Dutch trauma system performance: are injured patients treated at the right place?

Background: The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS).Methods: Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC.Results: Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times.Conclusions: Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements. (C) 2021 Elsevier Ltd. All rights reserved.Trauma Surger

The Dutch nationwide trauma registry: The value of capturing all acute trauma admissions

Introduction: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National Trauma Registry (DNTR) to evaluate epidemiology, patient distribution, resource use and quality of care. In this study we describe the DNTR, the incidence and main characteristics of Dutch acutely admitted trauma patients, and evaluate the value of including all acute trauma admissions compared to more stringent criteria applied by the national trauma registries of the United Kingdom and Germany. Methods: The DNTR includes all injured patients treated at the ED within 48 hours after trauma and consecutively followed by direct admission, transfers to another hospital or death at the ED. DNTR data on admission years 2007-2018 were extracted to describe the maturation of the registry. Data from 2018 was used to describe the incidence rate and patient characteristics. Inclusion criteria of the Trauma Audit and Research (TARN) and the Deutsche Gesellschaft für Unfallchirurgie (DGU) were applied on 2018 DNTR data. Results: Since its start in 2007 a total of 865,460 trauma cases have been registered in the DNTR. Hospital participation increased from 64% to 98%. In 2018, a total of 77,529 patients were included, the median age was 64 years, 50% males. Severely injured patients with an ISS≥16, accounted for 6% of all admissions, of which 70% was treated at designated RTCs. Patients with an ISS≤ 15were treated at non-RTCs in 80% of cases. Application of DGU or TARN inclusion criteria, resulted in inclusion of respectively 5% and 32% of the DNTR patients. Particularly children, elderly and patients admitted at non-RTCs are left out. Moreover, 50% of ISS≥16 and 68% of the fatal cases did not meet DGU inclusion criteria Conclusion: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,000 inclusions annually, the DNTR has become one of the largest trauma databases in Europe The registries strength lies in the broad inclusion criteria which enables studies on the burden of injury and the quality and efficiency of the entire trauma care system, encompassing all trauma‐receiving hospitals

Funnel plots a graphical instrument for the evaluation of population performance and quality of trauma care: a blueprint of implementation

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. Moreover, we aimed to present a set of regulations on how to interpret and act on underperformance or overperformance trends presented in funnel plots. Methods A retrospective observational cohort study was performed using the Dutch National Trauma Registry (DNTR). Two separate datasets were created to assess the effects of healthy and multiple imputations to cope with missing values. Funnel plots displaying the performance of all trauma-receiving hospitals in 2020 were generated, and in-hospital mortality was used as the main indicator of centre performance. Indirect standardization was used to correct for differences in the types of cases. Comet plots were generated displaying the performance trends of two level-I trauma centres since 2017 and 2018. Results Funnel plots based on data using healthy imputation for missing values can highlight centres lacking good data quality. A comet plot illustrates the performance trend over multiple years, which is more indicative of a centre's performance compared to a single measurement. Trends analysis offers the opportunity to closely monitor an individual centres' performance and direct evaluation of initiated improvement strategies. Conclusion This study describes the use of funnel and comet plots as a method to monitor and assure high-quality data and to evaluate trauma centre performance over multiple years. Moreover, this is the first study to provide a regulatory blueprint on how to interpret and act on the under- or overperformance of trauma centres. Further evaluations are needed to assess its functionality.Development and application of statistical models for medical scientific researc

Young traffic victims' long-term health-related quality of life: child self-reports and parental reports

OBJECTIVES: To describe the long-term health-related quality of life (HRQOL) reported by young traffic injury victims and to assess the child-parent agreement on the child's HRQOL. DESIGN: Cohort study with a mean follow-up of 2.4 years. SETTING: Traumatology department in a university hospital in The Netherlands. PARTICIPANTS: All traffic injury victims treated at the traumatology department in 1996-1997 and aged 8 to 15 years at follow-up (N = 254). The data of 157 child-parent pairs were available for analysis (mean follow-up age, 12+/-2.4 y; 57% boys; 24% hospitalized). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: TNO-AZL Children's Quality of Life parent and child questionnaires. RESULTS: Young traffic injury victims reported a significantly lower HRQOL in the motor and autonomy scales compared with contemporaries in the reference group. The child-parent agreement ranged from low to moderate (intraclass correlations,.35-.67). A comparison made between the children and their parents found that the children were more negative regarding the physical complaints and the motor, autonomy, and positive-emotion scales. CONCLUSIONS: Young traffic injury victims reported a reasonably good long-term HRQOL, and, surprisingly, few psychologic problems were revealed. Physicians who rely only on parental reports may overestimate the child's HRQOL, especially when assessing the physical functioning. The child's own reports should not be neglected in the assessment of a comprehensive picture of the child's HRQOL. Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Record 8 of 12 - SilverPlatter MEDLINE(R)

Characteristics of injured children attending the emergency department: patients potentially in need of rehabilitation

Objective: To provide an epidemiological overview of the characteristics of injured children and to compare hospitalized and nonhospitalized injured children to identify predictors of hospitalization and, with that, possible predictors of disablement. Design: Retrospective analysis of data obtained from a computerized trauma registration system and medical records. Setting: Department of Traumatology, University Hospital Groningen, the Netherlands. Subjects: Children (0-19 years) injured in 1996 and 1997 (n=5057). Results: The majority of children were injured in home and leisure accidents (53%) and sustained minor injuries. Only 55 (1%) children were severely injured (Injury Severity Score (ISS) greater than or equal to16). Overall, 512 (10%) patients required hospitalization, 19 children were referred to a rehabilitation centre, and 24 children died due to their injuries. The majority of these patients were injured in traffic. Compared with the group of nonhospitalized patients, the group of hospitalized patients consisted of more males and traffic victims, were more severely injured, and sustained more head/neck, spine, and thorax and abdomen injuries. Nonhospitalized patients incurred proportionally more upper and lower extremity injuries. The ISS, the body region of most severe injury, and injury cause (traffic accidents) were significant predictors of hospitalization. Conclusions: Young traffic victims, severely injured children in terms of high ISS scores, and children with injuries affecting the head/neck/face or thorax/abdomen carry the highest risk of hospitalization

The health-related quality of life of pediatric traffic victims

Objective: To describe the health-related quality of life (HRQoL) of young traffic victims and to identify those children who are at high risk of a reduced HRQoL. Methods: Retrospective analysis of data obtained from a registration system and from questionnaires completed by 211 parents of young traffic victims who attended the department of traumatology in 1996 and 1997. Results: The overall group of young traffic victims experienced a lower HRQoL sumscore compared with the reference population (p = 0.001). A total of 48 parents (23%) attributed their child's reduced HRQoL specifically to the traffic accident. The socioeconomic status (SES) of the father (p = 0.018) and the Injury Severity Score (p < 0.001) emerged as significant predictors of traffic-related HRQoL. Conclusion: Children of low SES parents and severely injured children are at particularly high risk of a reduced HRQoL following a traffic accident. However, not solely severely injured and hospitalized young traffic victims may suffer a diminished HRQoL but traffic-related injuries of minor or moderate severity may cause substantial problems as well

A prospective study on paediatric traffic injuries: health-related quality of life and post-traumatic stress

Objectives: To examine children's reports of their health- related quality of life ( HRQoL) following paediatric traffic injury, to explore child and parental post- traumatic stress, and to identify children and parents with adverse outcomes. Design: Prospective cohort study. Assessments: shortly after the injury, three months and six months post injury. Setting: Department of Traumatology, University Hospital. Subjects: Fifty- one young traffic injury victims aged 8 - 15 years. Main measures: TNO- AZL Children's Quality of Life questionnaire and the Impact of Event Scale. Results: Short- term adverse changes in the child's HRQoL were observed for the child's motor functioning and autonomy. At three months, 12% of the children and 16% of the parents reported serious post- traumatic stress symptoms. Increased stress at three months, or across follow- up, was observed among hospitalized children, children with head injuries, and children injured in a motor vehicle accident. Parental stress was related to low socioeconomic status and the seriousness of the child's injury and accident ( hospitalization, head injury, serious injury, motor vehicle involved, others injured). Conclusions: The children reported only temporary effects in their motor functioning and autonomy. Post- traumatic stress symptoms following paediatric traffic injury were not only experienced by the children, but also by their parents