The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma

doi:10.1016/j.resuscitation.2009.12.014

Resuscitation

Volume 81, Issue 4, April 2010, Pages 440-445

https://doi.org/10.1016/j.resuscitation.2009.12.014 Get rights and content

Abstract

Aim

The benefit of a well organised trauma system is acknowledged but doubts remain concerning the optimal pre-hospital trauma care model. We hypothesise that the treatment of life-threatening events before arrival at trauma centre – either pre-hospital or first hospital – may be more relevant to decreasing mortality than shortening the time to trauma centre.

Methods

A cohort of 727 trauma patients with life-threatening events – identified as airway, breathing, circulation or neurological disability – requiring transfer to a trauma centre were studied. Data on patient's characteristics, trauma features, and mortality were taken from a trauma registry. Patients were divided into 3 groups depending on the place of treatment of life-threatening events: pre-hospital, first hospital or trauma centre. Survival Kaplan–Meier curves and logistic regression were used to assess the effect of place of treatment of life-threatening events on mortality.

Results

Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre.

Conclusion

In trauma patients requiring transfer to a trauma centre, pre-hospital interventions to treat life-threatening events may significantly decrease mortality when compared to similar interventions performed later at the trauma centre.

Introduction

The benefit of a well organised trauma system with specialized trauma centres is fully acknowledged,1, 2, 3, 4 but doubts still remain concerning what could be considered as the optimal pre-hospital trauma care. Several authors have studied the effect of pre-hospital advanced life support (ALS) in comparison with pre-hospital basic life support (BLS) approaches on trauma mortality and other outcomes.5, 6, 7, 8, 9 However, there are no large or controlled studies on that subject and the controversy is far from being resolved. Even studies that address the effect of specialized trauma teams and helicopters on trauma patients’ outcome showed conflicting results.10, 11, 12

Moreover, studies that compare pre-hospital ALS and BLS approaches often have different definitions for ALS and BLS, study only partial ALS attitudes or techniques – instead of the whole concept – and above all do not study and compare ALS and BLS in a population of trauma patients with life-threatening events needing treatment.¹³

Traumatic life-threatening events were defined in the medical literature as events that endanger life and that should be corrected during the primary survey of treatment of trauma patients. By definition life-threatening events should be treated urgently. The methodology to identify and treat life-threatening events is also known as ABCD methodology and is taught in different trauma courses around the world namely European Trauma Course¹⁴ and ATLS.¹⁵

Our aim was to estimate the effect on mortality of treating the life-threatening events prior to arrival at the trauma centre (either in the pre-hospital scene or in the first hospital) in comparison with treatment of life-threatening events only at the trauma centre. We considered two hypotheses: (1) The early treatment of life-threatening events in trauma patients decreases the risk of death. (2) Time from accident to definitive treatment at trauma centre is an independent factor contributing to mortality.

Section snippets

Setting

We analysed data from a trauma registry that includes all patients admitted to a neurosurgical centre in the North of Portugal (Hospital de Santo António—HGSA). HGSA is a 700 bedded University acute central hospital with neurosurgical cover and intensive care facilities. No other hospital within this trauma system has emergency neurosurgical coverage. HGSA serves Northeast Portugal (a mixed urban/rural area) with a catchment area of approximately 2,500,000 inhabitants. The Emergency Medical

Population characteristics

Between 1st January 2001 and 31st December 2006, 1050 trauma patients were admitted to the emergency room of HGSA and enrolled in the prospective registry. We included in this study 761 trauma patients transferred from another hospital. Twenty-five patients who had no life-threatening events identified were excluded from subsequent analyses. We also excluded 8 patients with missing data related to the presence or the treatment of life-threatening events.

Patients included had a mean age of 44

Discussion

Our main finding was that the treatment of life-threatening events in the pre-hospital scene (compared to the treatment of life-threatening events only at first hospital or the trauma centre) decreased the mortality of severe trauma patients transferred to a trauma centre. A reduction of almost 50% in crude mortality was found for those patients having their life-threatening events treated in the pre-hospital phase. This observed benefit was maintained after adjustment for confounders in

Conflict of interest statement

All authors’ deny any conflicts of interest.

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Of 1046 data sources screened, 36 were included for full review (29 journal articles, 7 abstracts/posters without full text). Educational initiatives including the Rural Trauma Team Development Course and the Advanced Trauma Life Support course were the most common QI interventions investigated. Study outcomes included process metrics such as transfer time to tertiary care and hospital LOS, along with measures of provider perception and knowledge. Improvement in mortality was reported in a single study evaluating the impact of establishing a dedicated trauma service at a community hospital.
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As modern healthcare resources are stretched thin, this reduced LOS will free up critical resources to be used for treating additional patients. Our results are comparable with prior research linking pre-hospital treatment in life-threatening situations to reduced mortality compared with deferring treatment to the trauma centre [20,21]. However, further analysis of mortality is required.
Helicopter Emergency Medical Services (HEMS) allow critical care personnel to attend incidents alongside transporting patients to hospital. The study site is a UK based emergency department and major trauma centre, accepting flights from a wide geographical area.
To characterise the impact of HEMS on a major trauma centre clinical resources and the impact of the UK regional trauma network launch on HEMS asset provision.
Flight case-mix data were obtained from Emergency Department (ED) records (non-trauma patients) and from the Trauma Audit and Research Network database (trauma patients). Statistical analysis was in Excel.
432 flights landed at the site between August 2018 and July 2019. 178 flights originated from the incident scene (145 trauma, 26 non-trauma), 107 from other hospitals, and 5 to other hospitals. Hospitalisation was reduced to a median of 6 days.
Primary HEMS trauma patients utilised significant clinical resources but had shorter hospitalisations than those without HEMS intervention. The regional trauma network improved HEMS tasking and utilised critical car cars to provide advanced pre-hospital care locally. Further work should compare HEMS versus ground ambulance to determine the impact of HEMS on patient outcomes and cost implications to both HEMS operators and receiving hospital.
Epidemiology of trauma: A population-based study of geographical risk factors for injury deaths in the working-age population of Norway
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Although a national trauma system has yet to be implemented in Norway, there is a tendency to centralise trauma care [24,25], increasing the distances to definite care for rural areas. Optimal initial stabilisation by the emergency medical service (EMS) and local hospitals and efficient interhospital transfers are suggested resources for rural trauma care [16,26,27]. Targeted primary prevention and optimisation of trauma systems necessitate an increased understanding of etiological, demographical and geographical risk factors [3,28,29].
Trauma is a major global cause of morbidity and mortality. Population-based studies identifying high-risk populations and regions may facilitate primary prevention and the development of optimal trauma systems. This study describes the epidemiology of adult trauma deaths in Norway and identifies high-risk areas by assessing different geographical measures of rurality.
All trauma-related deaths in Norway from 1998 to 2007 among individuals aged 16–66 years were identified by accessing national registries. Mortality data were analysed by linkage to population and geographical data at municipal, county and national levels. Three measures of rurality (centrality, population density and settlement density) were compared based on their association with trauma mortality rates.
The study included 8466 deaths, of which 78% were males. The national annual trauma mortality rate was 28.7 per 100,000. Population density was the best predictor of high-risk areas, and there was a consistent inverse relationship between mortality rates and population density. The most rural areas had 52% higher trauma mortality rates compared to the most urban areas. This difference was largely due to deaths following transport-related injury. Seventy-eight per cent of all deaths occurred in the prehospital phase. Rural areas and death following self-harm had higher proportion of prehospital deaths.
Rural areas, as defined by population density, are at a higher risk of deaths following traumatic injuries and have higher proportions of prehospital deaths and deaths following transport-related injuries. The heterogeneous characteristics of trauma populations with respect to geography and mode of injury should be recognised in the planning of preventive strategies and in the organisation of trauma care.
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In 2002, the West-African nation of Gabon established an emergency medical system (EMS), Service d’Aide Médicale Urgente (SAMU), in Libreville, yet few people access it. Our objective was to describe Libreville residents’ knowledge and attitudes toward the SAMU in an effort to understand why this service is underutilized.
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View all citing articles on Scopus

^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.12.014.

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Clinical paperThe importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma☆

Abstract

Aim

Methods

Results

Conclusion

Introduction

Section snippets

Setting

Population characteristics

Discussion

Conflict of interest statement

Am J Emerg Med

Injury

Resuscitation

Resuscitation

Injury

A national evaluation of the effect of trauma-center care on mortality

N Engl J Med

Relationship between trauma center volume and outcomes

JAMA

The effect of trauma center designation and trauma volume on outcome in specific severe injuries

Ann Surg

A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems

J Trauma

Predictive effect of out-of-hospital time in outcomes of severely injured young adult and elderly patients

Prehosp Disaster Med

Scottish urban versus rural trauma outcome study

J Trauma

Is total out-of-hospital time a significant predictor of trauma patient mortality?

Acad Emerg Med

Mortality of blunt polytrauma: a comparison between emergency physicians and emergency medical technicians—prospective cohort study at a level I hospital in eastern Switzerland

J Trauma

Advanced or basic life support for trauma: meta-analysis and critical review of the literature

J Trauma

The golden hour: scientific fact or medical “urban legend”?

Acad Emerg Med

Effectiveness of pre-hospital trauma care

Cochrane Injuries Group

The European Trauma Course (ETC) and the team approach: past, present and future

Resuscitation

Advanced Trauma Life Support Course for doctors, faculty manual

Clinical paper
The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma☆