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
|
Order of admission |
Yearly distribution |
|||
| 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
| WHO age categories |
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.