Dutch trauma system performance: Are injured patients treated at the right place?

BACKGROUND: The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS). METHODS: Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC. RESULTS: Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times. CONCLUSIONS: Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.

The Dutch nationwide trauma registry: The value of capturing all acute trauma admissions.

INTRODUCTION: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National Trauma Registry (DNTR) to evaluate epidemiology, patient distribution, resource use and quality of care. In this study we describe the DNTR, the incidence and main characteristics of Dutch acutely admitted trauma patients, and evaluate the value of including all acute trauma admissions compared to more stringent criteria applied by the national trauma registries of the United Kingdom and Germany. METHODS: The DNTR includes all injured patients treated at the ED within 48 hours after trauma and consecutively followed by direct admission, transfers to another hospital or death at the ED. DNTR data on admission years 2007-2018 were extracted to describe the maturation of the registry. Data from 2018 was used to describe the incidence rate and patient characteristics. Inclusion criteria of the Trauma Audit and Research (TARN) and the Deutsche Gesellschaft für Unfallchirurgie (DGU) were applied on 2018 DNTR data. RESULTS: Since its start in 2007 a total of 865,460 trauma cases have been registered in the DNTR. Hospital participation increased from 64% to 98%. In 2018, a total of 77,529 patients were included, the median age was 64 years, 50% males. Severely injured patients with an ISS≥16, accounted for 6% of all admissions, of which 70% was treated at designated RTCs. Patients with an ISS≤ 15were treated at non-RTCs in 80% of cases. Application of DGU or TARN inclusion criteria, resulted in inclusion of respectively 5% and 32% of the DNTR patients. Particularly children, elderly and patients admitted at non-RTCs are left out. Moreover, 50% of ISS≥16 and 68% of the fatal cases did not meet DGU inclusion criteria CONCLUSION: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,000 inclusions annually, the DNTR has become one of the largest trauma databases in Europe The registries strength lies in the broad inclusion criteria which enables studies on the burden of injury and the quality and efficiency of the entire trauma care system, encompassing all trauma-receiving hospitals.

[Coagulation disorders in patients with trauma to the skull and brain: a frequent and potentially fatal combination]. / Stollingsstoornissen bij patiënten met schedel-hersentrauma: een frequente en potentieel fatale combinatie.

Abnormalities in blood coagulation are relatively common after traumatic brain injury (TBI) and play an important role in the morbidity and mortality after head injuries. Exposure oftissue factor, which is abundantly present in brain tissue, is the initiator of the coagulation cascade and plays an important role in the pathogenesis of coagulopathy after TBI. Coagulopathy after TBI is actually a manifestation of the disseminated intravascular coagulation (DIC) syndrome. The interplay between hypothermia, acidosis and progressive coagulopathy, referred to as the 'lethal triad', results in high mortality. This necessitates damage control in the treatment of such TBI patients. Repeated laboratory evaluation of the coagulation parameters in TBI patients is indicated, even if the initial values are normal. The DIC score, a combination of frequently used coagulation parameters, is not only a measure of the coagulopathy but can also predict the outcome and prognosis following TBI. Primary and secondary prevention of coagulopathy together with timely and effective intervention are the most important elements in the treatment of coagulation disorders. Nevertheless, the risk of death remains high.

Pharmaceutical development of a parenteral lyophilized formulation of the investigational polymer-conjugated platinum anticancer agent AP 5280.

AP 5280 is a novel polymer-conjugated platinum anticancer agent showing promising in vitro and in vivo activity against solid tumors. The aim of this study was to develop a parenteral pharmaceutical dosage form for phase I clinical trials. AP 5280 drug substance was characterized by using a wide range of analytical techniques and showed excellent solubility in water. However, as aqueous solutions of AP 5280 proved to be labile upon sterilization by moist heat, it was decided to develop a lyophilized dosage form. Initially, glass vials were used as primary packaging, but this led to a high breakage rate, which could be completely prevented by the use of CZ resin vials. Stability studies to date show that the lyophilized product in glass vials is stable for at least 12 months when stored at 2-8 degrees C in the dark and the lyophilized product in CZ resin vials is stable for at least 6 months under these conditions. Photostability testing revealed photolability of AP 5280 drug substance and lyophilized product in both types of primary container, necessitating storage in the dark. The first clinical experiences indicate that the proposed formulation is fully applicable for use in the clinical setting.

Supine and prone head orientation preference in term infants.

Head orientation preference in the supine and prone positions was studied in 62 healthy term born infants at three different times within 24 hours after delivery. Head orientation preference was related to: the foetal position, the initial head position when the newborn was lying prone on the abdomen of the mother, the handedness of the parents and the state of the infant (according to Prechtl). Although for the whole group a head orientation preference for the right side was observed, an individual significant head orientation preference was observed in less than 50% of the infants studied. Neither the occurrence nor the direction of head orientation per individual was constant during the observation period. No relationship was found between an infant's head orientation and foetal position, initial head position, handedness of the parents, or the state of the infant. Our data suggest that persistent head orientation preference to one side in a healthy term born infant within 24 hours after delivery is a sign of abnormality. Head orientation to the right should not be considered as a sign of normality.