30-Day In-hospital Trauma Mortality in Four Urban University Hospitals Using an Indian Trauma Registry

Introduction

In India, half of the annual 200,000 road traffic deaths occur in hospitals, but the exact in-hospital trauma mortality rate remains unknown. A research consortium of universities, with a mandate to reduce trauma mortality, measured the baseline 30-day in-hospital mortality rate.

Methods

Between September 2013 and February 2015, trained data collectors collected on-admission demographic, physiological vital signs, and health service performance indicators (time of injury to admission, investigation, or intervention) on all patients with traumatic injuries admitted to four public university hospitals in three Indian megacities.

Results

Of the 11,202 hospitalized trauma patients, 21.4 % died within 30 days of hospitalization. The median age was 30 years for survivors and 37 years for non-survivors. The on-admission systolic blood pressure and Glasgow Coma Score was near-normal in survivors, but was significantly lower in non-survivors and associated with both early and late mortality (p = 0.001). In the absence of a trauma system, there were process-of-care delays from injury to reaching and being examined, investigated, or operated in the hospital.

Conclusion

Using a multi-institutional Indian registry, this study is the first to systematically document that the 30-day in-hospital trauma mortality was twice that found in similar registries from high-income countries. Physiological scoring of on-admission vitals was clinically useful to predict mortality. More research is needed to understand the causes of high mortality and time delays in the process of delivering trauma care in India, which has no prehospital or trauma system.

     

Whole-Body Computed Tomography During Initial Management and Mortality Among Adult Severe Blunt Trauma Patients: A Nationwide Cohort Study

Background

Whole-body computed tomography (WBCT) is increasingly being incorporated into the initial management of blunt trauma patients. Several observational studies have suggested that, compared to selective CT, WBCT is associated with lower mortality. In contrast, a randomized controlled trial found no significant difference in survival between patients undergoing WBCT compared to selective CT. Our objective was to confirm the association between WBCT and in-hospital mortality among adult severe blunt trauma patients.

Methods

This was a retrospective cohort study based on Japan Trauma Data Bank 2004–2015 registry data. The study population comprised adult severe blunt trauma patients with at least one abnormal vital sign: systolic blood pressure ≤100 mmHg, heart rate ≥120, respiratory rate ≥30 or ≤10, or Glasgow Coma Score ≤13. The primary outcome was in-hospital mortality. To adjust for both measured and unmeasured confounders, we performed instrumental variable (IV) analysis to compare the in-hospital mortality of patients undergoing WBCT with those undergoing selective CT.

Results

Of 40,435 patients who were eligible for this study, 19,766 (48.9%) patients underwent WBCT. The proportion of patients undergoing WBCT significantly increased during the study period, from 10.7% in 2004 to 59.6% in 2015. Primary IV analysis showed a significant association between WBCT and lower in-hospital mortality (odds ratio 0.84, 95% confidence interval 0.72–0.98).

Conclusions

WBCT can be beneficial in patients with blunt trauma which has compromised vital signs. These findings from a nationwide study suggest that physicians should consider WBCT for blunt trauma patients when warranted by vital signs.

     

Additional Imaging in Alert Trauma Patients with Cervical Spine Tenderness and a Negative Computed Tomographic Scan: Is it Needed?

Background

The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients with tenderness on clinical exam and a negative computed tomographic (CT) scan is still unclear.

Methods

All adult trauma patients with a Glasgow Coma Scale of 15, C-spine tenderness in the absence of neurologic signs, and a negative C-spine CT were included. The study period extended from September 2011 to June 2012. C-spine CT scans were interpreted in detail and considered negative in the absence of any findings indicating bony, ligamentous, or soft tissue injury around the C-spine. The incidence of C-spine injury was evaluated using early (<24 h) repeat physical examination, MRI, and/or flexion–extension films.

Results

Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30–53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent MRI (3.7 %), flexion–extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging.

Conclusion

C-spine precautions can be withdrawn without additional imaging in most blunt trauma patients with C-spine tenderness but negative neurologic evaluation and C-spine CT. Focus should be placed on the detailed and comprehensive interpretation of the C-spine CT.

     

The Respiratory Rate: A Neglected Triage Tool for Pre-hospital Identification of Trauma Patients

Background

Under-triaged trauma patients have worse clinical outcomes. We evaluated the capability of four pre-hospital variables to identify this population at the lowest level trauma activation (level 3).

Methods

A retrospective review of adult trauma activations from 2004 to 2014 was completed. Pre-hospital vital signs and Glasgow Coma Scale were converted to categorical variables. Patients were under-triaged based on meeting current level 1 or 2 criteria, or requiring a pre-defined critical intervention. Logistic regression was used to determine the association between the pre-hospital variables and under-triaged patients. Odds ratios and 95% confidence intervals were calculated for a comprehensive model, grouping all causes of under-triage as a single unit, and 16 individual models, one for each under-triage criterion. A new level 2 criterion was generated and internally validated.

Results

In total, 12,332 activations occurred during the study period. Four hundred and sixty-six (5.9%) patients were under-triaged. Compared to patients with a normal respiratory rate (RR), tachypneic patients were more likely to be under-triaged for any reason, OR 1.7 [1.3–2.1], p < 0.001. In the individual event analysis, tachypneic patients were more likely to have flail chest, OR 22 [2.9–168.3], p = 0.003; require a chest tube, OR 3 [1.8–4.9], p < 0.001; or require emergent intubation, OR 1.6 [1.1–2.8], p = 0.04, compared to patients with a normal RR. The data-driven triage modification was tachypnea with suspected thoracic injury which reduced the under-triage rate by 1.2%.

Conclusion

Tachypnea with suspected thoracic injury is the strongest level 2 triage modification to reduce level 3 under-triage.

     

Epidemiologic study in hospitalized patients with head injuries

Purpose

The aim of this study was to analyze epidemiologic data of patients with head injuries (HI) who were admitted to the Trauma and Emergency Surgery Department.

Methods

The hospital records of 497 patients with HI who were admitted to the Trauma and Emergency Surgery Department from January 1, 2014, through 31 December, 2014, were analyzed retrospectively.

Results

The male-to-female ratio was 2:1, and the mean age was 16.3 years. The rates of patients with mild, moderate, and severe HI were 93, 3, and 4 %, respectively. The most common cause of trauma was falls. Linear fractures were the most common radiologic diagnoses with 242 cases (49 %). Of the patients admitted to hospital, 22 % presented 4 h after the trauma had occurred. Mortality rate due to HI was 3 % (15 patients). Outcome was associated with admission Glasgow Coma Scale and presence of additional trauma.

Conclusions

The number of traffic accidents and assaults were considerably higher in the young adult population compared with the other age groups. Traffic accidents accounted for 46.6 % of the mortality rate. Mortality in HI patients mostly arises from preventable conditions, and the young adult population seems to be the most affected group. HI should be considered as a public health issue, and prevention of HI should be the primary goal.

     

Nine-year change of mortality and discharge against medical advice among major trauma patients in a Chinese Intensive Care Unit

Background

The mortality/morbidity of patients can be used to evaluate the quality of a trauma care, which can be influenced by incidence of discharge against medical advice (DAMA).

Objective

This study was to investigate annual changes of mortality/morbidity and DAMA of trauma patients in one Chinese Intensive Care Unit (ICU) in 9 years.

Methods

A retrospective analysis of data [age, Injury Severity Score (ISS), Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), mortality rate, and DAMA] was performed with trauma patients admitted in the emergency ICU of the Second Affiliated Hospital of Zhejiang University from 2003 to 2011.

Results

The rate of total mortality (in-hospital death and dying at discharge) was 6.9 % and the rate of DAMA (deterioration at discharge and improvement at discharge) was 6.6 %. The mortality rate was significantly decreased from 11.1 to 4.6 %, and the rate of deterioration at discharge was increased from 2.8 to 6.4 %. Among the three periods (2003–2005, 2006–2008, and 2009–2011), the age and APACHE II score of patients in total death, deterioration at discharge, and death plus deterioration at discharge groups were highest in the period 2009–2011, whereas the GCS was statistically lower in all groups except in the deterioration at discharge group.

Conclusion

The medical quality of trauma care has been improved through gradual improvement of instruments and trained medical staffs. The rate of deterioration at discharge was increased, especially in elder patient group. The DAMA had a significant impact on the accurate assessment of trauma care, which should be paid more attention on its potential roles in the future.

     

Impact of urgent resuscitative surgery for life-threatening torso trauma

Purpose

This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs.

Methods

We divided 264 eligible cases into a URS group (n = 97) and a non-URS group (n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS).

Results

While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP) <90 mmHg and a Glasgow coma scale (GCS) score of ≥9 had significantly higher observed survival rates than predicted survival rates (0.433 vs. 0.309, p = 0.008), (0.795 vs. 0.681, p = 0.004). The implementation of damage control surgery (DCS) was found to be a significant predictor of survival (OR 5.23, 95% CI 0.113–0.526, p < 0.010).

Conclusion

The best indications for the URS policy are an SBP <90 mmHg, a GCS ≥9 on ED arrival, and/or the need for DCS. By implementing our URS policy, satisfactory survival of patients requiring immediate hemostatic surgery was achieved.

     

Observation period for asymptomatic penetrating chest trauma: 1 or 3 h?

Background

Current recommendations for evaluation and safe discharge of penetrating chest trauma patients regarding pneumothorax (PTX) include a Chest X Ray (CXR) at the Emergency Department (ED) upon arrival and second CXR after 3 h if the first one is negative.

Purpose

To compare CXRs taken at the first and third hours of ED arrival and evaluate a 1 h period of observation instead of 3 h for safe discharge of patients with penetrating chest trauma.

Methods

In this cross-sectional study, all asymptomatic patients with penetrating chest trauma referred to a level 1 trauma center with negative initial Postero-Anterior (PA) CXRs (hour 0) were enrolled. Those with intoxication, tube thoracostomy, chest computed tomography, evidence of abdominal penetration, an overall elapsed timed of more than 1 h for admission to the ED, and refusal to take part in the study were excluded. Patients underwent subsequent PA CXRs at hours 1 and 3. A phone call follow up after 24 h was organized for each patient.

Results

A total of 68 patients were enrolled. There was 100 % concordance among CXRs performed at hours 1 and 3 in the study population. None of the patients showed clinical deterioration or PTX in CXR at hour 1 if remained asymptomatic during the first hour of observation.

Conclusion

Asymptomatic patients with penetrating chest trauma, negative initial PA CXR, no signs of intoxication, and no deterioration during the first hour of observation may be considered for discharge. Further evidence is required to make recommendations based on these findings.

     

Algorithm for activation of coagulation support treatment in multiple injured patients––cohort study

Background

Early recognition and management of trauma related coagulopathy improves the outcome. Trauma facilities should implement an algorithm to identify the bleeding trauma patient with coagulopathy.

Objective

The scope of the paper is to identify the indicators of early coagulopathy and to optimize the indications for thromboelastometry and coagulation support.

Design

Cohort study based on data from trauma registry.

Setting

Data of 493 major trauma patients treated in GH Celje from 2006 to 2014 were included into The TraumaRegister DGU^® (TR-DGU).

Patients

Patients were selected for inclusion into TR-DGU according to the following criteria: polytraumatized patients with Injury severity score (ISS) ≥ 18, patients with injuries to single region with AIS 5, patients with major injuries to a single region and abnormal vital signs. All patients that were dead on arrival to hospital, patients presented to hospital >24 h after the injury, and head injuries that occurred with a low energy mechanism in patients on anticoagulation drugs were excluded.

Measurements

Two groups were formed (with or without coagulopathy). Mortality, morbidity, length of mechanical ventilation, ICU and hospital stay were used as outcome and compared between the groups. A coagulopathy prediction model (CPM) was developed to identify the patients who were at high risk of coagulopathy.

Results

Coagulopathy was present in 51 % of patients. Severe injuries to the torso and limbs, infusion of >1000 ml of fluids in the prehospital settings, and hypotension were included into CPM. If all three criteria were present, the sensitivity of the model to predict coagulopathy was 93 %. By adding the blood gas analysis (BE ≤ ?5), the specificity increased to 81.7 %.

Limitations

Shortcomings of our analysis are mainly related to the quality of data in the registry that may not be comparable to a clinical trial where data are collected specifically to address a given issue.

Conclusions

The Criteria for activation of coagulation support treatment remain centre dependent. In our settings the CPM is the tool to select patients for ROTEM^® analysis. By adding data from blood gas analysis, treatment of coagulopathy is justifiable before complete test results are available.

     

Preoperative serum lactate cannot predict in-hospital mortality after decompressive craniectomy in traumatic brain injury

Purpose

Despite the utility of serum lactate for predicting clinical courses, little information is available on the topic after decompressive craniectomy. This study was conducted to determine the ability of perioperative serum lactate levels to predict in-hospital mortality in traumatic brain-injury patients who received emergency or urgent decompressive craniectomy.

Methods

The medical records of 586 consecutive patients who underwent emergency or urgent decompressive craniectomy due to traumatic brain injuries from January 2007 to December 2014 were retrospectively analyzed. Pre- and intraoperative serum lactate levels and base deficits were obtained from arterial blood gas analysis results.

Results

The overall mortality rate after decompressive craniectomy was 26.1 %. Mean preoperative serum lactate was significantly higher in the non-survivors (P = 0.034) than the survivors but had no significance for predicting in-hospital mortality in the multivariate regression analysis (P = 0.386). Rather, preoperative Glasgow Coma Score was a significant predictor for in-hospital mortality (hazard ratio 0.796, 95 % confidence interval 0.755–0.836, P < 0.001).

Conclusion

Preoperative lactate level is not an independent predictor of in-hospital mortality after decompressive craniectomy in traumatic brain-injury patients.

     

Early Management of Retained Hemothorax in Blunt Head and Chest Trauma

Background

Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3–4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries.

Materials and methods

From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation.

Result

All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were discharged (11.74 vs. 14.10, p < 0.05).

Discussion

In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma.

     

Unconscious trauma patients: outcome differences between southern Finland and Germany—lesson learned from trauma-registry comparisons

Purpose

International trauma registry comparisons are scarce and lack standardised methodology. Recently, we performed a 6-year comparison between southern Finland and Germany. Because an outcome difference emerged in the subgroup of unconscious trauma patients, we aimed to identify factors associated with such difference and to further explore the role of trauma registries for evaluating trauma-care quality.

Methods

Unconscious patients [Glasgow Coma Scale (GCS) 3–8] with severe blunt trauma [Injury Severity Score (ISS) ≥16] from Helsinki University Hospital’s trauma registry (TR-THEL) and the German Trauma Registry (TR-DGU) were compared from 2006 to 2011. The primary outcome measure was 30-day in-hospital mortality. Expected mortality was calculated by Revised Injury Severity Classification (RISC) score. Patients were separated into clinically relevant subgroups, for which the standardised mortality ratios (SMR) were calculated and compared between the two trauma registries in order to identify patient groups explaining outcome differences.

Results

Of the 5243 patients from the TR-DGU and 398 from the TR-THEL included, nine subgroups were identified and analyzed separately. Poorer outcome appeared in the Finnish patients with penetrating head injury, and in Finnish patients under 60 years with isolated head injury [TR-DGU SMR = 1.06 (95 % CI = 0.94–1.18) vs. TR-THEL SMR = 2.35 (95 % CI = 1.20-3.50), p = 0.001 and TR-DGU SMR = 1.01 (95 % CI = 0.87–1.16) vs. TR-THEL SMR = 1.40 (95 % CI = 0.99-1.81), p = 0.030]. A closer analysis of these subgroups in the TR-THEL revealed early treatment limitations due to their very poor prognosis, which was not accounted for by the RISC.

Conclusion

Trauma registry comparison has several pitfalls needing acknowledgement: the explanation for outcome differences between trauma systems can be a coincidence, a weakness in the scoring system, true variation in the standard of care, or hospitals’ reluctance to include patients with hopeless prognosis in registry. We believe, however, that such comparisons are a feasible method for quality control.

     

Fibrinogen and base excess levels as predictive markers of the need for massive blood transfusion after blunt trauma

Background

Assessment blood consumption and trauma-associated severe hemorrhage scores are useful for predicting the need for massive transfusion (MT) in severe trauma patients. However, fibrinogen (Fbg) and base excess (BE) levels might also be useful indicators for the need for MT. We evaluated the accuracy of prediction for MT of the scoring system vs. Fbg and BE.

Methods

The subjects of this retrospective single center observational study were patients with injury severity score ≥16 trauma, divided into a non-MT group and an MT group. We compared variables, including the scoring system (comprising vital signs and focused assessment with sonography for trauma; FAST) and Fbg between the groups. We then performed a multiple logistic regression modeling and a receiver operating characteristic analysis to clarify which value was the most useful predictive indicator for MT.

Results

There were 114 patients in the non-MT group and 39 in the MT group. The level of Fbg and BE were independent predictors of MT. The area under the curve values for Fbg and BE were 0.765 and 0.845, respectively, and the optimal cutoff values of Fbg and BE were 211 mg/dL and ?1.4, respectively.

Conclusions

Fbg and BE levels can be used as an independent predictor for MT.

     

Severe Trauma in Estonia: 256 consecutive cases analysed and the impact on outcomes comparing two regions

Purpose

The purpose of this study was to investigate epidemiology of severe injuries in Estonia while comparing outcomes at regional trauma facilities.

Methods

After the ethics review board approval, all consecutive trauma admissions with Injury Severity Score (ISS) > 15 to North Estonia Medical Center/Tallinn Children’s Hospital (NEMC + TCH) and Tartu University Hospital (TUH) were identified between 1/1/2013 and 31/12/2013. Data collection included demographics, admission data, injury severity variables, interventions, and in-hospital outcomes. Primary outcome was in-hospital mortality. Secondary outcomes were complications per Clavien–Dindo and hospital length of stay (HLOS). Logistic regression analysis was used to compare adjusted mortality between the two regional hospitals.

Results

A total of 256 patients met inclusion criteria. The mean ISS for the cohort was 23.6 ± 7.8, 13.3 % were hypotensive on admission, and 44.1 % had a Glasgow Coma Scale < 9. Overall rate of complications was 40.2 % that did not differ between the facilities. The mean HLOS at the NEMC + TCH and the TUH were 20.1 ± 25.1 and 10.5 ± 11.2 days (p < 0.001), respectively. Overall mortality was 20.7 % (n = 53). Mortality was 25.4 and 14.9 % for the NEMC + TCH and the TUH, respectively (p = 0.04). Logistic regression analysis resulted in comparable mortality at the regional trauma facilities (adj. OR 1.38; 95 % CI 0.66–2.92; p value 0.39).

Conclusions

The annual incidence of injuries with ISS > 15 was 256 cases with overall mortality at 20.7 % in Estonia. We observed comparable adjusted outcomes at the major regional trauma facilities. This study contains benchmarking data on severely injured patients in Estonia providing potential for future trauma care evaluation and regional outcome comparisons.

     

Triage using the Emergency Severity Index (ESI) and seven versus three vital signs

Purpose

The aim of this study was to compare sensitivity and validity of the emergency severity index (ESI) using 3 vital signs vs. the modified ESI (mESI) with 7 vital signs.

Methods

This prospective, observational study comprised all patients without trauma (>18 years old), presenting between 1 September 2014 and 1 October 2014 from 08:00–16:00 h, and having ESI triage scores levels 3, 4, and 5. Different from the ESI, 7 vital signs for patients in levels 3, 4, and 5 were determined. When the result revealed an abnormality in at least one of the 7 vital signs, these patients were designated as level 2 and the mESI triage was applied to them.

Results

A total of 4536 patients were included in the study. Comparing the hospitalized patient group and the patients treated as outpatients according to the ESI and mESI levels, the ESI and the mESI level median values were 4 (3–4) and 3 (2–4), respectively, and those of patients treated on an outpatient basis were 4 (4–5) and 4 (3–5). A significant difference was observed between the two groups with regard to both the ESI and the mESI scores (p?<?0.001). Furthermore, when the ESI and the mESI were compared with regard to the sensitivity and the reliability in determining the patients for hospitalization, a significant difference was determined favoring ESI [ROC curve: area under the curve mESI: 0.690, 95?% confidence interval (Cl) 0.666–0.713; ESI 0.753, ?95?% Cl 0.733–0.774; p?<?0.001].

Conclusion

The ESI, in which 3 vital signs are measured in order to distinguish only level 2 and 3 patients, is an adequate and reliable triage system.

     

Validation of a base deficit-based trauma prediction model and comparison with TRISS and ASCOT

Background

Base deficit provides a more objective indicator of physiological stress following injury as compared with vital signs constituting the revised trauma score (RTS). We have previously developed a base deficit-based trauma survival prediction model [base deficit and injury severity score model (BISS)], in which RTS was replaced by base deficit as a measurement of physiological imbalance.

Purpose

To externally validate BISS in a large cohort of trauma patients and to compare its performance with established trauma survival prediction models including trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT). Moreover, we examined whether the predictive accuracy of BISS model could be improved by replacement of injury severity score (ISS) by new injury severity score (NISS) in the BISS model (BNISS).

Methods

In this retrospective, observational study, clinical data of 3737 trauma patients (age ≥15 years) admitted consecutively from 2003 to 2007 were obtained from a prospective trauma registry to calculate BISS, TRISS, and ASCOT models. The models were evaluated in terms of discrimination [area under curve (AUC)] and calibration.

Results

The in-hospital mortality rate was 8.1 %. The discriminative performance of BISS to predict survival was similar to that of TRISS and ASCOT [AUCs of 0.883, 95 % confidence interval (CI) 0.865–0.901 for BISS, 0.902, 95 % CI 0.858–0.946 for TRISS and 0.864, 95 % CI 0.816–0.913 for ASCOT]. Calibration tended to be optimistic in all three models. The updated BNISS had an AUC of 0.918 indicating that substitution of ISS with NISS improved model performance.

Conclusions

The BISS model, a base deficit-based trauma model for survival prediction, showed equivalent performance as compared with that of TRISS and ASCOT and may offer a more simplified calculation method and a more objective assessment. Calibration of BISS model was, however, less good than that of other models. Replacing ISS by NISS can considerably improve model accuracy, but further confirmation is needed.

     

Analysis of Prospective Trauma Registry Data in Francophone Africa: A Pilot Study from Cameroon

Introduction

Injury rates in sub-Saharan Africa are among the highest in the world, but prospective, registry-based reports from Cameroon are limited. We aimed to create a prospective trauma registry to expand the data elements collected on injury at a busy tertiary center in Yaoundé Cameroon.

Methods

Details of the injury context, presentation, care, cost, and disposition from the emergency department (ED) were gathered over a 6-month period, by trained research assistants using a structured questionnaire. Bivariate and multivariate models were built to explore variable relationships and outcomes.

Results

There were 2,855 injured patients in 6 months, comprising almost half of all ED visits. Mean age was 30 years; 73 % were male. Injury mechanism was road traffic injury in 59 %, fall in 7 %, penetrating trauma in 6 %, and animal bites in 4 %. Of these, 1,974 (69 %) were discharged home, 517 (18 %) taken to the operating room, and 14 (1 %) to the intensive care unit. The body areas most severely injured were pelvis and extremity in 43 %, head in 30 %, chest in 4 %, and abdomen in 3 %. The estimated injury severity score (eISS) was <9 in 60 %, 9–24 in 35 %, and >25 in 2 %. Mortality was 0.7 %. In the multivariate analysis, independent predictors of mortality were eISS ≥9 and Glasgow Coma Score ≤12. Road traffic injury was an independent predictor for the need to have surgery. Trauma registry results were presented to the Ministry of Health in Cameroon, prompting the formation of a National Injury Committee.

Conclusions

Injuries comprise a significant proportion of ED visits and utilization of surgical services in Yaoundé. A prospective approach allows for more extensive information. Thorough data from a prospective trauma registry can be used successfully to advocate for policy towards prevention and treatment of injuries.

     

Reducing Operating Room Turnover Time for Robotic Surgery Using a Motor Racing Pit Stop Model

Background

Operating room (OR) turnover time, time taken between one patient leaving the OR and the next entering, is an important determinant of OR utilization, a key value metric for hospital administrators. Surgical robots have increased the complexity and number of tasks required during an OR turnover, resulting in highly variable OR turnover times. We sought to streamline the turnover process and decrease robotic OR turnover times and increase efficiency.

Methods

Direct observation of 45 pre-intervention robotic OR turnovers was performed. Following a previously successful model for handoffs, we employed concepts from motor racing pit stops, including briefings, leadership, role definition, task allocation and task sequencing. Turnover task cards for staff were developed, and card assignments were distributed for each turnover. Forty-one cases were observed post-intervention.

Results

Average total OR turnover time was 99.2 min (95% CI 88.0–110.3) pre-intervention and 53.2 min (95% CI 48.0–58.5) at 3 months post-intervention. Average room ready time from when the patient exited the OR until the surgical technician was ready to receive the next patient was 42.2 min (95% CI 36.7–47.7) before the intervention, which reduced to 27.2 min at 3 months (95% CI 24.7–29.7) post-intervention (p < 0.0001).

Conclusions

Role definition, task allocation and sequencing, combined with a visual cue for ease-of-use, create efficient, and sustainable approaches to decreasing robotic OR turnover times. Broader system changes are needed to capitalize on that result. Pit stop and other high-risk industry models may inform approaches to the management of tasks and teams.

     

Subjective impact of traumatic brain injury on long-term outcome at a minimum of 10 years after trauma– first results of a survey on 368 patients from a single academic trauma center in Germany

Background

Traumatic Brain Injury (TBI) may lead to significant impairments in personal, social and professional life. However, knowledge of the influence on long-term outcome after TBI is sparse. We therefore aimed to investigate the subjective effects of TBI on long-term outcome at a minimum of 10 years after trauma in one of the largest study populations in Germany.

Methods

The current investigation represents a retrospective cohort study at a level I trauma center including physical examination or standardized questionnaires of patients with mild, moderate or severe isolated TBI with a minimum follow-up of 10 years. We investigated the subjective physical, psychological and social outcome evaluating the Glasgow Outcome Scale, short-form 12, and social as well as vocational living circumstances.

Results

368 patients aged 0 to 88 years were included. Patients with severe TBI were younger compared to patients with moderate or mild TBI (p?<?0.05). Patients with severe TBI lived more often as single after the trauma impact. A significantly worse outcome was associated with higher severity of TBI resulting in an increased incidence of mental disability. A professional decline was analyzed in case of severe TBI resulting in significant loss of salary.

Conclusions

The severity of TBI significantly influenced the subjective social and living conditions. Subjective mental and physical outcome as well as professional life depended on the severity of TBI 10 years after the injury.