The ABCDE of Dutch trauma system performance

Abstract

Trauma registries have been established to collect comprehensive data for quality assessment, improvement, and research purposes. Trauma registries document a range of information on injured patients such as demographics, injury details, pre-hospital care, hospital presentation, interventions, and outcomes. The Dutch Nationwide Trauma Registry is an all-inclusive registry meaning all acutely admitted trauma patients are included. This fundamental difference compared to other national trauma registries, described and analyzed in this thesis, provides the opportunity to assess the total burden of injury and to evaluate the quality of care of the entire trauma system. Consequently, this thesis discloses the accuracy with which severely injured patients are centralized and treated at the designated level-I trauma centres in the Netherlands. Moreover, our multivariable regression analysis revealed that elderly patients, females, patients injured due to ground-level falls or with severe thoracic or abdominal injuries were associated with undertriage. Current practice to identify severely injured patients tends to focus mainly on the presence of multiple anatomical injuries. By comparing widely used definitions describing severely injured patients we provided supporting evidence that a patient with a severe isolated injury poses an equal threat to life, and requires a substantial number of medical resources compared to those with multiple injuries. In addition, we confirmed that the combination of physiological disturbances and anatomical injury classification are more indicative of a poor prognosis and medical resource use. Furthermore, we evaluated the epidemiological changes and the level of provided trauma care during a period of relentless healthcare. These studies provided new insights into the secondary behavioral shifts leading to increased incidence of violence and self-harm. Moreover, we revealed that the pressure on the Intensive Care Unit has likely led to the preventable death of a specific group of trauma patients with minor to moderately severe traumatic brain injuries. Lastly, in order to facilitate continuous monitoring of the quality of trauma care in the Netherlands, a prediction model and a regulatory guideline for the evaluation of hospital-specific survival performance was developed. This model accurately estimates the probability of death for all acutely hospitalized trauma patients. Trends at hospital level can be visualized by means of a graphical representation of the ratio of the actual number and the predicted number of deaths.