Comparison of trauma systems in Asian countries: a cross-sectional study

Disparity in guideline adherence for prehospital care according to patient age in emergency medical service transport for moderate to severe trauma

OBJECTIVES

The aim of this study was to investigate the association between patient age and guideline adherence for prehospital care in emergency medical services (EMS) for moderate to severe trauma.

METHODS

This was a retrospective observational study that used a nationwide EMS-based trauma database from 2016 to 2019. Adult trauma patients whose injury severity score was greater than or equal to nine were screened, and those with cardiac arrest or without outcome data were excluded. The enrolled patients were categorized into four groups according to patient age: young (<45 years), middle-aged (45-64 years), old (65-84 years), and very old (>84 years). The primary outcome was guideline adherence, which was defined as following all prehospital care components: airway management for level of consciousness below verbal response, oxygen supply for pulse oximetry under 94 %, intravenous fluid administration for systolic blood pressure under 90 mmHg, scene resuscitation time within 10 min, and transport to the trauma center or level 1 emergency department. Multivariable logistic regression was conducted to calculate the adjusted odds ratios (aORs) and 95 % confidence intervals (95 % CIs).

RESULTS

Among the 430,365 EMS-treated trauma patients, 38,580 patients were analyzed-9,573 (24.8 %) in the young group, 15,296 (39.7 %) in the middle-aged group, 9,562 (24.8 %) in the old group, and 4,149 (10.8 %) in the very old group. The main analysis revealed a lower probability of guideline adherence in the old group (aOR 95 % CI = 0.84 (0.76-0.94)) and very old group (aOR 95 % CI = 0.68 (0.58-0.81)) than in the young group.

CONCLUSION

We found disparities in guideline adherence for prehospital care according to patient age at the time of EMS assessment of moderate to severe trauma. Considering this disparity, the prehospital trauma triage and management for older patients needs to be improved and educated to EMS providers.

Trauma systems in Asian countries: challenges and recommendations

INTRODUCTION

Trauma burden is one of the leading causes of young human life and economic loss in low- and middle-income countries. Improved emergency and trauma care systems may save up to 2 million lives in these countries.

METHOD

This is a comprehensive expert opinion participated by 4 experts analyzing 6 Asian countries compiling the most pressing trauma care issues in Asia as well as goal directed solutions for uplifting of trauma care in these countries.

RESULT

Lack of legislation, stable funding under a dedicated lead agency is a major deterrent to development and sustainment of trauma systems in most Asian countries. While advocating trauma, critical care as a specialty is a key event in the system establishment, Trauma specialized training is challenging in low resource settings and can be circumvented by regional cooperation in creating trauma specialized academic centers of excellence. Trauma quality improvement process is integral to the system maturity but acquisition and analysis of quality data through trauma specific registries is the least developed in the Asian setting.

Emergency Medical Services in Taiwan: Past, Present, and Future

This review assessed the development of Taiwan's emergency medical services (EMS) and focused on the optimizing initiatives of the EMS systems, the current state of Taiwan's EMS system, EMS benchmarks in different regions of Taiwan, EMS response during the coronavirus disease 2019 (COVID-19) pandemic, and future design. In the past decade, there has been a noticeable increase in prehospital services, numerous optimizing initiatives to improve patient prognosis, and the medical oversight model. Taiwan's current EMS system, including the dispatch system, out-of-hospital cardiac arrest (OHCA) patient management, time-sensitive critical illness in prehospital settings, and disaster response, has undergone significant improvements. These improvements have been demonstrated to have a measurable impact on patient outcomes, as supported by medical literature. Each region in Taiwan has developed a unique EMS system with local characteristics, such as the implementation of the Global Resuscitation Alliance 10 steps for OHCA-related quality control, hearing automated external defibrillator program, a five-level prehospital triage system, an island-hopping strategy for patients with major trauma, dispatcher-assisted teamwork for OHCA resuscitation, and optimized prehospital care for acute coronary syndrome patients. In response to the COVID-19 pandemic from 2019 to 2023, Taiwan's EMS implemented measures to combat the outbreak such as interagency collaboration to obtain patient's personal information, to optimize prehospital management initiatives, and to provide financial compensation and personal insurance for emergency medical technicians. The areas that need focus include integrating prehospital and in-hospital information to build a national-level database (One-Stop Emergency Management), increasing public awareness of first responders and emergency casualty care, and evolving the EMS system by incorporating private EMS system, initiating school-based education of paramedicine, and legally recognizing paramedics as medical and health care personnel. By improving these areas, we can better prepare for the future and ensure that Taiwan's EMS system continues to provide high-quality care to those in need.

The preventability of trauma-related death: A two-year cohort study in a trauma center in middle Taiwan

INTRODUCTION

The preventable death rate (PDR) is an important parameter in the quality assurance of traumatic care. Medical errors or untimely management may occur during stressful trauma care, resulting in preventable deaths. We aimed to develop an applicable PDR model in a trauma center in middle Taiwan.

MATERIALS AND METHODS

We identified adult trauma-related deaths which occurred from January 1, 2018 to December 31, 2019 at our hospital. Patients with a trauma and injury severity score (TRISS) <75% or ≥75% but with a chance of preventability, as determined by a trauma surgeon, were discussed by a panel comprising an emergency physician and surgeons specializing in different fields of medicine. Deaths were subsequently classified as definitely preventable (DP), potentially preventable (PP), or non-preventable (NP). Causes of DP or PP deaths were categorized as delayed diagnosis, delayed treatment, technical error, or inadequate infection prevention/control. The relationship between the time and cause of preventable deaths was also analyzed.

RESULTS

This study included 127 trauma-related deaths, of which 39 were discussed by the panel. Eight patients (6.3%) were categorized as DP, eight (6.3%) as PP, and 111 (87.4%) as NP. Among patients with preventable deaths, inadequate infection prevention/control, delayed treatment, delayed diagnosis, and technical error were identified in six (37.5%), five (31.2%), three (18.8%), and two (12.5%) patients, respectively. Four patients in the inadequate infection prevention/control group (4/6, 66.7%) died of aspiration pneumonia during the recovery phase.

CONCLUSION

A PDR evaluation model was developed and revealed that postoperative care is as important as a timely diagnosis and treatment to avoid preventable deaths following trauma.

Association between Scene Time Interval and Survival in EMS-Treated Major Trauma Admitted to the Intensive Care Unit: A Multinational, Multicenter Observational Study

Objective: Major trauma is a major concern in public health and a leading cause of mortality worldwide. This study aimed to evaluate the association between the prehospital scene time interval (STI) and survival in emergency medical service (EMS)-assessed major trauma patients admitted to the intensive care unit (ICU). Methods: A retrospective observational study using the Pan-Asian Trauma Outcomes Study (PATOS) database was conducted. Adult trauma patients with injury severity scores (ISSs) greater than 15 who were admitted to the ICU were selected. EMS STIs were categorized into three groups: short (0-8 minutes), intermediate (9-16 minutes), and long (over 16 minutes). The primary outcome was survival to hospital discharge, and the secondary outcome was good neurological outcome at hospital discharge. Multivariable logistic regression analysis was conducted to calculate odds ratios and confidence intervals, adjusting for age, sex, mechanism of injury, prehospital alertness, prehospital shock index, response time interval, and EMS intervention (airway, oxygen supplementation, and intravenous fluid administration). Sensitivity analysis for patients who underwent surgery or nontraumatic brain injury cases and interaction analysis by EMS intervention were performed. Results: Data from a total of 1,874 eligible patients were analyzed. Intermediate and long STIs showed significant associations with outcomes, with adjusted ORs (95% CI) of 1.21 (1.07-1.38) in the intermediate STI group and 1.74 (1.55-1.96) in the long STI group for survival and 1.37 (1.32-1.40) in the intermediate STI group and 1.31 (1.22-1.41) in the long STI group for neurological outcome. In the sensitivity analysis, the highest ORs were found in the intermediate STI group, with adjusted ORs (95% CI) of 1.40 (1.37-1.42) for survival and 1.32 (1.26-1.38) for neurological outcome. In the interaction analysis, EMS intervention showed a positive interaction effect with an intermediate STI on survival. Conclusion: In EMS-assessed adult major trauma patients admitted to the ICU, we found significant associations between STIs longer than 8 minutes and outcomes. EMS intervention has a positive interaction effect with an intermediate STI on survival. More research is needed to understand the implications of practice for major trauma in the field.