Long-Lasting Performance Improvement After Formalization of a Dedicated Trauma Service

Groven, Sigrid; Eken, Torsten; Skaga, Nils Oddvar; Røise, Olav; Næss, Paal Aksel; Gaarder, Christine

doi:10.1097/ta.0b013e31820d1a9b

Cited by 39 publications

(33 citation statements)

References 59 publications

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“…Despite the implementation of damage control resuscitation principles, exsanguination remains a frequent cause of death in hospital [1,2]. Early coagulopathy is identified in 10 to 34% of patients arriving in hospital and is associated with increased mortality [3].…”

Section: Introductionmentioning

confidence: 99%

Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study

et al. 2014

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IntroductionExsanguination due to trauma-induced coagulopathy is a continuing challenge in emergency trauma care. Fibrinogen is a crucial factor for haemostatic competence, and may be the factor that reaches critically low levels first. Early fibrinogen substitution is advocated by a number of authors. Little evidence exists regarding the indications for fibrinogen supplementation in the acute phase. This study aims to estimate the prevalence of hypofibrinogenaemia in a multi-center trauma population, and to explore how initial fibrinogen concentration relates to outcome. Also, factors contributing to low fibrinogen levels are identified.MethodsPatients arriving in hospital less than 180 minutes post-injury requiring full trauma team activation in four different centers were included in the study. Time from injury, patient demographics, injury severity scores (ISS) and 28 days outcome status were recorded. Initial blood samples for coagulation and blood gas were analyzed. Generalized additive regression, piecewise linear regression, and multiple linear regression models were used for data analyses.ResultsOut of 1,133 patients we identified a fibrinogen concentration ≤1.5g/L in 8.2%, and <2 g/L in 19.2%. A non-linear relationship between fibrinogen concentration and mortality was detected in the generalized additive and piecewise linear regression models. In the piecewise linear regression model we identified a breakpoint for optimal fibrinogen concentration at 2.29 g/L (95% confidence interval (CI): 1.93 to 2.64). Below this value the odds of death by 28 days was reduced by a factor of 0.08 (95% CI: 0.03 to 0.20) for every unit increase in fibrinogen concentration. Low age, male gender, lengthened time from injury, low base excess and high ISS were unique contributors to low fibrinogen concentrations on arrival.ConclusionsHypofibrinogenaemia is common in trauma and strongly associated with poor outcome. Below an estimated critical fibrinogen concentration value of 2.29 g/L a dramatic increase in mortality was detected. This finding indicates that the negative impact of low fibrinogen concentrations may have been previously underestimated. A number of clinically identifiable factors are associated with hypofibrinogenaemia. They should be considered in the management of massively bleeding patients. Interventional trials with fibrinogen substitution in high-risk patients need to be undertaken.

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Section: Introductionmentioning

confidence: 99%

Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study

et al. 2014

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“…Our trauma registry did not include, until the beginning of 2011, the initial vital signs of patients, which unfortunately meant that the calculation of Revised Trauma Score and subsequent Trauma and Injury Severity Score, which is one of the standard methods of comparing trauma service outcomes, was unavailable. 4 Furthermore, data regarding complications such as deep vein thrombosis, ventilator-associated pneumonia, and pulmonary embolism would have been valuable to assess the effect on trauma associated morbidity; however, these were also not included in our hospital's initial minimal data, and so our focus remained on the association between the development of our trauma system and the trends in mortality. Given the limited scope of available data, it does potentially leave the results open to confounders; however, the improvement in survival with consistent ISS and the increasing age is a reassuring factor.…”

Section: Discussionmentioning

confidence: 99%

The impact of specialist trauma service on major trauma mortality

Wong

Lumsdaine

Hardy

et al. 2013

Journal of Trauma and Acute Care Surgery

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“…Blunt trauma is the mechanism of injury in 90% of the patients. Consistently, approximately 40% [20] are severely injured with an injury severity score (ISS) >15 [21]. …”

Section: Methodsmentioning

confidence: 99%

Abdominal injuries in a major Scandinavian trauma center – performance assessment over an 8 year period

Groven

Gaarder

Eken

et al. 2014

J Trauma Manage Outcomes

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IntroductionDamage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries. The shift towards non-operative management in haemodynamically stable patients suffering blunt abdominal trauma has further contributed to the improved results. However, in many countries, low volume of trauma cases and limited exposure to trauma laparotomies constitute a threat to trauma competence. The aim of this study was to evaluate the institutional patient volume and performance for patients with abdominal injuries over an eight-year period.MethodsData from 955 consecutive trauma patients admitted in Oslo University Hospital Ulleval with abdominal injuries during the eight-year period 2002-2009 were retrospectively explored. A separate analysis was performed on all trauma patients undergoing laparotomy during the same period, whether abdominal injuries were identified or not. Variable life-adjusted display (VLAD) was used in order to describe risk-adjusted survival trends throughout the period and the patients admitted before (Period 1) and after (Period 2) the institution of a formal Trauma Service (2005) were compared.ResultsThere was a steady increase in admitted patients with abdominal injuries, while the number of patients undergoing laparotomy was constant exposing the surgical trauma team leaders to an average of 8 trauma laparotomies per year. No increase in missed injuries or failures of non-operative management was detected. Unadjusted mortality rates decreased from period 1 to period 2 for all patients with abdominal injuries as well as for the patients undergoing laparotomy. However, this apparent decrease was not confirmed as significant in TRISS-based analysis of risk-adjusted mortality. VLAD demonstrated a steady performance throughout the study period.ConclusionEven in a high volume trauma center the exposure to abdominal injuries and trauma laparotomies is limited. Due to increasing NOM, an increasing number of patients with abdominal injuries was not accompanied by an increase in number of laparotomies. However, we have demonstrated a stable performance throughout the study period as visualized by VLAD without an increase in missed injuries or failures of NOM.

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Long-Lasting Performance Improvement After Formalization of a Dedicated Trauma Service

Abstract: We have shown that the start of the long-lasting performance improvement coincided with formalization of a dedicated trauma service, providing increased multidisciplinary focus on all aspects of trauma care.

Cited by 39 publications

References 59 publications

Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study

Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study

The impact of specialist trauma service on major trauma mortality

Abdominal injuries in a major Scandinavian trauma center – performance assessment over an 8 year period

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