Optimizing trauma system design: the GEOS (Geospatial Evaluation of Systems of Trauma Care) approach.

BACKGROUND: Trauma systems have been shown to reduce death and disability from injury but must be appropriately configured. A systematic approach to trauma system design can help maximize geospatial effectiveness and reassure stakeholders that the best configuration has been chosen. METHODS: This article describes the GEOS [Geospatial Evaluation of Systems of Trauma Care] methodology, a mathematical modeling of a population-based data set, which aims to derive geospatially optimized trauma system configurations for a geographically defined setting. GEOS considers a region's spatial injury profile and the available resources and uses a combination of travel time analysis and multiobjective optimization. The methodology is described in general and with regard to its application to our case study of Scotland. RESULTS: The primary outcome will be trauma system configuration. CONCLUSION: GEOS will contribute to the design of a trauma system for Scotland. The methodology is flexible and inherently transferable to other settings and could also be used to provide assurance that the configuration of existing trauma systems is fit for purpose.

Dispatch-assisted CPR: where are the hold-ups during calls to emergency dispatchers? A preliminary analysis of caller-dispatcher interactions during out-of-hospital cardiac arrest using a novel call transcription technique.

BACKGROUND: Survival from out-of-hospital cardiac arrest (OHCA) is dependent on the chain of survival. Early recognition of cardiac arrest and provision of bystander cardiopulmonary resuscitation (CPR) are key determinants of OHCA survival. Emergency medical dispatchers play a key role in cardiac arrest recognition and giving telephone CPR advice. The interaction between caller and dispatcher can influence the time to bystander CPR and quality of resuscitation. We sought to pilot the use of emergency call transcription to audit and evaluate the holdups in performing dispatch-assisted CPR. METHODS: A retrospective case selection of 50 consecutive suspected OHCA was performed. Audio recordings of calls were downloaded from the emergency medical dispatch centre computer database. All calls were transcribed using proprietary software and voice dialogue was compared with the corresponding stage on the Medical Priority Dispatch System (MPDS). Time to progress through each stage and number of caller-dispatcher interactions were calculated. RESULTS: Of the 50 downloaded calls, 47 were confirmed cases of OHCA. Call transcription was successfully completed for all OHCA calls. Bystander CPR was performed in 39 (83%) of these. In the remaining cases, the caller decided the patient was beyond help (n = 7) or the caller said that they were physically unable to perform CPR (n = 1). MPDS stages varied substantially in time to completion. Stage 9 (determining if the patient is breathing through airway instructions) took the longest time to complete (median = 59 s, IQR 22-82 s). Stage 11 (giving CPR instructions) also took a relatively longer time to complete compared to the other stages (median = 46 s, IQR 37-75 s). Stage 5 (establishing the patient's age) took the shortest time to complete (median = 5.5s, IQR 3-9s). CONCLUSION: Transcription of OHCA emergency calls and caller-dispatcher interaction compared to MPDS stage is feasible. Confirming whether a patient is breathing and completing CPR instructions required the longest time and most interactions between caller and dispatcher. Use of call transcription has the potential to identify key factors in caller-dispatcher interaction that could improve time to CPR and further research is warranted in this area.

Demographic and geographical characteristics of pediatric trauma in Scotland.

BACKGROUND: Trauma systems reduce mortality and improve functional outcomes. The aim of this study was to analyse the demographic and geospatial characteristics of pediatric trauma patients in Scotland, and determine the level of destination healthcare facility which injured children are taken to, to determine the need for, and general feasibility, of developing a pediatric trauma system for Scotland. METHODS: Retrospective analysis of incidents involving children aged 1-14 attended to by the Scottish Ambulance Service between 1 November 2008 and 31 October 2010. A subgroup with physiological derangement was defined. Incident location postcode was used to determine incident location by health board region, rurality and social deprivation. Destination healthcare facility was classified into one of six categories. RESULTS: Of 10,759 incidents, 72.3% occurred in urban areas and 5.8% in remote areas. Incident location was associated with socioeconomic deprivation. Of the patients, 11.6% were taken to a pediatric hospital with pediatric intensive care facilities, 21.8% to a pediatric hospital without pediatric intensive care service, and 50.2% to an adult large general hospital without pediatric surgical service. CONCLUSIONS: The majority of incidents involving children with injuries occurred in urban areas. Half were taken to a hospital without pediatric surgical service. There was no difference between children with normal and deranged physiology.

Destination healthcare facility of shocked trauma patients in Scotland: analysis of transfusion and surgical capability of receiving hospitals.

AIMS: Haemorrhage is a leading cause of death from trauma. Management requires a combination of haemorrhage control and resuscitation which may incur significant surgical and transfusion utilisation. The aim of this study is to evaluate the resource provision of the destination hospital of Scottish trauma patients exhibiting evidence of pre-hospital shock. METHODS: Patients who sustained a traumatic injury between November 2008 and October 2010 were retrospectively identified from the Scottish Ambulance Service electronic patients record system. Patients with a systolic blood pressure less than 110 mmHg or if missing, a heart rate greater than 120 bpm, were considered in shock. The level of the destination healthcare facility was classified in terms of surgical and transfusion capability. Patients with and without shock were compared. RESULTS: There were 135,004 patients identified, 133,651 (99.0%) of whom had sustained blunt trauma, 68,411 (50.7%) were male and the median (IQR) age was 59 (46). There were 6721 (5.0%) patients with shock, with a similar age and gender distribution to non-shocked patients. Only 1332 (19.8%) of shocked patients were taken to facilities with full surgical capability, 5137 (76.4%) to hospitals with limited (general and orthopaedic surgery only) and 252 (3.7%) to hospitals with no surgical services. In terms of transfusion capability, 5556 (82.7%) shocked patients were admitted to facilities with full capability and 1165 (17.3%) to a hospital with minimal or no capability. CONCLUSIONS: The majority of Scottish trauma patients are transported to a hospital with full transfusion capability, although the majority lack surgical sub-specialty representation.

Capability of Scottish emergency departments to provide physician-based prehospital critical care teams: a national survey.

OBJECTIVE: The aim of this study was to establish the current capabilities of emergency departments in Scotland to provide a prehospital medical team at the request of the ambulance service. METHODS: A prospective telephone survey of all major emergency departments in Scotland was conducted, requesting information on their ability to provide a prehospital team, the configuration of the team and the equipment, transport, training and governance arrangements for this service. RESULTS: All 25 major emergency departments in Scotland responded to the survey (100% response). Eighteen departments (72%) were able to provide a prehospital team, with 15 (60%) able to provide a team 24 h/day. Team composition was variable and only one-third of teams were able to deploy within 15 min. In total, 50% of departments able to respond had received no requests in the preceding 12 months and only two departments had each received more than 50 requests. Less than half of the departments checked prehospital equipment on a weekly or a more frequent basis and only three departments provided ongoing training in prehospital care. CONCLUSION: The majority of emergency departments in Scotland are able to provide a prehospital team on the request of the ambulance service. There is high variability in the composition and seniority of the team, with less ability to provide a team out of hours. With two notable exceptions, the overall activation of these prehospital teams is infrequent, and there are significant improvements required with regard to the clinical governance surrounding the provision of these teams.

Destination healthcare facility of patients with suspected traumatic brain injury in Scotland: analysis of pre-hospital data.

BACKGROUND: Traumatic brain injury is common. Guidelines from the Brain Trauma Foundation and the Scottish Intercollegiate Guidelines Network recommend that patients with suspected severe traumatic brain injury should be treated in centres with neurosurgical expertise. Scotland does not have a framework for the delivery of trauma care. The aim of this study was to examine the demographic characteristics of incidents involving patients who have suffered a suspected traumatic brain injury, and to evaluate the level of the destination healthcare facility which patients are currently taken to. METHODS: Retrospective analysis of prospectively collected Scottish Ambulance Service data on incidents involving traumatic injury, between Nov 2008 and Oct 2010. Two groups of casualties were analysed: those who had a Glasgow coma scale of less than 14 (GCS<14), and those who had a Glasgow coma scale of less than 9 (GCS<9). RESULTS: 126,934 incidents were identified and analysed. 3890 (3.1%) patients had a GCS of less than 14, and 657 (0.5% of total) had a GCS of less than 9. Almost one-third of incidents involving patients with either a GCS<14 or GCS<9 occurred in the greater Glasgow health board area. The Lothian health board region had the second-highest number of patients with either a GCS<14 or GCS<9. Only 13.8% of patients with a GCS<14, and 16.7% of those with a GCS<9, were taken to a hospital with a neurosurgical service. CONCLUSIONS: Many patients who may harbour a traumatic brain injury are taken to a facility which may not be equipped or staffed to deal with such injuries. This mismatch needs to be addressed. However, the care of patients with head injuries is only one aspect of trauma care. The UK has long lagged behind North America in terms of the quality of trauma care provided, although the provision of trauma care in England is currently undergoing major changes. Scotland should consider the development of a similar service delivery framework.

Issues around conducting prehospital research on out-of-hospital cardiac arrest: lessons from the TOPCAT study.

Outcome from OHCA is primarily determined by prehospital events and meaningful clinical OHCA research must include data recorded in this setting. There is little evidence on which to base the practice of prehospital resuscitation and research in this area presents huge challenges but is required if survival from OHCA is to improve. This short report aims to provide a practical guide to performing prehospital research on OHCA, based on lessons learned from the Temperature Post Cardiac Arrest (TOPCAT) research; an observational study into OHCA.