Impact of a Patient Blood Management monitoring and feedback programme on allogeneic blood transfusions and related costs.

A Patient Blood Management programme was established at the University Hospital of Zurich, along with a monitoring and feedback programme, at the beginning of 2014 with a first analysis reported in 2015. Our study aimed to investigate the further impact of this Patient Blood Management monitoring and feedback programme on transfusion requirements and related costs. We included adult patients discharged between 2012 and 2017. A total of 213,882 patients underwent analysis: 66,659 patients in the baseline period (2012-2013); 35,309 patients in the year after the introduction of the Patient Blood Management monitoring and feedback programme (2014) and 111,914 patients in the continued sustainability period (2015-2017). The introduction of the Patient Blood Management monitoring and feedback programme reduced allogeneic blood product transfusions by 35%, from 825 units per 1000 hospital discharges in 2012 to 536 units in 2017. The most sustained effect was an approximately 40% reduction in red blood cell transfusions, from 535 per 1000 discharges to 319 units. Fewer patients were transfused in the periods after the introduction of the Patient Blood Management monitoring and feedback programme (6251 (9.4%) vs. 2932 (8.3%) vs. 8196 (7.3%); p < 0.001). Compared with 2012, the yearly OR for being exposed to any blood transfusion declined steadily after the introduction of the Patient Blood Management monitoring and feedback programme to 0.64 (95%CI 0.61-0.68; p < 0.001) in 2017. For patients requiring extracorporeal membrane oxygenation, transfusion requirements were also sustainably reduced. This reduction in allogeneic blood transfusions led to savings of 12,713,754 Swiss francs (£ 9,497,000 sterling; EUR 11,100,000; US$ 12,440,000) in blood product acquisition costs over 4 years. In-hospital mortality was not affected by the programme. The Patient Blood Management monitoring and feedback programme sustainably reduced transfusion requirements and related costs, without affecting in-hospital mortality.

Impact of haemorrhagic shock intensity on the dynamic of alarmins release in porcine poly-trauma animal model.

PURPOSE: Traumatic insults result in an altered inflammatory response, in which alarmins release has a central role. The impact of haemorrhagic shock intensity on the long-term kinetics of alarmins is not yet fully elucidated. We investigated these aspects in a combined trauma (chest, abdominal, and extremities injury) porcine model with different severities and durations of haemorrhagic shock. METHODS: After induction of combined trauma (tibia fracture, lung contusion, and liver laceration), haemorrhagic shock was induced at different intensities: moderate haemorrhage (MH; n = 15): mean arterial pressure (MAP) <30 ± 5 mmHg [maximum loss of total blood volume (TBVmax): 45 %] for 90 min, and severe haemorrhage (SH; n = 10): MAP <25 ± 5 mmHg (TBVmax 50 %) for 120 min. Resuscitation was performed using a standardized crystalloid infusion protocol. Animals were mechanically ventilated and underwent ICU-monitoring for 48 h (MH) and 48.5 h (SH). Blood samples were collected over the clinical time course, and systemic levels of serum alarmins [High-Mobility Group Protein B-1 (HMGB-1) and Heat Shock Protein 70 (HSP70)] were measured using an ELISA kit. RESULTS: Heart rate, systemic blood pressure, lactate, and base excess were significantly altered as a function of haemorrhagic shock in both trauma groups (MH and SH). Systemic HMGB-1 levels were significantly elevated in both trauma groups when compared to the sham group. Haemorrhagic shock severity and duration were positively correlated with HMGB-1 levels and compared to baseline values, concentrations remained significantly increased in SH when compared to MH. On the other hand, we observed a significant decrease in the systemic HSP70 levels of trauma groups (MH, and SH) when compared to the sham group, which was significantly decreased compared to baseline values in SH over the entire time course. CONCLUSION: Our data show that haemorrhagic shock duration and severity affect the systemic levels of HMGB-1 and HSP70. This early alarmins release after trauma can be used to guide the treatment strategies (e.g. surgical procedures) of polytrauma patients.

Assessment of elevated compartment pressures by pressure-related ultrasound: a cadaveric model.

PURPOSE: There is a risk of misinterpreting the clinical signs of acute compartment syndrome of the lower limb resulting in delayed fasciotomy. Up to date, the diagnosis of compartment syndrome is based on clinical assessment and of invasive needle pressure measurement in uncertain cases. Close monitoring is necessary for early recognition of raising compartment pressures. Clinical assessment of muscle firmness by the physician's palpation alone is unreliable. Thus, a device objectifying this assessment would be beneficial. The purpose of this study was to determine the feasibility of muscle compartment elasticity measurements by a novel and non-invasive device using pressure-related ultrasound. METHODS: In a cadaveric model, the anterior tibial compartment was prepared to simulate raising intra-compartmental pressures (0-80 mmHg) by saline infusion. Standard invasive pressure monitoring was compared with a novel method to determine tissue elasticity. Changing cross-sectional view in B-mode ultrasound was exerted to measure the compartment depth before and after physician's probe compression of 100 mmHg. Compartment displacement (∆d) was measured and related to the corresponding compartmental pressure (Spearman correlation coefficient). Delta (mm) of the control group at 10 mmHg compartment pressure was compared with measured data at rising compartmental pressures of 30, 50, and 70 mmHg using the Wilcoxon rank-sum test. The intra-observer reliability (κ) was additionally calculated. RESULTS: Fresh and never frozen lower human limbs (n = 6) were used. The average displacement measured in the anterior tibial compartment was 2.7 mm (0.3-6.7 mm). A concordant consistent correlation between the compartmental displacement and the intra-compartmental pressure occurred. The Spearman coefficient (r s = 0.979) showed a significant correlation between the rising pressure and the decreasing tissue displacement visualized by ultrasound. The intra-observer value kappa showed reliable values (κ 10 = 0.73, κ 30 = 0.80, and κ 70 = 0.79). CONCLUSIONS: We introduce a new method of ultrasound imaging enhanced with probe pressure measurement to determine changes of the visco-elastic behavior of isolated muscle compartments. Pressure-related ultrasound could be a reliable tool to determine the correlation between the measured compartmental displacement and the increasing intra-compartmental pressure. Its accuracy revealed promising results. This technique may help the physician to objectify the clinical assessment of compartment elasticity, mainly indicated in cases of unconscious patients and imminent pathology. Further clinical studies and improvements of this technique are required to prove its accuracy and reliability in cases of compartment syndrome.

[Cost-benefit analysis of cranial computed tomography in mild traumatic brain injury--appropriate depiction within the G-DRG system?]. / Kosten-Nutzen-Analyse der Schnittbildgebung beim leichten Schädel-Hirn-Trauma--Wie sachgerecht ist die Abbildung im G-DRG-System?

BACKGROUND: The treatment of patients with mild head injury is related to a continuous lack of finances. The current investigation summarises radiological costs of patients from a level I trauma centre and discusses the indication for CT scanning within the G-DRG system. MATERIAL AND METHODS: The study includes all patients who underwent a CCT scan in 2011. Diagnosis, length of stay and cost data were recorded for every patient. Finally, frequent diagnosis groups were summarised to clusters (Basis-DRG/MDC 21A). RESULTS: A total of 380 patients was treated. Within the largest group (G-DRG B80Z) the costs for a CCT already took up one quarter of the total proceedings. In combination with the high cost for monitoring patients with mild head injuries this causes an ongoing lack of finances. CONCLUSION: In spite of the often necessary CCT investigation in mild head injuries, the earnings do not cover the costs of the patients. To improve the situation clear guidelines for CCT scanning should be provided and the reimbursement in particular in the diagnosis group of the G-DRG B80Z has to be improved.

Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study.

OBJECTIVE: Bankart and Hill-Sachs lesions are often associated with anterior shoulder dislocation. The MRI technique is sensitive in diagnosing both injuries. The aim of this study was to investigate Bankart and Hill-Sachs lesions with MRI to determine the correlation in occurrence and defect sizes of these lesions. METHODS: Between 2006 and 2013, 446 patients were diagnosed with an anterior shoulder dislocation and 105 of these patients were eligible for inclusion in the study. All patients were examined using MRI. Bankart lesions were classified as cartilaginous or bony lesions. Hill-Sachs lesions were graded I-III using a modified Calandra classification. RESULTS: The co-occurrence of injuries was high [odds ratio (OR) = 11.47; 95% confidence interval (CI) = 3.60-36.52; p < 0.001]. Patients older than 29 years more often presented with a bilateral injury (OR = 16.29; 95% CI = 2.71-97.73; p = 0.002). A correlation between a Bankart lesion and the grade of a Hill-Sachs lesion was found (ρ = 0.34; 95% CI = 0.16-0.49; p < 0.001). Bankart lesions co-occurred more often with large Hill-Sachs lesions (O = 1.24; 95% CI = 1.02-1.52; p = 0.033). CONCLUSION: If either lesion is diagnosed, the patient is 11 times more likely to have suffered the associated injury. The size of a Hill-Sachs lesion determines the co-occurrence of cartilaginous or bony Bankart lesions. Age plays a role in determining the type of Bankart lesion as well as the co-occurrence of Bankart and Hill-Sachs lesions. ADVANCES IN KNOWLEDGE: This study is the first to demonstrate the use of high-quality MRI in a reasonably large sample of patients, a positive correlation of Bankart and Hill-Sachs lesions in anterior shoulder dislocations and an association between the defect sizes.

[Cost analysis of emergency room patients in the German diagnosis-related groups system. A practice relevant depiction subject to clinical parameters]. / Kostenanalyse von Schockraumpatienten im DRG-System. Eine praxisnahe Abbildung in Abhängigkeit klinischer Parameter.

BACKGROUND: Since the implementation of the diagnosis-related system there has been a continuous lack of finances in the treatment of multiple injured patients. The current investigation summarizes consecutive patients from a level I trauma centre and tests the hypothesis that an injury severity score (ISS) based reimbursement would be an improvement in the cost-effectiveness of this patient population. METHODS: The study is based on multiple injured patients admitted to the emergency department in 2009. The ISS, intensive care unit (ICU) stay and cost data were recorded for every patient and two subgroups were formed: group I ISS < 16 and group II ISS ≥ 16. RESULTS: A total of 442 patients with an average age of 40.5 ± 9.1 years (ISS 12) were included. The average amount of coverage during an average length of stay of 13.15 ± 6.3 was -2,752 per patient. Patients in group I (n = 296, ISS 6.3) showed a value of -1,163 with an average length of stay of 8 ± 4.6 days. In group II (n = 146, ISS 23.6) the average amount of coverage was -5,973 during an average hospital stay of 23 ± 8.7 days. CONCLUSION: Improvements have been made with the recent adjustment of the reimbursement within the last year. Nevertheless, several factors identified in this study require additional adjustment: the ISS, the requirement of blood transfusion and the presence of additional chest trauma should be weighted in the calculation of reimbursement.

Physiological assessment of the polytrauma patient: initial and secondary surgeries.

The timing of fracture fixation in polytrauma patients has been debated for a long time. The decision between DCO (damage control orthopaedics) and ETC (early total care) is a difficult dilemma. Overzealous ETC in haemodynamically compromised patients with significant chest and head injuries can be detrimental. It has been shown, however, that early fracture fixation has a trend towards better outcome in patients with less severe injuries. Delaying all orthopaedic surgery in critically injured patients can be a safe alternative, but has several disadvantages like longer ICU stay and septic complications. The literature shows equivocal evidence for both settings. This article will summarize the historical background and controversies regarding patient assessment and decision making during the treatment of polytrauma patients. It will also give guidance for choosing DCO versus ETC in the clinical setting.

[Hannover-Polytrauma-Longterm-Study HPLS]. / Hannover-Polytrauma-Langzeit-Studie HPLS (I).

UNLABELLED: From the period of September 2000 to March 2006 Hannover Reinsurance and the Department of Traumatology of the Hanover Medical School conducted a retrospective observational study of the long-term outcome of patients after polytrauma. The follow-up period was on average 17 +/- 5 years. The goal of the study was to determine the social, financial, medical and psychological long-term outcome after a severe accident. Of the 1560 enrolled patients 519 patients died in the observed period, 397 patients were followed up but could not be examined, 637 patients (female n = 158, male n = 479) were examined and answered detailed questionnaires concerning their social, financial medical and psychological situation. 6 patients did not fullfil the input criteria and one patient had two polytraumata. The average age at the time of accident was 26.5 years (+/- 12.3). RESULTS: Financial losses were observed in 41.1% of all males and 44.4% of females. 21.7% of all male (female 18.4%) had no financial protection at all. Due to the accident 30.1% of all men were unemployed and 19.8% permanently disabled (women 27.4% and 27.6% respectively). Psychological treatment almost doubled after discharge from rehabilitation centres. Even 20 years after the accident extra-mortality was substantially increased by 79%. CONCLUSION: Ten to twenty years after polytrauma significant financial, social and medical impairments are still present.

Open pelvic fractures: epidemiology, current concepts of management and outcome.

Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.

[Evaluation of costs incurred for patients with multiple trauma particularly from the perspective of the hospital]. / Evaluation der Kosten von polytraumatisierten Patienten insbesondere aus der Perspektive des Krankenhauses.

The aim of this study was to evaluate the costs involved in treating severely injured patients at the clinic differentiated by several characteristics (injury, age), sectors (emergency room, surgery, intensive and normal care), and kinds of costs (fixed costs, variable costs) and to determine influencing factors regarding costs based on the register of the DGU (Deutsche Gesellschaft für Unfallchirurgie). All patients were taken into account who had an injury severity score (ISS) of at least 16. On this basis costs of 3702 patients were analyzed. They were compared by using analysis of variance for different groups of patients classified according to kind of injury, severity of injury, and age. Moreover, multiple regression was performed to control the common influence of demographic factors and the type of injury on costs. The average ISS of the analyzed patients was 30.6 (+/-11.6) points. The average costs of the clinic were 32,166 (+/-25,404) EUR per patient. More than half of the costs was incurred by intensive care and about one-fourth by surgery. On average 30.6% were variable costs and 69.4% were fixed costs. The analysis of variance revealed that costs increased with advancing age and severity of injury (ISS). Multiple regression confirmed these interrelations indicating that extremities are very cost intensive. Due to the high portion of fixed costs, the overall costs strongly depend on the capacity utilization and less on hospital stay. That is why it may be necessary in the future to create centers for trauma care to maintain economic efficiency for treatment of these patients. Besides large differences of costs within closely defined groups of patients, hospitals carry a high economic risk so that a more complex reimbursement system should be discussed than implemented by the German DRGs.

[DRG reimbursement for multiple trauma patients -- a comparison with the comprehensive hospital costs using the German trauma registry]. / DRG-Entlohnung beim Polytrauma. Ein Vergleich mit den tatsächlichen Krankenhauskosten anhand des DGU-Traumaregisters.

UNLABELLED: The introduction of diagnosis related groups (DRG) will radically change the payment system for German hospitals. In 2002 the values for most DRG's were published for the german system (G-DRG). The polytrauma working group of the German Trauma Society developed a calculating algorithm to estimate the comprehensive hospital costs for every patient in the German trauma registry. The aim of this study was to compare these costs with the reimbursement according the the G-DRG's for a standardized population of polytrauma patients. MATERIAL AND METHODS: For polytrauma patients treated at Hannover Medical School in 2000 and 2001 the reimbursement according to the G-DRG's was calculated using a base value of 2900 euro. In the same patients the total cost of inpatient treatment was calculated according to the algorithm developed by the polytrauma working group of the German Trauma Society. The difference between these values represents the economic result. This was calculated as an overall result, but also for specific subgroups of patients (injury severity, mortality, G-DRG grouping). RESULTS: Datasets of 103 polytrauma patients were included. The following G-DRG's were most frequently occuring: A06Z (n=41), A07Z (n=16), W01Z (n=13). All other G-DRG's were documented less than 3 times. The mean reimbursement according to the G-DRG was 21.380+/-12.300 euro for a polytrauma patient. However, the mean hospital cost accounted to 34.274+/-22.501 euro, which resulted in a mean deficit of 12.893+/-15.534 euro. Analysis of subgroups revealed, that an ISS of more than 35 points, patients with a prolonged hospital stay and patients of the G-DRG group A06Z show a particularly negative result. CONCLUSION: The comprehensive hospital costs for treating polytrauma patients are on average 12.893 euro higher than the reimbursement according the G-DRG's. For hospitals to be fully reimbursed G-DRG values have to be reconfigured according to the German health care system. Thus, inclusion criteria to specific G-DRG have to be changed and a specific G-DRG group for very severely injured patients needs to be established.

Trauma care in Germany.

Trauma Care in Germany fulfils all requirements to deal with injured young and mobile individuals as well as with an increasing number of injured elderly patient. Furthermore, it is prepared to cope with mass casualties of injured. As a public task the Trauma System in Germany is well organized and follows clear cut demands. To perform technical and medical therapy at highest available level as soon as possible, a ground system of physician staffed ambulances is supported by a network of physician-staffed HEMS all over Germany. Therefore, enormous efforts in financing, basic research and quality management have been undertaken during recent years to create such a sophisticated rescue system.

[Development of a standardized instrument for quantitative and reproducible rehabilitation data assessment after polytrauma (HASPOC)]. / Entwicklung eines standardisierten Instruments zur quantitativen und reproduzierbaren Rehabilitationserfassung nach Polytrauma (HASPOC).

INTRODUCTION: Previous scoring systems for measurement of the quality of outcome are based on scores regarding injuries to individual body regions. Known scores which describe several organ regions are of no importance for trauma patients. Therefore a new rehabilitation outcome evaluation score was developed at our hospital. METHODS: Based on a prospective reinvestigation, a score system was developed that allows a quantitative appraisal of the subjective and objective outcome. A complete physical examination was performed, including ROM, neurologic examination and strength analysis. Part I (113 questions) is to be filled out by the patient; part II (191 questions) focusses on different body regions, physical examination and functional scoring. Included are the MFA, FIM, GCO and Frankel score. A final score (HASPOC) was developed to give a quantitative result of the outcome. RESULTS: The new score has a range from 5 to 411 points. One hundred and fifty patients were re-examined. The mean follow-up time was 2.2 +/- 0.1 years. The SF 12 indicated an outcome more than satisfactory in 63% of cases. The MFA demonstrated moderate or severe restrictions in 41%, in the case of injuries of the lower extremity in 52% of patients. The HASPOC indicated a mean of 44.5 points. CONCLUSION: This paper describes the development, structure, and the quantitative outcome of rehabilitation in polytrauma patients. This standardized rehabilitation instrument deals with a very heterogeneous patient population and shows the rehabilitation deficits accurately. Implemented recognized evaluations allow comparison of these results with those of other scoring systems.