Effect of Rural Trauma Team Development on the Outcomes of Motorcycle Accident-Related Injuries (Motor Registry Project): Protocol for a Multicenter Cluster Randomized Controlled Trial.

BACKGROUND: Injury is a global health concern, and injury-related mortality disproportionately impacts low- and middle-income countries (LMICs). Compelling evidence from observational studies in high-income countries shows that trauma education programs, such as the Rural Trauma Team Development Course (RTTDC), increase clinician knowledge of injury care. There is a dearth of such evidence from controlled clinical trials to demonstrate the effect of the RTTDC on process and patient outcomes in LMICs. OBJECTIVE: This multicenter cluster randomized controlled clinical trial aims to examine the impact of the RTTDC on process and patient outcomes associated with motorcycle accident-related injuries in an African low-resource setting. METHODS: This is a 2-arm, parallel, multi-period, cluster randomized, controlled, clinical trial in Uganda, where rural trauma team development training is not routinely conducted. We will recruit regional referral hospitals and include patients with motorcycle accident-related injuries, interns, medical trainees, and road traffic law enforcement professionals. The intervention group (RTTDC) and control group (standard care) will include 3 hospitals each. The primary outcomes will be the interval from the accident to hospital admission and the interval from the referral decision to hospital discharge. The secondary outcomes will be all-cause mortality and morbidity associated with neurological and orthopedic injuries at 90 days after injury. All outcomes will be measured as final values. We will compare baseline characteristics and outcomes at both individual and cluster levels between the intervention and control groups. We will use mixed effects regression models to report any absolute or relative differences along with 95% CIs. We will perform subgroup analyses to evaluate and control confounding due to injury mechanisms and injury severity. We will establish a motorcycle trauma outcome (MOTOR) registry in consultation with community traffic police. RESULTS: The trial was approved on August 27, 2019. The actual recruitment of the first patient participant began on September 01, 2019. The last follow-up was on August 27, 2023. Posttrial care, including linkage to clinical, social support, and referral services, is to be completed by November 27, 2023. Data analyses will be performed in Spring 2024, and the results are expected to be published in Autumn 2024. CONCLUSIONS: This trial will unveil how a locally contextualized rural trauma team development program impacts organizational efficiency in a continent challenged with limited infrastructure and human resources. Moreover, this trial will uncover how rural trauma team coordination impacts clinical outcomes, such as mortality and morbidity associated with neurological and orthopedic injuries, which are the key targets for strengthening trauma systems in LMICs where prehospital care is in the early stage. Our results could inform the design, implementation, and scalability of future rural trauma teams and trauma education programs in LMICs. TRIAL REGISTRATION: Pan African Clinical Trials Registry (PACTR202308851460352); https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=25763. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55297.

Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation.

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted, sent to the intensive care unit (ICU), and sent to the operating room (OR).  Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentage of TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

Do emergency medical dispatchers choose the same response to serious injury in men and women - a qualitative study.

BACKGROUND: Recent research has indicated that sex is an important determinant of emergency medical response in patients with possible serious injuries. Men were found to receive more advanced prehospital treatment and more helicopter transportation and trauma centre destinations and were more often received by an activated trauma team, even when adjusted for injury mechanism. Emergency medical dispatchers choose initial resources when serious injury is suspected after a call to the emergency medical communication centre. This study aimed to assess how dispatchers evaluate primary responses in trauma victims, with a special focus on the sex of the victim. METHODS: Emergency medical dispatchers were interviewed using focus groups and a semistructured interview guide developed specifically for this study. Two vignettes describing typical and realistic injury scenarios were discussed. Verbatim transcripts of the conversations were analysed via systematic text condensation. The findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist. RESULTS: The analysis resulted in the main category "Tailoring the right response to the patient", supported by three categories "Get an overview of location and scene safety", "Patient condition" and "Injury mechanism and special concerns". The informants consistently maintained that sex was not a relevant variable when deciding emergency medical response during dispatch and claimed that they rarely knew the sex of the patient before a response was implemented. Some of the participants also raised the question of whether the Norwegian trauma criteria reliably detect serious injury in women. CONCLUSIONS: The results indicate that the emergency medical response is largely based on the national trauma criteria and that sex is of little or no importance during dispatch. The observed sex differences in the emergency medical response seems to be caused by other factors during the emergency medical response phase.

Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

Impact of video recordings review with structured debriefings on trauma team performance: a prospective observational cohort study.

PURPOSE: To determine the impact of structured debriefings (SD) with audio/video review of trauma patients' resuscitation events on trauma team (TT) technical and non-technical skills. METHODS: Single-center prospective observational cohort study. The study included all emergency department patients aged 18 years or older who received resuscitation from the TT. Virtual meeting was held with the TT using SD to review one trauma patient resuscitation video. Technical skills improvement was based on adherence to the ATLS protocol and non-technical skills based on T-NOTECHS scale. RESULTS: There was statistically significant improvement in adherence to the ATLS protocol: 73% [55-82%] vs 91% [82-100%] (p < 0.001); and improvement in T-NOTECHS scale: 12 [10-14] vs 16 [14-19] points (p < 0.001). CONCLUSION: In this study, we found that structured debriefings with review of patients' resuscitation video recordings can have a significant positive impact on trauma team performance in the emergency department in both technical and non-technical skills.

State of the art of trauma teams in Italy: A nationwide study.

Trauma teams play a vital role in providing prompt and specialized care to trauma patients. This study aims to provide a comprehensive description of the presence and organization of trauma teams in Italy. A nationwide cross-sectional epidemiological study was conducted between July and October 2022, involving interviews with 137 designated trauma centers. Centers were stratified based on level: higher specialized trauma centers (CTS), intermediate level trauma centers (CTZ + N) and district general hospital with trauma capacity (CTZ). A standardized structured interview questionnaire was used to gather information on hospital characteristics, trauma team prevalence, activation pathways, structure, components, leadership, education, and governance. Descriptive statistics were used for analysis. Results showed that 53 % of the centers had a formally defined trauma team, with higher percentages in CTS (73 %) compared to CTZ + N (49 %) and CTZ (39 %). The trauma team activation pathway varied among centers, with pre-alerts predominantly received from emergency medical services. The study also highlighted the lack of formally defined massive transfusion protocols in many centers. The composition of trauma teams typically included airway and procedure doctors, nurses, and healthcare assistants. Trauma team leadership was predetermined in 59 % of the centers, with anesthesiologists/intensive care physicians often assuming this role. The study revealed gaps in trauma team education and governance, with a lack of specific training for trauma team leaders and low utilization of simulation-based training. These findings emphasize the need for improvements in trauma management education, governance, and the formalization of trauma teams. This study provides valuable insights that can guide discussions and interventions aimed at enhancing trauma care at both local and national levels in Italy.

Rural Trauma Team Development Course Positively Impacts its Desired Objectives.

BACKGROUND: The Rural Trauma Team Development Course (RTTDC) is designed to help rural hospitals better organize and manage trauma patients with limited resources. Although RTTDC is well-established, limited literature exists regarding improvement in the overall objectives for which the course was designed. The aim of this study was to analyze the goals of RTTDC, hypothesizing improvements in course objectives after course completion. METHODS: This was a prospective, observational study from 2015 through 2021. All hospitals completing the RTTDC led by our Level 1, academic trauma hospital were included. Our institutional database was queried for individual patient data. Cohorts were delineated before and after RTTDC was provided to the rural hospital. Basic demographics were obtained. Outcomes of interest included: Emergency Department (ED) dwell time, decision time to transfer, number of total images/computed tomography scans obtained, and mortality. Chi square and non-parametric median test were used. Significance was set at P < .05. RESULTS: Sixteen rural hospitals were included with a total of 472 patients transferred (240 before and 232 after). Patient demographics were similar before and after RTTDC. ED dwell time was significantly reduced by 64 min (P = .003) and decision to transfer time was cut by 62 min (P = .004) after RTTDC. Mean total radiographic images and CT scans were significantly reduced (P < .001 and P = .002, respectively) after RTTDC. Mortality was unaffected by RTTDC completion (P = .941). CONCLUSION: The RTTDC demonstrates decreased ED dwell time, decision time to transfer, and number of radiographic images obtained prior to transfer. More rural hospitals should be offered this course.

Team communication patterns during real and simulated trauma resuscitation-a social network analysis.

In trauma teams, coordination can be established through a centralised leader. The team can also use a decentralised strategy. In this descriptive study of video-recorded trauma resuscitations, using quantification of qualitative data, Social Network analysis of all real-time communications of eight in-real-life (IRL) and simulated trauma teams explained team social structure. The communication network structures in the simulated scenarios were more centralised using individually directed speech and had a high proportion of communication to update all team members. Such a structure might be the result of work performed in a complexity-stripped simulation environment where simplified task-executions required less interactions, or from work revolving around a deteriorating patient, imposing high demands on rapid decision-making and taskwork. Communication IRL was mostly decentralised, with more variability between cases, possibly due to unpredictability of the IRL case. The flexibility to act in a decentralised manner potentiates adaptability and seems beneficial in rapidly changing situations.Practitioner summary: Efficient collaboration in trauma teams is essential. Communication in in-real-life and simulated trauma teams was analysed using social network analysis. The simulation teams were overall more centralised compared to the IRL teams. The flexibility to act decentralised seems beneficial for emergency teams as it enables adaptability in unpredictable situations.

Current trauma team activation processes at Canadian trauma centres: A national survey.

BACKGROUND: Trauma team activation (TTA) allows the provision of specialized and timely care to improve outcomes for severely injured patients. Limited information is available on the current state of TTA in Canadian trauma centres (TC). Study objectives were to describe TTA processes, data and reports, along with the challenges and successes from a national perspective. METHODS: A mixed-methods, cross-sectional survey was undertaken with Canadian trauma leadership, utilizing a total population sampling strategy. The questionnaire, containing 108-items, was administered online between February-April 2022, utilizing a modified Dillman technique. Descriptive statistics and thematic analyses were performed. RESULTS: Trauma leaders from 9 out of 10 provinces responded for a response rate of 68% (32/47). Two-thirds (67%) of respondents worked in adult TC; 63% in a level I center. A higher proportion of pediatric TC had a two-tiered TT response (60% pediatric; 35% adult). The most common criteria were neurologic compromise (100% one-level TTA) and hypotension (pediatric: 100% one-level, 100% tier 1; adult: 92% one-level, 86% tier 1). All one-level TTA included penetrating trauma criteria. One-third of respondents reported using TTA subgroup criteria for pediatric, pregnant, and/or geriatric patients. There was variability with disciplines responding to TTA, with largest, most comprehensive teams for tier 1. Two-thirds of TC review activation compliance (under/overtriage), while 55% focus on non-compliance and reasons for missed TTA. The most frequent challenges related to TTA practices were reliable data collection (60%) while successes included were the establishment of TTA guidelines to improve team compliance (33%) and RN initiated TTA. CONCLUSIONS: Some TTA practices were similar among Canadian TC, while others showed variability. Findings provide opportunities for improvement, including a two-tier system, geriatric-specific criteria, and RN initiated TTA, and could help establish national standards and best practices. Compliance with standards has the potential to improve Canadian TTA practices and patient outcomes.

Resource Deployment in Response to Trauma Patients.

Background Variance in the deployment of the trauma team to the emergency department (ED) can result in patient treatment delays and excess burden on ED personnel. Characteristics of trauma patients, including mechanism of injury, injury type, and age, have been associated with differences in trauma resource deployment. Therefore, this retrospective, single-site study aimed to examine the deployment patterns of trauma resources, the characteristics of the trauma patients associated with levels of trauma resource deployment, and the deployment impact on ED workforce utilization and non-trauma ED patients. Methodology This was an investigator-initiated, single-institution, retrospective cohort study of all patients designated as a trauma response and admitted to a community hospital's ED from July 01, 2019, through July 01, 2022. Results Resource deployment for trauma patients varied by mechanism of injury (p < 0.001), injury type (p < 0.001), and patient age groups (p < 0.001). Specifically, there was a lower average trauma activation for geriatric trauma patients with a fall as a mechanism of injury compared to all younger patient groups with any mechanism of injury (F(5) = 234.49, p < 0.001). In the subsample, there was an average of 3.35 ED registered nurses (RNs) allocated to each trauma patient. Additionally, the ED RNs were temporarily reallocated from an average of 4.09 non-trauma patients to respond to trauma patients, despite over a third of the trauma patients in the subsample being the trauma patients being discharged home from the ED. Conclusions Trauma activation responses need to be standardized with a specific plan for geriatric fall patients to ensure efficient use of trauma and ED personnel resources.

Evaluating the impact of pre-hospital trauma team activation criteria.

BACKGROUND: Little evidence exists studying the benefits of pre-hospital trauma team activation. Our study measured the impact of pre-hospital trauma team activation on 24-h survival. Our secondary objectives assessed the effects of pre-hospital trauma team activation on time to emergency procedure, computed tomography, blood transfusion, and critical administration threshold, as well as emergency department length of stay. METHODS: We conducted a 40-month health records review on all trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Outcomes were compared between pre-hospital and in-hospital trauma team activations. We used logistic and linear regression models to assess outcomes, while controlling for injury severity score, age, systolic blood pressure, and anti-coagulation use. A P value < 0.05 was considered statistically significant. A sensitivity analysis was also used to validate the primary outcome results. RESULTS: Of the 1013 trauma team activations occurring during the study period, 762 patients were included. The mean age (41.3 vs. 43.8) and percentage of males (79.4% vs. 77.5%) for pre-hospital activations were similar to their counterparts. Pre-hospital activations did not have a statistically significant effect on 24-h mortality (14.4% vs. 4.5%; P = 0.30). However, pre-hospital activations did demonstrate a statistically significant reduction in time (minutes) to emergency procedure (18.0 vs. 27.0; P < 0.001), computed tomography (37.0 vs 42.0; P = 0.009), and blood transfusion (14.0 vs. 28.0; P < 0.001), as well as emergency department length of stay (101.0 vs. 171.0; P < 0.001). CONCLUSION: When controlling for key covariates, pre-hospital trauma team activation did not have a significant effect on 24-h mortality, but did result in a significant reduction in time to emergency procedure, computed tomography, and blood transfusion, as well as emergency department length of stay. Our study demonstrates that pre-hospital trauma team activation can expedite patient intervention and disposition.

RéSUMé: CONTEXTE: Il existe peu de données sur les avantages de l'activation de l'équipe de traumatologie préhospitalière. Notre étude a mesuré l'impact de l'activation de l'équipe de traumatologie pré-hospitalière sur la survie à 24 heures. Nos objectifs secondaires ont évalué les effets de l'activation de l'équipe de traumatologie préhospitalière sur le délai de la procédure d'urgence, de la tomodensitométrie, de la transfusion sanguine et du seuil d'administration critique, ainsi que sur la durée du séjour dans les services d'urgence. MéTHODES: Nous avons procédé à un examen des dossiers médicaux sur 40 mois pour toutes les activations de l'équipe de traumatologie à l'Hôpital d'Ottawa, un centre de traumatologie de niveau 1. Les résultats ont été comparés entre les activations des équipes de traumatologie pré-hospitalières et intra-hospitalières. Nous avons utilisé des modèles de régression logistique et linéaire pour évaluer les résultats, tout en contrôlant le score de gravité des blessures, l'âge, la pression artérielle systolique et l'utilisation d'anticoagulants. Une valeur P < 0.05 a été considérée comme statistiquement significative. Une analyse de sensibilité a également été utilisée pour valider les résultats primaires. RéSULTATS: Sur les 1013 activations d'équipes de traumatologie survenues pendant la période de l'étude, 762 patients ont été inclus. L'âge moyen (41.3 contre 43.8) et le pourcentage d'hommes (79.4% contre 77.5%) pour les activations préhospitalières étaient similaires à ceux de leurs homologues. Les activations préhospitalières n'ont pas eu d'effet statistiquement significatif sur la mortalité à 24 heures (14.4% contre 4.5%; P = 0.30). Cependant, les activations préhospitalières ont démontré une réduction statistiquement significative du temps (minutes) nécessaire à la procédure d'urgence (18.0 contre 27.0; P < 0.001), à la tomodensitométrie (37.0 contre 42.0; P = 0.009) et à la transfusion sanguine (14.0 contre 0.009). 28.0; P < 0.001), ainsi que la durée du séjour aux urgences (101.0 contre 171.0; P < 0.001). CONCLUSION: En tenant compte des principales covariables, l'activation de l'équipe de traumatologie préhospitalière n'a pas eu d'effet significatif sur la mortalité à 24 heures, mais a entraîné une réduction significative du temps nécessaire à l'intervention d'urgence, à la tomodensitométrie et à la transfusion sanguine, ainsi que de la durée de séjour dans les services d'urgence.

The effect of a clock's presence on trauma resuscitation times in a Dutch level-1 trauma center: a pre-post cohort analysis.

PURPOSE: Interventions performed within the first hour after trauma increase survival rates. Literature showed that measuring times can optimize the trauma resuscitation process as time awareness potentially reduces acute care time. This study examined the effect of a digital clock placement on trauma resuscitation times in an academic level-1 trauma center. METHODS: A prospective observational pre-post cohort analysis was conducted for six months before and after implementing a visible clock in the trauma resuscitation room, indicating the time passed since starting the in-hospital resuscitation process. Trauma patients (age ≥ 16) presented during weekdays between 9.00 AM and 9.00 PM were included. Time until diagnostics (X-Ray, FAST, or CT scan), time until therapeutic intervention, and total resuscitation time were measured manually with a stopwatch by a researcher in the trauma resuscitation room. Patient characteristics and information regarding trauma- and injury type were collected. Times before and after clock implementation were compared. RESULTS: In total, 100 patients were included, 50 patients in each cohort. The median total resuscitation time (including CT scan) was 40.3 min (IQR 23.3) in the cohort without a clock compared to 44.3 (IQR 26.1) minutes in the cohort with a clock. The mean time until the first diagnostic and until the CT scan was 8.3 min (SD 3.1) and 25.5 min (SD 7.1) without a clock compared to 8.6 min (SD 6.5) and 26.6 min (SD 11.5) with a clock. Severely injured patients (Injury Severity Score (ISS) ≥ 16) showed a median resuscitation time in the cohort without a clock (n = 9) of 54.6 min (IQR 50.5) compared to 46.0 min (IQR 21.6) in the cohort with a clock (n = 8). CONCLUSION: This study found no significant reduction in trauma resuscitation time after clock placement. Nonetheless, the data represent a heterogeneous population, not excluding specific patient categories for whom literature has shown that a short time is essential, such as severely injured patients, might benefit from the presence of a trauma clock. Future research is recommended into resuscitation times of specific patient categories and practices to investigate time awareness.

On the edge of decision-making in trauma care: A focus group study on radiographers' experiences of interprofessional collaboration.

INTRODUCTION: The temporary trauma teams in trauma alerts consist of a diverse group of unique professionals requiring interprofessional collaboration and coordination to achieve efficient, high-quality care. The uncertain situation and complex care environment impose high demands on team dynamics such as individual attitudes and team behaviours. Within interprofessional teams, interaction and coordination reflect the collective success of collaboration and the achievement of goals. Interactions with radiographers have increased in trauma teams given computed tomography's prominent role in providing crucial knowledge for decision-making in trauma care. This study aimed to explore radiographers' experiences of interprofessional collaboration during trauma alerts. METHOD: The study was designed with focus group methodology, including 17 radiographers participating in five focus groups, analysed with an inductive focus group analysis. RESULTS: An overarching theme, "On the edge of decision-making", emerged along with three sub-themes: "Feeling included requires acknowledgement", "Exclusion precludes shared knowledge", and "Experience and mutual awareness facilitate team interaction". CONCLUSIONS: Interprofessional collaboration from the radiographer's perspective within trauma teams requires a sense of inclusion and the ability to interact with the team. Exclusion from vital decision-making obstructs radiographers' comprehension of situations and thereby the interdependence in interprofessional collaboration. IMPLICATIONS FOR PRACTICE: Common platforms are needed for knowledge sharing and team practices, including radiographers' areas of responsibility and relational coordination to foster interprofessional relationships. Through these means interdependence through awareness and shared knowledge can be facilitated on trauma teams.

Who are the trauma team leaders across Canada? A national survey evaluating the profession in adult and pediatric level one trauma centres.

OBJECTIVES: Trauma Team Leaders (TTLs) are critical for coordinating and leading trauma resuscitations. This survey sought to characterize the demographics and professional practices of Canadian TTLs at level one trauma centres. As a secondary objective, this information will be utilized to inform the operational goals of the Trauma Association of Canada (TAC) TTL Committee. METHODS: A detailed survey, developed by the TAC board of directors and TTL committee leads, was sent to 225 TTLs across Canada's level one trauma centres. TTLs were identified via contacting trauma directors at each level one centre, in addition to public registry searches. This survey captured demographics, professional background, resuscitation practices, trauma team composition, and TTL involvement in trauma responses. RESULTS: The response rate was 41.7%. Mean respondent age was 42 (SD 7.4) and 71.0% were male. Most TTLs trained in emergency medicine (53.1%) or general surgery (25.5%); 63.8% underwent TTL training: either via a trauma surgery fellowship or TTL fellowship. All centres have a massive hemorrhage protocol implemented, and there is no large variation between the rates of use of cryoprecipitate and fibrinogen, nor the ratio of blood products transfused (2:1 vs 1:1). Most TTL respondents intend to participate in a TTL group associated with TAC (85.1%). CONCLUSION: The results of this survey will contribute to the recognition of TTLs as a crucial role in the initial phase of care of severely injured trauma patients and serves as the first publication to document professional backgrounds and practices of Canadian TTLs at level one trauma centres. All the information gathered via this survey will be used by the TAC TTL Committee, which will focus on several initiatives such as the dissemination of best practice guidelines and creation of a TTL stream at the TAC Annual Conference.

RéSUMé: OBJECTIFS: Les chefs d'équipe de traumatologie (TTL) sont essentiels pour coordonner et diriger les réanimations traumatiques. Cette enquête visait à caractériser la démographie et les pratiques professionnelles des TTL canadiens dans les centres de traumatologie de niveau 1. À titre d'objectif secondaire, cette information sera utilisée pour éclairer les objectifs opérationnels du Comité TTL de l'Association canadienne de traumatologie (ATC). MéTHODES: Un sondage détaillé, élaboré par le conseil d'administration de l'ATC et les responsables des comités de TTL, a été envoyé à 225 TTL dans les centres de traumatologie de niveau 1 du Canada. Les TTL ont été identifiés en contactant les directeurs de traumatologie de chaque centre de niveau 1, en plus des recherches dans le registre public. Cette enquête a porté sur la démographie, les antécédents professionnels, les pratiques de réanimation, la composition de l'équipe de traumatologie et la participation de la TTL aux réponses traumatologiques. RéSULTATS: Le taux de réponse était de 41,7 %. L'âge moyen des répondants était de 42 ans (ET 7,4) et 71,0 % étaient des hommes. La plupart des TTL ont suivi une formation en médecine d'urgence (53,1%) ou en chirurgie générale (25,5%); 63,8% ont suivi une formation TTL : soit via une bourse en chirurgie traumatologique ou une bourse TTL. Tous les centres ont mis en œuvre un protocole d'hémorragie massive, et il n'y a pas de grande variation entre les taux d'utilisation du cryoprécipité et du fibrinogène, ni entre le rapport des produits sanguins transfusés (2:1 vs 1:1). La plupart des répondants TTL ont l'intention de participer à un groupe TTL associé au TAC ( 85,1 %). CONCLUSION: Les résultats de ce sondage contribueront à la reconnaissance des TTL comme un rôle crucial dans la phase initiale des soins aux patients ayant subi un traumatisme grave et serviront de première publication pour documenter les antécédents et les pratiques professionnelles des TTL canadiens au niveau un centres de traumatologie. Toutes les informations recueillies dans le cadre de cette enquête seront utilisées par le Comité TAC TTL, qui se concentrera sur plusieurs initiatives telles que la diffusion de lignes directrices sur les meilleures pratiques et la création d'un flux TTL à la conférence annuelle TAC.

Pediatric Trauma and Trauma Team Activation in a Swiss Pediatric Emergency Department: An Observational Cohort Study.

BACKGROUND: Trauma is one of the most common causes of death in childhood, but data on severely injured Swiss children are absent from existing national registries. Our aim was to analyze trauma activations and the profiles of critically injured children at a tertiary, non-academic Swiss pediatric emergency department (PED). In the absence of a national pediatric trauma database, this information may help to guide the design of infrastructure, processes within organizations, training, and policies. METHODS: A retrospective analysis of pediatric trauma patients in a prospective resuscitation database over a 2-year period. Critically injured trauma patients under the age of 16 years were included. Patients were described with established triage and injury severity scales. Statistical evaluation included logistic regression analysis. RESULTS: A total of 82 patients matched one or more of the study inclusion criteria. The most frequent age group was 12-15 years, and 27% were female. Trauma team activation (TTA) occurred with 49 patients (59.8%). Falls were the most frequent mechanism of injury, both overall and for major trauma. Road-traffic-related injuries had the highest relative risk of major trauma. In the multivariate analysis, patients receiving medicalized transport were more likely to trigger a TTA, but there was no association between TTA and age, gender, or Injury Severity Score (ISS). Nineteen patients (23.2%) sustained major trauma with an ISS > 15. Injuries of Abbreviated Injury Scale severity 3 or greater were most frequent to the head, followed by abdomen, chest, and extremities. The overall mortality rate in the cohort was 2.4%. Conclusions: Major trauma presentations only comprise a small proportion of the total patient load in the PED, and trauma team activation does not correlate with injury severity. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED. Our findings indicate that high priority should be given to training in the management of severely injured children in the PED. The leading major trauma mechanisms were preventable, which should prompt further efforts in injury prevention.

Implantación de un equipo de asistencia al trauma grave. Análisis de la activación y tiempos de asistencia en pacientes ingresados en UCI / Implementation of a severe trauma assistance team: Analysis of activation and attendance times in patients admitted to the ICU

Objetivo Analizar los factores asociados a la activación del equipo de asistencia al trauma grave (EATG) en pacientes que ingresan en la Unidad de Cuidados Intensivos (UCI), medir su repercusión en los tiempos de asistencia, y analizar los grupos de pacientes según activación y nivel de afectación anatómica. Diseño Estudio de cohortes prospectivo del trauma grave que ingresan en UCI. Desde junio 2017 a mayo 2019. Factores de riesgo de la activación analizados con regresión logística y árbol de clasificación tipo CART. Ámbito UCI hospital de segundo nivel. Pacientes Pacientes ingresados de forma consecutiva. Intervenciones Ninguna. Variables de intereses principales Activación del EATG. Variables demográficas. Puntuación de la gravedad de la lesión (ISS), intencionalidad, mecanismo, tiempos de asistencia, complicaciones evolutivas y mortalidad. Resultados Ingresaron un total de 188 pacientes (46,8% de activación EATG), edad mediana de 52 (37-64) años (activados 47 (27-62) vs. no activados 55 (42-67) p = 0,023), varones 84,0%. No diferencias en la mortalidad según activación. El modelo logístico encuentra como factores: la atención (16,6 [2,1-13,2]) e intubación prehospitalaria (4,2 [1,8-9,8]) y, la lesión grave de extremidades inferiores (4,4 [1,6-12,3]). Padecer una caída accidental (0,2 [0,1-0,6]) hace menos probable la activación. El modelo CART selecciona el tipo de mecanismo del traumatismo y es capaz de separar los traumatismos de alta y baja energía. Conclusiones Los factores asociados con activación del ETAG fueron la atención prehospitalaria, requerir intubación previa, mecanismos de alta energía y lesiones graves de extremidades inferiores. Menores tiempos de asistencia si activación sin influir en la mortalidad. Debemos mejorar la activación en pacientes mayores con traumatismos de baja energía y sin atención prehospitalaria (AU)

Objective To analyse the factors associated with the activation of the severe trauma care team (STAT) in patients admitted to the ICU, to measure its impact on care times, and to analyse the groups of patients according to activation and level of anatomical involvement. Design Prospective cohort study of severe trauma admitted to the ICU. From June 2017 to May 2019. Risk factors for the activation of the STAT analysed with logistic regression and CART type classification tree. Setting Second level hospital ICU. Patients Patients admitted consecutively. Interventions No. Main variables of interest STAT activation, demographic variables, injury severity (ISS), intentionality, mechanism, assistance times, evolutionary complications, and mortality. Results A total of 188 patients were admitted (46.8% of STAT activation), median age of 52 (37–64) years (activated 47 (27–62) vs. not activated 55 (42–67), p = 0.023), males 84.0%. No difference in mortality according to activation. The logistic model finds as factors: care (16.6 (2.1–13.2)) and prehospital intubation (4.2 (1.8–9.8)) and severe lower extremity injury (4.4 (1.6–12.3)). Accidental fall (0.2 (0.1–0.6)) makes activation less likely. The CART model selects the type of trauma mechanism and can separate high and low energy trauma. Conclusions Factors associated with STAT activation were prehospital care, requiring prior intubation, high-energy mechanisms, and severe lower extremity injuries. Shorter care times if activated without influencing mortality. We must improve activation in older patients with low-energy trauma and without prehospital care (AU)

Development of trauma team cognition can be explained by "split vision": A grounded theory study.

The aim of this study was to explore interaction of interprofessional hospital trauma teams. A theory about how team cognition is developed through a dynamical process was established using grounded theory methodology. Video recordings of in-real-life resuscitations performed in the emergency ward of a Scandinavian mid-size urban hospital were collected and eligible for inclusion using theoretical sampling. By analyzing interactions during seven trauma resuscitations, the theory that trauma teams perform patient assessment and resuscitation by alternating between two process modes, the two main categories "team positioning" and "sensitivity to the patient," was generated. The core category "working with split vision" explicates how the teams interplay between the two modes to coordinate team focus with an emergent mental model of the specific situation. Split vision ensures that deeper aspects of the team, such as culture, knowledge, empathy, and patient needs are absorbed to continuously adapt team positioning and create precision in care for the specific patient.

Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey.

Background: Trauma is the leading cause of death in India resulting in a significant public health burden. Indian Society of Critical Care Medicine (ISCCM) has established a trauma network committee to understand current practices and identify the gaps and challenges in trauma management in Indian settings. Material and methods: An online survey-based, cross-sectional, descriptive study was conducted with high-priority research questions based on hospital profile, resource availability, and trauma management protocols. Results: Data from 483 centers were analyzed. A significant difference was observed in infrastructure, resource utilization, and management protocols in different types of hospitals and between small and big size hospitals across different tier cities in India (p < 0.05). The advanced trauma life support (ATLS)-trained emergency room (ER) physician had a significant impact on infrastructure organization and trauma management protocols (p < 0.05). On multivariate analysis, the highest impact of ATLS-trained ER physicians was on the use of extended focused assessment with sonography in trauma (eFAST) (2.909 times), followed by hospital trauma code (2.778 times), dedicated trauma team (1.952 times), and following trauma scores (1.651 times). Conclusion: We found that majority of the centers are well equipped with optimal infrastructure, ATLS-trained physician, and management protocols. Still many aspects of trauma management need to be prioritized. There should be proactive involvement at an organizational level to manage trauma patients with a multidisciplinary approach. This survey gives us a deep insight into the current scenario of trauma care and can guide to strengthen across the country. How to cite this article: Sodhi K, Khasne RW, Chanchalani G, Jagathkar G, Kola VR, Mishra M et al. Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey. Indian J Crit Care Med 2023;27(1):38-51.

Does mortality after trauma team activation peak at shift change?

BACKGROUND: Prior institutional data have demonstrated trauma mortality to be highest between 06:00-07:59 at our center, which is also when providers change shifts (07:00-07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA). METHODS: All TTA patients at our ACS-verified Level I trauma center were included (01/2008-07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00-07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching. RESULTS: After exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32-50] vs. 34[27-50], p < 0.001). Time to CT scan (36[23-66] vs. 38[23-61] minutes, p = 0.638) and emergent surgery (94[35-141] vs. 63[34-107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764). CONCLUSIONS: Early morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.

STRAUMA: A Novel Alert System for a Combined Stroke and Trauma.

INTRODUCTION: Cerebrovascular accident (CVA) can lead to traumatic injury. While timely administration of tissue plasminogen activator (tPA) can be lifesaving in CVAs, it is contraindicated with active bleeding. A STRAUMA is a combined stroke and highest-level trauma activation for patients with suspected CVA and signs of trauma. The purpose of this study is to evaluate the impact of the STRAUMA activation on time to CT and patient outcomes. METHODS: A retrospective review was conducted on adult patients presenting to a Level 1 trauma and comprehensive stroke center with signs of CVA between 01/2019 and 09/2020. Patients who had a STRAUMA activation were compared to patients who had a stroke alert. RESULTS: Five hundred and eighty patients met the inclusion criteria. Of these, 111 had STRAUMA activations and 469 had stroke alerts. There were no differences in age, gender, or anticoagulation use. The STRAUMA group had a higher NIH stroke scale (NIHSS) (11 vs 5, P<.0001). The STRAUMA group had a longer time to CT (23.1 min vs 16.9 min, P<.0001) and a lower rate of tPA (13.5% vs 27.9%, P = .001). Time to tPA and thrombectomy were similar. The STRAUMA group had a 15% rate of traumatic injury with a median injury severity score of 9. Mortality was higher in the STRAUMA group (14.4% vs 6.0%, P = .003). Multivariable logistic regression identified NIHSS and time to CT as predictors of mortality. STRAUMA did not predict mortality. CONCLUSION: The novel STRAUMA activation allows for an evaluation of both stroke and trauma to facilitate safe and timely administration of lifesaving interventions.