the dutch trauma registry facts and figures 2015

The Dutch Trauma Registry facts and figures 2015

2nd November 2016

Symposium Trauma Systems

Leontien Sturms ([email protected])

Dutch Network for Acute Care

NO CONFLICT OF INTEREST

Regionalisation Dutch trauma Care

11 designated level 1 regional trauma centers (1999)

Responsibilities regional trauma centers:

care for the most severely injured (deployment Mobile Medical Team)

set up 11 trauma networks

monitor trauma care with trauma registry

knowledge/expert center (guidelines etc)

MMT

MMT

MMT

MMT

Dutch Trauma Registry (2007)

The Dutch Trauma Registry

Inclusion criteria:

All injured patients treated at ED (≤ 48h accident) and directly admitted to the hospital (including transfers/death at ED (excl. DOA))

Dataset

- 2007-2013: MTOS1 dataset (AIS98) + prehospital data

- 2014: addition items - Utstein Template2

- 2015: implementation Abbreviated Injury Scale 2008

1. Champion HR, Copes WS, Sacco WJ et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma. 1990; 30: 1356-65.

2. KG Ringdal et al. The Utstein template for uniform reporting of data following trauma: a joint revision by SCANTEM, TARN, DGU-TR and RIGT. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2008; 16:3-19.

• Implementation AIS2008

• Patient characteristics and care process

• Outcome evaluation

Highlights registry data 2015

Implementation AIS2005, update 2008 in 2015

New codes/removed codes/severity changes of codes

ISS on average lower

Injury Severity Score (ISS)

- anatomical scoring system

- based on the Abbreviated Injury Scale (AIS)

- overall score for patients with multiple injuries

- severely injured => ISS≥16

AIS 1998 - AIS 2008

Severely injured AIS98-AIS08

2014

ISS>15 (AIS98) 2015

ISS>15 (AIS08)

n=5.882 (7%) n=4.202 (5%)

prehospital MMT 15% 21%

prehospital RTS≤10 23% 34%

directly to theatre 7% 12%

ICU admission 47% 56%

Hospital mortality 12% 17%

Number of patients

Dutch Trauma Registry Database: 630.000 admitted trauma patients (2007-2015)

43.317

56.924 62.990

68.600 71.609

76.351 79.520

83.287 83.870

64%

74% 77%

84% 89%

96% 98% 99% 100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

10.000

20.000

30.000

40.000

50.000

60.000

70.000

80.000

90.000

100.000

2007 2008 2009 2010 2011 2012 2013 2014 2015

Par

tici

pat

ion

rat

e

Nu

mb

er c

ase

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Number cases Participation hospitals

The Dutch Trauma Registry: Patient characteristics and care process

230 trauma admissions per day

Trauma admissions per hospital (2015)

2.280

0

500

1.000

1.500

2.000

2.500

Nu

mb

er

trau

ma

adm

issi

on

s

Non trauma center Trauma center

Age x gender admitted trauma patients (2015)

0

200

400

600

800

1000

1200

1400

66 95+

Nu

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Age (per year)

males females


0

100

200

300

400

500

600

700

66 95+

Nu

mb

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adm

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d t

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ts x

10

.00

0

males females

Age x gender admitted trauma patients (incidence rate x 10.000) (2015)


Injury cause admitted trauma patients (2015)


All Severely injured (ISS>15)

Transport admitted trauma patients (2015)


31%

15%

1% 6%

10%

3%

25%

47%

5%

Pe

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f p

atie

nts

Injury distribution admitted trauma patients (2015)

20% hip fracture


Hospital stay – admitted* trauma patients (2015)


3 5

8

11

14

12

6

ISS 1-3 ISS 4-8 ISS 9-15 ISS 16-24 ISS 25-49 ISS 50-75 Total

Me

an n

um

be

r o

f d

ays

ho

spit

al

(95

%C

I)

* Excluding transfers out

ICU – admitted trauma patients (2015)


Hospital mortality* (2015) (2.5%)

* Excluding transfers out

1% 1% 3% 8%

39%

68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

5.000

10.000

15.000

20.000

25.000

30.000

ISS 1-3 ISS 4-8 ISS 9-15 ISS 16-24 ISS 25-49 ISS 50-75

Number patients % mortality


Glasgow Outcome Score at discharge - survivors (2015)

Preliminary results (31% missing)


Outcome evaluation

(a) right patient, right place, right time

(b) observed versus expected mortality

Right patient, right place, right time

In general:

• Less severe injuries (ISS 1-15) → nearby hospital

• Severely injured (ISS>15) → 11 level 1 regional trauma centers

Time required to first CT ISS≥16 (2015)

Outcome: getting the right patient to the right hospital?

ISS ≥ 16 67% trauma centers

“getting the patient to the right hospital?”

ISS 1-15 21% trauma centers

61%

58%

77%

70%

74%

73%

63%

87%

68%

62%

36%

Trauma networks overall percentage ISS>15 in trauma centers (36%-87%) Figure 45 annual report

0

50

100

150

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350

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500

Nu

mb

er

ISS≥

16

Non trauma center Trauma center Volume n=100

Volume per hospital ISS≥16 (2015)

Outcome: getting the right patient to the right hospital?

Figure 44 annual report

Performance

- Hospital mortality

- Expected versus observed

=> expected = TRISS (psurvival) (1987)

- US MTOS coefficients (1982-1987, update 1995)

- US NTDB coefficients (2002-2006)

MTOS coefficients = Champion HR et al. Injury Severity Scoring Again. Journal of Trauma 1995; 38: 94-95.

NTDB coefficients = Schluter et al. Trauma and Injury Severity Score (TRISS) Coefficients 2009 Revision. Journal of Trauma 2010.

Missing RTS = max value ; Ws = Hollis S. et al. Standardized comparison of performance indicators in trauma: a new approach to case-mix variation. J Trauma 1995; 38: 763-766

Outcome: expected versus observed mortality

Netherlands versus US

-0,19 -0,03

0,13 0,26

-0,36

-1,50

-1,00

-0,50

0,00

0,50

1,00

1,50

2011 2012 2013 2014 2015

Ws Netherlands [NTDB (2002-2006) TRISS coefficients]

Missing RTS = max value ; NTDB fractions; Ws = Hollis S. et al. Standardized comparison of performance indicators in trauma: a new approach to case-mix variation. J Trauma 1995; 38: 763-766

‘standardised excess survival rate’ : Ws = direct comparison (standardised US national case-mix)


AIS 98 AIS 08

Dutch - TRISS coefficients 2015

NTDB coefficients = Schluter et al. Trauma and Injury Severity Score (TRISS) Coefficients 2009 Revision. Journal of Trauma 2010.

BLUNT INJURIES – DUTCH TRISS COEFFICIENTS 2015

ED measurement Dutch

PS NL 2015 NTDB

(Schluter 2010) Δ p value

b0 Intercept 1,509 1,649 -0,140 0,719

b1 RR 0,237 0,010 0,228 0,001

b2 SBP 0,646 0,426 0,220 0,004

b3 GCS 0,401 0,631 -0,230 0,001

b4 ISS -0,109 (AIS08) -0,080 (AIS98) -0,029 0,000

b5 AGE (>55) -2,209 -1,627 -0,588 0,000

Psurvival = 1 / (1+e-b) ;

b=b0 + b1(RR code) + b2(SBP code) + b3(GCS code) + b4(ISS) + b5(Age)


Psurvival distribution (PSNL15) (2015)

77.027

4.816 1.147 491 178 149

21% 25%

59%

80% 84% 87%

0%

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90%

100%

0

10.000

20.000

30.000

40.000

50.000

60.000

70.000

80.000

1.00-0.96 0.95-0.91 0.90-0.76 0.75-0.51 0.50-0.26 0.25-0.00

Pe

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PSurvival (PSNL15)

Total % trauma center


SMR Funnelplot

Standardized Mortality Ratio (SMR): observed/expected : indirect comparison


Figure 55 annual report

Improvements need to be made…

• More direct treatment ISS≥16 at 11 regional trauma centers

• Probability of survival -‘Ps’ risk adjustment model Dutch Trauma Registry

• Improve completeness of registry data

• …. Further analyses!

AGENDA

Special thanks to

- All participants

- Scientific committee

- Reports: Carin Zwartjes (IVZ)

- Analyses: Sonia Amodio & Erik van Zwet (biostatistics LUMC)

- Database: Brigit Kooijman & Ronald Brand (Advanced Datamanagement LUMC)

the dutch trauma registry facts and figures 2015

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