Trauma research in low- and middle-income countries is urgently needed to strengthen the chain of survival

Trauma is a major - and increasing - cause of death, especially in low- and middle income countries. In all countries rural areas are especially hard hit, and the distribution of physicians is skewed towards cities. To reduce avoidable deaths from injury all links in the chain of survival after trauma needs strengthening. Prioritizing in each country should be done by local researchers, but little research on injuries emerges from low- and middle income countries. Researchers in these countries need support and collaboration from their peers in industrialized countries. This partnership will be of mutual benefice

Norwegian trauma team leaders - training and experience : a national point prevalence study

The treatment of trauma victims is a complex multi-professional task in a stressful environment. We previously found that trauma team members perceive leadership as the most important human factor. The aim of the present study was to assess the experience and education of Norwegian trauma team leaders, and allow them to describe their perceived educational needs. We conducted an anonymous descriptive study using a point prevalence methodology based on written questionnaires. All 45 hospitals in Norway receiving severely injured trauma victims were contacted on a randomly selected weeknight during November 2009. Team leaders were asked to specify what trauma related training programs they had participated in, how much experience they had, and what further training they wished, if any. Response rate was 82%. Slightly more than half of the team leaders were residents. The median working experience as a surgeon among team leaders was 7.5 years. Sixty-eight percent had participated in multiprofessional training in non-technical skills, while 54% had passed the advanced trauma life support(ATLS) course. Fifty-one percent were trained in damage control surgery. A median of one course per team leader was needed to comply with the new proposed national standards. Team leaders considered training in damage control surgery the most needed educational objective. Level of experience among team leaders was highly variable and their educational background insufficient according to international and proposed national standards. Proposed national standards should be urgently implemented to ensure equal access to high quality trauma care

Dispatch guideline adherence and response interval—a study of emergency medical calls in Norway

Background: The Emergency Medical Communication Centre (EMCC) operators in Norway report using the Norwegian Index for Medical Emergency Assistance (Index), a criteria-based dispatch guideline, in about 75 % of medical emergency calls. The main purpose of a dispatch guideline is to assist the operator in securing a correct response as quickly as possible. The effect of using the guideline on EMCC response interval is as yet unknown. We wanted to ascertain an objective measure of guideline adherence, and explore a possible effect on emergency medical dispatch (EMD) response interval. Methods: Observational cross-sectional study based on digital telephone recordings and EMCC records; 299 random calls ending in acute and urgent responses from seven strategically selected EMCCs were included. Ability to confirm location and patient consciousness within an acceptable time interval and structural use of criteria cards were indicators used to create an overall guideline adherence variable. We then explored the relationship between different levels of guideline adherence and EMD response interval. Results: The overall guideline adherence was 80 %. Location and patient consciousness were confirmed within 1 min in 83 % of the caolls. The criteria cards were used systematically as intended in 64 % of the cases. Total median response interval was 2:28, with 2:01 for acute calls and 4:10 for urgent calls (p < 0.0005). Lower guideline adherence was associated with higher EMD response interval (p < 0.0005). Conclusion: The measured guideline adherence was higher than previously reported by the operators themselves. Patient consciousness was rapidly confirmed in the majority of cases. Failure to use Index criteria as intended result in delayed ambulance dispatch and a potential risk of undertriage

The development of a tool to assess medical students’ non-technical skills–The Norwegian medical students’ non-technical skills (NorMS-NTS)

Purpose - New physicians need to master non-technical skills (NTS), as high levels of NTS have been shown to increase patient safety. It has also been shown that NTS can be improved through training. This study aimed to establish the necessary NTS for Norwegian medical students to create a tool for formative and summative assessments. Methods - Focus group interviews were conducted with colleagues and patients of newly graduated physicians. Interviews were then analyzed using card sort methods, and the identified NTS were used to establish a framework. Focus groups commented on a prototype of an NTS assessment tool. Finally, we conducted a search of existing tools and literature. The final tool was developed based on the combined inputs. Results - We created Norwegian medical students’ non-technical skills (NorMS-NTS) assessment tool containing four main categories; together comprising 13 elements and a rating scale for the NTS of the person observed. Conclusions - The NorMS-NTS represents a purpose-made tool for assessing newly graduated physicians’ NTS. It is similar to existing assessment tools but based on domain-specific user perspectives obtained through focus group interviews and feedback, integrated with results from a literature search, and with consideration of existing NTS tools

Differences in time-critical interventions and radiological examinations between adult and older trauma patients: A national register-based study

BACKGROUND Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients hold important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations. METHODS Retrospective analysis of the Norwegian Trauma Registry for 2015 through 2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score of 9 or greater were included, dichotomized into age groups 16 years to 64 years and 65 years or older. Prehospital and emergency department clinical management, advanced airway management, chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests. RESULTS There were 9543 patients included, of which 28% (n = 2711) were 65 years or older. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.57–0.71), conveyed by air ambulance (OR, 0.65; 95% CI, 0.58–0.73), and transported directly to a trauma center (OR, 0.86; 95% CI, 0.79–0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with New Injury Severity Score of 25 or greater, showing lower rates for older adults (advanced airway management: OR, 0.60; 95% CI, 0.47–0.76; chest decompression: OR, 0.46; 95% CI, 0.25–0.85; x-ray chest: OR, 0.54; 95% CI, 0.39–0.75; x-ray pelvis: OR, 0.69; 95% CI, 0.57–0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups. CONCLUSION Older trauma patients were less likely to receive advanced prehospital care compared with younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities

Geographical risk of fatal and non-fatal injuries among adults in Norway

Introduction: A rural gradient in trauma mortality disfavoring remote inhabitants is well known. Previous studies have shown higher risk of traumatic deaths in rural areas in Norway, combined with a paradoxically decreased prevalence of non-fatal injuries. We investigated the risk of fatal and severe non-fatal injuries among all adults in Norway during 2002–2016. Methods: All traumatic injuries and deaths among persons with a residential address in Norway from 2002–2016 were included. Data were collected from the Norwegian National Cause of Death Registry and the Norwegian Patient Registry. All cases were stratified into six groups of centrality based on Statistics Norway's classification system, from most urban (group one) to least urban/most rural (group six). Mortality and injury rates were calculated per 100,000 inhabitants per year. Results: The mortality rate differed significantly among the centrality groups (p Conclusions: Fatal and non-fatal injury risks increased in parallel with increasing rurality. The lowest risk was in the second most urban region, followed by the most urban (capital) region, yielding a J-shaped risk curve. Transport injuries had the steepest urban–rural gradient

Leadership is the essential non-technical skill in the trauma team - results of a qualitative study

<p>Abstract</p> <p>Background</p> <p>Trauma is the leading cause of death for young people in Norway. Studies indicate that several of these deaths are avoidable if the patient receives correct initial treatment. The trauma team is responsible for initial hospital treatment of traumatized patients, and team members have previously reported that non-technical skills as communication, leadership and cooperation are the major challenges. Better team function could improve patient outcome. The aim of this study was to obtain a deeper understanding of which non-technical skills are important to members of the trauma team during initial examination and treatment of trauma patients.</p> <p>Methods</p> <p>Twelve semi-structured interviews were conducted at four different hospitals of various sizes and with different trauma load. At each hospital a nurse, an anaesthesiologist and a team leader (surgeon) were interviewed. The conversations were transcribed and analyzed using systematic text condensation according to the principles of Giorgi's phenomenological analysis as modified by Malterud.</p> <p>Results and conclusion</p> <p>Leadership was perceived as an essential component in trauma management. The ideal leader should be an experienced surgeon, have extensive knowledge of trauma care, communicate clearly and radiate confidence. Team leaders were reported to have little trauma experience, and the team leaders interviewed requested more guidance and supervision. The need for better training of trauma teams and especially team leaders requires further investigation and action.</p

The lateral trauma position: What do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services

<p>Abstract</p> <p>Background</p> <p>Trauma patients are customarily transported in the supine position to protect the spine. The Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) principles clearly give priority to airways. In Norway, the lateral trauma position (LTP) was introduced in 2005. We investigated the implementation and current use of LTP in Norwegian Emergency Medical Services (EMS).</p> <p>Methods</p> <p>All ground and air EMS bases in Norway were included. Interviews were performed with ground and air EMS supervisors. Questionnaires were distributed to ground EMS personnel.</p> <p>Results</p> <p>Of 206 ground EMS supervisors, 201 answered; 75% reported that LTP is used. In services using LTP, written protocols were present in 67% and 73% had provided training in LTP use. Questionnaires were distributed to 3,025 ground EMS personnel. We received 1,395 (46%) valid questionnaires. LTP was known to 89% of respondents, but only 59% stated that they use it. Of the respondents using LTP, 77% reported access to written protocols. Flexing of the top knee was reported by 78%, 20% flexed the bottom knee, 81% used under head padding. Of 24 air EMS supervisors, 23 participated. LTP is used by 52% of the services, one of these has a written protocol and three arrange training.</p> <p>Conclusions</p> <p>LTP is implemented and used in the majority of Norwegian EMS, despite little evidence as to its possible benefits and harms. How the patient is positioned in the LTP differs. More research on LTP is needed to confirm that its use is based on evidence that it is safe and effective.</p

Implementation of new guidelines in the prehospital services: a nationwide survey of Norway

Background A debate regarding the potential harmful effects of rigid neck collar and backboard usage among prehospital and hospital care providers in Norway provoked the development of an evidence-based guideline. “The Norwegian guideline for the prehospital management of adult trauma patients with potential spinal injury” was developed with rigorous scientific methods and published in 2016. An e-learning course was developed in parallel. The aim of this study is to explore whether emergency medical services personnel in Norway have implemented the guideline, and to what extent the e-learning course was applied during the implementation process. Method An electronic survey was distributed individually to registered prehospital personnel in Norway 18 months after publication of the guideline. Results In all, 938 of 5500 (17%) EMS personnel responded to the survey. More than one-half confirmed knowledge of the guideline; among these, 56% claimed that the guideline was implemented in the service they work. Not having responded to trauma cases in real life was the main reason for not having executed the guideline. The e-learning course had been completed by 18% of respondents. Conclusion Although the guideline has not been authorized or made compulsory by national authorities, one-half of respondents with knowledge of the guideline reported it as implemented. E-learning did not seem to have affected the implementation. The guideline was developed based on perceived needs among care providers, and this probably facilitated implementation of the guideline.publishedVersio