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A WORKING MODEL OF A TRAUMA REGISTER Kasimov R.R., Makhnovskiy A.I., Zavrazhnov A.A., Ergashev O.N., Sudorgin K.E.

442nd Military Clinical Hospital,

Kirov Military Medical Academy,

Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia,

Gatchina Clinical Interregional Hospital, Gatchina, Russia

The problem of registration of multiple and concomitant injuries has not still been solved in Russia. The official statistical recording is carried out with use of low informative codes T00 − T07 ICD-10 or with a code for one of dominating injuries. At the same time, it is inappropriate to separate one injury as the main disease, and other injuries as concurrent diseases when describing and coding the diagnosis multiple or concomitant injury. Other severe multiple and concomitant injuries, which are combined with the term polytrauma (1), are characterized by the mutual burdening phenomenon and various clinical manifestations of condition severity (traumatic shock, traumatic coma, acute respiratory failure etc.), which are absent in federal forms of statistical recording and in economic analysis.

During three decades, the Russian societies of traumatologists, surgeons and other medical specialists have been discussing the issues and have been making the attempts to create a full-featured domestic trauma register which would have the main tasks in improvement of statistical informational resources and in realization of researchers of polytrauma problem (2-4). The foreign trauma registers (the Trauma Audit and Research Network – TARN, Major Trauma Outcome Study– MTOS, Israeli  National Trauma Registry, Trauma Registry of the German Society of Trauma Surgery and others) have become demanded for medical and statistical analysis of efficiency of various approaches to polytrauma and to economic planning of financial costs for improvement in national trauma systems (5-7). We understand that creation and management of a trauma register is a very difficult task, which is actual both for civilian healthcare and military medicine.

Objective − development of a working version of the trauma register of the military district (regional).

 

MATERIALS AND METHODS

The software for recording of severe injuries (trauma register) was developed on the basis of Microsoft Access XP. In this register, the clinical diagnoses were classified according to statistical codes of single injuries of ICD-10, and injury severity indices according to Abbreviated Injury Scale (AIS). Additionally, the classification of patients according to circumstances of injury was conducted. Currently, the register considers 227 cases of severe concomitant, multiple and isolated injury with traumatic shock (coma) in military men in the Western Military District over last five years.

 

RESULTS AND DISCUSSION

The register consists of the blocks: the block of general information, the block of diagnosis registration, the block of registration of time course of condition. The block of general information registers personal data of a patient, a cohort, a date of an injury and hospital admission, a type and features of interhospital transportation, a clinical diagnosis, a date and completeness of a case. Also it shows points of ISS/NISS and Military Field Surgery Score on the information panel (Fig. 1). The block of registration of diagnosis components systematizes the diagnosis and fixes the time of identification of injuries and complications (Fig. 2). The information on injuries and lesions is presented in text format and is coded by mean of separation of full clinical diagnosis into its monodiagnoses. All components of concomitant, multiple and combined injuries and lesions are included into the register with use of ICD-10. Also the damaging factor is considered in compliance with the developed classifier.

Figure 1

The block of general information on the patient

Figure 2

The block of registration of components of the diagnosis

The program calculates the indices of injury severity according to Military Field Surgery Score­ − Injury. The complex algorithm of score calculation with dominating (multiple) injuries is realized with ISS/NISS. The block of patients' condition time course gives a possibility for registration of condition severity and considers the performed operations (manipulations) according to dates and conditions (ambulance car/aircraft, admission department, anesthesiology/intensive care unit, concomitant injury/specialized unit). The program performs statistical analysis with formulas. A an example, we present a request for distribution of patients according to types of medical evacuation (interhospital transportation) in dependence on injury severity (Fig. 3).

Figure 3

Distribution according to types of medical evacuation and severity of injury

The main cause of severe injuries (the table 1) and polytrauma was road traffic accidents − 120 cases (52.9 %).

Table 1

Distribution of patients according to circumstances of injury (ICD-10)

ICD-10 code	Circumstances of injuries	Total	Proportion, %
V01-04	A pedestrian who suffered  from accident with car, truck or bus	33	14.5
V05	A pedestrian who suffered from accident with railway transport	1	0.4
V18	A bicyclist who suffered from accident without collision	2	0.9
V23	A motorcyclist who suffered from collision with a car	3	1.3
V28	A motorcyclist who suffered from accident without collision	1	0.4
V44	A car passenger who suffered from collision with car, truck or bus	80	35.2
W13	Falling from a building or a construct	22	9.7
W16	Falling into water	2	0.9
W22	Hitting an object or by an object	13	5.7
W23	Hitching, compression or jamming	5	2.2
W26	A hit by a knife, a sword or a dagger	10	4.4
W30	Missile or mine blast	15	6.6
W32	Handgun shot	9	4.0
W51	A hit by other person or collision with him/her	20	8.8
W87	An accident with electric shock	2	0.9
X02	Influence of uncontrolled fire in a building or a in a construct	2	0.9
X04	Injury after inflammation of highly flammable substances	7	3.1

Most patients had mild injuries (ISS/NISS < 18) − 109 persons. 3 (2.8 %) patients died (deep extensive burns). ISS was 18-24 points in 49 cases, 25-42 − in 64 (28.2 %), > 42 − in 5 (2.2 %).

Two patients (4 %) with severe injuries died, as well as 24 (37.5 %) patients with extremely severe injuries. Severe traumatic brain injury prevailed among dominating injuries. The second place was taken by severe chest injury, the third place − by injury to two and more anatomic fields (the table 2).

Table 2

Distribution of injuries according to frequency of the dominating injury

Dominating injury	Amount	Mean values of scores
		Military Field Surgery	ISS
Trauma without main severe injury (maxAIS = 2)	106	4.9	12.6
Severe traumatic brain injury	58	17.2	25.6
Severe chest injury	22	17.2	33.3
Severe injury to two or more anatomic fields	16	26.5	43.4
Severe abdominal injury	11	10.8	25.82
Severe skin or soft tissue injury	8	19.5	30.4
Severe skeletal injury	3	10.8	25.3
Severe facial injury	3	10.4	21.7

After urgent medical care in medical facilities and trauma centers of Health Ministry of the Russian Federation, most patients were transported to military medical facilities with resources for specialized and high tech medical care within the full volume − 206 cases (90.7 %).

Other patients completed the treatment in initial medical facilities. Often it was related with admission to trauma centers with sufficient medicodiagnostic resources. The second cause was long term non-transportability of patients due to severe conditions. There were not any lethal outcomes during interhospital transportation. Sanitary evacuation was realized in 152 cases (73.8 %), sanitary aviation evacuation − in 54 cases (26.2 %). Sanitary aviation evacuation was used more often for cases with extremely severe injuries(table 3).

Table 3

Distribution of evacuated patients according to injury severity

Groups of patients (ISS)	Casualty evacuation	Casualty aviation evacuation
	Amount, %	Amount, %
Less than 18	83 (54.6)	18 (33.3)
18-24	32 (21)	16 (29.6)
25-42	35 (23)	19 (35.2)
More than 42	2 (1.4)	1 (1.9)

57 patients with extremely severe injuries (ISS > 24) were evacuated, 15 patients died (26.3 %); 12 patients were not evacuated according to various causes, 9 patients (75 %) died. The differences in mortality were statistically significant (p < 0.05). It means timely organization of medical evacuation to trauma centers of higher level regardless of severity of basic condition.

 

CONCLUSION

In our country, the available registers of severe injuries are formed regardless of scientific and clinical interests of developers and are far from perfection. It is difficult to  overestimate the need for the domestic trauma register. The society of specialists in treatment of severe injuries require for the uniform and automatic tool for statistical recording to compare results of medical care for patients with polytrauma, to improve existing models of regional trauma systems, to perform economical analysis of costs for treatment of severe injuries, and to plan the optimal volume of financing of this  field of medicine. Our working variant of recording of causes and results of treatment of severe injuries can be the beginning of big cooperative work for creation of the national trauma register.

 

Information on financing and conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.