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EMJ Online First, published on March 25, 2014 as 10.1136/emermed-2013-203402 Original article

An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre P Jenkins,1 J Rogers,2 A Kehoe,2 J E Smith2,3,4 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ emermed-2013-203402). 1

University of Plymouth, Plymouth, UK 2 Emergency Department, Derriford Hospital, Plymouth, UK 3 Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK 4 College of Emergency Medicine, UK Correspondence to Dr Jason E Smith, Emergency Department, Derriford Hospital, Plymouth PL6 8DH, UK; [email protected] Received 8 November 2013 Revised 11 February 2014 Accepted 1 March 2014

ABSTRACT Objectives and background Appropriate activation of multidisciplinary trauma teams improves outcome for severely injured patients but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a twotiered trauma team activation system. The emergency department trauma team (EDTT) is activated in response to a significant traumatic mechanism; the hospital trauma team (HTT) is activated when this mechanism coexists with physiological abnormality or specific anatomical injury. The aim of this study was to compare characteristics, process measures and outcomes between patients treated by EDTTs or HTTs to evaluate the approach in a UK setting. Methods A retrospective database review was performed using Trauma Audit Research Network (TARN) and the local source trauma database. Patients who activated a trauma team between 1 April and 30 September 2012 were included. Patients were categorised according to the type of trauma team activated. Data included time to X-rays, time to CT, time to intubation, numbers discharged from ED, intensive care unit admission, injury severity score and mortality. Results During the study period, 456 patients activated a trauma team with 358 EDTT and 98 HTT activations. Patients seen by the ED team were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion. Differences in time taken to key investigations were statistically but not clinically significant. Conclusions A two-tiered trauma team activation system is an efficient and cost-effective way of dealing with trauma patients presenting to a major trauma centre in the UK.

INTRODUCTION

To cite: Jenkins P, Rogers J, Kehoe A, et al. Emerg Med J Published Online First: [please include Day Month Year] doi:10.1136/emermed2013-203402

Traumatic injury is the commonest cause of death and disability in patients under 40 years old in Western countries.1 Outcome from traumatic injury can be optimised by the appropriate activation of a multidisciplinary trauma team to receive the patient on arrival at hospital, reducing time to effective diagnosis and intervention, influencing both morbidity and mortality.2 In a major trauma centre (MTC), in addition to seriously injured patients, a large number of less severely injured patients may also need to be treated.3 As activation of trauma teams is time and labour intensive, it is essential that resources are appropriately used. However, underactivation of a trauma team may lead to poorer outcomes.1 4 A two-tier activation system may be an appropriate system to manage trauma in a UK MTC. This approach consists of a smaller emergency department trauma team (EDTT) being activated in

Jenkins P, et al. Emerg Med J 2014;0:1–4. doi:10.1136/emermed-2013-203402 Copyright Article author (or their employer) 2014.

response to certain mechanistic triggers and a larger hospital trauma team (HTT) being activated according to additional specific physiological and anatomical criteria. If it becomes apparent that a patient who is the subject of an EDTT activation would benefit from the larger multidisciplinary team, then the trauma call can be escalated to a HTT response at any stage. Although this approach has been previously described in other countries, there have been no UK studies demonstrating the effectiveness and safety of such a system.5 Our hospital has used a two-tier system since 2005 and was designated as a MTC in April 2012. We suggest that a two-tier system distinguishes between patients with serious injuries requiring intervention and those less seriously injured, requiring less intensive treatment. In an age when healthcare is dominated by efficiency savings and lean methodology, a two-tier system may be the most appropriate way to manage trauma within the UK.6 7 Prealerts are received from the prehospital environment using the ATMIST structure (Age of the patient; Time of injury; Mechanism of injury; Injuries apparent; vital Signs; Treatment administered).8 Activation of trauma teams is then performed via switchboard and the ED intercom system using a predefined triage strategy (available as a web resource).5 These criteria are based on recommendations made by the American College of Surgeons (ACS) Committee on Trauma and Royal College of Surgeons modified according to local experience and clinical policy.4 9 Trauma teams are assembled prior to patient arrival and are briefed by the team leader with roles allocated and the expected resuscitation trajectory outlined. Data are transcribed in real time in trauma booklets by the scribe, and subsequently analysed by trauma nurse coordinators, who populate a local trauma database prior to data submission to the Trauma Audit Research Network (TARN). The aim of this study was to compare characteristics, process measures, resource use and outcomes between patients treated by EDTT or HTT in our hospital to evaluate the approach in a UK setting.

METHODS Derriford Hospital ED receives approximately 90 000 patients per year and is the MTC within the Peninsula Trauma Network, where there are four other designated trauma units. We conducted a retrospective analysis of all adult and paediatric trauma calls attending the ED during the period 1 April to 30 September 2012 using the local source trauma database and the national TARN database. TARN eligibility includes trauma patients of any age who are admitted to hospital

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Original article for 72 h or more, are admitted to a critical care unit, die in hospital or are transferred to another hospital for specialist care. Specific patient groups, such as those aged over 65 years, who are admitted due to a fracture of the neck of femur, are excluded.10 11 Patients were categorised according to the type of trauma team activated to receive them (EDTT or HTT). Data collected included mechanism of injury, grade of trauma team leader, time to primary survey radiographs, time and nature of advanced imaging, interventions required in the resuscitation room, blood products used, prehospital vital signs, injury severity score (ISS), disposal and outcome. Patients transferred in from other centres were not included in this study as the two-tier activation system is not used for these patients in our trust (all are routinely met by a HTT, and time-critical investigations and interventions will usually already have been performed at the referring hospital). There were no other exclusion criteria. Patients in whom an EDTT was initially called, and then escalated to a HTT on arrival, were classified as HTT for the purposes of the analysis. Although prehospital systems alert the department to the majority of trauma patients, occasionally cases are not appropriately alerted, or patients self-present following significant trauma. These patients were also taken into account, consulting the TARN database for those patients that did not receive a

trauma team response. These were then cross-referenced with the ED electronic system to determine the appropriateness of care. Data analysis was performed using SPSS software (IBM Armonk, New York, USA). The study was registered with the Plymouth Hospitals NHS Trust Clinical Audit Department.

RESULTS During the 6-month period, there were 456 primary trauma team activations. Of these, 358 patients (78.7%) prompted EDTT activation and 98 (21.3%) provoked a HTT response. A further 101 patients were transferred urgently from referring trauma units and either received a HTT response or bypassed the ED and were admitted directly to theatre, the intensive care unit (ICU) or specialist wards. This group was not included in our analysis. Mechanism of injury differed somewhat between the two remaining groups (see table 1). Motor vehicle collision was the predominant mechanism in both groups, followed by falls from height. There was a significant difference in resource use between the two groups. Presence of an ED Consultant was achieved in 98% of HTT activations compared with 71% of the EDTT activations (p2 m Fall

An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre.

Appropriate activation of multidisciplinary trauma teams improves outcome for severely injured patients but can disrupt normal service in the rest of ...
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