RESUMO
Considerable political, structural, environmental and epidemiological change will affect high socioeconomic index (SDI) countries over the next 25 years. These changes will impact healthcare provision and consequently trauma systems. This review attempts to anticipate the potential impact on trauma systems and how they could adapt to meet the changing priorities. The first section describes possible epidemiological trajectories. A second section exposes existing governance and funding challenges, how these can be met, and the need to incorporate data and information science into a learning and adaptive trauma system. The last section suggests an international harmonization of trauma education to improve care standards, optimize immediate and long-term patient needs and enhance disaster preparedness and crisis resilience. By demonstrating their capacity for adaptation, trauma systems can play a leading role in the transformation of care systems to tackle future health challenges.
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Planejamento em Desastres , Humanos , Atenção à Saúde , Fatores SocioeconômicosRESUMO
BACKGROUND: Trauma-induced coagulopathy (TIC) is common in trauma patients with major hemorrhage. Prothrombin complex concentrate (PCC) is used as a potential treatment for the correction of TIC, but the efficacy, timing, and evidence to support its use in injured patients with hemorrhage are unclear. METHODS: A systematic search of published studies was performed on MEDLINE and EMBASE databases using standardized search equations. Ongoing studies were identified using clinicaltrials.gov. Studies investigating the use of PCC to treat TIC (on its own or in combination with other treatments) in adult major trauma patients were included. Studies involving pediatric patients, studies of only traumatic brain injury (TBI), and studies involving only anticoagulated patients were excluded. Primary outcomes were in-hospital mortality and venous thromboembolism (VTE). Pooled effects of PCC use were reported using random-effects model meta-analyses. Risk of bias was assessed for each study, and we used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence. RESULTS: After removing duplicates, 1745 reports were screened and nine observational studies and one randomized controlled trial (RCT) were included, with a total of 1150 patients receiving PCC. Most studies used 4-factor-PCC with a dose of 20-30U/Kg. Among observational studies, co-interventions included whole blood (n = 1), fibrinogen concentrate (n = 2), or fresh frozen plasma (n = 4). Outcomes were inconsistently reported across studies with wide variation in both measurements and time points. The eight observational studies included reported mortality with a pooled odds ratio of 0.97 [95% CI 0.56-1.69], and five reported deep venous thrombosis (DVT) with a pooled OR of 0.83 [95% CI 0.44-1.57]. When pooling the observational studies and the RCT, the OR for mortality and DVT was 0.94 [95% CI 0.60-1.45] and 1.00 [95% CI 0.64-1.55] respectively. CONCLUSIONS: Among published studies of TIC, PCCs did not significantly reduce mortality, nor did they increase the risk of VTE. However, the potential thrombotic risk remains a concern that should be addressed in future studies. Several RCTs are currently ongoing to further explore the efficacy and safety of PCC.
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Transtornos da Coagulação Sanguínea , Tromboembolia Venosa , Adulto , Humanos , Criança , Fatores de Coagulação Sanguínea/uso terapêutico , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Transtornos da Coagulação Sanguínea/etiologia , Hemorragia/tratamento farmacológico , Hemorragia/etiologia , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
INTRODUCTION: While numerous randomized controlled trials (RCTs) have been conducted in the field of trauma, a substantial portion of them are yielding negative results. One potential contributing factor to this trend could be the lack of agreement regarding the chosen definitions across different trials. The primary objective was to identify the terminology and definitions utilized for the characterization of multiple trauma patients within randomized controlled trials (RCTs). METHODS: A systematic review of the literature was performed in MEDLINE, EMBASE and clinicaltrials.gov between January 1, 2002, and July 31, 2022. RCTs or RTCs protocols were eligible if they included multiple trauma patients. The terms employed to characterize patient populations were identified, and the corresponding definitions for these terms were extracted. The subsequent impact on the population recruited was then documented to expose clinical heterogeneity. RESULTS: Fifty RCTs were included, and 12 different terms identified. Among these terms, the most frequently used were "multiple trauma" (n = 21, 42%), "severe trauma" (n = 8, 16%), "major trauma" (n = 4, 8%), and trauma with hemorrhagic shock" (n = 4, 8%). Only 62% of RCTs (n = 31) provided a definition for the terms used, resulting a total of 21 different definitions. These definitions primarily relied on the injury severity score (ISS) (n = 15, 30%), displaying an important underlying heterogeneity. The choice of the terms had an impact on the study population, affecting both the ISS and in-hospital mortality. Eleven protocols were included, featuring five different terms, with "severe trauma" being the most frequent, occurring six times (55%). CONCLUSION: This systematic review uncovers an important heterogeneity both in the terms and in the definitions employed to recruit trauma patients within RCTs. These findings underscore the imperative of promoting the use of a unique and consistent definition.
Assuntos
Traumatismo Múltiplo , Choque Hemorrágico , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Traumatismo Múltiplo/terapia , Mortalidade Hospitalar , Escala de Gravidade do FerimentoRESUMO
OBJECTIVES: To determine the incidence, demographics and injury patterns involved in E-Scooter-related hospital admissions due to significant trauma compared with bicycle-related trauma within England and Wales. To compare morbidity and mortality between groups. DESIGN: A retrospective cohort study based on data which has been prospectively collected and submitted to the UK Trauma Audit and Research Network (TARN) registry. SETTING: Major trauma centres and trauma units within England and Wales. PARTICIPANTS: Patients of any age who were admitted to hospitals in England and Wales with injuries following E-Scooter or bicycle incidents between the dates 1 January 2021-31 December 2021. All patients must have met TARN database inclusion criteria. OUTCOMES: In-hospital mortality, critical care admission and length of stay (LoS), hospital LoS and discharge destination. RESULTS: There were 293 E-Scooter trauma incidents compared with 2538 bicycle incidents. E-Scooter users were more likely to be admitted to a major trauma centre (p=0.019) or a critical care unit (p<0.001). Serious head and limb trauma (Abbreviated Injury Scale >2) occurred more frequently among the E-Scooter cohort (35.2% vs 19.7%, p<0.001 and 39.9% vs 27.2%, p<0.001, respectively) while serious chest and pelvic trauma were greater among bicycle users (p<0.001 and p=0.003, respectively). Over one-third of E-Scooter injuries were incurred outside the current legislation by patients who were intoxicated by alcohol and drugs (26%, 75/293) or under the age of 17 (14%, 41/293). CONCLUSIONS: These early results suggest a greater relative incidence of serious trauma and an alternative pattern of injury among E-Scooter users compared with bicycles. TRIAL REGISTRATION NUMBER: TARN210101.
Assuntos
Ciclismo , Dispositivos de Proteção da Cabeça , Humanos , Estudos de Coortes , Estudos Retrospectivos , Ciclismo/lesões , Hospitalização , Acidentes de Trânsito/prevenção & controleRESUMO
There is emerging evidence of inequalities in healthcare provision between women and men. Trauma care is no exception with a number of studies indicating lower levels of prioritisation for injured female patients. The antifibrinolytic drug tranexamic acid, reduced trauma deaths to a similar extent in females and males in the international Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) randomised controlled trials, but in real-world practice, national registry data shows females are less likely to receive tranexamic acid than males. Inequity in the provision of tranexamic acid may extend beyond sex (and gender), and further study is required to examine the effect of age and mechanism of injury differences between men and women in the decision to treat.
Assuntos
Antifibrinolíticos , Ácido Tranexâmico , Antifibrinolíticos/uso terapêutico , Feminino , Hemorragia/tratamento farmacológico , Humanos , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Sexismo , Ácido Tranexâmico/uso terapêuticoRESUMO
BACKGROUND: Preparatory, written plans for mass casualty incidents are designed to help hospitals deliver an effective response. However, addressing the frequently observed mismatch between planning and delivery of effective responses to mass casualty incidents is a key challenge. We aimed to use simulation-based iterative learning to bridge this gap. METHODS: We used Normalisation Process Theory as the framework for iterative learning from mass casualty incident simulations. Five small-scale 'focused response' simulations generated learning points that were fed into two large-scale whole-hospital response simulations. Debrief notes were used to improve the written plans iteratively. Anonymised individual online staff surveys tracked learning. The primary outcome was system safety and latent errors identified from group debriefs. The secondary outcomes were the proportion of completed surveys, confirmation of reporting location, and respective roles for mass casualty incidents. RESULTS: Seven simulation exercises involving more than 700 staff and multidisciplinary responses were completed with debriefs. Usual emergency care was not affected by simulations. Each simulation identified latent errors and system safety issues, including overly complex processes, utilisation of space, and the need for clarifying roles. After the second whole hospital simulation, participants were more likely to return completed surveys (odds ratio=2.7; 95% confidence interval [CI], 1.7-4.3). Repeated exercises resulted in respondents being more likely to know where to report (odds ratio=4.3; 95% CI, 2.5-7.3) and their respective roles (odds ratio=3.7; 95% CI, 2.2-6.1) after a simulated mass casualty incident was declared. CONCLUSION: Simulation exercises are a useful tool to improve mass casualty incident plans iteratively and continuously through hospital-wide engagement of staff.
Assuntos
Atenção à Saúde/organização & administração , Planejamento em Desastres/métodos , Incidentes com Feridos em Massa , Recursos Humanos em Hospital/educação , Avaliação Educacional , Hospitais , Humanos , Aprendizagem , Treinamento por SimulaçãoRESUMO
BACKGROUND: The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known. OBJECTIVE: The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK. METHODS: A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each. RESULTS: Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age. CONCLUSIONS: This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.
Assuntos
Cuidados Críticos , Procedimentos Clínicos , Humanos , Idoso , Estudos Transversais , Centros de Traumatologia , Reino Unido/epidemiologiaRESUMO
OBJECTIVE: The aim of this study was to identify the effects of recent innovations in trauma major hemorrhage management on outcome and transfusion practice, and to determine the contemporary timings and patterns of death. BACKGROUND: The last 10 years have seen a research-led change in hemorrhage management to damage control resuscitation (DCR), focused on the prevention and treatment of trauma-induced coagulopathy. METHODS: A 10-year retrospective analysis of prospectively collected data of trauma patients who activated the Major Trauma Centre's major hemorrhage protocol (MHP) and received at least 1 unit of red blood cell transfusions (RBC). RESULTS: A total of 1169 trauma patients activated the MHP and received at least 1 unit of RBC, with similar injury and admission physiology characteristics over the decade. Overall mortality declined from 45% in 2008 to 27% in 2017, whereas median RBC transfusion rates dropped from 12 to 4 units (massive transfusion rates from 68% to 24%). The proportion of deaths within 24âhours halved (33%-16%), principally with a fall in mortality between 3 and 24âhours (30%-6%). Survivors are now more likely to be discharged to their own home (57%-73%). Exsanguination is still the principal cause of early deaths, and the mortality associated with massive transfusion remains high (48%). Late deaths are now split between those due to traumatic brain injury (52%) and multiple organ dysfunction (45%). CONCLUSIONS: There have been remarkable reductions in mortality after major trauma hemorrhage in recent years. Mortality rates continue to be high and there remain important opportunities for further improvements in these patients.
Assuntos
Transfusão de Sangue , Hemorragia/terapia , Ressuscitação/métodos , Adulto , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Ressuscitação/tendências , Estudos Retrospectivos , Índice de Gravidade de Doença , Sobreviventes , Fatores de Tempo , Resultado do Tratamento , Ferimentos e Lesões/complicações , Adulto JovemRESUMO
OBJECTIVE: This study aimed to evaluate the effectiveness of surgical airway education composed of training using cadavers. The secondary aim was to evaluate the presence and degree of knowledge and skill fade 3 months after training. METHODS: Thirteen participants were recruited from a helicopter emergency medical services program. Participants were assessed at multiple points during training using a multiple-choice examination and a timed evaluation of the ability to establish a surgical airway. RESULTS: Training was effective at increasing knowledge and skill, with a mean increase in multiple-choice examination scores of 14.6 percentage points after training (P < .01) and a mean decrease in time to airway establishment of 26 seconds (P < .01). The training was not associated with the ability to establish a surgical airway in less than 40 seconds, with only 46% of participants able to do so. There was no evidence of knowledge or skill fade at 3 months after training. CONCLUSION: Surgical airway training that includes both didactic and clinical learning using human cadavers is effective at increasing both knowledge and skill. Additional training is needed to establish competency in consistently performing surgical airways in less than 40 seconds. No knowledge or skill fade was present at 3 months after training.
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Manuseio das Vias Aéreas/normas , Competência Clínica , Auxiliares de Emergência/educação , Retenção Psicológica , Avaliação Educacional , Serviços Médicos de Emergência , HumanosRESUMO
BACKGROUND: Metrics exist to assess and validate trauma system outcomes; however, these are clinically focused and do not evaluate the appropriateness of admission patterns, relative to geography and triage category. We propose the term "functional inclusivity", defined as the number and proportion of triage-negative, and/or nonseverely injured patients, who were injured in proximity to a level II/III trauma center but admitted to a level I facility. The aim of this study was to evaluate this metric in the North West London Trauma Network. METHODS: Retrospective, geospatial, observational analysis of registry data from the North West London Trauma Network. We included all adult (≥16 years) patients transported to the level I trauma center at St. Mary's Hospital between 1/1/13-31/12/16. Incident location data were geocoded into longitude/latitude, and drive times were calculated from incident location to each hospital in London's Trauma System, using Google Maps. RESULTS: Of 2051 patients, 907 (44%) were severely injured (injury severity score [ISS] ≥15), and 1144 (56%) were nonseverely injured (ISS 1-15). Seven hundred ninety five of the 1144 nonseverely injured patients (69%) were injured in proximity to a level II/III but taken to the level I facility. A total of 488 (24%) patients were triage-negative, and 229 (47%) of these were injured in proximity to a level II/III, but taken to the level I trauma center. CONCLUSIONS: This study has demonstrated the concept of functional inclusivity in characterizing trauma system performance. Further work is required to establish what constitutes an acceptable level of functional inclusivity and what the denominator should be, as well as validating and further evaluating the concept of functional inclusivity.
Assuntos
Centros de Traumatologia/organização & administração , Adulto , Idoso , Feminino , Humanos , Londres , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Análise Espacial , Centros de Traumatologia/estatística & dados numéricos , Centros de Traumatologia/provisão & distribuiçãoRESUMO
'My goal as a nurse is to ensure that every child attending our department is given the best care possible. We should treat the families as if they were our own, and I knew we were not good enough at dealing with sepsis.'
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Distinções e Prêmios , Enfermeiros Pediátricos , Avaliação em Enfermagem , Sepse/diagnóstico , Serviço Hospitalar de Emergência , Humanos , Triagem , Reino UnidoRESUMO
A school-age immunisation programme set up from scratch and launched within six months is delivering impressive take-up results thanks to the leadership and commitment of the two nurses who run it.
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Distinções e Prêmios , Serviços de Saúde da Criança/organização & administração , Programas de Imunização/organização & administração , Liderança , Enfermagem , Criança , Humanos , Avaliação de Programas e Projetos de SaúdeRESUMO
Liaison psychiatry team lead Nicola Wood's collaborative approach to improving the care of older patients with dementia is enabling nurses to reduce the risk of delirium and distress.
Assuntos
Comportamento Cooperativo , Delírio/enfermagem , Delírio/prevenção & controle , Demência/enfermagem , Relações Enfermeiro-Paciente , Recursos Humanos de Enfermagem Hospitalar/psicologia , Transferência de Pacientes/organização & administração , HumanosRESUMO
Susan Wills and Dena Ross have reduced unplanned and avoidable admissions by supporting the carers to manage residents safely in their nursing homes.
Assuntos
Pessoal Técnico de Saúde/educação , Distinções e Prêmios , Serviço Hospitalar de Emergência/estatística & dados numéricos , Enfermagem Geriátrica , Casas de Saúde/organização & administração , Idoso , Idoso de 80 Anos ou mais , Comportamento Cooperativo , Humanos , Capacitação em Serviço , Sociedades de Enfermagem , Desenvolvimento de PessoalRESUMO
OBJECTIVES: To evaluate the impact of the implementation of an inclusive pan-regional trauma system on quality of care. BACKGROUND: Inclusive trauma systems ensure access to quality injury care for a designated population. The 2007 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) found quality deficits for 60% of severely injured patients. In 2010, London implemented an inclusive trauma system. This represented an opportunity to evaluate the impact of a pan-regional trauma system on quality of care. METHODS: Evaluation of the London Trauma System (ELoTS) utilized the NCEPOD study core methodology. Severely injured patients were identified prospectively over a 3-month period. Data were collected from prehospital care to 72âh following admission or death. Quality, processes of care, and outcome were assessed by expert review using NCEPOD criteria. RESULTS: Three hundred and twenty one severely injured patients were included of which 84% were taken directly to a major trauma center, in contrast to 16% in NCEPOD. Overall quality improved with the proportion of patients receiving "good overall care" increasing significantly [NCEPOD: 48% vs ALL-ELoTS: 69%, RR 1.3 (1.2 to 1.4), Pâ<â0.01], primarily through improvements in organizational processes rather than clinical care. Improved quality was associated with increased early survival, with the greatest benefit for critically injured patients [NCEPOD: 31% vs All-ELoTS 11%, RR 0.37 (0.33 to 0.99), Pâ=â0.04]. CONCLUSIONS: Inclusive trauma systems deliver quality and process improvements, primarily through organizational change. Most improvements were seen in major trauma centers; however, systems implementation did not automatically lead to a reduction in clinical deficits in care.
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Traumatismo Múltiplo/terapia , Qualidade da Assistência à Saúde/normas , Centros de Traumatologia/organização & administração , Triagem/organização & administração , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Londres , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Early survival following severe injury has been improved with refined resuscitation strategies. Multiple organ dysfunction syndrome (MODS) is common among this fragile group of patients leading to prolonged hospital stay and late mortality. MODS after trauma is widely attributed to dysregulated inflammation but the precise mechanics of this response and its influence on organ injury are incompletely understood. This study was conducted to investigate the relationship between early lymphocyte responses and the development of MODS during admission. METHODS: During a 24-month period, trauma patients were recruited from an urban major trauma centre to an ongoing, observational cohort study. Admission blood samples were obtained within 2 h of injury and before in-hospital intervention, including blood transfusion. The study population was predominantly male with a blunt mechanism of injury. Lymphocyte subset populations including T helper, cytotoxic T cells, NK cells and γδ T cells were identified using flow cytometry. Early cytokine release and lymphocyte count during the first 7 days of admission were also examined. RESULTS: This study demonstrated that trauma patients who developed MODS had an increased population of NK dim cells (MODS vs no MODS: 22 % vs 13 %, p < 0.01) and reduced γδ-low T cells (MODS vs no MODS: 0.02 (0.01-0.03) vs 0.09 (0.06-0.12) × 10^9/L, p < 0.01) at admission. Critically injured patients who developed MODS (n = 27) had higher interferon gamma (IFN-γ) concentrations at admission, compared with patients of matched injury severity and shock (n = 60) who did not develop MODS (MODS vs no MODS: 4.1 (1.8-9.0) vs 1.0 (0.6-1.8) pg/ml, p = 0.01). Lymphopenia was observed within 24 h of injury and was persistent in those who developed MODS. Patients with a lymphocyte count of 0.5 × 10(9)/L or less at 48 h, had a 45 % mortality rate. CONCLUSIONS: This study provides evidence of lymphocyte activation within 2 h of injury, as demonstrated by increased NK dim cells, reduced γδ-low T lymphocytes and high blood IFN-γ concentration. These changes are associated with the development of MODS and lymphopenia. The study reveals new opportunities for investigation to characterise the cellular response to trauma and examine its influence on recovery.
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Biomarcadores/análise , Subpopulações de Linfócitos/fisiologia , Insuficiência de Múltiplos Órgãos/diagnóstico , Traumatismo Múltiplo/complicações , Adulto , Biomarcadores/sangue , Estudos de Coortes , Feminino , Humanos , Interferons/análise , Interferons/sangue , Células Matadoras Naturais/citologia , Modelos Logísticos , Londres , Subpopulações de Linfócitos/metabolismo , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/mortalidade , Traumatismo Múltiplo/sangue , Estudos Prospectivos , Linfócitos T/citologiaRESUMO
My staff are more engaged and motivated in supporting our care home residents with hydration. Urinary tract infections and unplanned hospital admissions have been reduced.'
Assuntos
Desidratação/prevenção & controle , Comportamento de Ingestão de Líquido , Avaliação em Enfermagem/métodos , Casas de Saúde , Idoso , Desidratação/enfermagem , Hospitalização , Humanos , Medição de Risco/métodos , Infecções Urinárias/enfermagem , Infecções Urinárias/prevenção & controleRESUMO
OBJECTIVE: To characterize the relationship between tranexamic acid (TXA) use and patient outcomes in a severely injured civilian cohort, and to determine any differential effect between patients who presented with and without shock. BACKGROUND: TXA has demonstrated survival benefits in trauma patients in an international randomized control trial and the military setting. The uptake of TXA into civilian major hemorrhage protocols (MHPs) has been variable. The evidence gap in mature civilian trauma systems is limiting the widespread use of TXA and its potential benefits on survival. METHODS: Prospective cohort study of severely injured adult patients (Injury severity score > 15) admitted to a civilian trauma system during the adoption phase of TXA into the hospital's MHP. Outcomes measured were mortality, multiple organ failure (MOF), venous thromboembolism, infection, stroke, ventilator-free days (VFD), and length of stay. RESULTS: Patients receiving TXA (n = 160, 42%) were more severely injured, shocked, and coagulopathic on arrival. TXA was not independently associated with any change in outcome for either the overall or nonshocked cohorts. In multivariate analysis, TXA was independently associated with a reduction in MOF [odds ratio (OR) = 0.27, confidence interval (CI): 0.10-0.73, P = 0.01] and was protective for adjusted all-cause mortality (OR = 0.16 CI: 0.03-0.86, P = 0.03) in shocked patients. CONCLUSIONS: TXA as part of a major hemorrhage protocol within a mature civilian trauma system provides outcome benefits specifically for severely injured shocked patients.
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Antifibrinolíticos/uso terapêutico , Hemorragia/tratamento farmacológico , Ácido Tranexâmico/uso terapêutico , Ferimentos e Lesões/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Esquema de Medicação , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Choque Hemorrágico/tratamento farmacológico , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Resultado do Tratamento , Ferimentos e Lesões/mortalidade , Adulto JovemRESUMO
Management of severely injured patients is complex and requires organised, expert care. Regionalised trauma systems are relatively new in the UK and aim to deliver optimal, timely care to injured patients at the most appropriate location. This article discusses the drivers, organisation, processes and outcomes of regionalised trauma care. It also describes the challenges and benefits of working within a trauma system to enable emergency practitioners to reflect on their roles in contemporary trauma care.
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Modelos Organizacionais , Avaliação de Processos e Resultados em Cuidados de Saúde , Melhoria de Qualidade , Programas Médicos Regionais/organização & administração , Centros de Traumatologia/organização & administração , Pesquisa sobre Serviços de Saúde , Humanos , Objetivos Organizacionais , Triagem , Reino UnidoRESUMO
OBJECTIVES: The present study aimed to identify the impact of age on current trauma team activation (TTA) processes and outcomes for patients with pelvic fractures. METHODS: Adult patients with moderate and/or severe pelvic fractures (Abbreviated Injury Scale ≥ 2) between 1 January 2016 and 31 December 2021 were included utilising major trauma hospital data in Queensland. Characteristics of older (age ≥ 65) and younger patients including TTA, interventions and outcomes were examined. Multivariate analysis was used to determine factors associated with TTA in older patients. RESULTS: Data from 637 patients was included. Despite comparable injury severity, a TTA was activated in fewer older people (older: 65% vs. younger: 79%, P < 0.001). Older patients had more falls leading to the trauma presentation (54.4% vs. 22.6%, P < 0.001), with higher initial systolic BP (131 vs. 125 mmHg, P = 0.04). Outcomes were worse for older people, with greater rates of in-hospital complications (27.2% vs. 16.4%, P = 0.004), and longer hospital stays (12 vs. 8 days, P = 0.04). Fewer older patients could be discharged independently to home (46.3% vs. 74.5%, P < 0.001). In older patients, falls and haemodynamic parameters were strongly associated with the reduced likelihood of TTA (fall mechanism [odds ratio (OR)] 0.33; 95% confidence interval [CI] 0.15-0.74; P = 0.01; systolic BP [OR 0.98; 95% CI 0.97-0.99; P = 0.03], heart rate [OR 0.97; 95% CI 0.95-0.99; P = 0.02]). CONCLUSION: Current TTA criteria based on higher energy mechanisms and traditional vital sign thresholds are inadequate for identifying injury in older patients. Sensitive triage criteria and increased clinician awareness are required to enhance injury recognition and improve outcomes in older trauma patients.