[Prehospital management in trauma patients and the increasing number of helicopter EMS transportations : An epidemiological study of the TraumaRegister DGU®]. / Präklinisches Management bei Traumapatienten und die zunehmende Zahl von Helikopter-Rettungstransporten : Eine epidemiologische Studie des TraumaRegister DGU®.

BACKGROUND/OBJECTIVE: To compare the prehospital treatment modalities and intervention regimens for major trauma patients with comparable injury patterns between Austria and Germany. PATIENTS AND METHODS: This analysis is based on data retrieved from the TraumaRegister DGU®. Data included severely injured trauma patients with an injury severity score (ISS) ≥ 16, an age ≥ 16 years, and who were primarily admitted to an Austrian (n = 4186) or German (n = 41,484) level I trauma center (TC) from 2008 to 2017. Investigated endpoints included prehospital times and interventions performed until final hospital admission. RESULTS: The cumulative time for transportation from the site of the accident to the hospital did not significantly differ between the countries (62 min in Austria, 65 min in Germany). Overall, 53% of all trauma patients in Austria were transported to the hospital with a helicopter compared to 37% in Germany (p < 0.001). The rate of intubation was 48% in both countries, the number of chest tubes placed (5.7% Germany, 4.9% Austria), and the frequency of administered catecholamines (13.4% Germany, 12.3% Austria) were comparable (Φ = 0.00). Hemodynamic instability (systolic blood pressure, BP ≤ 90 mmHg) upon arrival in the TC was higher in Austria (20.6% vs. 14.7% in Germany; p < 0.001). A median of 500 mL of fluid was administered in Austria, whereas in Germany 1000 mL was infused (p < 0.001). Patient demographics did not reveal a relationship (Φ = 0.00) between both countries, and the majority of patients sustained a blunt trauma (96%). The observed ASA score of 3-4 was 16.8% in Germany versus 11.9% in Austria. CONCLUSION: Significantly more helicopter EMS transportations (HEMS) were carried out in Austria. The authors suggest implementing international guidelines to explicitly use the HEMS system for trauma patients only a) for the rescue/care of people who have had an accident or are in life-threatening situations, b) for the transport of emergency patients with ISS > 16, c) for transportation of rescue or recovery personnel to hard to reach regions or, d) for the transport of medicinal products, especially blood products, organ transplants or medical devices.

Design and implementation of a "crisis resource management" training program for the initial assessment of polytrauma patients.

INTRODUCTION: To describe the design and implementation of a Crisis Resource Management (CRM) training program for the initial assessment of polytrauma patients. METHODS: Prospectively implemented CRM training program in acute-care tertiary hospital by hospital personnel involved in the care of polytraumatisms. The program has a blended format and 23-h duration, including 11 h of online theoretical training followed by 12-h simulation modules and practical cases devoted to the roles of members of the trauma team, functioning of the polytrauma room, and key aspects of teamwork. The Human Factors Attitude Survey (HFAS) was used to assess attitudes related to non-technical skills, and the End-of-Course Critique (ECC) survey to evaluate satisfaction with training. We evaluated changes in the pre- and post-training assessments. RESULTS: Eighty staff personnel (26% specialists, 16% residents, 29% nurses, 14% nursing assistant, 15% stretcher bearer) participated in three editions of the program. Theoretical knowledge improved from a mean (SD) of 5.95 (1.7) to 8.27 (2.1) (P < .0001). In the HFAS, statistically significant differences in 18 of 23 attitudinal markers were observed, with improvements in all items of "leadership" and "roles", in 4 of 5 items of "situational awareness", and in 4 of 8 items of "communication". Mean values obtained in the ECC questionnaire were also very high. CONCLUSIONS: A CRM training model developed for the initial care of polytrauma patients improved theoretical knowledge and participants perceptions and attitudes regarding leadership, communication, roles, and situational awareness of members of the trauma team.

Improvement of Teamwork Nontechnical Skills Through Polytrauma Simulation Cases Using the Communication and Teamwork Skills (CATS) Assessment Tool.

OBJECTIVE: To assess acquisition of nontechnical skills (NTS) through clinical simulation cases by healthcare personnel who participated in a Crisis Resource Management (CRM) training program for the initial care of polytraumatisms. DESIGN: Pre-and postintervention study. SETTING: Acute-care teaching hospital in Sabadell, Barcelona (Spain). PARTICIPANTS: Healthcare personnel that composed teamworks providing initial care to polytraumatized patients attended 12-hour simulation training using a SimMan 3G manikin and performed exercises corresponding to 3 clinical scenarios. All simulations lasted 15 to 25 min and were video recorded. The CATS Assessment tool was used for analysis of teamwork NTS, which included 21 behaviors clustered into the categories of coordination, situational awareness, cooperation, communication, and crisis situation. RESULTS: Three editions of the CRM training course were carried out with 12 trauma team groups composed by team leader, anesthesiologist, general surgeon, traumatologist, registered nurses, nursing assistant, and stretcher bearer. There were statistically significant (p <0.001) improvements in the speed of key times of total duration of case resolution, transfusion of hemoderivatives, Focused Assessment Sonography for Trauma, and chest and pelvic X-rays. The percentage of cases correctly resolved improved from 75% to 91.7% but differences were not statistically significant (p = 0.625). Precourse and postcourse results of CATS scores showed a statistically significant increase in the weighted total score as well as in all behavioral categories of coordination, situational awareness, cooperation, communication, and crisis situation. CONCLUSIONS: Simulation-based training of NTS was associated with significant improvements in teamwork behaviors in the setting of the initial care of patients with polytraumatisms.

[Is polytrauma treatment in deficit in the aG-DRG system?] / Ist die Polytraumaversorgung im aG-DRG-System defizitär?

BACKGROUND: The interdisciplinary care of severely injured patients is staff and resource intensive. Since the introduction of the G­DRG system in Germany in 2003, most studies have identified a financial deficit in the care of severely injured patients. The aim of this study was to analyze the effects of the new aG-DRG system introduced in 2020 on cost recovery in the treatment of severely injured patients. For the first time, the costs for organization, certification and documentation as well as the costs for non-seriously injured shock room patients were included. METHODS: All patients who were treated in the surgical shock room of the emergency department of the Leipzig University Hospital in 2017 were included. For the analysis, the cost model according to Pape et al. was extended by the module organization, documentation and certification and for the first time the costs for overtriaged patients were considered. A cost calculation was performed for the years 2017-2020 as well a comparison with the respective earnings. RESULTS: A total of 834 patients were treated in the shock room and 258 severely injured patients were divided into 3 groups: ISS 9-15 + ICU (n 72; ∅ ISS 11.9; costs per patient 14,715 €),ISS ≥ 16 (n 186; ∅ ISS 27.7; costs per patient 30,718 €) and DRG polytrauma (n 59; ∅ ISS 32.4; costs per patient 26,102 €). CONCLUSION: Polytrauma care under the aG-DRG 2020 is in deficit. Overall, in 2020 a deficit of 5858 € per severely injured patient resulted.

Assessment of patient-reported outcomes after polytrauma - instruments and methods: a systematic review.

OBJECTIVES: We (1) collected instruments that assess health-related quality of life (HRQoL), activities of daily living (ADL) and social participation during follow-up after polytrauma, (2) described their use and (3) investigated other relevant patient-reported outcomes (PROs) assessed in the studies. DESIGN: Systematic Review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. DATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, as well as the trials registers ClinicalTrials.gov and WHO ICTRP were searched from January 2005 to April 2018. ELIGIBILITY CRITERIA: All original empirical research published in English or German including PROs of patients aged 18-75 years with an Injury Severity Score≥16 and/or an Abbreviated Injury Scale≥3. Studies with defined injuries or diseases (e.g. low-energy injuries) and some text types (e.g. grey literature and books) were excluded. Systematic reviews and meta-analyses were excluded, but references screened for appropriate studies. DATA EXTRACTION AND SYNTHESIS: Data extraction, narrative content analysis and a critical appraisal (e.g. UK National Institute for Health and Care Excellence) were performed by two reviewers independently. RESULTS: The search yielded 3496 hits; 54 publications were included. Predominantly, HRQoL was assessed, with Short Form-36 Health Survey applied most frequently. ADL and (social) participation were rarely assessed. The methods most used were postal surveys and single assessments of PROs, with a follow-up period of one to one and a half years. Other relevant PRO areas reported were function, mental disorders and pain. CONCLUSIONS: There is a large variation in the assessment of PROs after polytrauma, impairing comparability of outcomes. First efforts to standardise the collection of PROs have been initiated, but require further harmonisation between central players. Additional knowledge on rarely reported PRO areas (e.g. (social) participation, social networks) may lead to their consideration in health services provision. PROSPERO REGISTRATION NUMBER: CRD42017060825.

Polytrauma outcome: implementation of health-related quality of life assessment into the German Trauma Registry.

INTRODUCTION: As a result of improvement in polytrauma management within the last years, more patients survive a significant trauma. Trauma registers, such as the TraumaRegister DGU®, played a role in identifying risk factors of poor outcomes which led to an improvement of survival rates. In recent years the health-related quality of life (HRQoL) after trauma got into the focus of trauma studies. MATERIALS AND METHODS: Under the sponsorship of the German Society of Trauma Surgery (DGU) the members of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) convened intending to identify an assessment tool for implementation into the TraumaRegister DGU®. RESULTS: After the conduct of a systematic literature review, the working group decided to choose the 12-item Short-Form Health Survey (SF-12) and five more questions, capturing the satisfaction of treatment, work capacity and trauma-related medical treatment. CONCLUSION: The data collection of HRQoL and the additional variables started in 2017 in participating clinics as a part of the regular data collection of the TraumaRegister DGU®.

[Care Management for Polytrauma Patients in a Level-1 Trauma Centre]. / Care Management für Polytrauma-Patientinnen und -Patienten in einem überregionalen Level-1- Traumazentrum.

Care Management for Polytrauma Patients in a Level-1 Trauma Centre Abstract. In our level-1 trauma institution, polytrauma patients with an Injury Severity Score of 16 or higher are facing waiting times for transfer to a rehabilitation facility, causing a negative financial outcome for our institution. The purpose of this study is to stimulate rapid transfer to a rehabilitation facility. In a single-centre case study, care management for (poly)trauma patients was started to ensure time-directed treatment for trauma patients related to Diagnosis-Related Groups (DRG). In the period of 2013-2018 there was an increase in trauma admissions up to 14 % (n = 16 157) with a mean length of hospital stay of 6.4 days, together with a reduction in the number of trauma bed capacity from 50 to 42. In relation to the DRGs, regular trauma patients who were not in need of a stationary rehabilitation facility stayed in line with the expected time of hospital stay. But (poly)trauma patients (n = 1831) with the need of a stationary stay in a rehabilitation centre were faced with waiting times before they could be transferred. The average excess waiting time in relation to DRG for polytrauma patients was 5.1 days. Trauma patients for a rehabilitation centre have a higher Case Mix Index (CMI) compared to those who do not require inpatient rehabilitation (4.22 versus 1.04, p <0.0001). With about 280 trauma patients annually waiting an extra 5.1 days for transfer to a rehabilitation facility, the financial burden for our department amounts to Swiss francs 885,360 without reimbursement. Since no extra bed capacities in rehabilitation facilities are available in our area, it may be advised to set up an early in-hospital trauma rehabilitation program in a level-1 trauma centre in order to reduce financial loss.

Can Initial Hematocrit Predict Blood Transfusions, Hospital Cost, and Mortality in Polytrauma Patients?

Knowing the initial hematocrit of a polytrauma patient can assist his trauma management. This paper describes a four-year study of 88 polytrauma patients. Fifty-nine were transfused, and eight were women (13.5%). The mean cost of the first hospitalization of patients who were transfused was 14,503 €; the mean cost of patients who were not transfused was 5,718 €. HCT did not correlate with ICU stay; nor did days of hospitalization. The mean HCT of those who died was not much different from that of survivors (33.23 with standard deviation [SD] 7.43 versus 32.37 with SD 5.89). This study showed that initial HCT does not correlate with days of hospitalization or days in ICU, but that transfusion can predict higher total cost.

Prevalence of anemia and therapeutic behavior in the emergency department at a tertiary care Hospital: Are patient blood management principles applied?

BACKGROUND: The aim of this study was to assess the general prevalence and the treatment policy of anemic patients referring to the Emergency Department (ED) of a tertiary care Hospital during 2015. STUDY DESIGN AND METHODS: The full blood cell count data from patients admitted to the ED for any reason,excepted for those with massive hemorrhage and multiple trauma, were studied. The prevalence of anemic patients and the degree of anemia were recorded, along with the transfusion policy applied. Transfusion appropriateness was retrospectively evaluated with a specific algorithm, that also considered the administered volume of red blood cells. A particular focus was made on patients with microcytosis about the physicians' awareness of the underlying iron deficiency and the consequent iron prescription. RESULTS: In a group of 22,329 patients the overall prevalence of anemia was 27.5% (6144 patients). Among the anemic patients, 281 / 6144 (4.6%) were transfused. The applied transfusion policy, as evaluated with the algorithm showed an overall good level of appropriateness (74.5% of transfusion episodes) but the appropriateness of the administered red blood cell mass was low (8.8%), due to over-transfusion. In microcytic transfused patients (mean MCV 69.0 ± SD 9.1), the iron balance tests were rarely ordered (22 patients out of 98-22.2%) and intravenous iron was prescribed in only 9 patients out of the 98 eligible (9.2%). CONCLUSION: The Patient Blood Management principles should be applied also in the ED setting, to promote a more appropriate and effective clinical approach to anemic patients.

Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy.

PURPOSE: Blunt aortic injuries (BAI) have historically been considered an indication for emergent surgical intervention. Nevertheless, the observation that the outcome of the concomitant traumatic injuries has a major impact on prognosis and the rise of thoracic endovascular aortic repair (TEVAR) as an effective therapy for BAI have significantly changed in recent years the treatment algorithm of this condition. Our objective was to identify findings associated with the aortic injury which would be the best predictor of prognosis, with the objective of guiding the decision-making process for selecting the optimal timing of aortic repair. METHODS: We reviewed blunt aortic injuries from 3 Level I Trauma Centers from July 2008 to December 2016. We analyzed overall and BAI-related 30-day mortality in relation to: hemodynamics, timing of treatment, TEVAR vs open repair, and aortic injury grade as defined by the Society for Vascular Surgery. Based on computed tomographic angiography (CT scan) imaging, we selected the radiologic aortic findings most indicative of high mortality risk, which we defined as "Radiographic Severe Injury" (RSI): (1) total/partial aortic transection, (2) active contrast extravasation, or (3) the association of 2 of more of the following: contained contrast extravasation > 10 mm, periaortic hematoma, and/or mediastinal hematoma with thickness > 10 mm, or significant left pleural effusion. RESULTS: Of a total of 76 consecutive patients, 50 (66%) underwent immediate repair, 24 (31%) delayed aortic repair, and 2 (3%) died prior to repair. 58 patients (76%) had TEVAR, while 16 (24%) had open repair. Overall mortality was 18% and BAI-related mortality was 13%. In BAI-related mortalities, 70% of patients had RSI. Patients with high risk of overall mortality had hypotension and tachycardia (SBP < 100, HR ≥ 100), high ISS, and required vasopressors. Factors only associated with BAI-related mortality included RSI. CONCLUSION: CT scan findings suggestive of RSI are predictive of mortality associated with BAI. Radiologic assessment of the severity of the aortic injury with characterization for the presence of RSI may represent the key factors to determine the optimal timing of treatment of the aortic injury and guide the overall treatment strategy. LEVEL OF EVIDENCE: IV.

Assessment of safety and bleeding risk in the use of extracorporeal membrane oxygenation for multitrauma patients: A multicenter review.

BACKGROUND: Respiratory failure is the most common form of organ failure following traumatic injury. Previously, there have been concerns regarding extracorporeal membrane oxygenation (ECMO) use in the trauma setting because of the increased risk of bleeding and thrombotic complications. We sought to examine the management of trauma patients with ECMO and to assess the safety and outcome of its use. METHODS: Data of all patients who experienced a traumatic injury and were supported with ECMO were collected from the five National Respiratory ECMO centers in the United Kingdom over the period from December 2011 to May 2017. Primary outcome variables included 30-day and 6-month mortality and exacerbation of underlying traumatic injury after ECMO commencement. Secondary outcome variables included duration of ECMO support, thrombotic complications, and worsening of intracranial injury. RESULTS: Fifty-two patients were identified. The overall hospital mortality was 15%. The incidence of bleeding complications was 50%, the majority of these not requiring intervention. Forty patients underwent surgical management prior to ECMO commencement; only four patients required take-back to the operating theater. There was no significant difference between the bleeding and nonbleeding groups in time of injury to ECMO commencement (median difference, 4.5 days; 95% CI, -3 to 3 days; p = 0.75). There was no statistically significant difference between the bleeding and nonbleeding groups in regard to time to anticoagulation commencement after starting ECMO (median difference, - 1 hour; 95% CI, -48 to 2 hours; p = 0.29) or after trauma (median difference, - 1 day; 95% CI, -4 to 2 days; p = 0.41). Nineteen patients were diagnosed with significant neurological injury. Twelve of these patients were anticoagulated. Two patients died as a direct result of worsening neurological injury. CONCLUSIONS: Our findings suggest that the use of ECMO in trauma patients does not exacerbate primary traumatic injury regardless of anticoagulation commencement and may confer a survival benefit. Neurological injury should not be seen as an absolute contraindication to ECMO. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level V.

The Economic Burden of Non-fatal Musculoskeletal Injuries in Northeastern Tanzania.

BACKGROUND: Although musculoskeletal injuries have increased in sub-Saharan Africa, data on the economic burden of non-fatal musculoskeletal injuries in this region are scarce. OBJECTIVE: Socioeconomic costs of orthopedic injuries were estimated by examining both the direct hospital cost of orthopedic care as well as indirect costs of orthopedic trauma using disability days and loss of work as proxies. METHODS: This study surveyed 200 patients seen in the outpatient orthopedic ward of the Kilimanjaro Christian Medical Center, a tertiary hospital in Northeastern Tanzania, during the month of July 2016. FINDINGS: Of the patients surveyed, 88.8% earn a monthly income of less than $250 and the majority of patients (73.7%) reported that the healthcare costs of their musculoskeletal injuries were a catastrophic burden to them and their family with 75.0% of patients reporting their medical costs exceeded their monthly income. The majority (75.3%) of patients lost more than 30 days of activities of daily living due to their injury, with a median (IQR) functional day loss of 90 (30). Post-injury disability led to 40.6% of patients losing their job and 86.7% of disabled patients reported a wage decrease post-injury. There were significant associations between disability and post-injury unemployment (p < .0001) as well as lower post-injury wages (p = .022). CONCLUSION: This exploratory study demonstrates that in this region of the world, access to definitive treatment post-musculoskeletal injury is limited and patients often suffer prolonged disabilities resulting in decreased employment and income.

[Costs and proceeds from patients admitted via the emergency room with mild craniocerebral trauma]. / Kosten und Erlöse von über den Schockraum eingelieferten Patienten mit leichtem Schädel-Hirn-Trauma.

The introduction of the diagnosis-related groups (DRG) in 2003 radically changed the billing of the treatment costs. From the very beginning, trauma surgeons questioned whether the introduction of the DRG could have a negative impact on the care of the severely injured. "Trauma centers in need" was the big catchword warning against shortfalls at trauma centers due to the billing via DRG. This situation was confirmed in the first publications after introduction of the DRG, showing a clearly deficient level of care of polytrauma cases. Over the years, adjustments have led to an improvement in the remuneration for polytraumatized patients. In the emergency room, polytrauma is not always the final diagnosis. A considerable proportion of patients are only slightly injured, but must be admitted via the emergency room due to the circumstances of the accident or suspected diagnosis at the scene of the accident to exclude life-threatening injuries. In this study, patients with the billing diagnosis of mild craniocerebral trauma were selected as an example. The proportion of these patients was 22% during the period of observation in 2017. For these patients, the proportional costs during treatment were calculated. It could be shown that 60.36% of the costs during a 2­day treatment of these patients were incurred in the emergency room. Costs for material and personnel could not be considered. Despite not including these expenses, the costs were never covered for any of these patients. For patients with slight injuries after trauma management in the emergency room, the present adjustments to the DRG system by increasing the basic case value seem to be insufficient. Additional remuneration for these patients seems absolutely justified to further ensure adequate quality of care.

[Consistency study of indirect calorimetry and HB equation for measuring energy expenditure of patients with multiple injury receiving mechanical ventilation].

OBJECTIVE: To evaluate the difference and correlation of 24-hour energy expenditure in patients with multiple trauma receiving mechanical ventilation predicted by indirect calorimetry (IC) and HB formula. METHODS: 140 patients with multiple trauma receiving mechanical ventilation admitted to intensive care unit (ICU) of the General Hospital of Ningxia Medical University from December 1st, 2016 to August 31st, 2017 were enrolled. The 24-hour energy expenditure of patients was repeatedly measured at 1, 3, 5, and 7 days after ICU admission by IC method, and the 24-hour energy expenditure measured by IC method was used as the "gold standard" to calculate the 24-hour kilogram body weight energy expenditure. The 24-hour energy expenditure value measured by IC method was compared with the 24-hour energy expenditure predicted value calculated by HB formula method, the consistency of the two measurement methods was detected by Bland-Altman method, and the correlation between the two measurement methods was analyzed by Pearson method and the linear equation was fitted. RESULTS: The 24-hour energy expenditure of patients at 1, 3, 5 and 7 days after ICU was repeatedly measured by IC method for 501 times, and there was no significant difference in 24-hour energy expenditure (kJ/d: 8 163.1±1 599.4, 8 221.1±1 694.7, 8 445.8±1 756.4, 8 707.0±1 820.7, respectively, F = 2.451, P = 0.063) and 24-hour kilogram body weight energy expenditure (kJ×kg-1×d-1: 120.5±18.9, 121.4±19.7, 122.7±19.3, 121.4±19.3, respectively, F = 0.252, P = 0.860) at each time point, indicating that the first week of multi-injury patients had no significant changes in energy metabolism. The consistency between the 24-hour energy expenditure measured by IC method on the first day [(8 163.1±1 599.4) kJ/d] and that predicted by HB formula method [(6 568.8±782.0) kJ/d] was analyzed. The results showed that there was significant bias between the two methods, with an average bias of -(1 591.8±121.4) kJ/d, but the correlation analysis showed that there was a linear correlation between them (r = 0.439, P = 0.000), using one-way regression, the fitted linear equation was Y = 2 270.5+0.897X (X was 24-hour energy expenditure predicted by the HB formula). CONCLUSIONS: The energy metabolism of patients with multiple trauma receiving mechanical ventilation is not obvious within 1 week. The HB formula method underestimates the 24-hour energy expenditure of patients. The prediction formula can be used to correct the HB formula and further to improve the accuracy of predicting the 24-hour energy consumption of patients.

Assessment of clinical parameters of the polytraumatized patient as predictors of hospital expenditure and of its distribution. / Valoración de parámetros clínicos del paciente politraumatizado como predictores del gasto hospitalario y de su distribución.

INTRODUCTION: Traumatic pathology continues to represent an important socio-health problem. The aim of the study was to assess the clinical predictors of total expenditure, as well as to analyze which components of the cost are modified with each clinical parameter of the polytraumatized patient. MATERIAL AND METHODS: Retrospective study of 131 polytrauma patients registered prospectively. A statistical analysis was carried out to assess the relationship between clinical parameters, the total cost and the cost of various treatment components. RESULTS: The total cost of hospital admission was 3,791,879 euros. The average cost per patient was € 28,945. Age and gender were not predictors of cost. The scales ISS, NISS and PS were predictors of the total cost and of multiple treatment components. The AIS of Skull and Thorax predicted a higher cost of admission to ICU and Total Cost. The AIS of lower limbs was associated with greater spending on facets of treatment related to surgical activity. DISCUSSION: There are clinical parameters that are predictors of the treatment cost of the polytraumatized patient. The study describes how the type of trauma that the patient suffers modifies the type of expenses that will present in their hospital admission. CONCLUSIONS: Polytraumatized patients with severe multisystem injury present increased costs in multiple components of the treatment cost. Patients with TBI or chest trauma present a higher cost for admission to ICU and those with orthopaedic trauma are associated with greater expenditure on surgical activity.

Assessment of patient-reported outcomes after polytrauma: protocol for a systematic review.

INTRODUCTION: Survivors of polytrauma experience long-term and short-term burden that influences their lives. The patients' view of relevant short-term and long-term outcomes should be captured in instruments that measure quality of life and other patient-reported outcomes (PROs) after a polytrauma. The aim of this systematic review is to (1) collect instruments that assess PROs (quality of life, social participation and activities of daily living) during follow-up after polytrauma, (2) describe the instruments' application (eg, duration of period of follow-up) and (3) investigate other relevant PROs that are also assessed in the included studies (pain, depression, anxiety and cognitive function). METHODS AND ANALYSIS: The systematic review protocol is developed in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials and the trials registers ClinicalTrials.gov and WHO International Clinical Trials Registry Platform will be searched. Keywords, for example, 'polytrauma', 'multiple trauma', 'quality of life', 'activities of daily living' or 'pain' will be used. Publications published between January 2005 and the most recent date (currently: August 2016) will be included. In order to present the latest possible results, an update of the search is conducted before publication. The data extraction and a content analysis will be carried out systematically. A critical appraisal will be performed. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected. The results will be published in a peer-reviewed publication. PROSPERO REGISTRATION NUMBER: CRD42017060825.

Appropriateness of patients transferred with orthopedic injuries: experience of a level I trauma center.

BACKGROUND: Trauma patients are frequently transferred to a higher level of care for specialized orthopedic care. Many of these transfers are not necessary and waste valuable resources. The purpose of this study was to quantify our own experience and to assess the appropriateness of orthopedic transfers to a level I trauma center emergency department. METHODS: A retrospective review of orthopedic emergency department transfers to a level I trauma center was performed. Data collected included time of transfer, injury severity score (ISS), age, gender, race, orthopedic coverage at transfer institution, and insurance status. Two orthopedic trauma surgeons graded the appropriateness of transfer. A weighted logistic regression model was used to compare dependent and independent variables. RESULTS: A total of 324 patient transfers were reviewed; 65 (20.1%) of them were graded as inappropriate. There was no statistically significant relationship between appropriateness of transfer and age, availability of orthopedic coverage, night/weekend transfer, or insurance status. Regression analysis showed that only ISS (OR 1.130, p = .008) and "polytrauma" (OR 25.39, p < .0001) designation were associated with increased odds ratio of appropriate transfer. The kappa coefficient for inter-rater reliability between the two raters was 0.505 (95% CI, 0.388-0.623) reflecting moderate agreement. CONCLUSION: Inappropriate transfers create a significant medical burden to our health care system using valuable resources. Our study found similar results of inappropriate transfers compared to previous studies. However, we did not find a relationship between insurance status or nights/weekends and transfer appropriateness.

[The new treatment procedures of the DGUV from the perspective of an injury type procedure (VAV) clinic]. / Die neuen Heilverfahren der DGUV aus der Sicht einer VAV-Klinik.

The new treatment procedures of the German Statutory Accident Insurance (DGUV) have ramifications for the injury type procedure clinics (VAV) from medical, economic and structural aspects. Whereas the latter can be assessed as positive, the medical and economical aspects are perceived as being negative. Problems arise from the partially unclear formulation of the injury type catalogue, which results in unpleasant negotiations with the occupational insurance associations with respect to financial remuneration for services rendered. Furthermore, the medical competence of the VAV clinics will be reduced by the preset specifications of the VAV catalogue, which opens up an additional field of tension between medical treatment, fulfillment of the obligatory training and acquisition of personnel as well as the continually increasing economic pressure. From the perspective of the author, the relinquence of medical competence imposed by the regulations of the new VAV catalogue is "throwing the baby out with the bathwater" because many VAV clinics nationwide also partially have competence in the severe injury type procedure (SAV). A concrete "competence-based approval" for the individual areas of the VAV procedure would be sensible and would maintain the comprehensive care of insured persons and also increase or strengthen the willingness of participating VAV hospitals for unconditional implementation of the new VAV procedure.

[The cost estimator in the TraumaRegister DGU]. / Der Kostenschätzer im TraumaRegister DGU®.

BACKGROUND AND OBJECTIVES: Estimated treatment costs of severely injured patients were often added to registry-based analyses. In the past, the TraumaRegister DGU® used a modular cost estimator for this purpose. A recent research project initiated by the German Trauma Society (DGU) evaluated the reimbursement of severely injured patients in the German DRG system. This project also allowed the generation of an improved update of the registry's cost estimator. METHODS: Detailed cost data for the acute therapy of severely injured patients were available from 10 hospitals that also participate in the TraumaRegister DGU®. Cost and registry data were matched using hospital code, date of admission, age, sex, and length of stay. A multivariate regression analysis with hospital costs as dependent variable included patients with an injury severity score (ISS) ≥ 9 points who stayed in hospital at least three days. All injuries were coded using the abbreviated injury scale (AIS). A total of 1002 patients treated in 2007 and 2008 were successfully matched. Cost data was collected for each case according to the method of calculation provided by the German DRG Institute (InEK). RESULTS: The mean age was 44 years and 73 % were males; the mean ISS was 27 points. The following aspects were significantly associated with the overall hospital costs: length of stay on the intensive care unit (ICU) (1152 € per day); length on intubation/ventilation (568 € per day); length of stay on normal ward (531 € per day); number of blood products (packed red blood cells; fresh frozen plasma) transfused until ICU admission (258 € per unit); a serious abdominal injury (AIS ≥3; 2849 €); an instable pelvic fracture with relevant blood loss (AIS 5; 7505 €); and a serious injury of the extremities (AIS 3-4; 2418 €). The estimated overall treatment costs calculated by the above mentioned formula averaged 22,138 € per case. The deviation from the measured real costs (21,546 € per case) was less than 3 %. CONCLUSION: Using only key data available for all patients in the registry, a valid cost estimator for acute care costs is now available in the TraumaRegister DGU®.