Reporting data following major trauma and analysing factors associated with outcome using the new Utstein style recommendations

doi:10.1016/S0300-9572(01)00361-6

Resuscitation

Volume 50, Issue 3, September 2001, Pages 263-272

https://doi.org/10.1016/S0300-9572(01)00361-6 Get rights and content

Abstract

Study objective: To collect and present retrospectively the recommended core data from the Utstein style, analyse factors associated with outcome in major trauma, and discuss the value of the Utstein style definition of major trauma. Design: A retrospective trauma cohort study. Setting: A Norwegian trauma system with a 1200 bed combined local and referral trauma hospital without a formal trauma registry, covering a population of ≈2.0 million. Participants: 3391 injured patients admitted 12 months from January 15, 1996. Main outcome measures: Recommended core data from the Utstein style, and factors associated with outcome defined as in-hospital death within 30 days. Results: 225 patients had an injury severity score (ISS)>15. In each of the 225 patients, we were able to obtain at least 47% of the recommended core data. Age >70 years, fall as a mechanism of injury, and a Trauma Score (TS)≤14 were significantly associated with poor outcome. Of 22 with no major trauma (ISS<16), two died in hospital and 20 had an intensive care unit stay of more than 2 days. Conclusion: We found it difficult to collect retrospectively the recommended core data of the Utstein style. Age and physiological alterations (TS) were significantly related to outcome. The recommended definition of major trauma (ISS>15) did not cover all life-threatening injuries. The implementation of trauma registries based on the Utstein style recommendations could facilitate system evaluation and comparison, but definitions and categorisations should be further developed. Efforts should be made to reduce the number of core data.

Sumàrio

Objectivo do estudo: Recolher e apresentar retrospectivamente os dados nucleares segundo as recomendações do “Utstein style”, analisar factores associados com prognóstico no trauma e discutir o valor da definição de trauma major das recomendações do “Utstein style”. Tipo de estudo: Estudo retrospectivo de uma coorte de doentes com trauma. Ambiente: Sistema norueguês de trauma que conta com 1200 camas associadas entre um sistema local e um hospital de referência em trauma, sem registo formal de trauma, cobrindo uma população de 2 milhões. Participantes: 3391 traumatizados admitidos a partir de 15 de Janeiro de 1996. Medidas principais de prognóstico: Dados nucleares recomendados no Estilo Utstein e factores associados com o prognóstico definido como mortalidade hospitalar em 30 dias. Resultados: 225 pacientes tinham um ı́ndice de gravidade (ISS)>15. Em cada um deles conseguimos obter pelo menos 47% dos dados nucleares recomendados. Idade > 70 anos, queda como causa do trauma, e ı́ndice de trauma (TS)=14 estavam significativamente associadas a mau prognóstico. Dos 22 doentes sem trauma major (ISS<16), dois morreram no hospital e 20 tiveram internamento em UCI mais de 2 dias. Conclusão: Foi-nos difı́cil recolher retrospectivamente os dados recomendados pelo “Utstein style”. A idade e alterações fisiológicas (TS) estavam significativamente relacionados com o prognóstico. A definição recomendada de trauma major (ISS>15) não abrangia a totalidade das lesões com risco de vida. A implementação de registos de trauma baseados na recomendação do Estilo Utstein podem facilitar a avaliação e comparação do sistema, mas as categorizações e definições devem ser mais desenvolvidos. Devem-se envidar esforços para diminuir o número de dados nucleares.

Introduction

The importance of organised trauma care is documented [1], [2], [3], [4], [5], [6], [7], [8]. Even though there are formal trauma registries in some countries [9], [10], it is difficult to compare different trauma systems due to a lack of data standardisation. In the case of cardiac arrest, international recommendations for uniform reporting of clinical data (The Utstein Template) have been proven valuable and have become an internationally used standard [11]. In 1994 the International Trauma Anesthesia and Critical Care Society (ITACCS) initiated an international task force in order to draw up recommendations for uniform reporting of data following major trauma based on the Utstein concept.

These recommendations for reporting of data following major trauma in the Utstein style have recently been published in several journals, including Resuscitation [12]. To our knowledge studies have not been published which test the applicability of these recommendations from any trauma system.

The implementation of a trauma registry is resource demanding. Hence, we wanted to test how easy it was to collect and present retrospectively the recommended core data of the Utstein style from already existing pre-hospital and hospital records in our own trauma system, and then, use the collected data to analyse factors influencing with outcome in major trauma. We also found it appropriate to discuss the value of the definition of major trauma. Does it ensure inclusion of all life-threatening cases?

Section snippets

Materials and methods

Ulleval University Hospital is a 1200 bed local and regional hospital. It has an established trauma organisation [13], and serves as the primary trauma hospital for the population of Oslo (≈500 000), and as a trauma referral centre for an urban and rural population of about 2 million people. Trauma patients are admitted by either ground or air ambulances directly from the scene or transferred from local hospitals. Basic pre-hospital trauma care is performed by regular ambulance crews and

Results

During the study period a total of 20 500 patients were admitted to Ulleval Hospital, of which 3391 (17%) were trauma related admissions. Two hundred and twenty five fulfilled the Utstein style recommended criterion for major trauma (ISS>15) and were included in the study. In every one of these 225 patients, we were able to obtain at least 47% of the recommended core data.

One hundred and fifty nine (71%) of the 225 with major trauma were admitted directly from the scene, and 66 (29%) were

Discussion

Evaluating and comparing trauma systems is necessary to develop trauma care further. In most cases randomised, controlled trials are unacceptable, both for logistical and ethical reasons. Other different methods have been used to investigate the efficiency of trauma systems; evaluation of patient outcome by expert panels [18], [19], trauma registry based studies [9], [10], and population based studies [5], [13], [20], [21], [22]. In all type of studies, clear and standardised definitions are

Conclusions

In summary, our study emphasises the problems of retrospective extrication of data and a small sample size, which is representative for many trauma centres. Since the study was retrospective, its value in the evaluation of the Utstein style recommendations as such is limited. By using the Utstein style recommendations, we found that the definition of major trauma did not cover all injuries that led to death or prolonged ICU stay. In uni- and multivariate analyses, we found only three factors

Acknowledgements

The authors want to acknowledge Bo Conneryd, Norwegian Air Ambulance, for superior computer software support, senior consultant Nils-Oddvar Skaga and Dr. Torsten Eken, Ulleval University Hospital, for constructive discussions, and Rolf Geir Gjertsenı́s Memorial Foundation for the financial support.

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On scene injury severity prediction (OSISP) algorithm for car occupants
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Citation Excerpt :
While there are many ways to dichotomize between severe and non-severe injury, the US National Expert Panel recommended ISS > 15 as partition threshold (Sasser et al., 2012). In addition, a substantial majority of data registries (Lossius et al., 2001; MacLeod et al., 2003) use that threshold for defining very severe injury. ISS > 15 was first described by Boyd et al. (1987) as being predictive of 10% mortality and it is widely accepted as corresponding to the highest priority level in an Emergency Department (ED) (Palmer, 2007).
Many victims in traffic accidents do not receive optimal care due to the fact that the severity of their injuries is not realized early on. Triage protocols are based on physiological and anatomical criteria and subsequently on mechanisms of injury in order to reduce undertriage. In this study the value of accident characteristics for field triage is evaluated by developing an on scene injury severity prediction (OSISP) algorithm using only accident characteristics that are feasible to assess at the scene of accident. A multivariate logistic regression model is constructed to assess the probability of a car occupant being severely injured following a crash, based on the Swedish Traffic Accident Data Acquisition (STRADA) database. Accidents involving adult occupants for calendar years 2003–2013 included in both police and hospital records, with no missing data for any of the model variables, were included. The total number of subjects was 29 128, who were involved in 22 607 accidents. Partition between severe and non-severe injury was done using the Injury Severity Score (ISS) with two thresholds: ISS > 8 and ISS > 15. The model variables are: belt use, airbag deployment, posted speed limit, type of accident, location of accident, elderly occupant (>55 years old), sex and occupant seat position. The area under the receiver operator characteristic curve (AUC) is 0.78 and 0.83 for ISS > 8 and ISS > 15, respectively, as estimated by 10-fold cross-validation. Belt use is the strongest predictor followed by type of accident. Posted speed limit, age and accident location contribute substantially to increase model accuracy, whereas sex and airbag deployment contribute to a smaller extent and seat position is of limited value. These findings can be used to refine triage protocols used in Sweden and possibly other countries with similar traffic environments.
Quality of trauma care and trauma registries
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La enfermedad traumática es un gran problema de salud pública. La monitorización de la calidad de los servicios prestados es esencial para el mantenimiento y la mejora de los mismos. La evaluación y monitorización de la calidad asistencial en la atención al paciente traumatizado, a través de indicadores de calidad, permitiría la detección de oportunidades de mejora cuya implementación mejoraría los resultados en mortalidad hospitalaria, resultados funcionales y calidad de vida de los supervivientes. Se han usado muchos indicadores de calidad en esta patología, aunque muy pocos tienen un nivel de evidencia científica sólido para recomendar su uso rutinario. La información recogida en los registros de trauma, de importante difusión en el mundo en las últimas décadas, es fundamental para conocer la realidad asistencial actual, detectar oportunidades de mejora y contribuir en la investigación clínica y epidemiológica.
Traumatic disease is a major public health concern. Monitoring the quality of services provided is essential for the maintenance and improvement thereof. Assessing and monitoring the quality of care in trauma patient through quality indicators would allow identifying opportunities for improvement whose implementation would improve outcomes in hospital mortality, functional outcomes and quality of life of survivors. Many quality indicators have been used in this condition, although very few ones have a solid level of scientific evidence to recommend their routine use. The information contained in the trauma registries, spread around the world in recent decades, is essential to know the current health care reality, identify opportunities for improvement and contribute to the clinical and epidemiological research.
Trauma registries: A health priority, a strategic project for the SEMICYUC
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Sin olvidar que la aproximación más eficiente a la enfermedad traumática es la prevención, es también obligación monitorizar los cuidados de las víctimas. Un registro de trauma requiere, para ser operacional y efectivo, financiación, software adecuado, población bien definida, personal implicado con formación y un proceso detallado para la recolección de datos, elaboración de informes, validación y mantenimiento de la confidencialidad pero, sobre todo, motivación. Con los registros se puede obtener una gran cantidad de beneficios en una enfermedad muy prevalente con transcendencia en la promoción de la salud e incluso una reducción de los costes, así como un alivio del sufrimiento generado por esta enfermedad (mortalidad, discapacidad), contribuyendo a mejorar la eficiencia y la calidad de los cuidados de la enfermedad traumática crítica. La SEMICYUC ha demostrado su capacidad para establecer y mantener registros de interés nacional y este debe convertirse en un proyecto estratégico.
The most efficient approach to traumatologic disease is prevention, but physicians also must supervise care of the victims. An operational and effective trauma registry requires financial support, adequate software, a well-defined population, personnel committed to training, and a detailed process for data collection, reporting, validation and the maintenance of confidentiality. Above all, however, motivation is required. Registries can offer many benefits in relation to these highly prevalent disorders, with an impact in terms of health promotion and even advantages in the form of cost reductions, as well as relief from the suffering caused by trauma (mortality, disability)–contributing to improve the efficiency and quality of critical trauma care. The SEMICYUC has demonstrated its ability to establish and maintain records of national interest, and this should become a priority project.
Comorbidity-polypharmacy score: A novel adjunct in post-emergency department trauma triage
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Citation Excerpt :
In the presence of equivalent injury severity, mortality in elderly patients is known to be two times higher than that in younger patients [1]. Despite this, older patients are more likely to be undertriaged compared with other adult trauma victims [2–4]. Undertriage (UT) exposes patients to critical delays in diagnostic, resuscitative, and therapeutic measures [5].
Post–emergency department triage of older trauma patients continues to be challenging, as morbidity and mortality for any given level of injury severity tend to increase with age. The comorbidity-polypharmacy score (CPS) combines the number of pre-injury medications with the number of comorbidities to estimate the severity of comorbid conditions. This retrospective study examines the relationship between CPS and triage accuracy for older (≥45 y) patients admitted for traumatic injury.
Patients aged 45 y and older presenting to level 1 trauma center from 2005 to 2008 were included. Basic data included patient demographics, injury severity score, morbidity and mortality, and functional outcome measures. CPS was calculated by adding total numbers of comorbid conditions and pre-injury medications. Patients were divided into three triage groups: undertriage (UT), appropriate triage (AT), and overtriage (OT). UT criteria included initial admission to the floor or step-down unit followed by an unplanned transfer to intensive care unit (ICU) within 24 h of admission. OT was defined as initial ICU admission for <1 d without stated need for ICU level of care (i.e., lack of evidence for tracheal intubation or mechanical ventilation, injury-related hemorrhage, or other traditional ICU indications, such as intracranial bleeding). All other patients were presumed to be correctly triaged. The three triage groups were then analyzed looking for contributors to mistriage.
Charts for 711 patients were evaluated (mean age, 63.5 y; 55.7% male; mean ISS, 9.02). Of those, 11 (1.55%) met criteria for UT and 14 (1.97%) for OT. The remaining 686 patients had no evidence of mistriage. The three groups were similar in terms of injury severity and GCS. The groups were significantly different with respect to CPS, with UT CPSs (14.9 ± 6.80) being nearly three times higher than OT CPSs (5.14 ± 3.48). There were more similarities between AT and OT groups, with the UT group being characterized by greater number of complications and lower functional outcomes at discharge (all, P < 0.05). The UT group had significantly higher mortality (27%) than the AT and OT groups (6% and 0%, respectively).
In the era of medication reconciliation, CPS is easy to obtain and calculate in patients who are not critically injured. This study suggests that CPS may be a promising adjunct in identifying older trauma patients who are more likely to be undertriaged. The significance of our findings is especially important when considering that injury severity in the UT group was similar to that in the other groups. Further evaluation of CPS as a triage tool in acute trauma is warranted.
Re: Pre-hospital fluid therapy in the critically injured patient: need for clinical studies
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Pre-hospital fluid therapy in the critically injured patient - A clinical update
2005, Injury
Venous access and fluid therapy should still be considered to be essential elements of pre-hospital advanced life support (ALS) in the critically injured patient. Initiation of fluid therapy should be based on a clinical assessment, most importantly the presence, or otherwise, of a radial pulse. The goal in penetrating injury is to avoid hypovolaemic cardiac arrest during transport, but at the same time not to delay transport, or increase systolic blood pressure. The goal in blunt injury is to secure safe perfusion of the injured brain through an adequate cerebral perfusion pressure, which generally requires a systolic blood pressure well above 100 mmHg. Patients without severe brain injury tolerate lower blood pressures (hypotensive resuscitation). Importantly, using systolic blood pressure targets to titrate therapy is not as easy as it seems. Automated (oscillometric) blood pressure measurement devices frequently give erroneously high values. The concept of hypotensive resuscitation has not been validated in the few studies done in humans. Hence, the suggested targeted systolic blood pressures should only provide a mental framework for the decision-making. The ideal pre-hospital fluid regimen may be a combination of an initial hypertonic solution given as a 10–20 minutes infusion, followed by crystalloids and, in some cases, artificial colloids. This review is intended to help the clinician to balance the pros and cons of fluid therapy in the individual patient.

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Reporting data following major trauma and analysing factors associated with outcome using the new Utstein style recommendations

Abstract

Sumàrio

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgements

Am J Surg

Resuscitation

J Emerg Med

Resuscitation

Influence of a statewide trauma system on pediatric hospitalization and outcome

J Trauma

Effectiveness of implementing a trauma triage system on outcome: a prospective evaluation

J Trauma

An evaluation of ontario trauma outcomes and the development of regional norms for trauma and injury severity score (TRISS) analysis

J Trauma

Outcome of hospitalized injured patients after institution of a trauma system in an urban area

J Am Med Assoc

An evaluation of patient outcomes before and after trauma centre designation using trauma and injury severity score analysis

J Trauma

Improved trauma care after reorganisation: a retrospective analysis

Eur J Surg

The major trauma outcome study: establishing national norms for trauma care

J Trauma

UK major trauma outcome study

BMJ

Efficiency activation of the trauma team in a Norwegian trauma referral centre

Eur J Surg

The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care

J Trauma