Maturation of trauma systems in Europe

PURPOSE

To provide an overview of trauma system maturation in Europe.

METHODS

Maturation was assessed using a self-evaluation survey on prehospital care, facility-based trauma care, education/training, and quality assurance (scoring range 3-9 for each topic), and key infrastructure elements (scoring range 7-14) that was sent to 117 surgeons involved in trauma, orthopedics, and emergency surgery, from 24 European countries. Average scores per topic were summed to create a total score on a scale from 19 to 50 per country. Scores were compared between countries and between geographical regions, and correlations between scores on different sections were assessed.

RESULTS

The response rate was 95%. On the scale ranging from 19 to 50, the mean (SD, range) European trauma system maturity score was 38.5 (5.6, 28.2-48.0). Prehospital care had the highest mean score of 8.2 (0.5, 6.9-9.0); quality assurance scored the lowest 5.9 (1.7, 3.2-8.5). Facility-based trauma care was valued 6.9 (1.4, 4.1-9.0), education and training 7.0 (1.2, 5.2-9.0), and key infrastructure elements 10.3 (1.6, 7.6-13.5). All aspects of trauma care maturation were strongly correlated (r > 0.6) except prehospital care. End scores of Northern countries scored significantly better than Southern countries (p = 0.03).

CONCLUSION

The level of development of trauma care systems in Europe varies greatly. Substantial improvements in trauma systems in several European countries are still to be made, especially regarding quality assurance and key infrastructure elements, such as implementation of a lead agency to oversee the trauma system, and funding for growth, innovation and research.

The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands

Background

Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time.

Methods

All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008–2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS.

Results

The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63–74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC.

Conclusion

Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.

Quantification of Trauma Center Access Using Geographical Information System-Based Technology

OBJECTIVES

There is no generally accepted methodology to assess trauma system access. The goal of this study is to determine the influence of the number and geographical distribution of trauma centers (TCs) on transport times (TT) using geographic information system (GIS)-technology.

METHODS

Using ArcGIS-PRO, we calculated differences in TT and population coverage in 7 scenarios with 1, 2, or 3 TCs during rush (R) and low-traffic (L) hours in a densely populated region with 3 TCs in the Netherlands.

RESULTS

In all 7 scenarios, the population that could reach the nearest TC within <45 minutes varied between 96% and 99%. In the 3-TC scenario, roughly 57% of the population could reach the nearest TC <15 minutes both during R and L. The hypothetical geographically well-spread 2-TC scenario showed similar results as the 3-TC scenario. In the 1-TC scenarios, the population reaching the nearest TC <15 minutes decreased to between 19% and 32% in R and L. In the 3-TC scenario, the average TT increased by about 1.5 minutes to almost 21 minutes during R and 19 minutes during L. Similar results were seen in the scenarios with 2 geographically well-spread TCs. In the 1-TC scenarios and the less well-spread 2-TC scenario, the average TT increased by 5 to 8 minutes (L) and 7 to 9 minutes (R) compared to the 3-TC scenario.

CONCLUSIONS

This study shows that a GIS-based model offers a quantifiable and objective method to evaluate trauma system access under different potential trauma system configurations. Transport time from accident to TC would remain acceptable, around 20 minutes, if the current 3-TC situation would be changed to a geographically well-spread 2-center scenario.

Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study

BACKGROUND

Alcohol withdrawal syndrome (AWS) in surgical trauma patients is associated with significant morbidity and mortality. Benzodiazepines, commonly used for withdrawal management, pose unique challenges in this population given the high prevalence of head trauma and delirium. Phenobarbital is an antiepileptic drug that offers a viable alternative to benzodiazepines for AWS treatment.

METHODS

This is a retrospective chart review of patients with active alcohol use disorder who presented to a level 1 trauma center over a 4-year period and required medication-assisted management for AWS. The primary outcome variable examined was the development of AWS and associated complications. Additional outcomes measured included hospital length of stay, mortality, and medication-related adverse events.

RESULTS

Of the 85 patients in the study sample, 52 received a fixed-dose benzodiazepine-based protocol and 33 received phenobarbital-based protocol. In the benzodiazepine-based protocol group, 25 patients (48.2%) developed AWD and 38 (73.1%) developed uncomplicated AWS, as compared to 0 patients in the phenobarbital-based protocol (P = 0.0001). There were 10 (19.2%) patients with medication adverse side effects in the benzodiazepine-based protocol group versus 0 patients in the phenobarbital-based protocol group. There were no statically significant differences between the 2 groups as pertains to rates of other AWS-related complications, patient mortality, or length of stay.

CONCLUSION

The use of a phenobarbital-based protocol in trauma patients with underlying active alcohol use disorder resulted in a statistically significant decrease in the incidence of AWD and uncomplicated AWS secondary to AWS when compared to patients treated with a fixed-dose benzodiazepine-based protocol.

The malnutrition in polytrauma patients (MaPP) study: Research protocol

BACKGROUND

Polytrauma patients are at risk of considerable harm from malnutrition due to the metabolic response to trauma. However, there is little knowledge of (the risk of) malnutrition and its consequences in these patients. Recognition of sub-optimally nourished polytrauma patients and their nutritional needs is crucial to prevent complications and optimize their clinical outcomes.

AIM

The primary objective is to investigate whether polytrauma patients admitted to the Intensive Care Unit (ICU) who have or develop malnutrition have a higher complication rate than patients who are and remain well nourished. Secondary objectives are to determine the prevalence of pre-existent and in-hospital acquired malnutrition in these patients, to assess the association between malnutrition and long-term outcomes, and to determine the association between serum biomarkers (albumin and pre-albumin) and malnutrition.

METHODS

This international observational prospective cohort study will be performed at three Level-1 trauma centers in the United States and two Level-1 centers in the Netherlands. Adult polytrauma patients (Injury Severity Score ≥16) admitted to the ICU of one of the participating centers directly from the Emergency Department are eligible for inclusion. Nutritional status and risk of malnutrition will be assessed using the Subjective Global Assessment (SGA) scale and Nutritional Risk in Critically Ill (NUTRIC) score, respectively. Nutritional intake, biomarkers and complications will be collected daily. Patients will be followed up to one year after discharge for long-term outcomes.

CONCLUSIONS

This international prospective cohort study aims to gain more insight into the effect and consequences of malnutrition in polytrauma patients admitted to the ICU.

Development of trauma systems in Europe-reports from England, Germany, the Netherlands, and Spain

Major trauma systems have evolved in many European countries and have resulted in improved care in terms of mortality and morbidity. Many of the systems have similar history, with reports of either poor services, or a single disaster, driving change of policy and set up. We report on 4 European systems, looking at the background, set up and some of the results. Similar issues are identified including the importance of triage, the concentration of specialist skills which require patients to bypass hospitals, and the standardization of treatment protocols. The issues of rehabilitation and the increasing importance of measuring outcome with patient reported metrics are discussed.

Correction to: Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison

In the original article Dennis Den Hartog's name was tagged incorrectly. It is correct as reflected here.

Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison

INTRODUCTION

The incidence and nature of penetrating injuries differ between countries. The aim of this study was to analyze characteristics and clinical outcomes of patients with penetrating injuries treated at urban Level-1 trauma centers in the USA (USTC) and the Netherlands (NLTC).

METHODS

In this retrospective cohort study, 1331 adult patients (470 from five NLTC and 861 from three USTC) with truncal penetrating injuries admitted between July 2011 and December 2014 were included. In-hospital mortality was the primary outcome. Outcome comparisons were adjusted for differences in population characteristics in multivariable analyses.

RESULTS

In USTC, gunshot wound injuries (36.1 vs. 17.4%, p < 0.001) and assaults were more frequent (91.2 vs. 77.7%, p < 0.001). ISS was higher in USTC, but the Revised Trauma Score (RTS) was comparable. In-hospital mortality was similar (5.0 vs. 3.6% in NLTC, p = 0.25). The adjusted odds ratio for mortality in USTC compared to NLTC was 0.95 (95% confidence interval 0.35-2.54). Hospital stay length of stay was shorter in USTC (difference 0.17 days, 95% CI -0.29 to -0.05, p = 0.005), ICU admission rate was comparable (OR 0.96, 95% CI 0.71-1.31, p = 0.80), and ICU length of stay was longer in USTC (difference of 0.39 days, 95% CI 0.18-0.60, p < 0.0001). More USTC patients were discharged to home (86.9 vs. 80.6%, p < 0.001). Readmission rates were similar (5.6 vs. 3.8%, p = 0.17).

CONCLUSION

Despite the higher incidence of penetrating trauma, particularly firearm-related injuries, and higher hospital volumes in the USTC compared to the NLTC, the in-hospital mortality was similar. In this study, outcome of care was not significantly influenced by differences in incidence of firearm-related injuries.

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BACKGROUND

Modern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC).

METHODS

For this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed.

RESULTS

The USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p<0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17-29] vs. 21 [17-26], p<0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61-1.48, p=0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2-11] vs. 2 [2-7] days, p=0.006) but had a shorter hospital stay (median [IQR] 6 [3-13] vs. 8 [4-16] days, p<0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p<0.0001), and had a higher readmission rate (8% vs. 4%, p=0.01).

CONCLUSION

Although several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.

Histopathological assessment of OASIS Ultra on critical-sized wound healing: a pilot study

BACKGROUND

Dermatopathologists assess wounds secondary to trauma, infection, or oncologic resection that can be challenging to reconstruct. OASIS Ultra, an extracellular matrix, has been described for use in chronic and burn wounds. The aim of this pilot study is to assess wound healing in post-traumatic and infective wounds treated with OASIS using histological markers of repair.

MATERIALS AND METHODS

Adults with traumatic, infective or iatrogenic wound defects with size precluding primary closure were eligible. Half the wound was randomly assigned to receive OASIS plus standard therapy; the other half received standard of care (SOC) therapy. During dressing changes, standardized-scale photographs were taken and biopsies obtained. Histologic sections were reviewed for degree of acute inflammation and extent of tissue repair. Neutrophils, edema, hemorrhage, necrosis, fibroblasts, collagen density and neovascularization were semi-quantitatively assessed.

RESULTS

Forty-four skin biopsies from 7 patients with 10 acute wounds met eligibility criteria. Histologically, OASIS samples demonstrated improved acute inflammation scores compared to SOC. No patients experienced OASIS-related complications. OASIS-treated wound halves trended toward more wound contraction and improved tissue repair.

CONCLUSION

Our scoring system aids histopathological wound assessment. Treatment of critical-sized, post-traumatic, acute wounds with OASIS resulted in decreased inflammation, and potentially more advanced wound healing, compared to SOC.

Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates

BACKGROUND

Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP.

MATERIALS AND METHODS

This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes.

RESULTS

EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5-53.5) after ICU admission, with a mean duration of 8.7 ± 4.3 days. The median total caloric deficit was 2185 kcal (249-4730), with 900 kcal (551-1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5-250.4), with 51.9 g (20.6-83.3) caused by RAMP-UP (53%).

CONCLUSIONS

In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU.