Research Article
Does Trauma Room Duration Affect Patient Outcome in a Level I Trauma Center?
Ernstberger A*, Treffer D, Loibl M, Hilber F, Nerlich M and Angerpointner K
Department of Trauma Surgery, University Hospital Regensburg, Germany
*Corresponding author: Antonio Ernstberger, Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 1193053 Regensburg, Germany
Published: 23 Oct, 2018
Cite this article as: Ernstberger A, Treffer D, Loibl M, Hilber
F, Nerlich M, Angerpointner K. Does
Trauma Room Duration Affect Patient
Outcome in a Level I Trauma Center?.
Clin Surg. 2018; 3: 2176.
Abstract
Background: Trauma is the leading cause of death and morbidity in younger people aged 15-29
years worldwide. Implementation of guidelines, care algorithms, Standard Operating Procedures
(SOPs) or white books aim at improving quality and safety of trauma care. Therefore, time is a
common item to evaluate the quality of trauma care (e.g. the duration of trauma room care or the
duration of certain interventions). This study evaluates the influence of the duration of trauma room
care on patient outcome at a well-trained level I trauma center.
Materials and Methods: Study population: 382 (ISS > 16) patients primarily admitted to the trauma
room of a level I trauma center were included in a 64 month period. The study population was
grouped according to the prognostic RISC-Score for expected fatality (expected fatality rate: RISCgroup
1: [0%-5%], RISC-group 2: [5%-50%], RISC-group 3: [50%-100%]). Moreover, each RISCgroup
was sub-grouped according to the total duration of trauma room treatment (SHORT-subgroup:
Conclusion: This study indicates that the individual duration of trauma room care in the optimized
setting of a level I trauma center does not impact on patient outcome indicators. On the contrary, it
reflects a financially and resource demanding trauma room care, that has to be provided for a more
complex trauma patient care.
Keywords: Trauma room; Trauma center; Multiple trauma; ATLS; DGU; Traumanetzwerk;
RISC
Introduction
Injury can be considered as a global burden of disease. More than one million people are killed
while involved in Road Traffic Accidents (RTA) every year. RTAs are ranked as the 8th leading cause
of death all over the world with a rising trend, so that they are expected to be the 5th leading cause of
death in 2030 worldwide. Moreover, RTAs are ranked as the leading cause of death and morbidity
for younger people aged 15-29 years throughout the world [1].
An optimized trauma care system is essential to provide high quality trauma care to road users
and all the other seriously injured patients. Guidelines (e.g. S3-Guideline on Treatment of Patients
with Severe and Multiple Injuries), structured training courses (e.g. ATLS®, PHTLS®, ETC), Standard
Operating Procedures (SOPs) and designated white books (e.g. Whitebook Medical Care of the
Severely Injured) are valuable and established tools to improve trauma care in terms of structure,
process and outcome quality [2-7]. Several countries or regions run mature trauma systems (e.g.
TraumaNetzwerk DGU®) and quality management tools, like large-scale trauma registries (e.g.
TraumaRegister DGU® or TARN) [8-10]. In fact, these instruments proved to be feasible, effective
and efficient. However, they require continuing evaluation and adjustment [11-13].
“Time-to-intervention” belongs to the most well-known and referenced quality indicators in
the context of the time-critical prehospital and early in-hospital phase
[14-16]. It was Cowley in 1976 who illustrated the correlation of timeto-
intervention and outcome with the shining term “Golden Hour
of Shock” [17]. An example for the importance of time management
in trauma care is the “time to laparotomy for intra-abdominal
bleeding”, as Clarke showed in 2001 [18]. Nevertheless, recent data
indicates that “time-to-intervention” is not a universal or stand-alone
indicator for the assessment of trauma care quality [19-27]. Kleber
et al. Published that prolonged rescue time in the physician-based
German Emergency Medical System is not associated with worse
patient outcome in general [28]. With regard to early in-hospital
trauma management, it was shown that tools like SOPs, Quality
Management (QM) and early Multislice-Computed Tomography
(MSCT) can significantly reduce trauma room time and mortality
[11,16,29,30]. To the best knowledge of the author's systematic
investigations concerning the impact of trauma room time on the
outcome of seriously injured patients in an optimized trauma room
setting have not been published yet.
This study analyses the potential association of the duration of
trauma room care on diverse outcome parameters in a study sample
primarily admitted to a level I trauma center and university hospital.
In addition, various pre-hospital and early in-hospital interventions,
as well as the duration of these interventions, are investigated.
Figure 1
Materials and Methods
Study sample
The study was approved by the ethics committee of the University
of Regensburg (Nr: 14-101-0004). A total of 974 trauma room cases
were documented during the study period (64 months: 09/2007 -
12/2012), of which n=382 were included in this study and are referred
to as “study sample” from now on (Figure 1).
• 4.2. InclusionPrimary admission to the study hospital’s
trauma room
• Admission to the study hospital after trauma room care (no
referral to an external hospital)
• Injury Severity Score ISS ≥ 16
• Complete real-time documentation in the trauma room by
a qualified study assistant
• Calculation of RISC-score possible (no missing data)
Exclusion criteria
All cases that were initially treated in an outside hospital or
transferred to an outside hospital after trauma room care were
excluded. Moreover, cases with head injuries on admission that
cannot be survived (AIS-Head =6) and those with cardiopulmonary
resuscitation and no Return of Spontaneous Circulation (ROSC)
were also excluded.
Data recruitment
All cases were documented in a prospective manner by qualified
study assistants, who were present in the trauma room during trauma
management. In addition, the study assistants collected all other
data, i.e. regarding post-trauma room management and outcome.
This method has been established in the study hospital since 2007,
and is believed to generate the highest data quality feasible. The
standard data entry form of the German Trauma Society’s trauma
registry (TraumaRegister DGU®, http://www.traumaregister.de) was
applied as the framework of the study’s data entry form, and various
parameters were documented in addition (Table 1-4).
Comparative analysis of subgroups by risk of death and
duration of trauma room care
The prognostic RISC-score (Revised Injury Severity
Classification) was used to categorize the study population into three
groups. The RISC was developed and evaluated on basis of large-scale
data sets from the TraumaRegister DGU® and estimates the fatality
risk (comparable to the TRISS: Trauma Injury Severity Score) of an
individual case [31]. For the TraumaRegister DGU®, the RISC score
has an area under the curve (AUC) of 0.939 in the ROC-analysis 2012,
and is the most exact predictor score for this dataset [31,32].
As a result, the following three RISC-groups were analyzed:
RISC-group 1 (RG1), RISC = [0-5%], n=198 “low fatality risk“
RISC-group 2 (RG2), RISC = [5-50%], n=116 “medium fatality
risk“
RISC-group 3 (RG3), RISC = [50-100%], n=68 “high fatality risk“
Furthermore, each RISC-group was dichotomized according to
the duration of trauma room care:
SHORT-sub-group: Duration of trauma room time < median
trauma room time in study sample
LONG-sub-group: Duration of trauma room time ≥ median
trauma room time in study sample
In-hospital death was defined as the primary outcome. In order to
substantiate this parameter the Standardized Mortality Ratio (SMR)
was calculated as the ratio of observed letality and expected letality
(per RISC).
Trauma room management at the study hospital
Trauma room phase I is defined as the period from admission
to the trauma room until completion of the primary survey and
associated basic diagnostics/procedures. Following trauma room
phase I, MSCT was performed (mostly whole-body-MSCT). The
scanner is located next door to the trauma room. If necessary, a trauma
room phase II was instituted after completion of MSCT in order to
complete or extend emergency diagnostics or procedures. Following
MSCT or trauma room phase II, all patients were transferred to either
the Operating Room (OR) or the Intensive Care Unit (ICU).
The study hospital’s trauma room algorithm follows the ATLS®
principles and is compliant with the recommendations published
in the S3-guidelines of the German Trauma Society. In rare cases,
the routine trauma room algorithm was deviated due to need for
emergency surgery.
Statistical analysis
The results are presented as absolute and relative frequencies and
as mean value ± Standard Deviation (SD) where appropriate. In cases
of n=1 no frequencies are revealed. The SMR is shown as ratio plus
95% confidence interval (95%-CI). Normal distribution was tested
with the Kolmogorov-Smirnov test. Nominal variables were tested
for significance by the chi-squared and Fisher’s exact test where
appropriate. T-test and Mann-Whitney U test were used for ordinal/
metric variables where suitable. To test more than 2 groups at once
for significant discrepancy in ordinal/metric variables, the Kruskal-
Wallis test with paired post hoc test was applied. P-values of ≤ 0.05
were considered statistically significant. All results were calculated
with the IBM SPSS Statistics 21.0 software package.
Table 1
Table 1
Study sample key data (demographics, trauma scores, Pre-hospital interventions and injury pattern).
Table 2
Table 2
Frequency and length of trauma room phases, Multislice-CT and total length of trauma room care.
Results
Basic demographics of the study sample (n=382; male
n=273/71.5%; blunt trauma n=370/96.9%; mean age 39.2 ± 20.9
years) are comparable to ISS >16 samples originating from the
TraumaRegister DGU® [9,33].
Table 1 demonstrates a comparable distribution of sex and injury
mechanism in each of the RISC-groups. As expected (and due to the
calculation matrix of the RISC-score), the mean age, ISS, NISS and
RISC are increasing from RISC-group 1 to 3. Likewise, the percentage
of pre-hospital interventions (e.g. intubation or chest tube) increases
from RISC-group 1 to 3 (prehospital airway: RG1 55.1%, RG2 75.9%,
RG3 91.2%, p<0.001; prehospital chest tube: RG1 11.1%, RG2 19.0%,
RG3 22.1%, p=0.047).
On the contrary, there was no difference in gender-, age-, traumatype-,
ISS-, NISS- and RISC-allocation between the SHORT- and
LONG-sub-groups (p ≥ 0.076). Moreover, the percentage of prehospital
interventions (e.g. intubation or chest tube) was similar in
the SHORT- and LONG-sub-groups. Interestingly, prehospital time
tends to be longer in the three sub-groups with long trauma room
time (LONG-sub-groups), however missing statistical significance (p
≥ 0.06).Compared to the prehospital data set, the rate of shock (RRsys
<90 mmHg) at trauma room admission decreased in all RISC-groups.
Despite this finding, there was no difference in the rate of shock in the
SHORT and LONG-sub-groups (p ≥ 0.166).
While ISS and NISS within the three RISC-groups were
comparable between the sub-groups (p ≥ 0.177), serious head-,
chest-, and extremity-injuries (AIS ≥ 3) tended to be more frequent
in the LONG-sub-groups (p ≥ 0.036). On the other hand, serious
abdominal injuries (AIS ≥ 3) were more frequent in the SHORT-subgroups,
whereas severe bleeding (indicated per transfusion of > 10
blood units) was comparable in the SHORT- and LONG-sub-groups.
In general, long trauma room times were associated with a higher
number of diagnoses (Table 1).
The shortest total trauma room time was documented for the
RISC-group 3 (highest fatality rate prognosis), which goes along with
higher rates of trauma room care breaks and emergency surgeries.
Considering the SHORT- and LONG-sub-groups, trauma room
phases I and II were (with exception for RG2) significantly longer in
the LONG-sub-groups (p ≤ 0.003), while the isolated MSCT time was
not significantly different (p ≥ 0.182). Details are shown in Table 2.
Decision for a second trauma room phase following MSCT was
found to be the leading cause for an increased total trauma room
time. This is consistent with the finding of higher mean numbers of
interventions (intubation, chest tube, arterial and central lines) in
cases with longer trauma room times. Moreover, the time needed
to perform this intervention tended to be longer in the LONG-subgroups.
MSCT was performed in at least 96% of RISC-groups 1 and 2.
Interestingly cases from RISC-group 3 (SHORT-sub-group) have
significantly lower rates of MSCT (p=0.005), which goes along with
higher rates of trauma room breaks and emergency surgeries.
As a key result of the present study, we detected no significant
difference regarding the primary outcome of hospital fatality rate
between trauma room time SHORT- and LONG sub-groups (p ≥
0.324). Regarding secondary outcome indicators, the LONG-subgroups
were characterized by a longer hospital stay, with longer ICU
stay and longer intubation time. Moreover, Multi-Organ Failure
(MOF) rates were higher in these sub-groups. The rate of cases with
no or slight outcome disability (Glasgow Outcome Scale, GOS > 4)
was equal within the SHORT and LONG-sub-groups. Table 4 shows
the SMR of the trauma room time sub-groups. To conclude, the
study data showed no association of trauma room time and various
outcome indicators, such as fatality rates, SMR, and GOS.
Table 3
Table 4
Discussion
Time management is an essential component of trauma
management. Ruchholtz et al. as well as Bernhard et al. demonstrated
that the quality of trauma care is improved by implementation of a
structured trauma room algorithm [29,30]. The “Whitebook Medical
Care of the Severely Injured” of the German Trauma Society demands
such algorithms for all German Trauma Centers based on the body of
evidence indicating the positive effect on trauma outcomes [7].
To the best knowledge of the authors, this is the first study that
demonstrates that there is no association of length of trauma room
care and hospital fatality rates in the given setting. The study hospital
is a certified Level I trauma center in the German trauma network.
It operates based on a structured and priority-based trauma room
algorithm appropriate to the ATLS® principles and compliant with
the recommendations published in the S3-guidelines of the German
Trauma Society.
During the 64-months study period, a mean of 183 trauma room
patients were admitted to the trauma room every year. The SMR
of the study sample (SMR=0.63; 95%-CI: 0.47-0.79) is significantly
lower than the mean SMR (0.85; KI: 0.81–0.89) of the trauma centers
in the trauma registry of the German Trauma Society in 2012 [14].
Clarke et al. report a 1% increase of fatality rate in emergency
laparotomy cases due to intra abdominal bleeding with each three
minutes delay to surgery [18]. This underlines the significance of early
decision making and surgery. On the other hand, whole-body CT was
reported an effective diagnostic measure to reduce fatality rate, even
in haemodynamically unstable patients [34,35]. For this reason, the
simple and vague definition of optimized time management as “most
rapid diagnostic and therapy within seconds or at least few minutes“
has to be re-evaluated. In fact, every patient requires individual
interventions and an individual time management, which represents
key result of this study. This underlines and even expands the famous
statement of D. Trunkey with regard to pre-hospital trauma care:
“[…] get the right patient to the right hospital at the right time” [36].
This investigation found the shortest trauma room time in the
group with the highest RISC-prognosis for fatal outcome (RG 3),
which is due to emergency surgical procedures and trauma room care
breaks. All sub-groups with trauma room times equal or longer than
the median time (LONG-sub-groups) revealed significantly higher
rates of a second trauma room phase. This represents an expected
result, and the analysis of associated outcome parameters reveals the
significance of this finding.
First of all, the total pre-hospital rescue time is slightly longer
in all LONG-sub-groups compared to the SHORT-sub-groups.
Moreover, there is a higher rate of serious chest injuries (AIS Thorax
> 3), and a larger number of diagnoses. Furthermore, more invasive
interventions are performed in cases from all LONG-sub-groups, and
these interventions took longer to be performed as in the SHORTsub-
groups. In addition, more ICU days, higher rates of MOF, and
a higher number of diagnoses in these cases pinpoint a critical fact:
despite similar injury severity scores and RISC-prognosis, diagnostics
and initial care in cases with longer trauma room times are more
challenging compared to the SHORT-sub-group. Therefore, trauma
room time is the reflexion of the complexity of trauma management,
rather than an indicator for time lost. This is supported by the fact
that not only the number of interventions, but also the time for these
interventions is higher in the LONG-sub-groups. Again, trauma
room time at level I trauma centers appears to reflect the complexity
of individual procedures that in the end add up to a longer total
trauma room time.
To conclude, the authors are convinced that the injury severity
and prognostic scores used in this study allow for an objective and
valid categorization of the study sample, while the broad spectrum of
outcome indicators (e.g. length of stay, organ failure) were affected
by secondary factors that were supposedly not documented in this
study. The authors therefore believe that trauma room time is a
primary indicator for the complexity of trauma management and not
a function of (isolated) fatality risk or (isolated) injury severity scores.
Institution of life-saving procedures must not be refrained from in
order to produce shorter trauma room times.
Limitations
The study hospital routinely collects a broad spectrum of trauma room and associated data prospectively. Nevertheless, the dataanalysis of the present study was performed in a retrospective manner in a single center. This causes well-known limitations: The sub-groups are comparably small and the results may not be representative, or rather they are not transferable for all trauma centers.
Conclusion
Identifying life-threatening conditions (“deadly dozen”) and
instituting appropriate measures are the primary tasks of the trauma
room team [37]. This includes coordination of the complex chain
of care and its individual diagnostic and therapeutic components.
Assuming that high-class trauma care is provided, referred to
the actual guidelines and care algorithms, this study contradicts
the assumption that trauma room time is a marker for quality in
trauma care. For this purpose, there is no association between time
in trauma room and viability. Therefore, patient survival or other
relevant outcome benefits in consequence of limited diagnostics or
therapeutic procedures to reduce trauma room time is not supported
by this study.
To proof the findings of the current study, further research
should be carried out as multicenter-trials. Other levels of trauma
care should be addressed to find potential criteria that may indicate
resource demands in trauma care and outcome of patients with
similar injury severity and fatality risk.
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