Challenges developing evidence-based algorithms for the trauma reception and resuscitation project.

A project based at the Alfred Emergency and Trauma Centre in Melbourne, Australia aimed to standardise trauma resuscitation, documentation and interventions by developing best practice algorithms. The primary study objective was to demonstrate a reduction in management errors using a real-time computer based algorithm (the study group) compared to the control group in an open randomised controlled interventional study. A baseline control group was also used for comparison with usual (current) practice. In order to examine the existing evidence and algorithms in trauma care, nine teams of emergency nurses and doctors were formed. Specific literature searches performed by each team revealed a paucity of evidence supporting clinical practice in the trauma setting for procedures. Subsequently, the multidisciplinary teams worked together and developed algorithms based on best practice. The process revealed three main areas of challenges in the development of algorithms: (i) clinical, (ii) research and (iii) nursing challenges. The completion of the project demonstrated benefits in the real-time computer based algorithm with a reduction in the error rate per patient from the baseline control group to the intervention study group (2.30 vs. 2.13, p=0.04) and error-free resuscitations increasing from 16% to 21.8% (p=.049). This project supported the implementation of a real-time computer based algorithm system with improved protocol compliance and reduced errors and morbidity.

Development and validation of a complementary map to enhance the existing 1998 to 2008 Abbreviated Injury Scale map.

INTRODUCTION: Many trauma registries have used the Abbreviated Injury Scale 1990 Revision Update 98 (AIS98) to classify injuries. In the current AIS version (Abbreviated Injury Scale 2005 Update 2008 - AIS08), injury classification and specificity differ substantially from AIS98, and the mapping tools provided in the AIS08 dictionary are incomplete. As a result, data from different AIS versions cannot currently be compared. The aim of this study was to develop an additional AIS98 to AIS08 mapping tool to complement the current AIS dictionary map, and then to evaluate the completed map (produced by combining these two maps) using double-coded data. The value of additional information provided by free text descriptions accompanying assigned codes was also assessed. METHODS: Using a modified Delphi process, a panel of expert AIS coders established plausible AIS08 equivalents for the 153 AIS98 codes which currently have no AIS08 map. A series of major trauma patients whose injuries had been double-coded in AIS98 and AIS08 was used to assess the maps; both of the AIS datasets had already been mapped to another AIS version using the AIS dictionary maps. Following application of the completed (enhanced) map with or without free text evaluation, up to six AIS codes were available for each injury. Datasets were assessed for agreement in injury severity measures, and the relative performances of the maps in accurately describing the trauma population were evaluated. RESULTS: The double-coded injuries sustained by 109 patients were used to assess the maps. For data conversion from AIS98, both the enhanced map and the enhanced map with free text description resulted in higher levels of accuracy and agreement with directly coded AIS08 data than the currently available dictionary map. Paired comparisons demonstrated significant differences between direct coding and the dictionary maps, but not with either of the enhanced maps. CONCLUSIONS: The newly-developed AIS98 to AIS08 complementary map enabled transformation of the trauma population description given by AIS98 into an AIS08 estimate which was statistically indistinguishable from directly coded AIS08 data. It is recommended that the enhanced map should be adopted for dataset conversion, using free text descriptions if available.

Double coding and mapping using Abbreviated Injury Scale 1998 and 2005: identifying issues for trauma data.

INTRODUCTION: The 2005 version of the Abbreviated Injury Scale (AIS05) potentially represents a significant change in injury spectrum classification, due to a substantial increase in the codeset size and alterations to the agreed severity of many injuries compared to the previous version (AIS98). Whilst many trauma registries around the world are moving to adopt AIS05 or its 2008 update (AIS08), its effect on patient classification in existing registries, and the optimum method of comparing existing data collections with new AIS05 collections are unknown. The present study aimed to assess the potential impact of adopting the AIS05 codeset in an established trauma system, and to identify issues associated with this change. METHODS: A current subset of consecutive major trauma patients admitted to two large hospitals in the Australian state of Victoria were double-coded in AIS98 and AIS05. Assigned codesets were also mapped to the other AIS version using code lists supplied in the AIS05 manual, giving up to four AIS codes per injury sustained. Resulting codesets were assessed for agreement in codes used, injury severity and calculated severity scores. RESULTS: 602 injuries sustained by 109 patients were compared. Adopting AIS05 would lead to a decrease in the number of designated major trauma patients in Victoria, estimated at 22% (95% confidence interval, 15-31%). Differences in AIS level between versions were significantly more likely to occur amongst head and chest injuries. Data mapped to a different codeset performed better in paired comparisons than raw AIS98 and AIS05 codesets, with data mapping of AIS05 codes back to AIS98 giving significantly higher levels of agreement in AIS level, ISS and NISS than other potential comparisons, and resulting in significantly fewer conversion problems than attempting to map AIS98 codes to AIS05. CONCLUSIONS: This study provides new insights into AIS codeset change impact. Adoption of AIS05 or AIS08 in established registries will decrease major trauma patient numbers. Code mapping between AIS versions can improve comparisons between datasets in different AIS versions, although the injury profile of a trauma population will affect the degree of comparability. At present, mapping AIS05 data back to AIS98 is recommended.

Management of blunt bowel and mesenteric injuries: Experience at the Alfred hospital.

BACKGROUND: The incidence of blunt bowel and mesenteric injury (BBMI) has increased recently in blunt abdominal trauma, possibly due to an increasing number of high-speed motor accidents and the use of seat belts. OBJECTIVE: Our aim was to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with BBMI. This was achieved by reviewing our experience as a major Victorian trauma service in the management of bowel and mesenteric injuries and comparing this to the experiences reported in the literature. METHODS: A retrospective study reviewing 278 consecutive patients who presented to the Alfred trauma center with blunt bowel and mesenteric injuries over a 6-year period. RESULTS: The patient cohort comprised 278 patients with BBMI (66% were male, 34% were female), of whom 80% underwent a laparotomy, 17% were treated conservatively and 3% were diagnosed post-mortem. In terms of time from admission to laparotomy, 67% were treated within 0-4 h, 9% within 4-8 h, 3% within 8-12 h, 10% within 12-24 h, 4% within 24-48 h and 7% at >48 h. A focused abdominal sonography for trauma (FAST) was performed in 86 patients, of whom 51% had a positive FAST, 44% had a negative FAST and 4% had an equivocal FAST. Overall, 13% of the patient cohort did not have a FAST. Computerized tomography (CT) scans were undertaken preoperatively in 68% of the patients, revealing free gas (22% of patients), bowel-wall thickening (31%), fat and mesenteric stranding or hematoma (38%) and free fluid with no solid organ injury (43%). CONCLUSION: The timing of surgical intervention in cases of BBMI is mostly determined by the clinical examination and the results of the helical CT scan findings. The FAST lacks sensitivity and specificity for identifying bowel and mesenteric trauma. A delayed diagnosis of > 48 h has a significantly higher bowelrelated morbidity but not mortality.