Differences in trauma team activation criteria among Norwegian hospitals

<p>Abstract</p> <p>Background</p> <p>To ensure the rapid and correct triage of patients in potential need of specialized treatment, Norwegian hospitals are expected to establish trauma teams with predefined criteria for their activation. The objective of this study was to map and describe the criteria currently in use.</p> <p>Methods</p> <p>We undertook a cross-sectional survey in the summer of 2008, using structured telephone interviews to all Norwegian hospitals that might admit severely injured patients.</p> <p>Results</p> <p>Forty-nine hospitals were included, of which 48 (98%) had a trauma team and 20 had a hospital-based trauma registry. Criteria for trauma team activation were found at 46 (94%) hospitals. No single criterion was common to all hospitals. The median number of criteria per hospital was 23 (range 8-40), with a total number of 156 and wide variation with respect to physiological "cut-off" values. The mechanism of injury was commonly in use despite a well-known, large over-triage rate.</p> <p>Conclusions</p> <p>In recent years, Norwegian hospitals have gradually established trauma teams and criteria for their activation. These criteria show considerable variation, including physiological "cut-off" values.</p

Undertriage in Trauma: An Ignored Quality Indicator?

Background Early identification of life-threatening injuries is essential to reduce morbidity and mortality in trauma patients. Failure to detect severe injury may cause delayed diagnosis and therapeutic interventions and is associated with increased morbidity. A national trauma system will contribute to ensure the optimal care for seriously injured patients throughout the treatment chain by, among other things, defining a sensitive triage tool for identifying severe injury and contribute to correct treatment destination. In 2017, a National trauma plan was implemented in Norway and several quality indicators were recommended to ensure an evaluation of potential gaps between achieved and desired quality, and thereby highlighting areas with potential for quality improvement. With this commentary, we want to draw attention to, what we believe is, an ignoring of an important quality indicator: undertriage in trauma. Main body Severely injured patients not met by a trauma team is commonly referred to as undertriage. An undertriage rate below 5 % is an internationally recognized quality indicator in trauma care and is emphasized in the Norwegian national trauma plan. However, whether hospitals measure and report data about undertriage, have received little attention. Therefore, a national survey was performed among Norwegian hospitals, where thirty-seven of forty trauma receiving hospitals contributed. The results of the survey showed that only half of Norwegian trauma hospitals were capable of providing these data. The results of this survey show that currently the national trauma system is not equipped to obtain important data on an important and specific quality indicator. An ongoing discussion at a national level is how to define severe injury, which may alter future definitions on undertriage. Conclusions Knowledge of undertriage in trauma is important to enhance patient safety, increase the precision of the triage tool and provide valuable learning information to individual hospitals and prehospital services. Currently only half of Norwegian hospitals who receive trauma patients report undertriage rates and unfortunately, only few hospital administrators request these data.publishedVersio

Introducing fairness in Norwegian air ambulance base location planning

Background A primary task of the Norwegian helicopter emergency medical services (HEMS) is to provide advanced medical care to the critical ill and injured outside of hospitals. Where HEMS bases are located, directly influences who in the population can be reached within a given response time threshold and who cannot. When studying the locations of bases, the focus is often on efficiency, that is, maximizing the total number of people that can be reached within a given set time. This approach is known to benefit people living in densely populated areas, such as cities, over people living in remote areas. The most efficient solution is thus typically not necessarily a fair one. This study aims to incorporate fairness in finding optimal air ambulance base locations. Methods We solve multiple advanced mathematical optimization models to determine optimal helicopter base locations, with different optimization criteria related to the level of aversion to inequality, including the utilitarian, Bernoulli-Nash and iso-elastic social welfare functions. This is the first study to use the latter social welfare function for HEMS. Results Focusing on efficiency, a utilitarian objective function focuses on covering the larger cities in Norway, leaving parts of Norway largely uncovered. Including fairness by rather using an iso-elastic social welfare function in the optimization avoids leaving whole areas uncovered and in particular increases service levels in the north of Norway. Conclusions Including fairness in determining optimal HEMS base locations has great impact on population coverage, in particular when the number of base locations is not enough to give full coverage of the country. As results differ depending on the mathematical objective, the work shows the importance of not only looking for optimal solutions, but also raising the essential question of ‘optimal with respect to what’.publishedVersio

Prehospital Stressors: A Cross-sectional Study of Norwegian Helicopter Emergency Medical Physicians

Objective Personnel working in helicopter emergency medical services (HEMS) and search and rescue (SAR) are exposed to environmental stressors, which may impair performance. The aim of this survey was to study the extent HEMS and SAR physicians report the influence of specific danger-based and non–danger-based stressors. Methods The study was performed as a cross-sectional, anonymous, Web-based (Questback AS, Bogstadveien 54, 0366 Oslo, Norway) survey of Norwegian HEMS and SAR physicians between December 2, 2019, and February 25, 2020. Results Of the recipients, 119 (79.3%) responded. In helicopter operations, 33.6% (n = 40) reported involvement in a minor accident and 44.5% (n = 53) a near accident. In the rapid response car, 26.1% (n = 31) reported near accidents, whereas 26.9% (32) reported this in an ambulance. Of physicians, 20.2% (n = 24) received verbal abuse or threats during the last 12 months. When on call, 50.4% (n = 60) of physicians reported sometimes or often being influenced by fatigue. Conclusion This study shows that Norwegian HEMS and SAR physicians are exposed to several stressors of both a danger-based and non–danger-based nature, especially regarding accidents, threatening patient behavior, and fatigue. Very serious incidents appear to be seldom, and job satisfaction is high.publishedVersio

The effect of emergency department delays on 30-day mortality in Central Norway

publishedVersionPaid Open Acces

Comparing population and incident data for optimal air ambulance base locations in Norway

Background: Helicopter emergency medical services are important in many health care systems. Norway has a nationwide physician manned air ambulance service servicing a country with large geographical variations in population density and incident frequencies. The aim of the study was to compare optimal air ambulance base locations using both population and incident data. Methods: We used municipality population and incident data for Norway from 2015. The 428 municipalities had a median (5-95 percentile) of 4675 (940-36,264) inhabitants and 10 (2-38) incidents. Optimal helicopter base locations were estimated using the Maximal Covering Location Problem (MCLP) optimization model, exploring the number and location of bases needed to cover various fractions of the population for time thresholds 30 and 45 min, in green field scenarios and conditioned on the existing base structure. Results: The existing bases covered 96.90% of the population and 91.86% of the incidents for time threshold 45 min. Correlation between municipality population and incident frequencies was -0.0027, and optimal base locations varied markedly between the two data types, particularly when lowering the target time. The optimal solution using population density data put focus on the greater Oslo area, where one third of Norwegians live, while using incident data put focus on low population high incident areas, such as northern Norway and winter sport resorts. Conclusion: Using population density data as a proxy for incident frequency is not recommended, as the two data types lead to different optimal base locations. Lowering the target time increases the sensitivity to choice of data

The trauma system and the patient - a national, regional and individual perspective

Sammendrag Traumesystemet og pasienten - et nasjonalt, regionalt og individuelt perspektiv Morbiditet og mortalitet som følge av traumatiske skader utgjør på verdensbasis en betydelig helseutfordring både for samfunnet og det enkelte individ. Kunnskap om den historiske utviklingen, epidemiologiske utviklingstrekk og implementering av traumesystemer er et viktig element for å bidra til en kontinuerlig kvalitetsheving av den behandlingen disse pasientene mottar. Selv om skader utgjør en av våre største folkehelseutfordringer har man hatt begrenset kunnskap om epidemiologi og behandling av potensielt alvorlig skadde pasienter, både i Norge og i Midt-Norge. Delarbeid 1 er en nasjonal tverrsnitts studie som inkluderer alle førti-en norske sykehus som mottok potensielt alvorlig skadde pasienter i 2011. Vi observerte en betydelig reduksjon av antall sykehus over tid og at mange sykehus fremdeles mottok et lite antall pasienter. På et nasjonalt nivå bidro akuttsykehus med traumefunksjon betydelig i den primære vurderingen av traumepasienter. Vi konkluderte med at den fremtidige utviklingen av traumesystemet må ta hensyn til utfordringene med en spredt befolkningsstruktur og geografiske utfordringer veid opp mot behovet for sykehus med tilstrekkelig pasientvolum og behovet for intervensjoner til riktig tid. Delarbeid 2 er en retrospektiv multisenter observasjons studie som inkluderer 2323 pasienter ved åtte sykehus innenfor et definert geografisk område (Midt-Norge). Vi observerte at kun et lite antall av pasientene ble definert som alvorlige skadde pasienter, og at de fleste av disse pasientene mottok endelig behandling ved det regionale traumesenteret. Akuttsykehus med traumefunksjon bidro i betydelig grad, ettersom mer enn halvparten av alle pasienter initialt ankom disse sykehusene og at majoriteten av disse pasientene mottok sin endelige behandling der. Vi konkluderte med at i en region med et spredt nettverk av sykehus, geografiske utfordringer, lav andel av alvorlige skadde pasienter, er det avgjørende for et bra behandlingsutfall at det foreligger optimal triage, desentralisert kapasitet for tidlig stabilisering og effektiv overføring av pasienter til institusjon med endelig behandlingsmulighet. Delarbeid 3 er en studie med 1191 potensielt alvorlig skadde pasienter i arbeidsfør alder, hvor man benyttet retrospektive traumeregisterdata fra syv sykehus som ble koblet med nasjonale administrative databaser. Målet var å beskrive sammenhengen mellom hvordan skadealvorlighet på lang sikt påvirker evnen til å komme tilbake i jobb og behovet for medisinske støtteordninger. Vi observerte at pasienter med mindre og moderate skader hadde to- til tre ganger større risiko for å benytte medisinske støtteordninger i oppfølgningsperioden, sammenlignet med tiden før skaden. Median tid for å komme tilbake i jobb, var henholdsvis 1, 4 og 11 måneder hos pasienter med mindre, moderate og alvorlige skader. Studien bekreftet at alvorlige skader gir betydelige langtidseffekter, men viste også at pasienter med mindre og moderate skader har høyere risiko for negative langsiktige helseeffekter enn tidligere vist. Samlet bidrar artiklene til økt basiskunnskap om organiseringen, behandlingen og utkomme hos potensielt alvorlig skadde pasienter. Dette er viktig når man skal innføre traumesystemer, foreta analyser av nøkkelindikatorer og evaluere kvalitet innen traumeomsorgen. I tillegg understreker funnene også viktigheten av langtidsoppfølgning hos dem med mindre og moderate skader, som et ledd for å redusere samfunnets totale skadebyrde