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Protocol-driven trauma resuscitation: survey of UK practice
  1. J M S Andrews1,
  2. E J Dickson2,
  3. M A Loudon1,
  4. J O Jansen1
  1. 1
    Department of Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
  2. 2
    Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
  1. Correspondence to Mr Jan O Jansen, Department of Surgery, Ward 34, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK; jan.jansen{at}


Objective: To evaluate the use of protocol-driven trauma resuscitation strategies in UK emergency departments.

Methods: Postal/internet questionnaire survey of emergency departments to evaluate the existence of guidelines or protocols to direct resuscitation, blood component treatment, second line imaging of patients who had major trauma and the existence of a trauma team/trauma call system.

Results: 243 departments were identified and contacted, 183 responded. Five replies were excluded. Of the remaining 178 departments, 139 (78.1%) had a trauma team or trauma call system, but only 49 (27.5%) had a guideline or protocol for resuscitation. 92 (51.7%) had guidelines or protocols for blood component treatment in trauma, and 88 (49.4%) had guidelines or protocols for the use of second line imaging in trauma. The use of protocols and guidelines did not correlate with emergency department size, as measured by volume of activity.

Conclusions: The utilisation of trauma resuscitation protocols and guidelines in British emergency departments is limited. Given the clear benefits of these strategies, consideration should be given to greater integration of such algorithms into practice.

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Outcome after major trauma is to a large extent determined by the quality of the initial management.1 A recent, large, well-conducted study of trauma care provision in England and Wales concluded that 60% of patients had received a standard of care that was less than good practice. Deficiencies in both organisational and clinical aspects, particularly with reference to the initial assessment, were identified as major contributing factors.2

Although the Advanced Trauma Life Support (ATLS) programme has established a systematic approach for the evaluation of trauma patients,3 its focus is on sequential, single-provider care by non-specialists, whereas in most hospitals, the resuscitation of trauma patients is conducted by a team of doctors, surgeons, nurses and other staff.4 The value of the team approach in trauma resuscitation in general is well established, but there is increasing recognition that effective trauma teams require an organisational and procedural framework.1 5 6 7 8 9 Such a framework is best provided through a comprehensive management algorithm that incorporates horizontally organised team working strategies, pre-assigned task allocations and protocols for the management of associated aspects such as imaging and blood component administration.4 5 7 8 10 11 12 Protocolisation improves efficiency and outcome,1 4 7 8 13 14 and as a result, many leading centres have adopted trauma resuscitation algorithms as the standard of care.4 15 16 17 The aim of this study was to quantify the utilisation of such approaches in emergency departments in the UK.



We conducted a postal/internet questionnaire survey of UK emergency departments between October and December 2007. A list of departments was compiled from data provided by (Healthcare Knowledge, Harrogate, UK), a medical data mining company, and the websites of the Department of Health, Scottish Executive, Welsh Assembly and the Northern Ireland health department. Minor injury units, private hospitals and units that close overnight or on weekends were excluded. Questionnaires (see box) were mailed to the head of each unit, with the option to complete the survey online. Non-respondents were sent a second questionnaire 1 month after the initial mailing.

Outcome measures

The outcome measures were the existence of departmental guidelines or protocols to direct trauma resuscitation (beyond standard ATLS practices), blood component treatment and second line imaging of patients who had major trauma, and the existence of a trauma call or trauma team system to alert other specialties.


Response options are given in italics.

  1. Does your emergency department have a protocol or guideline, beyond standard Advanced Trauma Life Support practices, for the resuscitation of patients with major trauma (injury severity score >15)? (Yes/No)

  2. Does your emergency department have a protocol for the ordering and/or administration of fresh frozen plasma, clotting factors or platelets in major trauma? (Yes/No)

  3. Does your emergency department have a protocol or guideline for the second line imaging (ultrasound, CT, angiography) of trauma patients? (Yes/No)

  4. Does your emergency department have a “trauma team” or a “trauma call” system for alerting staff from other specialties to the arrival of a severely injured patient? (Yes/No)

  5. How many patients does your emergency department see per year? (<50000; 50000-75000; 75000-100000; >100000)

Statistical analysis

Data were collated on a Microsoft Excel database and analysed with SPSS V.15. The association between guideline use and size of emergency department was analysed using a linear-by-linear association χ2 test.


We identified and contacted 243 emergency departments across the UK, Northern Ireland, the Channel Islands and the Isle of Man. One hundred eight-three (75.3%) questionnaires were returned or completed online. Four respondents indicated that their departments no longer provided a trauma service and were therefore excluded from further analysis. One questionnaire was completed incorrectly and therefore also excluded. Of the remaining 178 departments, only 49 (27.5%) had resuscitation guidelines or protocols beyond ATLS practices, although 139 (78.1%) centres had a trauma team or trauma call system in place. Ninety-two (51.7%) had guidelines for blood component treatment in trauma, and 88 (49.4%) had guidelines for the use of second line imaging in trauma. There was no significant association between emergency department size, as measured by activity, and the use of protocols or guidelines for resuscitation (p = 0.397), blood component treatment (p = 0.326), imaging (p = 0.762) or the presence of a trauma team/trauma call system (p = 0.524).


Our survey shows that more than three-quarters of British hospitals now use a trauma team/trauma call system, compared with only 61% 5 years ago,3 which is encouraging. Paradoxically, however, few emergency departments have policies in place to coordinate and integrate the initial assessment and management of trauma patients. This finding raises concerns regarding how effectively trauma resuscitation is conducted, even when a trauma team is assembled. Furthermore, only a minority of emergency departments use protocols to guide other important aspects of management, such as imaging and blood component treatment. The availability of guidelines and protocols did not correlate with the size of emergency departments, as measured by volume of activity.

Protocols and guidelines should not replace reasoned and individualised patient care, but can facilitate thorough and efficient management. The lack of centralisation of trauma services in dedicated centres, as in North America, and the failure to recognise the management of torso trauma as a general surgical subspecialty, have resulted in a critical lack of experience in British hospitals. Using guidelines and protocols to facilitate the initial management of patients with major trauma is therefore arguably of even greater importance in the UK than in countries with more developed trauma services. This study identifies serious deficiencies in this area.

Our study has inherent limitations. The definitions were deliberately loose, and the questionnaire is intentionally brief, to maximise returns. Despite the encouraging return rate of >75%, 60 departments did not send back their questionnaires, leading to potential bias, although there would appear to be no obvious reason why the results should be different in non-responding departments. Furthermore, our study does not address other, equally important aspects of trauma resuscitation, such as leadership, experience and decision making.


Effective trauma resuscitation requires both efficiency and attention to detail, and thus lends itself to a protocol-driven approach.4 Contemporary practice demands frequent and critical reassessment of existing paradigms, and emergency departments should use resuscitation algorithms to direct the initial management of patients with major trauma. Best practice algorithms should be shared locally and ideally agreed nationally. This pertains especially to low-volume, decentralised, non-specialist-led trauma systems, as in the UK.



  • Funding Funding for the cost of obtaining a database of emergency departments in the UK and for postage costs came from a department fund.

  • Competing interests None.

  • Previous presentation: An abstract of this work was presented as a poster at the Association of Surgeons of Great Britain and Ireland annual scientific meeting in May 2008.

  • Contributors and guarantor: MAL, JOJ and EJD conceived the idea for the study. JOJ designed the questionnaire, set up the online survey and contributed to the writing of the article. JMSA mailed out the questionnaires, collated the results, performed the statistical analysis and contributed to the writing of the article. MAL and EJD edited the manuscript. JOJ is the guarantor.

  • Provenance and Peer review Not commissioned; externally peer reviewed.