[Optimization of criteria for activation of trauma teams : Avoidance of overtriage and undertriage]. / Optimierung der Kriterien zur Schockraumalarmierung : Vermeidung von Über- und Untertriage.

INTRODUCTION: Severely injured patients are supposed to be admitted to hospital via the trauma room. Appropriate criteria are contained in the S3 guidelines on the treatment of patients with severe/multiple injuries (S3-GL); however, some of these criteria require scarce hospital resources while the patients then often clinically present as uninjured. There are tendencies to streamline the trauma team activation criteria (TTAC); however, additional undertriage must be avoided. A study group of the emergency, intensive care medicine and treatment of the severely injured section (NIS) is in the process of optimizing the TTAC for the German trauma system. MATERIAL AND METHODS: In order to solve the objective the following multi-step approach is necessary: a) definition of patients who potentially benefit from TTA, b) verification of the definition in the TraumaRegister DGU® (TR-DGU), c) carrying out a prospective, multicenter study in order to determine overtriage and undertriage, thereby validating the activation criteria and d) revision of the current TTAC. RESULTS: This article summarizes the consensus criteria of the group assumed to be capable of identifying patients who potentially benefit from TTA. These criteria are used to test if TTA was justified in a specific case; however, as the TTCA of the S3-GL are not fully incorporated into the TR-DGU dataset and because cases must also be considered which were not subject to trauma room treatment and therefore were not included in the TR-DGU, it is necessary to perform a prospective full survey of all individuals in order to be able to measure overtriage and undertriage. CONCLUSION: Currently, the TR-DGU can only provide limited evidence on the quality of the TTAC recommended in Germany. This problem has been recognized and will be solved by conducting a prospective DGU-supported study, the results of which can be used to improve the TR-DGU dataset in order to enable further considerations on the quality of care (e. g. composition and size of the trauma team).

[Expectations from the TraumaNetwork DGU®: Which goals have been achieved? What can be improved?]. / Erwartungen an das TraumaNetzwerk DGU®: Welche Ziele wurden erreicht? Was kann verbessert werden?

INTRODUCTION: Following the establishment of the first trauma networks in 2009 an almost nationwide certification could be achieved. Despite the impressive number of 46 certified networks, little is known about the actual improvements and the satisfaction of the participating hospitals. OBJECTIVES: This article aims to give a first representative overview of the expectations and actual achievements. MATERIAL AND METHODS: An online survey with a total of 36 questions was conducted in 884 hospitals. The questionnaire could be filled out online, sent by post or fax to the AKUT- Office. Descriptive statistical analyses were performed with Microsoft Excel. RESULTS: With 326 responses, a response rate of 48.9% of all active hospitals was achieved. Of the participating hospitals 64.1% (209) were certified and had taken part in the project for an average of 3.9 years. The average score for satisfaction was 2.3, 72.4% (236) felt that there was a need for improvement in the care of severely injured patients and 46.6% (152) in the transfer of patients. In 47.2% (142) no improvement in cooperation with the ambulance service could be determined, 25.2% (82) documented an increase in the number of severely injured patients since participating in the trauma network (TNW-DGU) and 93.9% (306) of all hospitals wanted to participate in the trauma network in the future. DISCUSSION: It could be shown that important goals, such as simplification of patient transfer or general improvement in cooperation have been achieved. Overall there was a high level of satisfaction among the participating hospitals; however, the survey has identified some points which need to be improved by further intensive work.

[Polytrauma in children and adolescents. Choice of the primary care clinic and importance of pediatric traumatology competence centers]. / Das Polytrauma von Kindern und Jugendlichen. Auswahl der primärversorgenden Klinik und Bedeutung von kindertraumatologischen Kompetenzzentren.

BACKGROUND: The number of (seriously) injured children increased again for the first time in 2011. The aim of this study was to analyse differences compared to multiple injured adults and to show the reality of daily treatment. METHODS: All cases of the DGU Trauma Registry from the years 1997 to 2010 were examined. The documented cases were divided into different the age groups. The study investigated, e.g. the mechanism of accident, injury pattern, the number of hospital and ICU days, and lethality. RESULTS: At 38.8% the largest percentage of severely injured children and adolescents belongs to the group of 16-17 year olds. The group of 0-5 year olds (15.9%) has the lowest percentage. The most common accident cause was traffic accidents (58.5%). The mechanism of accident and the injury patterns changes with age. Younger patients are often treated in supraregional trauma centers (0-5 year olds: 78.2% vs. 16-17 year olds: 73.1% vs. > 65 years: 63.2%). The average lethality rate was 14.8% (16.3% RISC). CONCLUSIONS: The percentage of severely injured children in the overall population is only 7.4%. Because the majority of patients are primarily treated in supraregional trauma centers, trauma centers with specialisation in paediatric traumatology are mandatory.

[TraumaregisterTraumaNetwork DGU® und TraumaRegister DGU®. Success by cooperation and documentation]. / TraumaNetzwerk DGU® und TraumaRegister DGU®. Erfolge durch Kooperation und Dokumentation.

BACKGROUND: The TraumaNetwork DGU® (TNW) connects hospitals with different capacities for the treatment of severely injured patients who work together as superregional (STC), regional (RTC) and local trauma centres (LTC). The standards of treatment and equipment are defined on the basis of current guidelines as published in the"White book of the Treatment of Severely Injured Patients". An external audit process evaluates the organisation and structure of participating hospitals as well as the cooperation of the trauma centres within a regional TNW. RESULTS: In May 2013 a total of 618 hospitals were visited and assessed according to the White book and 39 fully certified regional TNWs covered around 85% of the area of Germany. Treatment quality in the certified TCs was analyzed on the basis of 25,249 severely injured patients in the TraumaRegister DGU® (2008-2011) and significant differences between the expected and observed mortality rates were found. These differences were most obvious in superregional and regional trauma centres. CONCLUSION: The TraumaNetwork represents an innovative, cooperative project for successfully improving the treatment of severely injured patients.

[Urgency of neurosurgical interventions for severe traumatic brain injury]. / Dringlichkeit neurochirurgischer Interventionen bei schwerem Schädel-Hirn-Trauma.

BACKGROUND: The aim of this study was to assess whether the time interval between accident and neurosurgical intervention has an influence on functional neurological outcome and mortality in severe traumatic brain injury (sTBI) or whether the further clinical course has already been determined by the initial severity of the injury. METHODS: Data were derived from the Trauma Registry of the German Society of Trauma Surgery. A total of 770 patients were identified who had undergone decompressive surgery, had an ISS ≥ 9 and for whom time of accident and start of surgery had been documented. To evaluate the possible influence of the time factor on outcome and mortality, these patients were subdivided into five groups according to time until decompression (I: < 2 h, II: 2-3 h, III: 3-6 h, IV: 6-24 h and V: > 24 h). Aside from mortality we analysed AIS, GCS, age and ISS in survivors and non-survivors. RESULTS: Complete data were available for 770 patients with sTBI (AIS skull ≥3). The average age was 39.9 years and 71.6% were male. The average overall injury severity was reflected by an ISS score of 31.3 and the average AIS head score was 4.51. Of the 570 who underwent surgery in less than 6 h (groups 1-III), 33% died (188/570). Of the remaining 200 patients 40 died (20%). Mortality decreased throughout the groups (49 to 14%), as did the severity of the head injury (AIS 4.66 to 4.23); GCS on the other hand increased with the time between accident and surgery (5.9 to 8.8). CONCLUSION: We could not substantiate that reducing the time between accident and neurosurgical decompression could decrease mortality. It rather seems that the initial magnitude of brain damage determines prognosis and outcome after sTBI. The interval between the appearance of neurological symptoms (e.g. anisocoria) and neurosurgical intervention plays an important role and should be kept as short as possible.

Regionalisation of trauma care in Germany: the "TraumaNetwork DGU(®)-Project".

PURPOSE: The care for severely injured patients is a demanding task for all medical professionals involved in both the pre-clinical and the clinical setting. While the overall quality of care in Germany is high, regional differences remain. These are due to geographical and infrastructural variations, as well as different personnel and equipment situations in the hospitals. METHODS: In September 2006, the white paper 'Treatment of the severely injured' was published by the German Society of Trauma Surgery (DGU). The white paper asks for the improvement of comprehensive care and postulates the foundation of networks between trauma centres: a regional TraumaNetwork (TNW). All hospitals within a TNW are classified as local, regional or supraregional trauma centres by distinct criteria regarding personnel and equipment, as well as admission capacity and responsibility. Furthermore, agreements between the trauma centres and the pre-hospital rescue systems regulate the admission and transfer of patients in a TNW. RESULTS: To date, 878 hospitals are registered in 53 regional TNWs. A total of 511 hospitals have already been audited on-site. Preparing for the audit, 54.4% of the hospitals implemented organisational changes (e.g. inter-disciplinary guidelines), while 31.4% introduced personnel and 14.7% structural (e.g. X-ray in the emergency room [ER]) changes. In September 2011, the certification process was completed in 19 TNWs, comprising a mean of 14 (range 5-26) hospitals each. Moreover, international TNWs in co-operation with hospitals in Holland, Luxemburg, Switzerland and Austria were established. CONCLUSIONS: The TraumaNetwork DGU(®) audits all hospitals participating in the care for severely injured patients and establishes a structured network between all the players involved in trauma care. Thirty TNWs will be certified by the end of 2011, covering 75% of Germany. The nationwide covering will be completed by the middle of 2012.

[Organizational, personnel and structural alterations due to participation in TraumaNetworkD DGU. The first stocktaking]. / Organisatorische, personelle und strukturelle Veränderungen durch die Teilnahme am TraumaNetzwerkD DGU. Eine erste Bestandsaufnahme.

BACKGROUND: By implementation of a nationwide trauma network in Germany a high quality standard of technical, personnel and scientific conditions should be attained in hospitals participating in care for severely injured patients. All hospitals audited within the framework of TraumaNetwork(D) DGU are also evaluated for the modifications undertaken by answering a questionnaire. Using this data it was possible to 1) obtain information about hitherto existing personnel and technical infrastructures of all participating hospitals and 2) to present first positive effects achieved by implementation and participating in TraumaNetwork(D) DGU. MATERIALS AND METHODS: The questionnaire contained 41 questions concerning organizational, personnel and structural changes to justify the motivation for participating in TraumaNetwork(D) DGU and regarding the degree of confidence with reference to the work of the AKUT office. Analysis of data has been carried out and given as a percentage of all useable questionnaires. RESULTS: Data of 138 hospitals has been evaluated. Regarding organizational changes 29% of national/supraregional trauma centers made fewer adjustments than local (44%) and regional (55%) trauma centers. Personnel changes mainly affected participation in ATLS courses, cooperation with a neurosurgical department and reorganization of work schedules. With respect to structural changes most frequently emergency operating sets for emergency surgery have been established, teleradiology systems have been implemented and in 25% of the cases a sonography unit has been acquired. The rarest, but also most cost-intensive, new acquisition has been a CT scanner in or close to the emergency trauma room (10%). The work of the AKUT office has been rated altogether more satisfying by local trauma centers (mean 2.4) than by regional and national trauma centers (mean 2.6). Prompt information by AKUT has been especially praised (mean 2.1). CONCLUSION: Being organized in trauma networks motivates hospitals to optimize their operational sequences and personnel and structural conditions. How much the care for multiple injured patients can be improved nationwide in Germany will be shown over the next few years. Through compulsive participation in TraumaRegister(QM) DGU (quality management) as a measurement for quality assurance this will be analyzed and evaluated scientifically.

Genetic selection for deafness: the views of hearing children of deaf adults.

The concept of selecting for a disability, and deafness in particular, has triggered a controversial and sometimes acrimonious debate between key stakeholders. Previous studies have concentrated on the views of the deaf and hard of hearing, health professionals and ethicists towards reproductive selection for deafness. This study, however, is the first of its kind examining the views of hearing children of deaf adults towards preimplantation genetic diagnosis and prenatal diagnosis to select for or against deafness. Hearing children of deaf adults (or CODAs, as they call themselves, and are widely known in the deaf community) straddle both the deaf and hearing worlds, and this dual perspective makes them ideally placed to add to the academic discourse concerning the use of genetic selection for or against deafness. The study incorporated two complementary stages, using initial, semistructured interviews with key informants (CODAs and health professionals) as a means to guide the subsequent development of an electronic survey, completed anonymously by 66 individuals. The participants shared many of the same views as deaf individuals in the D/deaf (or "culturally deaf") community. The similarities extended to their opinions regarding deafness not being a disability (45.5% believed deafness was a distinct culture rather than a disability), their ambivalence towards having hearing or deaf children (72.3% indicated no preference) and their general disapproval of the use of genetic technologies to select either for or against deafness (60% believed that reproductive technologies, when used to select for or against deafness, should not be available to the community).

[The Trauma Network of the German Society for Trauma 2009]. / Das TraumaNetzwerkD DGU 2009.

In 2009, 3 years after the foundation of the Trauma Network of the German Society for Trauma (TraumaNetzwerkD DGU), the majority of German hospitals participating in the treatment of seriously injured patients is registered in regional trauma networks (TNW). Currently there are 41 trauma networks with more than 660 hospitals in existence, 18 more are registered but are still in the planning phase. Each Federal State has an average of 39 trauma centres of different levels taking part in the treatment of seriously injured patients and every trauma network has an average catchment area of 8708 km(2). The most favourable geographical infrastructure conditions exist in Nordrhein-Westfalen, the least favourable in Sachsen-Anhalt and Mecklenburg-Vorpommern. A total of 95 hospitals have already fulfilled the first audit of the structural, personnel and qualitative requirements by the certification bodies. Examination of the check lists of 26 hospitals showed shortcomings in the clinical structure so that these hospitals must be rechecked after correction of the shortcomings. A total of 59 hospitals throughout Germany were successfully audited and only one failed to fulfil the requirements. Because of the varying sizes of the trauma networks there are differences in the areas covered by each trauma network and trauma centre. Concerning the process of certification and auditing (together with the company DIOcert) it could be seen that by careful examination of the check lists of each hospital unforeseen problems during the audit could be avoided. The following article will present the current state of development of the Trauma Network of the German Society for Trauma and describe the certification and auditing process.

[Treatment management of a multiply injured patient with HIV infection]. / Behandlungsmanagement eines polytraumatisierten Patienten mit HIV-Infektion.

In orthopaedic surgery and emergency medicine, patients of the age groups with a HIV risk represent the largest part of the entire population. As necessary steps have to be taken immediately at the scene of an accident and in the emergency room, contact with HIV-positive blood is often unavoidable, so that there is an increased risk of transmission for doctors and personnel. Due to the immunological state, the HIV patient is exposed to considerable post-operative complications such as wound infection, pneumonia and even sepsis. With the case of a 35-year-old HIV-positive patient who was multiply injured in a traffic accident, we want to present an interesting example of the problems that occur in the treatment of this patient group.