceived importance and performance of trauma nursing core competency, as well as the interprofessional collaborative competency and associated barriers. Data were analyzed using descriptive statistics, Pearson's correlation, and multiple regression (Enter method) analyses.

RESULTS

The perceived performance and importance of interprofessional collaborative competency, the perceived importance of trauma nursing core competency, and the perceived barriers to resources, training, competency, and interest significantly affected trauma nursing core competency performance, accounting for 64.5 % of the variance.

CONCLUSIONS

Training programs are needed to improve the core and interprofessional collaborative competencies of trauma nurses. Individual, team, and organizational approaches are essential to addressing the perceived barriers. The effects of training programs on the core competency of trauma nurses should be validated.

Serum Caffeine Concentration at the Time of Traumatic Brain Injury and Its Long-Term Clinical Outcomes

Caffeine is one of the most widely consumed psychoactive drugs in the general population. It has a neuroprotective effect in degenerative neurological disorders; however, the association between caffeine and traumatic brain injury (TBI) outcomes is contradictory. The objective of this study was to evaluate the association between serum caffeine concentration at the time of injury and long-term functional outcomes of patients with TBI visiting the emergency department (ED). This was a prospective multi-center cohort study including adult patients with intracranial injury confirmed by radiological examination, who visited five participating EDs within 72 h after TBI. The main exposure was the serum caffeine level within 4 h after injury, and the study outcome was a favorable functional recovery at 6 months after injury. Multi-variable logistic regression analysis adjusted for potential confounders was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Among the 334 study participants, caffeine was not detected in 102 patients (30.5 %). In patients with identifiable caffeine level, serum caffeine level was categorized into tercile groups; low (0.01-0.58 μg/mL), intermediate (0.59-1.66 μg/mL), and high (1.67-10.00 μg/mL). The proportions of patients with a 6-month favorable functional recovery were 56.9% in the no-caffeine group, 79.2% in the low-caffeine group, 75.3% in the intermediate-caffeine group, and 66.7% in the high-caffeine group (p = 0.006). In multi-variable logistic regression analysis, the low- and intermediate-caffeine groups were significantly associated with a higher probability of 6-month favorable functional recovery compared with the no-caffeine group [AORs (95% CI): 2.82 (1.32-6.02) and 2.18 (1.06-4.47], respectively. This study showed a significant association between a serum caffeine concentration of 0.01 to 1.66 μg/mL and good functional recovery at 6 months after injury compared with the no-caffeine group of patients with TBI with intracranial injury. These results suggest the possibility of using serum caffeine level as a potential biomarker for TBI outcome prediction and of using caffeine as a therapeutic agent in the clinical care of patients with TBI.

Does the Probability of Survival Calculated by the Trauma and Injury Severity Score Method Accurately Reflect the Severity of Neurotrauma Patients Admitted to Regional Trauma Centers in Korea?

BACKGROUND

Assessing and improving the quality of trauma care is crucial in modern trauma systems and centers. In Korea, evaluations of regional trauma centers are conducted annually to assess and improve trauma management quality. This includes using the Trauma and Injury Severity Score (TRISS) method to calculate the W-score and mortality Observed-to-Expected ratio (O:E ratio), which are used to evaluate the quality of care. We analyzed the potential for overestimation of the probability of survival using TRISS method for patients with neurotrauma, as well as the potential for errors when evaluating and comparing regional trauma centers.

METHODS

We included patients who visited the regional trauma center between 2019 and 2021 and compared their probability of survival of the TRISS method, W-score, mortality O:E ratio, and misclassification rates. The patient groups were further subdivided into smaller subgroups based on age, Glasgow Coma Scale (GCS), and Injury Severity Score, and comparisons were made between the neurotrauma and non-neurotrauma groups within each subgroup.

RESULTS

A total of 4,045 patients were enrolled in the study, with 1,639 of them having neurotrauma. The neurotrauma patient group had a W-score of -0.68 and a mortality O:E ratio of 1.044. The misclassification rate was found to be 13.3%, and patients with a GCS of 8 or less had a higher misclassification rate of 37.4%.

CONCLUSION

The limitations of using the TRISS method for predicting outcomes in patients with severe neurotrauma are exposed in this study. The TRISS methodology demonstrated a high misclassification rate of approximately 40% in subgroups of patients with GCS less than 9, indicating that it may be less reliable in predicting outcomes for severely injured patients with low GCS. Clinicians and researchers should be cautious when using the TRISS method and consider alternative methods to evaluate patient outcomes and compare the quality of care provided by different trauma centers.

National Assessment of Opportunities for Improvement in Preventable Trauma Deaths: A Mixed-Methods Study

Trauma is a significant public health issue worldwide, particularly affecting economically active age groups. Quality management of trauma care at the national level is crucial to improve outcomes of major trauma. In Korea, a biennial nationwide survey on preventable trauma death rate is conducted. Based on the survey results, we analyzed opportunities for improving the trauma treatment process. Expert panels reviewed records of 8282 and 8482 trauma-related deaths in 2017 and 2019, respectively, identifying 258 and 160 cases in each year as preventable deaths. Opportunities for improvement were categorized into prehospital, interhospital, and hospital stages. Hemorrhage was the primary cause of death, followed by sepsis/multiorgan failure and central nervous system injury. Delayed hemostatic procedures and transfusions were common areas for improvement in hospital stage. Interhospital transfers experienced significant delays in arrival time. This study emphasizes the need to enhance trauma care by refining treatment techniques, centralizing patients in specialized facilities, and implementing comprehensive reviews and performance improvements throughout the patient transfer system. The findings offer valuable insights for addressing trauma care improvement from both clinical and systemic perspectives.

Trauma system establishment and outcome improvement: a retrospective national cohort study in South Korea

BACKGROUND

Trauma is a major cause of mortality, disability, and health care costs worldwide. The establishment of a trauma system is known to solve these problems, but few studies have objectively evaluated the impact of a trauma system on outcomes. Since 2012, South Korea has established a national trauma system based on the implementation of 17 regional trauma centers nationwide and the improvement of the prehospital transfer system. This study aimed to measure the changes in performance and outcome according to the established national trauma system.

MATERIAL AND METHODS

In this national cohort-based, retrospective follow-up observational study, the authors calculated the preventable trauma death rate (PTDR) by conducting a multipanel review of patients who died in 2015, 2017, and 2019. Furthermore, the authors constructed a risk-adjusted mortality prediction model of 4 767 876 patients between 2015 and 2019 using the extended-International Classification of Disease Injury Severity Scores to compare outcomes.

RESULTS

The PTDR was lower in 2019 than in 2015 (15.7 vs. 30.5, P <0.001) and 2017 (15.7 vs. 19.9%, P <0.001) representing 1247 additional lives saved in 2019 compared to that in 2015. In the risk-adjusted model, total trauma mortality was highest in 2015 at 0.56%, followed by that in 2016 and 2017 (0.50%), 2018 (0.51%), and 2019 (0.48%), revealing a significant decrease in mortality over the years ( P <0.001 for trend), representing nearly 800 additional lives saved. The number of deaths for more severe patients with a probability of survival less than 0.25 significantly decreased from 81.50% in 2015 to 66.17% in 2019 ( P <0.001).

CONCLUSIONS

The authors observed a significant reduction in the PTDR and risk-adjusted trauma mortality in the 5-year follow-up since 2015 when the national trauma system was established. These findings could serve as a model for low-income and middle-income countries, where trauma systems are not yet established.

National Follow-up Survey of Preventable Trauma Death Rate in Korea

BACKGROUND

The preventable trauma death rate survey is a basic tool for the quality management of trauma treatment because it is a method that can intuitively evaluate the level of national trauma treatment. We conducted this study as a national biennial follow-up survey project and report the results of the review of the 2019 trauma death data in Korea.

METHODS

From January 1, 2019 to December 31, 2019, of a total of 8,482 trauma deaths throughout the country, 1,692 were sampled from 279 emergency medical institutions in Korea. All cases were evaluated for preventability of death and opportunities for improvement using a multidisciplinary panel review approach.

RESULTS

The preventable trauma death rate was estimated to be 15.7%. Of these, 3.1% were judged definitive preventable deaths, and 12.7% were potentially preventable deaths. The odds ratio for preventable traumatic death was 2.56 times higher in transferred patients compared to that of patients who visited the final hospital directly. The group that died 1 hour after the accident had a statistically significantly higher probability of preventable death than that of the group that died within 1 hour after the accident.

CONCLUSION

The preventable trauma death rate for trauma deaths in 2019 was 15.7%, which was 4.2%p lower than that in 2017. To improve the quality of trauma treatment, the transfer of severe trauma patients to trauma centers should be more focused.