Effective transport for trauma patients under current circumstances in Korea: a single institution analysis of treatment outcomes for trauma patients transported via the domestic 119 service

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Time-saving effects using helicopter transportation: comparison to a ground transportation time predicted using a social navigation software

Previous comparison studies regarding 2 types of transportation, helicopter (HEMS) versus ground emergency medical services (GEMS), have shown underlying heterogeneity as these options have completely different routes and consequent times with reference to one patient. To compare the 2 types of transportation on a case-by-case basis, we analyzed the retrospectively reviewed HEMS and predicted GEMS data using an open-source navigation software.Patients transferred by military HEMS from 2016 to 2019 were retrospectively enrolled. The HEMS records on the time of notification, injury point and destination address, and time required were reviewed. The GEMS data on distance and the predicted time required were acquired using open-source social navigation systems. Comparison analyses between the two types of transportation were conducted. Furthermore, linear logistic regression analyses were performed on the distance and time of the two options.A total of 183 patients were enrolled. There was no statistical difference (P = .3021) in the distance between the 2 types of transportation, and the HEMS time was significantly shorter than that of GEMS (61.31 vs 116.92 minutes, P < .001). The simple linear curves for HEMS and GEMS were separately secured, and two graphs presented the statistical significance (P) as well as reasonable goodness-of-fit (R2). In general, the HEMS graph demonstrates a more gradual slope and narrow distribution compared to that of GEMS.Ideally, HEMS is identified as a better transportation modality because it has a shorter transportation time (56 minutes saved) and a low possibility of potential time delays (larger R2). With a strict patient selection, HEMS can rescue injured or emergent patients who are "out of the golden hour."

Development and validation of a scoring system for mortality prediction and application of standardized W statistics to assess the performance of emergency departments

Background

In-hospital mortality and short-term mortality are indicators that are commonly used to evaluate the outcome of emergency department (ED) treatment. Although several scoring systems and machine learning-based approaches have been suggested to grade the severity of the condition of ED patients, methods for comparing severity-adjusted mortality in general ED patients between different systems have yet to be developed. The aim of the present study was to develop a scoring system to predict mortality in ED patients using data collected at the initial evaluation and to validate the usefulness of the scoring system for comparing severity-adjusted mortality between institutions with different severity distributions.

Methods

The study was based on the registry of the National Emergency Department Information System, which is maintained by the National Emergency Medical Center of the Republic of Korea. Data from 2016 were used to construct the prediction model, and data from 2017 were used for validation. Logistic regression was used to build the mortality prediction model. Receiver operating characteristic curves were used to evaluate the performance of the prediction model. We calculated the standardized W statistic and its 95% confidence intervals using the newly developed mortality prediction model.

Results

The area under the receiver operating characteristic curve of the developed scoring system for the prediction of mortality was 0.883 (95% confidence interval [CI]: 0.882–0.884). The Ws score calculated from the 2016 dataset was 0.000 (95% CI: − 0.021 – 0.021). The Ws score calculated from the 2017 dataset was 0.049 (95% CI: 0.030–0.069).

Conclusions

The scoring system developed in the present study utilizing the parameters gathered in initial ED evaluations has acceptable performance for the prediction of in-hospital mortality. Standardized W statistics based on this scoring system can be used to compare the performance of an ED with the reference data or with the performance of other institutions.

Sign of Life is Associated with Return of Spontaneous Circulation After Resuscitative Thoracotomy: Single Trauma Center Experience of Republic of Korea

BACKGROUND

Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been performed in Korea. In this study, we review our experience of RT after a regional trauma center was constructed.

METHODS

This is a retrospective study of RT conducted at a single Korean trauma center from May 2014 to March 2018. The primary outcome was survival, and the secondary outcome was return of spontaneous circulation (ROSC). The clinical characteristics of the patients were compared between the ROSC and non-ROSC groups. Survivors were also reviewed.

RESULTS

A total of 62 patients were reviewed, and 60 patients had experienced blunt injury. Thirty-nine patients had ROSC. The ROSC group had short cardiopulmonary resuscitation (CPR) time (6 [2-10] min vs 11 [8-12] min, p < 0.001), the presence of sign of life at the trauma bay [32 (86.5%) vs 7 (28.0%), p < 0.001], and a low Injury Severity Score [26 (25-39) vs 37 (30-75), p = 0.038] compared to the non-ROSC group. On multivariate analysis, only the presence of sign of life was significantly associated with ROSC [11.297 (1.496-85.309) OR (95% CI), p = 0.019]. The 24-h survival rate was 8.1%, and the successful discharge rate was 4.8%.

CONCLUSION

The outcome of RT in a Korean trauma center was favorable. ROSC after RT was strongly associated with the presence of sign of life, and RT may be performed in the presence of sign of life regardless of prehospital CPR time.

Reduced Mortality in Severely Injured Patients Using Hospital-based Helicopter Emergency Medical Services in Interhospital Transport

Recent evidence has demonstrated the survival benefits of helicopter transport for trauma patients. The purpose of this study was to evaluate the effectiveness of hospital-based helicopter emergency medical services (H-HEMS) in comparison with ground ambulance transport in improving mortality outcomes in patients with major trauma. Study participants were divided into 2 groups according to type of transport to the trauma center; that is, either via ground emergency medical services (GEMS) or via H-HEMS. The study was conducted from October 2013 to July 2015. Mortality outcomes in the H-HEMS group were compared with those in the GEMS group by using the Trauma and Injury Severity Score (TRISS) analysis. The number of participants finally included in the study was 312. Among these patients, 63 were adult major trauma patients transported via H-HEMS, and 47.6% were involved in traffic accidents. For interhospital transport, the Z and W statistics revealed significantly higher scores in the H-HEMS group than in the GEMS group (Z statistic, 2.02 vs. 1.16; P = 0.043 vs. 0.246; W statistic, 8.87 vs. 2.85), and 6.02 more patients could be saved per 100 patients when H-HEMS was used for transportation. TRISS analysis revealed that the use of H-HEMS for transporting adult major trauma patients was associated with significantly improved survival compared to the use of GEMS.

Hospital Mortality Based on the Mode of Emergency Medical Services Transportation

OBJECTIVE

We assessed the presentations and outcomes of trauma patients transported by helicopter emergency medical services (HEMS) versus ground emergency medical services (GEMS).

METHODS

A retrospective analysis of trauma registry data at a level I trauma center was conducted for patients transported by GEMS and HEMS between 2011 and 2013. Data were analyzed and categorized based on the mode of transportation.

RESULTS

A total of 4,596 trauma patients were admitted to the hospital with a mean age of 31 ± 15 years. Injured patients were transported to the trauma center by GEMS (93.3%) and HEMS (6.7%). The common mechanisms of injury were motor vehicle crash (37%) and falls (25%). Compared with GEMS, patients transported by HEMS were characterized by having a greater injury severity, more proportion of traumatic brain injury, on-scene intubation, and a 2.5-fold higher mortality. However, the impact of mode of transportation on the hospital mortality among severely injured patients has disappeared after adjusting for potential confounders.

CONCLUSION

Patients transported by HEMS may have different characteristic features and outcomes when compared with GEMS. However, further work is needed to identify the subgroups of trauma patients who clearly benefit from the use of HEMS.

Positive correlation between regional emergency medical resources and mortality in severely injured patients: results from the Korean National Hospital Discharge In-depth Survey

OBJECTIVES

In South Korea, injury is a public health problem due to its high incidence and high mortality. To improve emergency medical systems, the government announced plans to increase the emergency medical resources for each region. This study investigated the association between regional emergency medical resources and mortality during hospitalization in severely injured inpatients.

METHODS

To analyse mortality for severely injured inpatients, we used the Korean National Hospital Discharge In-depth Survey data, consisting of 18,621 hospitalizations from 2005-2012. Generalized estimating equations were analysed to examine the association between mortality during hospitalization and both individual and regional variables.

RESULTS

Mortality during hospitalization occurred in 913 (4.9%) cases. Patients in regions with a higher number of emergency departments (odds ratio [OR]=0.94, 95% confidence interval [CI]: 0.91-0.98), a higher number of ambulances (OR=0.99, 95% CI: 0.98-0.99), and a higher number of registered nurses per emergency department (OR=0.88, 95% CI: 0.83-0.94) had a lower risk of mortality during hospitalization.

CONCLUSIONS

Our findings suggest that regional emergency medical resources are associated with a lower risk of mortality during hospitalization in severely injured patients. Thus, health care policymakers need to determine the proper distribution of emergency medical resources for each region and the function of emergency departments to provide a superior quality of emergency medical services to patients.