Parameters influencing health-related quality of life after severe trauma: a systematic review (part II).

INTRODUCTION: It is increasingly recognized that health-related quality of life (HRQoL) is a relevant outcome to study in populations comprising severely injured patients. Although some studies have readily demonstrated a compromised HRQoL in those patients, evidence regarding factors that predict HRQoL is scarce. This hinders attempts to prepare patient-specific plans that may aid in revalidation and improved life satisfaction. In this review, we present identified predictors of HRQoL in patients that have suffered severe trauma. METHODS: The search strategy included a database search until the 1st of January 2022 in the Cochrane Library, EMBASE, PubMed, and Web of Science, and reference checking. Studies were eligible for inclusion when (HR)QoL was studied in patients with major, multiple, or severe injury and/or polytrauma, as defined by authors by means of an Injury Severity Score (ISS) cut-off value. The results will be discussed in a narrative manner. RESULTS: A total of 1583 articles were reviewed. Of those, 90 were included and used for analysis. In total, 23 possible predictors were identified. The following parameters predicted reduced HRQoL in severely injured patients and came forward in at least more than three studies: higher age, female gender, lower extremity injuries, higher rate of injury severity, lower achieved educational level, presence of (pre-existing) comorbidities and mental illness, longer duration of hospital stay, and high level of disability. CONCLUSION: Age, gender, injured body region, and severity of injury were found to be good predictors of health-related quality of life in severely injured patients. A patient-centered approach, based on individual, demographic, and disease-specific predictors, is highly recommended.

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis.

INTRODUCTION: Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center. METHODS: A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score. RESULTS: The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes. CONCLUSION: Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures. LEVEL OF EVIDENCE: Therapeutic level IIa.

National consensus on communication in prehospital trauma care, the DENIM study.

BACKGROUND: In the Netherlands prehospital trauma care is provided by emergency medical services (EMS) nurses. This care is extended by Physician staffed Helicopter Emergency Medical Services (P-HEMS) for the more severely injured patient. Prehospital communication is a factor of influence on the identification of these patients and the dispatch of P-HEMS. Though prehospital communication it is often perceived to be incomplete and unstructured. To elucidated factors of influence on prehospital triage and the identification of the severely injured patient a Delphi study was performed. METHODS: A three round modified Delphi study was designed to explore concepts amongst experts in prehospital trauma care. P-HEMS physicians/nurses, trauma surgeons, EMS nurses and dispatch center operators where asked to state their opinion regarding identification of the poly trauma patient, trauma patient characteristics, prehospital communication and prehospital handover. RESULTS: Seventy-one panellist completed all three rounds. For the first round seven cases and 13 theses were presented. From the answers/argumentation the second round was build, in which 68 theses had to be ranked within four principle themes: factors that influence prehospital communication, critical information for proper handover, factors influencing collaboration and how training/education can influence this. Out of these answers the third survey was build, focussing on determining the exact content of a prehospital trauma handover. The majority of the panellists agreed to a set of parameters resulting in a new model of inter-professional hand over regarding prehospital trauma patients. DISCUSSION: Exact identification of the poly trauma patient in need of care by P-HEMS is difficult though prehospital communication and the prehospital handover may be improved. CONCLUSION: The respondents report that prehospital communication needs to be unambiguous to improve trauma care. Consensus was reached on a set of ten parameters that should minimally be handed over with regard to a prehospital trauma patient. This to facilitate prehospital communication between the Dispatch centre, EMS, P-HEMS and the receiving hospital.

Protocol of the DENIM study: a Delphi-procedure on the identification of trauma patients in need of care by physician-staffed Mobile Medical Teams in the Netherlands.

BACKGROUND: In The Netherlands, standard prehospital trauma care is provided by emergency medical services and can be supplemented with advanced trauma care by Mobile Medical Teams. Due to observed over and undertriage in the dispatch of the Mobile Medical Team for major trauma patients, the accuracy of the dispatch criteria has been disputed. In order to obtain recommendations to invigorate the dispatch criteria, this study aimed at reaching consensus in expert opinion on the question; which acute trauma patient is in need of care by a Mobile Medical Team? In this paper we describe the protocol of the DENIM study (a Delphi-procedure on the identification of prehospital trauma patients in need of care by Mobile Medical Teams). METHODS: A national three round digital Delphi study will be conducted to reach consensus. Literature was explored for relevant topics. After agreement on the themes of interest, the steering committee will construct questions for the first round. In total, 120 panellists with the following backgrounds; Mobile Medical Team physicians and nurses, trauma surgeons, ambulance nurses, emergency medical operators will be invited to participate. Group opinion will be fed back between each round that follows, allowing the panellists to revise their previous opinions and so, converge towards group consensus. DISCUSSION: Successful prehospital treatment of trauma patients greatly depends on the autonomous decisions made by the different professionals along the chain of prehospital trauma care. Trauma patients in need of care by the Mobile Medical Team need to be identified by those professionals in order to invigorate deployment criteria and improve trauma care. The Delphi technique is used because it allows for group consensus to be reached in a systematic and anonymous fashion amongst experts in the field of trauma care. The anonymous nature of the Delphi allows all experts to state their opinion whilst eliminating the bias of dominant and/or hierarchical individuals on group opinion.