Assignment of pre-event ASA physical status classification by pre-hospital physicians: a prospective inter-rater reliability study.

BACKGROUND: Individualized treatment is a common principle in hospitals. Treatment decisions are made based on the patient's condition, including comorbidities. This principle is equally relevant out-of-hospital. Furthermore, comorbidity is an important risk-adjustment factor when evaluating pre-hospital interventions and may aid therapeutic decisions and triage. The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is included in templates for reporting data in physician-staffed pre-hospital emergency medical services (p-EMS) but whether an adequate full pre-event ASA-PS can be assessed by pre-hospital physicians remains unknown. We aimed to explore whether pre-hospital physicians can score an adequate pre-event ASA-PS with the information available on-scene. METHODS: The study was an inter-rater reliability study consisting of two steps. Pre-event ASA-PS scores made by pre- and in-hospital physicians were compared. Pre-hospital physicians did not have access to patient records and scores were based on information obtainable on-scene. In-hospital physicians used the complete patient record (Step 1). To assess inter-rater reliability between pre- and in-hospital physicians when given equal amounts of information, pre-hospital physicians also assigned pre-event ASA-PS for 20 of the included patients by using the complete patient records (Step 2). Inter-rater reliability was analyzed using quadratic weighted Cohen's kappa (κw). RESULTS: For most scores (82%) inter-rater reliability between pre-and in-hospital physicians were moderate to substantial (κw 0,47-0,89). Inter-rater reliability was higher among the in-hospital physicians (κw 0,77 to 0.85). When all physicians had access to the same information, κw increased (κw 0,65 to 0,93). CONCLUSIONS: Pre-hospital physicians can score an adequate pre-event ASA-PS on-scene for most patients. To further increase inter-rater reliability, we recommend access to the full patient journal on-scene. We recommend application of the full ASA-PS classification system for reporting of comorbidity in p-EMS.

Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review.

BACKGROUND: Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene. METHODS: A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables. RESULTS: We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers. CONCLUSIONS: Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway.

BACKGROUND: Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template. METHODS: The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties. RESULTS: All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method. CONCLUSIONS: We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Classification of comorbidity in trauma: the reliability of pre-injury ASA physical status classification.

BACKGROUND: Pre-injury comorbidities can influence the outcomes of severely injured patients. Pre-injury comorbidity status, graded according to the American Society of Anesthesiologists Physical Status (ASA-PS) classification system, is an independent predictor of survival in trauma patients and is recommended as a comorbidity score in the Utstein Trauma Template for Uniform Reporting of Data. Little is known about the reliability of pre-injury ASA-PS scores. The objective of this study was to examine whether the pre-injury ASA-PS system was a reliable scale for grading comorbidity in trauma patients. METHODS: Nineteen Norwegian trauma registry coders were invited to participate in a reliability study in which 50 real but anonymised patient medical records were distributed. Reliability was analysed using quadratic weighted kappa (κ(w)) analysis with 95% CI as the primary outcome measure and unweighted kappa (κ) analysis, which included unknown values, as a secondary outcome measure. RESULTS: Fifteen of the invitees responded to the invitation, and ten participated. We found moderate (κ(w)=0.77 [95% CI: 0.64-0.87]) to substantial (κ(w)=0.95 [95% CI: 0.89-0.99]) rater-against-reference standard reliability using κ(w) and fair (κ=0.46 [95% CI: 0.29-0.64]) to substantial (κ=0.83 [95% CI: 0.68-0.94]) reliability using κ. The inter-rater reliability ranged from moderate (κ(w)=0.66 [95% CI: 0.45-0.81]) to substantial (κ(w)=0.96 [95% CI: 0.88-1.00]) for κ(w) and from slight (κ=0.36 [95% CI: 0.21-0.54]) to moderate (κ=0.75 [95% CI: 0.62-0.89]) for κ. CONCLUSIONS: The rater-against-reference standard reliability varied from moderate to substantial for the primary outcome measure and from fair to substantial for the secondary outcome measure. The study findings indicate that the pre-injury ASA-PS scale is a reliable score for classifying comorbidity in trauma patients.

Abbreviated Injury Scale: not a reliable basis for summation of injury severity in trauma facilities?

BACKGROUND: Injury severity is most frequently classified using the Abbreviated Injury Scale (AIS) as a basis for the Injury Severity Score (ISS) and the New Injury Severity Score (NISS), which are used for assessment of overall injury severity in the multiply injured patient and in outcome prediction. European trauma registries recommended the AIS 2008 edition, but the levels of inter-rater agreement and reliability of ISS and NISS, associated with its use, have not been reported. METHODS: Nineteen Norwegian AIS-certified trauma registry coders were invited to score 50 real, anonymised patient medical records using AIS 2008. Rater agreements for ISS and NISS were analysed using Bland-Altman plots with 95% limits of agreement (LoA). A clinically acceptable LoA range was set at ± 9 units. Reliability was analysed using a two-way mixed model intraclass correlation coefficient (ICC) statistics with corresponding 95% confidence intervals (CI) and hierarchical agglomerative clustering. RESULTS: Ten coders submitted their coding results. Of their AIS codes, 2189 (61.5%) agreed with a reference standard, 1187 (31.1%) real injuries were missed, and 392 non-existing injuries were recorded. All LoAs were wider than the predefined, clinically acceptable limit of ± 9, for both ISS and NISS. The joint ICC (range) between each rater and the reference standard was 0.51 (0.29,0.86) for ISS and 0.51 (0.27,0.78) for NISS. The joint ICC (range) for inter-rater reliability was 0.49 (0.19,0.85) for ISS and 0.49 (0.16,0.82) for NISS. Univariate linear regression analyses indicated a significant relationship between the number of correctly AIS-coded injuries and total number of cases coded during the rater's career, but no significant relationship between the rater-against-reference ISS and NISS ICC values and total number of cases coded during the rater's career. CONCLUSIONS: Based on AIS 2008, ISS and NISS were not reliable for summarising anatomic injury severity in this study. This result indicates a limitation in their use as benchmarking tools for trauma system performance.

Differences and discrepancies between 2005 and 2008 Abbreviated Injury Scale versions - time to standardise.

The aim of this letter is to facilitate the standardisation of Abbreviated Injury Scale (AIS) codesets used to code injuries in trauma registries. We have compiled a definitive list of the changes which have been implemented between the AIS 2005 and Update 2008 versions. While the AIS 2008 codeset appears to have remained consistent since its release, we have identified discrepancies between the codesets in copies of AIS 2005 dictionaries. As a result, we recommend that use of the AIS 2005 should be discontinued in favour of the Update 2008 version.

Implementation of recommended trauma system criteria in south-eastern Norway: a cross-sectional hospital survey.

BACKGROUND: Formalized trauma systems have shown beneficial effects on patient survival and have harvested great recognition among health care professionals. In spite of this, the implementation of trauma systems is challenging and often met with resistance.Recommendations for a national trauma system in Norway were published in 2007. We wanted to assess the level of implementation of these recommendations. METHODS: A survey of all acute care hospitals that receive severely injured patients in the south-eastern health region of Norway was conducted. A structured questionnaire based on the 2007 national recommendations was used in a telephone interview of hospital trauma personnel between January 17 and 21, 2011. Seventeen trauma system criteria were identified from the recommendations. RESULTS: Nineteen hospitals were included in the study and these received more than 2000 trauma patients annually via their trauma teams. Out of the 17 criteria that had been identified, the hospitals fulfilled a median of 12 criteria. Neither the size of the hospitals nor the distance between the hospitals and the regional trauma centre affected the level of trauma resources available. The hospitals scored lowest on the criteria for transfer of patients to higher level of care and on the training requirements for members of the trauma teams. CONCLUSION: Our study identifies a major shortcoming in the efforts of regionalizing trauma in our region. The findings indicate that training of personnel and protocols for inter-hospital transfer are the major deficiencies from the national trauma system recommendations. Resources for training of personnel partaking in trauma teams and development of inter-hospital transfer agreements should receive immediate attention.

Inter-hospital transfer: the crux of the trauma system, a curse for trauma registries.

The inter-hospital transfer of patients is crucial to a well functioning trauma system, and the transfer process may serve as a quality indicator for regional trauma care. However, the assessment of the transfer process requires high-quality data from various sources. Prospective studies and studies based on single-centre trauma registries may fail to capture an appropriate width and depth of data. Thus the creation of inclusive regional and national trauma registries that receive information from all of the services within a trauma system is a prerequisite for high quality inter-hospital transfer studies in the future.

Trauma systems and early management of severe injuries in Scandinavia: review of the current state.

INTRODUCTION: Scandinavian countries face common challenges in trauma care. It has been suggested that Scandinavian trauma system development is immature compared to that of other regions. We wanted to assess the current status of Scandinavian trauma management and system development. METHODS: An extensive search of the Medline/Pubmed, EMBASE and SweMed+ databases was conducted. Wide coverage was prioritized over systematic search strategies. Scandinavian publications from the last decade pertaining to trauma epidemiology, trauma systems and early trauma management were included. RESULTS: The incidence of severe injury ranged from 30 to 52 per 100,000 inhabitants annually, with about 90% due to blunt trauma. Parts of Scandinavia are sparsely populated with long pre-hospital distances. In accordance with other European countries, pre-hospital physicians are widely employed and studies indicate that this practice imparts a survival benefit to trauma patients. More than 200 Scandinavian hospitals receive injured patients, increasingly via multidisciplinary trauma teams. Challenges remain concerning pre-hospital identification of the severely injured. Improved triage allows for a better match between patient needs and the level of resources available. Trauma management is threatened by the increasing sub-specialisation of professions and institutions. Scandinavian research is leading the development of team- and simulation-based trauma training. Several pan-Scandinavian efforts have facilitated research and provided guidelines for clinical management. CONCLUSION: Scandinavian trauma research is characterised by an active collaboration across countries. The current challenges require a focus on the role of traumatology within an increasingly fragmented health care system. Regional networks of predictable and accountable pre- and in-hospital resources are needed for efficient trauma systems. Successful development requires both novel research and scientific assessment of imported principles of trauma care.

The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG.

BACKGROUND: In 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases. METHODS: Over a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique. RESULTS: The expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping. CONCLUSION: Through a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.