Management of severe trauma in intensive care units and surgical wards

Developing a trauma care syllabus for intensive care nurses in the United Kingdom: A Delphi study

BACKGROUND

Increased rates of mortality in the intensive care unit (ICU) following injury have been associated with a lack of trauma specific training. Despite this, training relevant to nurses is limited. Currently, little consideration has been given to understanding the potential training needs of ICU nurses in caring for critically injured patients.

OBJECTIVES

The aim of this study was to construct a consensus syllabus of trauma care for registered nurses working in an intensive care setting.

DESIGN

A two round modified Delphi was conducted.

METHODS

Twenty-eight intensive care professionals participated in the study in 2014 in the United Kingdom. Data were analysed using content and descriptive statistics.

RESULTS

Round-1 generated 343 subjects. Following analysis these were categorised into 75 subjects and returned to the panel for rating. An 82% (23/28) response rate to round-2 identified high consensus (equal to or greater than 80%) in 55 subjects, which reflected the most severely injured patients needs.

CONCLUSIONS

There is a requirement for specific training to prepare the ICU nurse for caring for the critically injured patient. This survey presents a potential core syllabus in trauma care and should be considered by educators to develop a meaningful programme of trauma education for ICU nurses.

Evaluation of the Prehospital Management of Road Traffic Fatalities in Victoria, Australia

Introduction:

This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes.

Methods:

The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion.

Results:

One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable.

Conclusion:

The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.

A county hospital surgical practice: a model for acute care surgery

BACKGROUND

Trauma surgery has changed significantly over the past decade. Nonoperative evidence-based algorithms have become common and surgical trauma volume has become increasingly difficult to maintain. The acute care surgery (ACS) model, which integrates trauma, critical care, and emergency surgery, has been proposed as a future model of trauma practice.

METHODS

Database information from an academic, county-based, trauma center was reviewed. A performance improvement surgical procedure database and level I trauma registry from 2005 were used to evaluate one center's ACS practice.

RESULTS

There were 2,276 cases performed by 7 full-time and 5 part-time surgeons. Elective cases accounted for 64% (1,480) of caseload, emergency/urgent general surgery accounted for 32% (719) of cases, and emergency trauma surgeries accounted for 4% (96 procedures in 77 patients). In all, 23% were performed after hours. The ACS model supported controllable hours, adequate surgical volume, excellent patient care, and an appealing clinical practice.

CONCLUSION

Surgical practice in a county-run trauma hospital can be similar to the ACS model, with positive results in terms of clinical volume and physician satisfaction. As clinical practices shift to the ACS model, there are lessons to be learned from currently existing, thriving, long-standing similar prototypes.

Critical care issues in the early management of severe trauma

Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year, for a combined mortality of 48 deaths per 100,000 population per year. Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals. Preventability of trauma deaths has been reported as high as 76% and as low as 1% in mature trauma systems. Critical care errors may occur in a half of hospital trauma deaths, in most of the cases contributing to the death. The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions. A systematic approach to the trauma patient in the critical care unit would avoid errors and preventable deaths.

Transfer of facially injured road trauma victims and its impact on treatment

BACKGROUND

Road trauma is a common cause of severe facial injuries. The aim of the present study is to define patients involved, and determine the effect of their geographical origin on treatment and follow up.

METHODS

All patients over 14 years of age suffering facial injuries caused by road trauma presenting to the two study hospitals from 1994 to 1999 were identified and details were collected on demographic details and treatment.

RESULTS

Four hundred and nine patients met the inclusion criteria. The majority required hospital transfer. Young men were the most frequently injured group of patients. Patients from peripheral regions had significant delays in transfer and treatment. They were made fewer outpatient appointments but attended at the same frequency as patients from the immediate region of the study hospitals.

CONCLUSIONS

To minimize delays the process of patient transfer needs to be streamlined and education of staff in peripheral hospitals undertaken regarding facial injuries.

Missed diagnoses in trauma patients vis-à-vis significance of autopsy

Post-mortem examination is considered to be the gold standard for the critique of medical practice, providing a quality control tool for the retrospective evaluation of diagnoses and treatment. Performing autopsies also facilitates new insight about the pathogenesis of disease and effects of therapy, gives feedback to clinical research protocols, provides epidemiological information and occasionally helps to console and reassure grieving families that death was inevitable. Its significance becomes paramount in cases of missed diagnosis in trauma-related deaths. The true incidence of missed diagnoses in trauma-related deaths is unknown, because autopsy is conducted in only about 50% of injury-related deaths. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. The present study is an attempt to evaluate the incidence and nature of missed injuries and complications in trauma-related deaths given an autopsy rate of close to 100%. This study also sought to identify the primary factors contributing to each missed injury. However, the study is in no way intended to assigning blame to human or system errors. Rather, it is focussed specifically on the issue of whether autopsy can be useful to provide feedback in identifying clinical problems of trauma patients.

Evaluation of Management of Road Trauma Survivors with Brain Injury and Neurologic Disability in Victoria

BACKGROUND

Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999.

METHODS

The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records.

RESULTS

The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units.

CONCLUSION

Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury care.

Audits, errors and the misplace of clinical indicators: revisiting the Quality in Australian Health Care Study

Publication of the Quality in Australian Health Care Study in 1995 represented a defining moment for Australian health care providers. The high incidence and cost of preventable adverse events underscored a need for defined process, error recognition and audit cycle. Despite this, surgical audit has continued to emphasize clinical indicators relevant to technical performance. The greatest burden of preventable error can be traced to deficiencies in the process by which management expectations are supported. Recognizing this, the focus of clinical audit must be expanded. In particular, outcome assessment should be routine rather than sporadic, and should broadly encompass safety, effectiveness and efficiency. Devolving this responsibility to paraclinical groups is in itself insufficient. Quality and safety cannot be adequately addressed unless surgeons actively participate in audit cycle. Failure to meet this challenge in a transparent and timely manner potentially undermines the future of professional autonomy.

Unexpected findings in trauma patients dying in the intensive care unit: results of 153 consecutive autopsies

BACKGROUND

The true incidence of missed injuries in trauma-related deaths is unknown, because in only about 60% of injury-related deaths nationwide is an autopsy performed. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. We attempted to evaluate the incidence and nature of missed injuries and complications in trauma- and burn-related deaths in our ICU given an autopsy rate of close to 100%.

STUDY DESIGN

The medical records of all trauma- and burn-related deaths in the ICU over a 2-year period were reviewed retrospectively. Missed diagnoses were classified as class 1: major diagnosis that if recognized and treated appropriately might have changed outcomes; class II: major diagnosis that if recognized and treated appropriately would not have changed outcomes; and class III: minor diagnosis.

RESULTS

Complete antemortem records were available for 158 patients, of which 153 (97%) underwent autopsy. Mean age was 50 years, and 72% were males. Mean ICU stay was 10 15 days. Four (3%) patients had class I missed diagnoses: bowel infarction, meningitis, retroperitoneal abscess, and bleeding gastric ulcer. Twenty-five (16%) patients had class II diagnoses, and 12 (8%) patients had class III diagnoses. Overall, 81% of 153 patients had either class III diagnoses or no missed injuries or complications. Pneumonia was the most common missed diagnosis.

CONCLUSIONS

With an autopsy rate of 97%, 3% of deaths bad missed major diagnoses that might have affected outcomes if recognized antemortem. Autopsy findings can still provide valuable feedback in Improving the quality of care of critically ill trauma patients.

Trauma-Specific Intensive Care Units Can be Cost Effective and Contribute to Reduced Hospital Length of Stay

Our hypothesis was that clinical outcomes are improved and cost and hospital length of stay (LOS) reduced as a result of the opening of a closed trauma intensive care unit (ICU). We conducted a cross-sectional study in a university-affiliated Level I trauma center. Our study population comprised trauma patients admitted to the ICU between June 1, 1996 and July 1, 1998 for at least 24 hours and with an Injury Severity Score (ISS) >16 (excluding those with severe brain injury). The main outcome measures were changes in LOS and number of ventilator days, prevalence of complications, changes in patient charges, and hospital costs. Two hundred four patients were included [trauma ICU (TICU) 60, surgical ICU 144]. The two groups were not statistically different in age, ISS, mechanism of injury, infection rate, and mortality; however, the TICU patients had a lower number of ventilator hours (83.1 vs 100.0; P = 0.007), lower ICU LOS (9.4 vs 12.1 days; P = 0.06), and lower total hospital LOS (15.6 vs 22.3 days; P = 0.01). Although this was not of statistical significance TICU patients had lower hospital charges ($125,383 vs $152,994; P = 0.06) and lower cost per case ($42,306 vs $47,548; P = 0.35) for a net savings of $314,520 during the first 6 months of operation of the TICU. This study suggests that improved clinical outcomes and decreases in cost and LOS are directly related to the opening of a closed trauma ICU.