Do trauma teams make a difference?

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Resuscitation (2007) 73, 374—381


Do trauma teams make a difference? A single centre registry study夽 Timothy H. Rainer ∗, N.K. Cheung, Janice H.H. Yeung, Colin A. Graham Accident & Emergency Medicine Academic Unit, Chinese University of Hong Kong, Trauma & Emergency Centre, Prince of Wales Hospital, Shatin NT, Hong Kong, SAR, China Received 23 June 2006 ; received in revised form 29 September 2006; accepted 14 October 2006 KEYWORDS Hong Kong; Trauma system; Prehospital care; Triage

Summary Objective: To evaluate the association between trauma team activation according to well-established protocols and patient survival. Methods: Single centre, registry study of data collected prospectively from trauma patients (who were treated in a trauma resuscitation room, who died or who were admitted to ICU) of a tertiary referral trauma centre Emergency Department (ED) in Hong Kong. A 10-point protocol was used to activate rapid trauma team response to the ED. The main outcome measures were mortality, need for ICU care, or operation within 6 h of injury. Results: Between 1 January 2001 and 31 December 2005, 2539 consecutive trauma patients were included in our trauma registry, of which 674 patients (mean age 43 years, S.D. 22; 71% male; 94% blunt trauma) met trauma call criteria. Four hundred and eighty two (72%) correctly triggered a trauma call, and 192 (28%) were not called (‘undercall’). Patients were less likely to have a trauma call despite meeting criteria if they were aged over 64 years, had sustained a fall, had a respiratory rate 29 per minute, a systolic blood pressure between 60 and 89 mmHg, or a GCS of 9—13. In a sub-group of moderately poor probability of survival (probability of survival, Ps , 0.5—0.75), the odds ratio for mortality in the undercall group compared with the trauma call group was 7.6 (95% CI, 1.1—33.0). Conclusions: In our institution, undercalls account for 28% of patients who meet trauma call criteria and in patients with moderately poor probability of survival undercall is associated with decreased survival. Although trauma team activation does not guarantee better survival, better compliance with trauma team activation protocols optimises processes of care and may translate into improved survival. © 2006 Elsevier Ireland Ltd. All rights reserved.

夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.10.011. ∗ Corresponding author. Tel.: +852 2632 1033; fax: +852 2648 1469. E-mail address: [email protected] (T.H. Rainer).

Introduction Trauma is a leading cause of death worldwide including Hong Kong1,2 and the development of an effective trauma system is a vital strategy to

0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2006.10.011

Trauma call and mortality optimise patient morbidity and survival.3—5 Trauma systems involve a multitude of different prehospital and hospital based components, each of which contributes in varying degrees of importance to improving patient care.6—12 When a severely injured trauma patient arrives in hospital, one important aspect of a good trauma system is the early and rapid assembly of experienced clinical decision makers who can plan and implement early life and limb saving procedures.13—19 Multiple levels for trauma team activation have been described, according to individual systems’ triage protocols, but whichever system is used, a trauma team is assembled in the trauma resuscitation room in response to a trauma activation call. Such a system has been introduced in Hong Kong since 1994.6,20 Previous studies have shown that a good trauma system is likely to improve patient survival,6—12 that certain activation criteria may predict outcome better than others, that some absent factors should be included in trauma team protocols, e.g. age, gender, previous illness or mechanism of injury15,17 and some report under triage and over triage rates.19 However, none have yet reported on the impact of under triage on patient survival. Does it really make a difference to patient survival if trauma calls are not activated? The aim of this study was to evaluate the association between trauma team activation according to well-established protocols and patient survival.

Materials and methods Study design, patients and setting This single centre, registry study of data collected prospectively was conducted on all consecutive major trauma cases included in our trauma registry database at the emergency department (ED) of the Prince of Wales Hospital (PWH) between January 2001 and December 2005. PWH is a university teaching hospital with 1200 beds and is the regional major trauma centre for the New Territories East Cluster in Hong Kong. The ED has an annual attendance of 160,000 patients per annum. Approximately 520 trauma patients per annum are triaged to the designated trauma resuscitation rooms according to specific predetermined protocols, and approximately 160 patients per annum have an injury severity score (ISS) > 15.21,22 Ethical approval for this study was waived by the local institutional Research Ethics Committee as data were collected from a large trauma registry and patient data was anonymous. Health care was pro-

375 vided free at the point of access to the ED between January 2001 and October 2002, and during this period charges were only made if the patient was admitted to a hospital ward or referred for outpatient follow up. From November 2002, a HK$ 100 (∼US$ 13, GBP 7, EUR 10) charge was made for each ED attendance. Our trauma system has been set up according to well-established evidence based recommendations, to international standards and also according to local trauma needs.13—19,23 In the two tier system, the first response involves a team of three emergency physicians, at least one of whom is a specialist, and three nurses, at least one of whom is trained in trauma care. The second tier is the hospital trauma team who respond to a ‘‘trauma call’’, which includes two general surgeons (one trainee and a specialist), an orthopaedic surgeon and an intensive care unit physician (usually an anaesthetist). The purpose of the trauma team is to enable rapid assessment, resuscitation and operative or intensive care intervention for patients with potentially major trauma which has a high likelihood of life-threatening or life-disabling injury. The trauma registry of PWH was established in December 2000. Information is collected prospectively on trauma patients who sustained injuries that warranted resuscitation or close monitoring in a trauma resuscitation room, those patients who die or those patients who were admitted to ICU. Data from the trauma database were analysed retrospectively. Data analysed included demographic variables; mechanism of injury; anatomical and physiological trauma scores (including abbreviated injury scores for each body region (AIS), injury severity score (ISS) and revised trauma score (RTS)) and patient mortality and complications.21,22

Definitions Trauma is defined as an external blunt or penetrating injury. Adults are defined as aged ≥18 years. Pre-injury morbidity is defined as the presence of any pre-injury chronic systemic disease which may or may not limit normal activity (e.g. stroke, hypertension, diabetes mellitus, malignancy, psychiatric illness, respiratory, gastrointestinal, cardiovascular, hepatic, neurological, renal, endocrine or metabolic disease, chronic alcohol intake or active smoking). Trauma call activation criteria are described in Appendix A. For the purpose of this study, if any single criteria was met, then a trauma call should be activated. Haemodynamic instability is defined as a single systolic blood pressure reading of 29 or 64 years, 48 of 176 (27%) females, 78 of 402 (19%) patients with major trauma (ISS > 15), 73 of 326 (22%) patients with a head injury of AIS > 2, 26 of 164 (16%) patients with AIS > 2 extremity injury, 18 of 200 (9%) patients with AIS > 2 chest injury, 11 of 95 (12%) patients with abdominal injury AIS > 2, 64 of 158 (41%) patients with pre-injury illness, and 86 of 203 (42%) patients with a history of a fall. Univariate analysis revealed that the following factors were associated with undercall: aged >65 years, female, injury resulting from falls, and pre-injury comorbidity. Of the 10 trauma call activation criteria, the 3 criteria most associated with undercalls were GCS ≤ 13, respiratory distress and haemodynamic instability (Table 2). Despite meeting trauma call activation criteria, trauma calls were not activated in 22 of 68 (30%) patients with systolic blood pressures between 60 and 89 mmHg, 59 of 61 (97%) patients with a respiratory rate >29 breaths per minute, and 98 of 260 (38%) patients with a GCS ≤ 13. The undercall group left the ED on average 10 min quicker than the correct trauma call group. However, patients who required an urgent operation or ICU care waited an average of 23 min longer to leave the ED if they were in the undercall group compared with the correct call group (Table 3). The adjusted odds ratios of significant variables associated with undercall are shown in Table 4. Patients were less likely to have a trauma call despite meeting trauma call criteria if they were aged over 64 years, had sustained a fall, had a respiratory rate 29 per minute, a systolic blood pressure between 60 and 89 mmHg, or a GCS of 9—13. The probability of survival in the undercall group was generally higher than the correct call group, and this in turn was associated with lower mortality rates and less requirements for urgent operation and ICU care (Table 5). Nevertheless, of the 674 patients meeting trauma call activation criteria, 24 (4%) were undercalls and died, 23 (4%) were under-

Trauma call and mortality Table 1


Patient characteristics (N = 674)


Correct trauma call, N = 482

Undercall, N = 192


Age (years), mean ± S.D. ≥65, no. (%) Male sex, no. (%)

42 ± 21 67 (14) 354 (73)

45 ± 25 52 (27) 124 (65)

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