Mortality after hospital admission for trauma in Norway: A retrospective observational national cohort study.

BACKGROUND: National quality data for trauma care in Norway have not previously been reported. We have therefore assessed crude and risk-adjusted 30-day mortality in trauma cases after primary hospital admission on national and regional levels for 36 acute care hospitals and four regional trauma centres. METHODS: All patients in the Norwegian Trauma Registry in 2015-2018 were included. Crude and risk-adjusted 30-day mortality was assessed for the total cohort and for severe injuries (Injury Severity Score ≥16), and individual and combined effects of health region, hospital level, and hospital size were studied. RESULTS: 28,415 trauma cases were included. Crude mortality was 3.1% for the total cohort and 14.5% for severe injuries, with no statistically significant difference between regions. Risk-adjusted survival was lower in acute care hospitals than in trauma centres (0.48 fewer excess survivors per 100 patients, P<0.0001), amongst severely injured patients in the Northern health region (4.80 fewer excess survivors per 100 patients, P = 0.004), and in hospitals with <100 trauma admissions per year (0.65 fewer excess survivors than in hospitals with ≥100 admissions, P = 0.01). However, the only statistically significant effects in a multivariable logistic case mix-adjusted descriptive model were hospital level and health region. Case-mix adjusted odds ratio for survival for severely injured patients directly admitted to a trauma centre vs. an acute care hospital was 2.04 (95% CI 1.04-4.00, P = 0.04), and if admitted in the Northern health region vs. all other health regions was 0.47 (95% CI 0.27-0.84, P = 0.01). The proportion of cases admitted directly to the regional trauma centre in the sparsely populated Northern health region was half of that in the other regions (18.4% vs. 37.6%, P<0.0001). CONCLUSION: Differences in risk-adjusted survival for severe injuries can to a large extent be attributed to whether patients are directly admitted to a trauma centre. This should have implications for planning of transport capacity in remote areas.

Outcomes after cancelled helicopter emergency medical service missions due to concurrencies: a retrospective cohort study.

BACKGROUND: Appropriate dispatch criteria and helicopter emergency medical service (HEMS) crew decisions are crucial for avoiding over-triage and reducing the number of concurrencies. The aim of the present study was to compare patient outcomes after completed HEMS missions and missions cancelled by the HEMS due to concurrencies. METHODS: Missions cancelled due to concurrencies (AMB group) and completed HEMS missions (HEMS group) in Western Norway from 2004 to 2013 were assessed. Outcomes were survival to hospital discharge, physiology score in the emergency department, emergency interventions in the hospital, type of department for patient admittance, and length of hospital stay. RESULTS: Survival to discharge was similar in the two groups. One-third of the primary missions in the HEMS group and 13% in the AMB group were patients with pre-hospital conditions posing an acute threat to life. In a sub group analysis of these patients, HEMS patients were younger, more often admitted to an intensive care unit, and had an increased survival to discharge. In addition, the HEMS group had a greater proportion of patients with deranged physiology in the emergency department according to an early warning score. CONCLUSION: Patients in the HEMS group seemed to be critically ill more often and received more emergency interventions, but the two groups had similar in-hospital mortality. Patients with pre-hospital signs of acute threat to life were younger and presented increased survival in the HEMS group.

Helicopter-based emergency medical services for a sparsely populated region: A study of 42,500 dispatches.

BACKGROUND: The Helicopter Emergency Medical Service (HEMS) in Norway is operated day and night, despite challenging geography and weather. In Western Norway, three ambulance helicopters, with a rapid response car as an alternative, cover close to 1 million inhabitants in an area of 45,000 km(2) . Our objective was to assess patterns of emergency medical problems and treatments in HEMS in a geographically large, but sparsely populated region. METHODS: Data from all HEMS dispatches during 2004-2013 were assessed retrospectively. Information was analyzed with respect to patient treatment and characteristics, in addition to variations in services use during the day, week, and seasons. RESULTS: A total of 42,456 dispatches were analyzed. One third of the patients encountered were severely ill or injured, and two thirds of these received advanced treatment. Median activation time and on-scene time in primary helicopter missions were 5 and 11 min, respectively. Most patients (95%) were reached within 45 min by helicopter or rapid response car. Patterns of use did not change. More than one third of all dispatches were declined or aborted, mostly due to no longer medical indication, bad weather conditions, or competing missions. CONCLUSION: One third of the patients encountered were severely ill or injured, and more than two thirds of these received advanced treatment. HEMS use did not change over the 10-year period, however HEMS use peaked during daytime, weekends, and the summer. More than one third of all dispatches were declined or aborted.

The effects of safety checklists in medicine: a systematic review.

BACKGROUND: Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes. METHODS: The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was used. All studies in which safety checklists were used as an additional tool designed to assure that an operation or task was performed as planned were included. RESULTS: The initial search extracted 7408 hits. Twenty-nine articles met the inclusion criteria. Five additional studies were identified by a cross-referencing search. Four groups were made according to outcome measures. One group (n = 7) had 'hard' outcome measures, such as mortality and morbidity. The remaining studies, reporting 'softer' process-related measures, were divided into three categories: adherence to guidelines (n = 6), human factors (n = 16), and reduction of adverse events (n = 5). The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists. CONCLUSION: Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

The effect of a simple checklist on frequent pre-induction deficiencies.

BACKGROUND: A substantial proportion of anaesthesia-related adverse events are preventable by identification and correction of errors in planning, communication, fatigue, stress, and equipment. The aim of this study was to develop and implement a pre-induction checklist in order to identify and solve problems before induction of anaesthesia. METHODS: The checklist was developed in a stepwise manner using a modified Delphi technique, literature search, expert's opinion, and a pilot version, and then implemented in a clinical environment during a 13-week study period. Each list was registered and analysed using statistical process control. The checklist was mandatory, but emergency cases were excluded. RESULTS: The checklist, containing 26 items, was used in 502 (61%) of a total of 829 inductions. Eighty-five checklists (17%) identified one or more missing items. The number of missing items decreased significantly throughout the study period. The most important missing items were lack of a second laryngoscope available, introducer not having been fitted to the endotracheal tube, the endotracheal tube cuff not having been tested, and no separate ventilation bag being available. It took a median of 88.5 s (range 52-118) to perform the checklist when no items were missing. The pre-induction time was the same before and after the checklist was introduced (25.1 vs. 24.3 min, P50.25). CONCLUSIONS: It is possible to develop, introduce, and use a pre-induction checklist even in a hectic and stressful clinical environment. The checklist identified and reduced a surprisingly large number of missing items required in a standard induction protocol.

Does the horizontal position increase risk of rescue death following suspension trauma?

BACKGROUND: It is widely believed that placing a patient who has been subjected to suspension trauma in a horizontal position after rescue may cause rescue death. The discussion whether position is important has been dominated by non-medical personnel. Subsequently, this has led to a general advice on emergency treatment of these patients, which may cause incorrect or even fatal treatment. METHODS: To determine whether there is any medical evidence supporting that horizontal positioning after suspension trauma may cause rescue death, the authors located publications, reports, expert opinions and other sources of information addressing the acute treatment of suspension trauma. These sources were then evaluated. RESULTS: Several thousand hits regarding suspension trauma were located on the internet and five articles on the PubMed. Although most of them warned of the dangers of rescue death brought about by assuming the horizontal position after prolonged suspension, the authors found no clinical studies, and none of the sources offered any conclusive evidence as to whether the horizontal position increases the risk of rescue death. Neither the authors, nor the suspension trauma experts who were contacted, had ever experienced or heard of case reports supporting the causal relation between the horizontal position and rescue death. CONCLUSIONS: After evaluating the current literature, the authors found no support for the view that the horizontal position may be potentially fatal for patients exposed to suspension trauma. In the absence of any evidence to the contrary, the authors suggest that the initial management of patients who have had suspension trauma should follow normal guidelines for the acute care of traumatised patients, without special modifications.

Keeping the spirit high: why trauma team training is (sometimes) implemented.

BACKGROUND: Systematic and multiprofessional trauma team training using simulation was introduced in Norway in 1997. The concept was developed out of necessity in two district general hospitals and one university hospital but gradually spread to 45 of Norway's 50 acute-care hospitals over the next decade. Implementation in the hospitals has varied from being a single training experience to becoming a regular training and part of quality improvement. The aim of this study was to better understand why only some hospitals achieved implementation of regular trauma team training, despite the intentions of all hospitals to do so. METHODS: Focus group interviews were conducted with multiprofessional respondents in seven hospitals, including small and large hospitals and hospitals with and without regular team training. Interviews were transcribed and analyzed using a Grounded Theory approach. RESULTS: 'Keeping the spirit high' appeared to be the way to achieve implementation. This was achieved through 'enthusiasm,''strategies and alliances,' and 'using spin-offs.' It seems that the combination of enthusiasts, managerial support, and strategic planning are key factors for professionals trying to implement new activities. CONCLUSIONS: Committed health professionals planning to implement new methods for training and preparedness in hospitals should have one or more enthusiasts, secure support at the administrative level, and plan the implementation taking all stakeholders into consideration.

Survey of routines for sedation of patients on controlled ventilation in Nordic intensive care units.

BACKGROUND: Sedation strategies and practice for patients on controlled ventilation is variable from place to place as well as over time. Less sedation results in shorter ventilation time and new ventilatory modes permit more awake patients. Previous works estimated sedative and analgesic use in Nordic ICUs some years ago, but current practice is not known. We therefore designed this study to describe pharmacological and practical routines for sedation of patients on controlled ventilation. MATERIAL AND METHODS: We used an electronic questionnaire about characteristics of the participating ICUs and the routines for sedation of ventilator-treated patients, and secondly, an Internet-based 5-day registration on the use of drugs for sedation and analgesia. RESULTS: Eighty-eight of 220 ICUs (36%) responded to the questionnaire and 47 out of these 88 units (53%) used a sedation scale. Written guidelines for sedation were used in 41% of the units. Both daily interruption of sedation infusions and guidelines for weaning from the ventilator were used in 15% of the units. Data on 202 patients (633 patient days) from 55 ICUs were reported. Among analgesics, fentanyl predominated (240/633 days), followed by ketobemidon (160/633 days) and morphine (115/633 days). Propofol and midazolam were the most commonly used agents for sedation (345 and 238/633 days, respectively). CONCLUSION: Most units used a sedation scale, although other strategies to reduce the sedation level had not yet been fully introduced. Differences in pharmacological strategies were found between the Nordic countries, and some favourite drugs could be identified.

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit.

PROBLEM: Need for improved sedation strategy for adults receiving ventilator support. DESIGN: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative. BACKGROUND AND SETTING: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. KEY MEASURES FOR IMPROVEMENT: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. STRATEGIES FOR CHANGE: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. EFFECTS OF CHANGE: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. LESSONS LEARNT: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

Preparing teams for low-frequency emergencies in Norwegian hospitals.

BACKGROUND: Medical emergencies and major trauma require optimal team function. Leadership, co-operation and communication are the most essential issues. Due to low caseloads such emergencies occur rarely in most Norwegian hospitals. Team training of personnel between real emergencies is expected to improve performance in comparable settings. Most hospitals have cardiac arrest teams, but it is known that the training of such multiprofessional teams varies widely. We wanted to know if this also was the case for trauma teams and resuscitation teams for newborns. METHODS: A telephone survey of training practices in all the Norwegian hospitals with acute cover was conducted in 2002. Information was obtained on whether trauma teams and neonatal resuscitation teams had participated in practical multiprofessional training during the previous 6 or 12 months. RESULTS: Information was obtained from all 50 hospitals. Of the acute care hospitals, 30% had trained their trauma teams during the previous 6 months, and an additional 18% when considering the previous year, while 38% of neonatal wards had multiprofessional training during the previous 6 months, and additionally 13% had had training during the previous year. Additionally four neonatal wards had had regular training of nurses only. More than 80% of all respondents judged regular team training to be achievable, and none considered this training impossible. CONCLUSION: Only half the Norwegian acute care hospitals reported at least yearly training of trauma and neonatal resuscitation teams. Regular team training represents an underused potential to improve handling of low-frequency emergencies.

[Organization of trauma admissions at Norwegian hospitals]. / Organiseringen av traumemottak ved norske sykehus.

BACKGROUND: Treatment of major trauma is a demanding challenge for most hospitals. The potential benefits of improvement are substantial: it has been calculated that approx. 6,000 person-years are lost each year because of suboptimal treatment of trauma in Norway. Trauma teams, paging criteria, and manuals for appropriate resuscitative and diagnostic interventions are needed for improving the structure and quality of this service. MATERIAL AND METHODS: A telephone survey to Norwegian hospitals. RESULTS: 27 (52%) of all 52 Norwegian hospitals receiving trauma victims had dedicated trauma teams, while 19 (37%) had paging criteria for trauma teams. 22 hospitals (42%) confirmed that they had manuals for the initial treatment of trauma victims. Smaller hospitals tended to have trauma teams and trauma manuals to a lesser extent. An interesting finding was that hospitals that participated in a collaborative project on trauma treatment (the so-called BEST network) were significantly more likely to have trauma teams, paging criteria, and trauma manuals. INTERPRETATION: The results show that structural issues in relation to optimal trauma treatment still need more attention in Norwegian hospitals. Collaborative programmes for training and exchange of experience and procedures seem to be one way to go.

[Hyperbaric oxygen treatment for radiation reactions]. / Hyperbar oksygenbehandling ved strålereaksjoner.

BACKGROUND: A national hyperbaric centre was established in 1994 at Haukeland Hospital with responsibility for all hyperbaric oxygen (HBO) treatment in Norway. In hypoxic tissues with symptomatic radiation reactions, hyperbaric oxygen induces the formation of collagen and angiogenesis resulting in permanently improved local microcirculation. MATERIAL AND METHODS: 234 patients received elective HBO treatment at Haukeland Hospital in 1997 with a total of 4,048 treatments. All 47 patients treated for radiation reactions in the pelvic area in 1997 received a questionnaire 3-15 months after HBO therapy; 81% responded. RESULTS: Rectal bleeding and haematuria were reported as much improved in 61% and 55% respectively, while bladder incontinence was much improved in 46%. INTERPRETATION: This treatment modality may be an alternative in symptomatic radiation reactions of the urinary bladder and the bowel when conventional treatment has given unsatisfactory results.