trauma, emergency, critical care, quality assurance, quality, performance, improvement

BACKGROUND: The Haemorrhage, Airway, Breathing, Circulation, Disability, Exposure/Environmental control approach to individual patient management in trauma is well established and embedded in numerous training courses worldwide. Further improvements in trauma outcomes are likely to result from a combination of system-level interventions in prevention and quality improvement, and from a sophisticated approach to clinical innovation. TOP ELEVEN TRAUMA PRIORITIES: Based on a narrative review of remaining preventable mortality and morbidity in trauma, the top eleven priorities for those working throughout the spectrum of trauma care, from policy-makers to clinicians, should be: (1) investment in effective trauma prevention (likely to be the most cost-effective intervention); (2) prioritisation of resources, quality improvement and innovation in prehospital care (where the most preventable mortality remains); (3) building a high-performance trauma team; (4) applying evidence-based clinical interventions that stop bleeding, open & protect the airway, and optimise breathing most effectively; (5) maintaining enough circulating blood volume and ensuring adequate cardiac function; (6) recognising the role of the intensive care unit in modern damage control surgery; (7) prioritising good intensive care unit intercurrent care, especially prophylaxis for thromboembolic disease; (8) conducting a thorough tertiary survey, noting that on average the intensive care unit is where approximately 15% of injuries are detected; (9) facilitating early extubation; (10) investing in formal quantitative and qualitative quality assurance and improvement; and (11) improving clinical trial design...

BACKGROUND: Using patient outcomes to monitor medical centre performance has become an essential part of modern health care. However, classic league tables generally inflict stigmatization on centres rated as "poor performers", which has a negative effect on public trust and professional morale. In the present study, we aim to illustrate that funnel plots, including trends over time, can be used as a method to control the quality of data and to monitor and assure the quality of trauma care...

BACKGROUND: Multiple quality indicators are used by trauma programs to decrease variation and improve outcomes. However, little if any provider level outcomes related to surgical procedures are reviewed. Emergent trauma laparotomy (ETL) is arguably the signature case that trauma surgeons perform on a regular basis, but few data exist to facilitate benchmarking of individual surgeon outcomes. As part of our comprehensive performance improvement program, we examined outcomes by surgeon for those who routinely perform ETL...

BACKGROUND: Twenty years ago, the landmark report To Err Is Human illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Nevertheless, rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program developed a voluntary Mortality Reporting System to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths...

Surgical and trauma intensive care units provide the facilities, resources, and personnel needed to care for patients who have been severely injured, present with acute surgical emergencies, require prolonged and complex elective surgical procedures, or have severe underlying medical conditions. Correcting the immediately evident physiologic derangement is only the first step in the care of these patients, because in many cases their prognosis and ultimate outcome will depend on whether additional insults accrued during their intensive care unit and hospital stay will prevent them from a full recovery...

The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. With this combination of massive blood loss and coagulopathy, it has become increasingly more common to transfuse early the trauma patients and with a combination of PRBC, plasma, and platelets...

Trauma Triage errors are frequent and costly. What happens in pre-hospital care remains anecdotal because of the dual responsibility of treatment (resuscitation and stabilization) and documentation in a time-critical environment. Continuous pre-hospital vital signs waveforms and numerical trends were automatically collected in our study. Abnormalities of pulse oximeter oxygen saturation (< 95%) and validated heart rate (> 100/min) showed better prediction of injury severity, need for immediate blood transfusion, intra-abdominal surgery, tracheal intubation and chest tube insertion than Trauma Registry data or Pre-hospital provider estimations...

OBJECTIVES: Trauma is the leading cause of death in children. The quality of initial medical care received by injured children contributes to outcomes. Our objective was to assess effectiveness of an educational intervention on performance of emergency department (ED) teams during simulated pediatric trauma resuscitations. METHODS: A prospective, preinterventional and postinterventional study was performed on a random, convenience sample of 17% of EDs in North Carolina...

OBJECTIVE: The aim of this study was a retrospective analysis of polytraumatized patients who were treated by a helicopter emergency medical service (HEMS) crew. This study was performed to evaluate the level of prehospital care provided for severely injured patients. Special consideration was given to treatment strategies of specific injuries which led to multiple injuries, defined as "polytrauma." METHODS: From September 1992 to April 2001 data of 386 patients treated in the Department of Traumatology of the University of Vienna were collected...

The Trauma Registry of the German Society of Trauma Surgery represents a database for interhospital quality management in the field of treating severely injured patients. The presented study analyzes the Trauma Registry's impact on treatment quality in the participating hospitals. Since 1998 annual feedback on treatment quality was given to the hospitals of the Trauma Registry. Based on the data from 2001 (10,997 patients), 21 hospitals were studied that had provided data on more than 99 patients between 1999 and 2001...

Video recording is underused in improving patient safety and understanding performance shaping factors in patient care. We report our experience of using video recording techniques in a trauma centre, including how to gain cooperation of clinicians for video recording of their workplace performance, identify strengths of video compared with observation, and suggest processes for consent and maintenance of confidentiality of video records. Video records are a rich source of data for documenting clinician performance which reveal safety and systems issues not identified by observation...

BACKGROUND: Performance review using videotapes is a strategy employed to improve future performance. We postulated that videotape review of trauma resuscitations would improve compliance with a treatment algorithm. METHODS: Trauma resuscitations were taped and reviewed during a 6-month period. For 3 months, team members were given verbal feedback regarding performance. During the next 3 months, new teams attended videotape reviews of their performance. Data on targeted behaviors were compared between the two groups...

Basic and advanced care of trauma patients has always been an important aspect of prehospital and immediate in-hospital emergency medicine, involving a broad spectrum of disciplines, specialties and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources and operation. This complex background has, at least in part, hindered the development of a uniform pattern or set of criteria and definitions. This in turn has hitherto rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be readily evaluated or compared with acceptable validity...

INTRODUCTION: Little is known about how best to quantitatively measure air medical system performance and optimally manage air medical emergency medical services start-up, operation and growth. Moreover, very little has been done to produce and distribute relevant tools for these critical tasks. SETTING: A hypothetical system modeled on the Ontario, Canada, air ambulance operation. METHODS: A user-friendly, high-performance computer simulation tool for air ambulance system design, quality management and optimization was developed...

Quality management in early clinical care of patients with multiple injuries (description of actual process, identification of problems, implementation of quality improvement) is not possible without sufficient baseline data about the present situation of medical treatment. This study investigates whether the current documentation of treatment in the emergency room is appropriate to judge upon the quality of the process and to detect problems. In addition, a set of baseline data is presented. The performance in the treatment of 126 multiple injured patients was prospectively recorded from 1988 to 1993 and compared with an idealized process based upon an algorithm...

The current increase in the cost of health care must be considered as a severe threat to the prehospital emergency services system. Two examples have been selected--the patient with polytrauma and the patient in cardiac arrest--to demonstrate the dilemma between a need for objective data and the requirements of emergency patients. Study results obtained in trauma patients indicating that total prehospital time, including scene time, is correlated to patient outcome have led to the conclusion that at the scene treatment by emergency physicians may be dispensable...

Undue delay between hospital admission and the beginning or urgent operative procedures is considered as a major mortality risk for polytraumatized patients in any trauma center. As part of a quality control study at our institution (Kantonsspital, University of Basel), the time spent for early resuscitation and diagnostic procedures was therefore prospectively recorded in 20 patients (mean age 38 years) with a mean ISS of 26.9 (range: 13 to 43). Time spent in the resuscitation room averaged 31.4 min (range: 10 to 50 min)...

Endotracheal intubation by emergency medical services (EMS) personnel in the prehospital setting decreases morbidity and helps to improve the outcome of critically ill patients, especially those with cardiac or respiratory arrest, multiple injuries, or severe head trauma. The endotracheal tube facilitates better oxygenation and ventilation because it enhances lung inflation and protects the lungs from aspiration. No other alternative modality is as efficacious. Compared to physicians in general, properly instructed, well-supervised paramedics can be trained to perform this procedure safely and more efficiently in the emergency setting...

A prospective time-management analysis of trauma resuscitation (TR) of 431 patients arriving at a university trauma center documents timing and organization. Severity of injury, patient age, and potential airway injury were significant factors increasing the duration of TR up to a certain time (36 minutes). Moderately injured patients required less time (under 25 minutes). Patients needing emergent operations spent a minimal amount of time (20 minutes) in TR. Potential injuries involving the airway or cervical spine, or shock, added minutes...