Implementation of a two-tier trauma response.

OBJECTIVE: To apply a triage tool to patients on their arrival in the emergency department and determine the efficacy and safety of a two-tier trauma response. DESIGN: Descriptive prospective audit. SETTING: Principal urban referral hospital that provides a major trauma service. MATERIALS AND METHODS: The triage tool designated a major trauma or stable trauma response. A major trauma designation mobilised a multidisciplinary team and a stable trauma designation an expedited evaluation by emergency department staff. Chi-square test and Mann-Whitney U test were used to compare major and stable trauma designations. Triage accuracy was evaluated using outcome variables. MAIN RESULTS: 78% of 58 major trauma responses and 30% of 180 stable trauma responses were admitted. The median injury severity score (and interquartile range) of admitted patients was 9.0 (5.0-19.5) for major responses and 5.0 (2.0-9.0) for stable responses. The triage tool had a sensitivity of 65%, specificity of 87%, accuracy (appropriate triage rate) of 82%, undertriage rate of 8% and overtriage rate of 10%. CONCLUSION: The triage tool adequately distinguished between patients with and without major trauma. Undertriaged patients had timely and appropriate referral for definitive surgical care and had no adverse outcomes.

The hospital trauma team: a model for trauma management.

A triage system was established as the initiating mechanism for a trauma team response to assist the assessment and early management of patients presenting to an accident and emergency department. A checklist of triage criteria was used. During a 6-month period, 342 patients (29.7% of trauma admissions) satisfied the triage criteria, which should have resulted in an average of 1.9 trauma team calls per day. Staff compliance with the triage tool was 75.4%. The overtriage rate for the checklist criteria was 52.7%. The triage tool identified patients with severe injuries who were not initially considered sufficiently injured to justify initiation of the trauma team response. The sensitivity of the triage tool in identifying patients with serious injury was 95.0%. Comparison of the review with a similar review performed 12 months earlier demonstrated that staff compliance with initiating the trauma team response had improved. Using data from 564 patients from both series, logistic regression analysis of the power of the triage criteria to predict serious injury contributed to a revision of the triage criteria. This trauma triage tool and trauma team response constitute a valid approach to the early hospital management of trauma patients. This system may be more appropriate or achievable in many hospitals than the construction of dedicated trauma reception units or permanent surgical staffing of general Accident and Emergency departments.

Interhospital transfer in the management of acute trauma.

During an 8-month period, 538 injured patients were transferred from primary hospitals to a referral hospital for further management of their injuries. Delay at the primary hospital was identified in 20% of all transfers and in 40% of patients transferred for management of head injury or multisystem injury. Delay at the primary hospital resulted in a median time from injury to arrival at the second hospital of 4 h. Defects in clinical management during transport included inexperienced escorts, inadequate airway control, ventilation, fluid resuscitation and stabilization of chest injuries. Nearly half of transfers were inappropriate because of the relatively minor nature of the injuries. Most of these had solitary musculoskeletal injuries to the extremities. These patients reflect the marked deficiency of specialist orthopaedic services in western Sydney during the study. Development of a metropolitan regional system of trauma care in western Sydney requires urgent action towards reducing the frequency of transfer, minimizing delays in transfer and maximizing basic resuscitation of seriously injured patients. Some designation of hospital roles is required and needs to be accompanied by a prehospital triage process. The population also has a right to expect adequate specialty services at suburban hospitals to enable treatment of minor and moderate single system injuries. Future trauma system developments should adequately reflect population growth and technological advances in clinical care.

Implementation of a trauma team.

A team approach to the initial assessment, investigation and management of potentially seriously injured patients has been instituted. Team members are alerted through an emergency paging system which is activated when a patient fulfills one of a predetermined list of criteria relating to the injury incident, physiological status of the patients and anatomic injuries. Medical members of the team include surgical, intensive care, anaesthetic, and accident and emergency staff. The surgical representative acts as team co-ordinator. Aspects of the function of the trauma team system were assessed over 4 months during which time 721 injured patients were admitted, 240 patients satisfied the trauma team criteria, and the team was called 152 times. The observed 'false alarm' rate was 38% but the true false alarm rate would have been 46%. Injuries sustained by some patients, who satisfied the criteria but who were not evaluated by the team, were of sufficient severity to justify a greater compliance with the system than was observed at this early stage after its implementation. Although a false alarm rate of 46% is higher than desirable, the number of calls per day would still only average 2 in a hospital with a high trauma patient load. The checklist criteria were highly sensitive (97%) in identifying those patients who should have been evaluated by the trauma team. Although hospitals differ in workload and staffing, this trauma team model is recommended for more widespread use and for further evaluation and modification.

Prolonged Q-T interval following astemizole overdose.

Astemizole overdose has been reported to cause torsades-de-pointes and in the present case it caused prolongation of the Q-T interval. Astemizole overdoses should be managed in a similar way to overdose with other cardiotoxic drugs.

The management of injuries--a review of deaths in hospital.

A prospective review was undertaken of the management of 111 consecutive patients who died in hospital after admission for treatment of injuries. A standard set of data relating to each patient was reviewed by each member of a trauma death audit committee and then by the whole committee. Autopsy reports were available on all patients. Conclusions were drawn concerning defective aspects of patient management and possible avoidance of each death. Injury severity was assessed using the Trauma Score (TS) and Injury Severity Score (ISS). The possibly avoidable death (PAD) rate was 17%. The most common defects in management were related to inadequate fluid resuscitation and delays in definitive management. The greatest contributions to the PAD rate were from inadequate fluid resuscitation, delays and inadequate perception of the severity of injuries or significance of clinical deterioration. Increasing age was related to a higher frequency of PAD. PAD rate in the presence of severe head injury was 8%, but was 63% in the absence of a severe head injury. It is concluded that review of all trauma deaths is an achievable, beneficial and essential part of a hospital-based integrated trauma service. TS and ISS are not sufficiently sensitive to justify their use in selecting deaths for review. Improved blood volume replacement, earlier and more direct management and supervision by senior specialist staff, and elimination of causes of delay in patient management should all decrease the death rate from injuries particularly in patients without severe head injury.

Trauma triage--a comparison of the trauma score and the vital signs score.

A pilot study of the Trauma Score (TS) was performed from July to September 1983. The Vital Signs Score (VSS) used by the ambulance paramedics, was compared with TS. Of 266 patients suitable for study, TS data was collected for 110. Other exclusions resulted in a detailed analysis of data from 65 patients among whom there were eight deaths. There was a significant correlation between TS and VSS, however, TS more accurately defined the population at risk of death. A score greater than 12 correlated with a mortality of zero for the TS, but for the VSS it correlated with a mortality of 4.4%. A score less than or equal to 12 correlated with a mortality of 61.5% for the TS but only 30% for the VSS. Stepwise regression analysis of the TS, VSS and combinations of their components was performed to determine their capacities to predict death. A combination of three components of the TS, corresponding to the Triage Index of Champion, was a better predictor than the total TS. Neither the VSS nor any combinations of its components had the predictive capacity of the total TS. If the TS and the VSS were used to select high risk patients for a particular rescue or resuscitation protocol, and scores were selected which gave 100% sensitivity with the highest possible specificity, the positive predictive values of the TS and VSS would be respectively 61.5% and 26.7%. The protocol would be administered unnecessarily to 73.3% of patients selected by the VSS, but only to 38.5% of patients selected by the TS. The TS is proposed as an aid to triage.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients attending an accident and emergency department for primary medical care.

An increasing number of people seek primary care at casualty or accident and emergency departments of hospitals. A questionnaire was completed by patients attending for primary care at an Australian hospital. The study aimed to determine why patients chose the hospital for their medical care, whether patients triaged to the Primary Care Unit differed from patients triaged to the Casualty section of the Accident and Emergency Department, and whether the characteristics of patients attending at daytime differed from those attending out of hours. There were no significant differences between daytime and out-of-hours attenders according to sex or whether born in Australia or not. More children presented at night or at the weekend; more older people presented by day. There were more single, divorced, separated and widowed patients among the daytime attenders. Daytime attenders had significantly lower incomes than out-of-hours attenders, were less likely to have a local general practitioner or full health insurance: most had a health care card and cost may have been a factor in their attendance. Out-of-hours attenders who had a local general practitioner appeared to be unaware of any deputizing services or had rejected them in favour of the hospital service.

The pH and titratable acidity of stored CPD blood.

Blood stored in citrate-phosphate-dextrose (CPD) solution for periods up to 20 days had a mean pH 6.71. The mean metabolic hydrogen ion excess was 32 mmol/litre and the mean respiratory hydrogen ion excess was 80 mmol/litre. These results for CPD blood are compared with those obtained on acid-citrate-dextrose blood. A prediction is made that clnically, only small variations in metabolic and respiratory acid-base balance would be produced directly due to the acid and base loads in transfused blood.