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OPTIMIZATION OF ACTIVITY OF REGIONAL TRAUMA SYSTEM IN ARRANGEMENT OF MEDICAL CARE FOR PATIENTS WITH POLYTRAUMA
Baryshev A.G., Blazhenko A.N., Shevchenko A.V., Mukhanov M.L., Polyushkin K.S., Sholin I.Yu., Shkhalakhov A.K., Porkhanov V.A.
Research Institute – Ochapovsky Regional Clinical Hospital No.1, Kuban State Medical University, Krasnodar, Russia
Development
of civilization and economics of countries causes the increase in traumatic
mechanisms and high speed vehicles in human’s life, with increasing incidence
of local injuries and polytrauma [1-4]. Treatment of patients requires for
serious economic costs, and, in case of disability or lethal outcome, leads to
significant moral and financial damage to a state [2, 5].
The efforts
to decrease the rate of injuries are realized at the high federal level. They
include some various organizational measures: reinforcement of traffic
regulations and penalties, improvement in safety of motor vehicles, road
furniture and others. One of the most important components decreasing the
negative outcomes of injuries is a stage of emergency medical care and high
specialized aid for patients [6-8]. The basis providing the survival of trauma
patients is arrangement of system for medical care realization, which is based
on adherence to the modern diagnostic standards, correct interpretation of data
and making decisions on correction of life-threatening consequences of injuries
as a part of damage control surgery (DCS) [5, 9-11], possibilities for
qualitative transportation and subsequence in treatment of patients during
transfer to the level 1 trauma center. Owing to correct arrangement of stages
of treatment and to development of high specialized trauma centers, the rate of
mortality after polytrauma decreased to 15-20 % in our country, whereas it was
40-60 % in the end of 20th century [5, 6, 9, 10].
In
Krasnodar region, the rearrangement of trauma care was realized, and the strict
system for management of patients was created, including 3 trauma centers of
level 1 (among them, Research Institute –
Ochapovsky Regional Clinical Hospital No.1, which includes the Sanitary
aviation department), 27 trauma centers of level 2 and 13 trauma centers of
level 3 [12]. According to the order by Health Ministry of Krasnodar region
No.5844 from 14 October 2015, chief non-staff specialists in surgery and
traumatology receive the data on severity of injuries and condition of patients
within the first post-injury hours by means of phone connection and
telemedicine consultations. The analysis of the situation is conducted, and a
decision on selection of management for the patient, on necessity of arrival of
specialists from Research Institute – Ochapovsky Regional Clinical Hospital
No.1 to a level 2 or 3 trauma center and terms of further transfer to level 1
trauma center (with more than 700 thousand of patients with polytrauma for the
last 5 years annually) is made.
Objective – to study of the
effectiveness of the regional trauma system, and errors in diagnosis and
treatment to further improve the results of medical care for victims with
polytrauma.
MATERIALS AND METHODS
The efficiency of activity of the regional trauma system was studied. Its
modernization began in 2003. The results of medical consultation with the
Sanitary aviation service and telemedicine were examined. The retrospective
analysis of 2,847 hospital records of patients with polytrauma in the level 1
trauma center were investigated for the period of 2014-2017. One should note
that 549 (19.3 %) patients were initially admitted to the level 1 trauma
center, and 2,298 (80.7 %) were transferred from level 2-3 trauma centers
within 1-2 days after injury.
The study included patients with NISS > 17, with mean score of 24.9 ±
9.4 in the whole group; in patients with lethal outcome – 36.5 ± 9.1, in
survived – 23.1 ± 8.1.
All patients or their legal representatives gave the informed consent at
the moment of admission in concordance with requirements of the Federal Law
No.152-FZ from 27 June 2006 (modification from 22 February 2017) “About personal
data”, that corresponds to Ethical Principles for Medical Research with Human
Subjects 1964 revised in 2013, and the Rules for clinical practice in the
Russian Federation confirmed by the Order of Health Ministry of RF from 19 June
2003 No.266. The study data are anonymized.
The statistical analysis of the data was
conducted with PC and appropriate software (table processor Microsoft Excel
2010 and SPSS-16.0 for Windows), χ2-non-parametric
test (Student’s test) and linear correlation coefficient. The
statistically
significant
results
were
p value ≤ 0.05.
RESULTS AND DISCUSSION
The examination of mortality for the last 15 years showed the decrease from 39.7 % in 2003 to 10.9 % in 2017, but the rates of de-escalation of mortality slowed down since 2012, and it requires the search for new organizational and practical solutions (Fig. 1).
Figure 1. Decreasing mortality in patients with polytrauma admitted to Research Institute – Ochapovsky Regional
Clinical Hospital No.1
For this purpose, the analysis of treatment of patients with polytrauma for the period 2014-2017 was conducted. 2,847 patients with polytrauma (age of 17-88, the mean age of 38.6 ± 15.5) were treated. There were 2,152 men (75.6 %), the mean age of 37.9 ± 14.5, and 695 women (24.4 %), the mean age of 40.8 ± 16.9. The lethal outcome was in 316 (11.1 %) patients (the table 1).
Table 1. Total amount of patients with polytrauma in 2014-2017
|
Year |
2014 |
2015 |
2016 |
2017 |
Total for 2014-2017 |
|
Amount of patients (n = 2847), abs. |
705 |
712 |
722 |
708 |
2847 |
|
Mortality*, % |
11.6 % |
11.1 % |
10.8 % |
10.9 % |
11.1 % |
Note: * – mortality is calculated according to years for the whole group of patients, including patients transferred from level 2-3 trauma centers, and from accident site to Research Institute – Ochapovsky Regional Clinical Hospital No.1
Most patients had only a high energy injury: as result
of road traffic accidents – 2,058 (72.3 %) patients, catatrauma in 527 (18.5
%), industrial injury in 77 (2.7 %) patients, sport injury in 34 (1.2 %), other
causes in 151 (5.3 %).
The mean number of bed-days was 13.7 ± 9.8, the amount
of operations – 2.8 ± 1.7; in patients with lethal outcomes – 14.7 ± 11.1 and
2.2 ± 1.9 correspondingly; in survived – 13.5 ± 8.6 and 3.0 ± 1.7.
The examination of injuries patterns showed that locomotor system injury
and traumatic brain injury were main injuries. If injuries were of competitive
nature, than the mortality reached 65 %, in presence of a single organ with
dominating severity of an injury – 20 %; the most significant injury was traumatic
brain injury and disordered integrity of abdominal organs.
The examination of the features of distribution of the mortality rate in dependence
on a place of primary admission (level 1 trauma center or other hospitals) did
not show any significant differences.
For 4 years, our hospital admitted 549 patients, 2,298 patients were
transferred from level 2-3 trauma centers, with mortality varying from 10.7 %
to 11.9 % (the table 2). Unfortunately, now one cannot say about mathematical
reliability of this value, but we strife for the best result.
Table 2. Comparison of mortality in patients admitted from accident site and transferred to level 2-3 trauma centers in 2014-2017
|
Yearly distribution Order of admission |
2014 |
2015 |
2016 |
2017 |
|
Transfer from accident site, abs. / mortality, % |
110 / 11.9 % |
134 / 11.7 % |
168 / 10.8 % |
164 / 10.9 % |
|
Transfer from other medical facilities, abs. / mortality, % |
595 / 11.3 % |
578 /10.9 % |
554 / 10.9 % |
544 / 10.7 % |
Note: χ2 = 4.37, degrees of freedom df = 3, significance level p = 0.99.
After initial analysis of the results, we decided that absence of
reliable differences in mortality supposed the qualitative arrangement of
medical care for patients in level 2-3 trauma centers and correctness of
management of remote monitoring of this process by leading specialists of Research
Institute – Ochapovsky Regional Clinical Hospital No.1.
However we conducted more detailed
analysis of mortality with exclusion of patients who died in the first day after
trauma. We concluded that quality of medical care in regional hospitals and
level 2-3 trauma centers is to be improved.
After analysis of mortality
(n = 136), we received the following results: fatal injuries caused death in
132 (41.8 %) patients, early and late complications – in 184 (58.2 %), with 119
deaths (37.7 %) from early complications and 65 deaths (20.5 %) from late
complications.
The rate of lethal outcomes
after early and late complications of traumatic disease in the group of
patients transferred from central regional hospitals was reliably higher than
in patients admitted to Research Institute – Ochapovsky Regional Clinical
Hospital No.1 from the accident site despite of comparable severity of injuries
(Fig. 2).
Figure 2. Comparison of incidence of lethal outcomes as result of early and late
complications in dependence on a place of primary admission in 2014-2017
The incidence of lethal outcomes
as result of complications of traumatic disease in patients who were primarily
admitted to Research Institute – Ochapovsky Regional Clinical Hospital No.1
was: 16 (2.3 %) cases after early complications and 12 cases (2.2 %) after late
complications, and in patients transferred from level 2-3 trauma centers – 103
(4.5 %) and 53 (2.9 %) correspondingly.
The conducted statistical
analysis showed the reliable differences in the groups of patients who died
after early complications of traumatic disease: critical value of χ2 = 4.001; the number of freedom
degrees df = 1; p = 0.853.
According to age, the patients were distributed into
three groups: age of 45, 45-49 and older 60 (the table 3).
Table 3. Age distribution of patients with polytrauma
|
Years |
2014 |
2015 |
2016 |
2017 |
||||
|
Number of patients, mortality
|
Amount of patients (abs.) |
Mortality (%) |
Amount of patients (abs.) |
Mortality (%) |
Amount of patients (abs.) |
Mortality (%) |
Amount of patients (abs.) |
Mortality (%) |
|
< 45 years (young age) |
441 |
10.2 |
455 |
12.1 |
444 |
9.3 |
434 |
9.6 |
|
45-59 years (middle age) |
189 |
10.4 |
183 |
10.6 |
198 |
10.4 |
191 |
10.5 |
|
> 60 years (older and senile age) |
75 |
28.4 |
74 |
28.5 |
80 |
26.7 |
83 |
26.9 |
The high level of mortality in the group of patients older 60 attracts
attention – up to 28.5 %. It is certainly associated with
burdened comorbid background of older and senile patients with increasing risk
of complications and lethal outcomes of trauma.
Estimating the efficiency of activity of the regional trauma system, we
performed a proper analysis of treatment results in dependence on terms of
transfer to a level 1 hospital, and identified an interesting relationship: the
mortality was the lowest (10.7 %) when transfer was performed within 6 hours
after trauma! One should note that all rules of medical care arrangement as a
part of DCS were followed in this group of patients, and most patients (317
persons, 69.7 %) were transported by a helicopter to the roof of the building.
Unfortunately, the amount of patients who can be transported within the first
hours after trauma is still not high – 21.2 ± 5.1 %; we think that success
supposes more proper monitoring of medical care on site and stimulating the
physicians performing medical care in level 2-3 trauma centers in view of
timely addressing to Sanitary aviation service.
The highest mortality is noted in the group of patients who were
transferred within 6-12 hours after injury. More proper analysis of causes of
mortality showed that transfers of patients in this group demonstrated the
feature of necessity in many cases. It is explained by absence of technical
possibilities for qualitative diagnosis or absence of specialists; it caused
errors and incorrect estimation of injuries. As result, to save a victim, a
risky solution was made for transfer of a patient to Research
Institute – Ochapovsky Regional Clinical Hospital No.1. The mortality rate had
been decreasing in this group from year to year (20.3-14.3 %). It is associated
with gradual improvement in material resources and regular training of
specialists. Moreover, a constant analysis and detailed review of causes of
negative outcomes of treatment were performed. After that, the leading
specialists of Research Institute – Ochapovsky Regional Clinical Hospital No.1
performed the control of arrangement and quality of medical care in level 2-3
trauma centers.
The analysis of results of
activity of Sanitary aviation service showed that 3,957 primary phone
consultations and 219 telemedicine consultations were conducted for patients
with polytrauma in 2014-2017. There were 305 recurrent connections to level 2-3
trauma centers, including 288 (94.5 %) active (i.e. upon an initiative of level
1 trauma center) consultations.
The highest efficiency of
remote discussion of a patient was achieved in phone call within 2-4 hours from
the moment of admission to level 2-3 trauma center. Information on mechanism
and circumstances of trauma, its features, clinical manifestations and
condition severity allowed concentrating attention by the team of specialists
to the most probable variants of location of and possible severity of injuries,
giving timely correction for diagnostic search and treatment algorithm.
Currently, the system for arrangement of care for patients is programmed for
active transfer of patients to level 1 trauma center, with 74.6 % of cases
transported by specialized machines of Sanitary aviation with presence of paramedic
and intensivist, which performs on-site correction of treatment and
stabilization of the patient’s condition. The team additionally includes
traumatologist who perform the adequate immobilization of injuries, if it is
impossible to fix fractures in a primary hospital (a decision is made by a
consultant).
Therefore, level 1 trauma
center, which is a powerful and multifunctional clinic (total of 1,786
inhospital beds, including 991 surgical and 240 intensive care unit beds),
admits more than 700 patients with polytrauma each year. In 2014, we accepted
the concept of active monitoring of arrangement of medical care for patients
with polytrauma in regional hospitals, and total internal evacuation that
resulted in the increase by 32.7 % of this category of patients in the hospital
as compared to previous years.
The highest amount of
patients was transported after 24 hours from the injury. All cases included
proper monitoring of clinical features and the analysis of indications for
transfer to level 1 trauma center. A decision on transfer was made on the basis
of stability of the patient’s condition and indications for surgical
intervention (Fig. 3).
Figure 3. Distribution of patients with polytrauma in dependence on time of
transfer from level 2-3 trauma centers
In transfer of a patient
with a severe injury in cases of difficult estimation of the patient’s
condition, the assessment was conducted by the specialists of Research
Institute – Ochapovsky Regional Clinical Hospital No.1 with use of specific
cars or a sanitary aviation helicopter.
During the process of
regular monitoring of efficiency of activity of the level 2-3 trauma centers,
we found that results of diagnosis and treatment of patients can be improved
with constant control of adherence to modern standards and algorithms, and with
readiness to 24 hour work of all services. It was shown by the results of
salvation of patients in serious road traffic accidents, after trainings in
level 2 trauma centers in combination with Disaster medicine service, regionary
divisions of Ministry of Emergency Situations and Road Police. The efficiency
of such work was once and again confirmed by real results of arrangement of
medical care for victims of road traffic accidents on the federal and regional
roads of Krasnodar Region.
CONCLUSION
1. The efficiency of
activity of the trauma system of Krasnodar Region was confirmed by decreasing
mortality in patients with severe polytrauma from 39.7 % in 2003 to 10.9 % in
2017.
2. The best results of treatment
of patients were noted in primary admission from the accident site to the level
1 trauma center. The optimal option is transfer of patients who received DCS
within the first 6 hours after trauma.
3. It is necessary to
perform further development of remote control of arrangement of care for
patients in level 2-3 trauma centers which is performed by leading specialists
of level 1 trauma center.
4. Transportation of the
most severe patients is performed by specialized teams of Sanitary aviation
service with active use of a medical helicopter.
5. Regular control of
activity of level 2-3 trauma centers, and trainings and exercises by profile
services allow synchronizing the interaction of all components of regionary
trauma system and achieving the decrease in mortality in patients with severe
associated injury.
Information on financing and conflict of interests
The study was conducted
without sponsorship.
The authors declare the
absence of any clear or potential conflicts of interests relating to
publication of this article.
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