A quality-improvement approach to effective trauma team activation

Generation of Trauma Rush Call in Managing Patients With Road Traffic Injuries Visiting the Emergency Department: A Retrospective Analysis

BACKGROUND

Road traffic injuries (RTIs) are currently the ninth most common cause of mortality and are expected to increase in the future. RTIs rank in the top three reasons why young people die. Because of the high incidence and mortality risk, proper trauma care has been prioritized for RTI patients who present to the emergency department. Making appropriate and prompt trauma emergency calls can save lives. Poor resource use and an increased burden of inquiry can result from the inappropriate development of trauma rush calls (TRCs). Therefore, this study aims to evaluate the appropriate generation of TRCs to manage patients with RTIs presenting to the emergency department (ED).

METHODS

A retrospective analysis was conducted at the ED of the private tertiary care hospital in Karachi, Pakistan. Patients with RTIs and TRCs generated for the management were included. Dead on arrival was excluded. A total of 322 patients were enrolled using convenient sampling. A standard Performa was developed to collect the data from medical records, including demographics, clinical characteristics, radiological findings, TRC characteristics, and disposition. Multivariable logistic regression analysis was applied to determine the TRC justified using odds ratios, considering a p-value ≤0.05 as significant.

RESULTS

Of the total 322 patients, the majority were males (n=266, 82.61%) between 21 and 40 years of age. Most patients reported injury/accident through high-speed vehicle crash (n=102, 31.68%). A Glasgow Coma Scale (GCS) score of <14 was recorded in 119 (36.96%) patients, and of 208 patients, 153 (73.55%) had positive computed tomography (CT) head findings, majorly subdural hematoma (n=43, 28.10%). CT cervical spine showed fractures in 14 patients (11.29%). Only one patient had both a positive CT abdomen and focused assessment with sonography in trauma (FAST), with a low systolic blood pressure (SBP) of 85 mmHg, and the CT abdomen showed a grade 3 spleen laceration. TRC was justified in 248 (77.01%) patients. Multivariable analysis showed that a GCS <14 [adjusted odds ratio (aOR) 3.03 (95% CI: 2.58-5.04)] and cervical collar [aOR 3.12 (95% CI: 1.63-5.98)] were the significant predictors for the TRC justified.

CONCLUSION

A GCS <14 and cervical collar significantly justify the generation of TRC. These findings are crucial in educating ED staff regarding optimal care delivery. The future deployment of resources depends on these findings for skill development.

Traffic Patterns and Emergency Medical Services Prenotification Transport Estimates in Trauma Activations

Objective

To determine whether traffic patterns affect the accuracy of emergency medical services (EMS) prediction of transport interval to the emergency department (ED).

Methods

Using a retrospective study, we examined all trauma activations at a level one, urban trauma center in Manhasset, New York, between 5/22/2021 and 3/30/2022. Inclusion criteria included patients ≥18 years and arrival by EMS. Field trauma activations involve prenotification communication through a government intermediary. Transport during "peak hours" was defined as hospital arrival of EMS between 06:00-10:00 and 16:00-20:00, Monday through Friday. ETI and actual transit interval (ATI) were extracted from the recorded prenotification calls and hospital records respectively. In instances with a time range, the arithmetic mean was used. ATI was defined as the time from prenotification call to arrival at the hospital. A 25% difference between EMS ETI and ATI was chosen to categorize each arrival as overestimated (ATI/ETI < 0.75), accurate (ATI/ETI within 0.75-1.25), and underestimated (ATI/ETI > 1.25). Fisher's exact and Wilcoxon Rank Sum tests were used for comparative analysis as appropriate.

Results

Of the 369 trauma transports, 117 had prenotification reports with an ETI and were included in our analysis. Of those, 29 (25%) occurred during peak hours. Overall, EMS more often underestimated ETI (55%) than exactly (32%), or overestimated ETI (12%) (p<0.0001). This was true during peak and off-peak hours with underestimated, accurate, and overestimated arrivals being 59%, 31%, 10% (p<0.01); and 54%, 33%, 12% (p<0.001), respectively. There was no statistically significant difference between peak vs off-peak hours when comparing the proportion of under vs over-estimated times of arrival (p=0.263).

Conclusion

While our hypothesis was not borne out, further research on the antecedents of underestimated transport intervals in traumas is warranted. This will allow for targeted solutions to best support EMS clinicians in communicating transport times back to the ED.

Interprofessional interventions that impact collaboration and quality of care across inpatient trauma care continuum: A scoping review

INTRODUCTION

Despite the recognized importance of interprofessional collaboration (IPC) in trauma care, healthcare professionals often work in silos. Interprofessional (IP) interventions are crucial for optimizing IPC and delivering high-quality care across clinical contexts, yet their effectiveness throughout the inpatient trauma care continuum is not well understood. Thus, this review aimed to examine the literature on the effectiveness of IP interventions on collaboration processes and related outcomes in inpatient trauma care.

METHODS

We conducted a scoping review following Joanna Briggs Institute's methodology. We searched six databases for studies from the last decade on IP interventions in inpatient trauma care. Two independent reviewers categorized IP interventions (education, practice, organization) and extracted their impact on IPC processes and related outcomes (team performance, patient, organization).

RESULTS

Of the 17,397 studies screened, 148 met the inclusion criteria. Most were cohort designs (72%), conducted in level I trauma centers (57%) and emergency departments (51%), and involved surgeons (56%) and nurses (53%). Studies focused on IP organization interventions (51%), such as clinical pathways; IP practice interventions (35%), such as trauma team activation protocols; and IP education interventions (14%) including multi-method education. IP practice interventions most effectively improved team performance results, while IP education interventions primarily improved IPC processes. Positive patient outcomes were limited, with few studies examining organizational effects.

CONCLUSIONS

Significant advancements are still required in IP interventions and trauma care research. Future studies should rigorously explore the effectiveness of interventions throughout the inpatient trauma care continuum and focus on developing robust measures for patient and organizational outcomes.

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study

Background

Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA.

Methods

The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury.

Results

14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%.

Conclusion

The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage.

Level of evidence

2.

Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted, sent to the intensive care unit (ICU), and sent to the operating room (OR).  Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentage of TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

Improving CT scanner efficiency for trauma team activations in the emergency department

BACKGROUND AND OBJECTIVES

A Trauma Team Activation (TTA) is initiated when a patient has sustained a life or limb-threatening injury thereby necessitating resources of a large care team. Previously, a CT scanner was cleared at the time of the prehospital TTA call. Wide variability in the time it took to stabilize patients often led to extended CT scanner idle time. A new policy was developed whereby the team leader would prompt the ED clerk to provide a '5-min heads-up' (5-min HU) notification to the CT scanner personnel as a patient was stabilized. At this point, the CT scanner was cleared. The purpose of this quality improvement project is to evaluate if the new policy saves CT scanner idle time.

METHODS

Research interns prospectively followed incoming TTAs in the ED of a large, urban, Level I Trauma Center in November 2022. The interns collected the following time points: TTA notification page, 5-min HU notification, and arrival to CT. Data was analyzed using a non-parametric comparison test (Mann-Whitney U).

RESULTS

A convenience sample of 46 TTAs was included. Trauma was blunt (85%; n = 39)) and penetrating (15%; n = 7). The median initial TTA announcement to CT arrival time was 24.0 min (IQR: 9.0 min). Previously, the scanner would have been held for this entire period. The median time from 5-min HU notification to CT arrival was 5.0 min (IQR: 4.0 min). The new policy saved a median of 19 min of CT scanner idle time per patient compared to the old policy (p < 0.0001). The total CT scanner time saved was 818 min (13.6 h).

CONCLUSION

These data support the implementation of a 5-min HU policy in the ED for patients arriving as TTAs. This maximizes the availability of CT scanners for other patients in the ED while TTA patients are being stabilized.

Impact of nonphysician, technology-guided alert level selection on rates of appropriate trauma triage in the United States: a before and after study

Purpose

Overtriage and undertriage rates are critical metrics in trauma, influenced by both trauma team activation (TTA) criteria and compliance with these criteria. Analysis of undertriaged patients at a level I trauma center revealed suboptimal compliance with existing criteria. This study assessed triage patterns after implementing compliance-focused process interventions.

Methods

A physician-driven, free-text alert system was modified to a nonphysician, hospital dispatcher-guided system. The latter employed dropdown menus to maximize compliance with criteria. The preintervention period included patients who presented between May 12, 2020, and December 31, 2020. The postintervention period incorporated patients who presented from May 12, 2021, through December 31, 2021. We evaluated appropriate triage, overtriage, and undertriage using the Standardized Trauma Assessment Tool. Statistical analyses were conducted with an α level of 0.05.

Results

The new system was associated with improved compliance with existing TTA criteria (from 70.3% to 79.3%, P=0.023) and decreased undertriage (from 6.0% to 3.2%, P=0.002) at the expense of increasing overtriage (from 46.6% to 57.4%, P<0.001), ultimately decreasing the appropriate triage rate (from 78.4% to 74.6%, P=0.007).

Conclusions

This study assessed a workflow change designed to improve compliance with TTA criteria. Improved compliance decreased undertriage to below the target threshold of 5%, albeit at the expense of increased overtriage. The decrease in appropriate triage despite compliance improvements suggests that the current criteria at this institution are not adequately tailored to optimally balance the minimization of undertriage and overtriage. This finding underscores the importance of improved compliance in evaluating the efficacy of TTA criteria.

Achievement of Key Performance Indicators in Initial Assessment and Care of Injured Patients in Ghanaian Non-tertiary Hospitals: An Observational Study

INTRODUCTION

We aimed to determine the level of achievement of key performance indicators (KPIs) during initial assessment and management of injured persons, as assessed by independent observers, at district and regional hospitals in Ghana.

METHODS

Trained observers were stationed at emergency units of six district (first level) and two regional (referral) hospitals, from October 2020 to February 2021, to observe management of injured patients by health service providers. Achievement of KPIs was assessed for all injured patients and for seriously injured patients (admitted for ≥ 24 h, referred, or died).

RESULTS

Management of 1006 injured patients was observed. Road traffic crash was the most common mechanism (63%). Completion of initial triage ranged from 65% for oxygen saturation to 92% for mobility assessment. For primary survey, airway was assessed in 77% of patients, chest examination performed in 66%, and internal abdominal bleeding assessed in 43%. Reassessment rates were low, ranging from 16% for respiratory rate to 23% for level of consciousness. Thirty-one percent of patients were seriously injured. Completion of KPIs was higher for these patients, but reassessment remained low, ranging from 25% for respiratory rate to 33% for level of consciousness.

CONCLUSION

KPIs were performed at a high level, but several specific elements should be performed more frequently, such as oxygen saturation and assessment for internal abdominal bleeding. Reassessment needs to be performed more frequently, especially for seriously injured patients. Overall, care for the injured at non-tertiary hospitals in Ghana could be improved with a more systematic approach.

A profile of a major trauma centre of North West England between 2011 and 2018

This study examined the trends and patterns of major trauma (MT) activities, causes, mortality and survival at the Aintree Major Trauma Centre (MTC), Liverpool, between 2011 and 2018. The number of trauma team activations (TTAs) rose sharply over time (n = 699 in 2013; n = 1522 in 2018). The proportion of TTAs that involved MT patients decreased from 75.1% in 2013 to 67.4% in 2018. The leading cause of MT was a fall from less than 2 m (36%). There has been a fivefold increase in the overall number of trauma procedures between 2011 and 2018. Orthopaedic surgeons have performed 80% of operations (n = 7732), followed by neurosurgeons, oral and maxillofacial surgeons, and general trauma surgeons. Both types of fall (> 2 m and < 2 m) and road traffic accidents were the three leading causes of death during the study period. The observed mortality rates exceeded that of expected rates in years 2012, 2014, 2016 and 2017. The all-cause observed to expected mortality ratio was 1.08 between 2012 and 2018. A change in care for MT patients was not directly associated with improved survival, although the marginally ascending trend line in survival rates between 2012 and 2018 reflects a gradual positive change.

Management of multiple traumas in emergency medicine department: A review

One of the main causes of adults' disability during their working age is multiple trauma. The process of medical care of patients who are injured seriously is still a challenging job. The primary treatment of these patients in the emergency medicine departments is the most required choice after the wilderness first aid and also would be very required before definitive care in the hospital. The main aim of emergency medicine departments is quick recognition and treatment of injuries which pose severe threat to patients' life in appropriate order of priority. The procedure of primary evaluation in emergency medicine department with the help of medical routine examination and ultrasonography is based on the concept of focused assessment with sonography in trauma (FAST) for identifying spontaneous intraperitoneal hemorrhage. Emergency patients who suffer from massive hematothorax, serious lung and heart traumas, and penetrating traumas to the chest would undergo thoracotomy and patients who have few symptoms of perforated hollow viscous will undergo emergency laparotomy. Based on the trauma severity, emergency treatment could be the way to fast recovery of the structure of injured organ and its function. The subsequent goal, in the acute phase, will concentrate on preventing and stopping bleeding and secondary injuries like painful compartment syndrome or intra-abdominal infections (IAIs). However, the main aim of emergency medicine department in taking care of severely injured patients is the management of airway, protecting circulation and breathing, identification of neurologic problems, and whole body clinical examination with the help of healthcare providers.