trends in the german trauma system registry, …...trends in the german trauma system registry,...

Institut für Forschung in der

Operativen Medizin (IFOM)

TraumaRegister DGU®

Trends in the German

trauma system

Registry, Network, Outcome

Rolf Lefering

Institute for Research in Operative Medicine (IFOM)

University Witten/Herdecke

Cologne, Germany

[email protected]




German Trauma Society DGU (Deutsche Gesellschaft für Unfallchirurgie)

TraumaNetzwerk DGU®


P.A.R.T.Y. Injury Prevention

TKmed ®

AltersTraumaZentrum DGU®

ATLS Courses

Sektion NIS

of DGU

Rolf Lefering

Scientific

Leadership

Cooperation / Service Owner

of the data




Trends ….

• TraumaRegister DGU®

• Regional trauma networks

• Number of trauma patients

• Trends in trauma care

• Better survival (?)




254 395 688 616 844 1066 15482465 2782 3098 3269 3279 3843

51566745 6711

10141

16985

24688

29998

34878

3804639346

0

5.000

10.000

15.000

20.000

25.000

30.000

35.000

40.000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Annual Number of Patients

Working group

‚Polytrauma‘

founded

National

research

grant

Online data

collection

introduced

Obligatory tool for quality

assessment in regional

trauma networks




TR-DGU Patients 2015

100%

89%

66%

78%

9%

55%

45%

26%

12%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




Paffrath et al, Injury 2014, 45S: S64-S69

Berlin

definition

Isolated

trauma

Severely

injured




5 Hospitals

Working Group „Polytrauma“ No Networks 1993




657 participating hospitals 52 certified networks 2016




2005

Participation in the registries of DGU

is obligatory.




2012

The TraumaRegister DGU® is the basis for

quality assessment in trauma care.




Trauma Networks in Germany

• Managed by Trauma Society / AUC GmbH

• Audit in each hospital (re-audit every 3 years)

• Three levels of care defined: local / regional / supra-regional trauma center

• Network contract of cooperation

• Regular meetings

• Registry participation obligatory

• Costs: 5000€ /audit; 650€ /year for registry

Ruchholtz et al. “TraumaNetzwerk DGU®: Optimizing patient flow

and management“ Injury 2014, 45 (Suppl. 3) S89-S92




14.04.2010: Zertifikatsübergabe für die TraumaNetzwerke

Südhessen, Mittelhessen und Osthessen in Wiesbaden




Number of Trauma Patients

Is there a general incease / decrease?

How many patients should be treated in a local

/ regional / supra-regional trauma center?




Three different approaches:

1. Hospital method

2. State method

3. Network method

TraumaRegister DGU® / AKUT

Year 2012: 450 hospitals

17 certified netwerks

ISS ≥ 16

Debus et al,

Ärzteblatt Int. 2015, 112: 823–9




1. Hospital method

Patientes with ISS≥16 in …

Supra-regional Trauma Centers

85 /year

Regional Trauma Centers

25 /year

Local Trauma Centers

3,5 /year




Hospital

method

State

method

Netzwork

method

No. of patients with

ISS 16+ 16.558 16.514 16.554

Estimated under-

reporting (10%) 18.214 18.165 18.209

Number of Trauma Patients




Trends in Trauma Networks

• Is there a shift from smaller to larger hospitals?

• Improved infrastructure?

• Adequate sample size per center?

• Is there a difference in outcome?




Trends in Trauma Networks

• Is there a shift from smaller to larger hospitals?

Partially, from level 3 to level 1/2

• Improved infrastructure?

Level 3 hospitals improved most

• Adequate sample size per center?

None / 20 / 40 (ISS 16+)

• Is there a difference in outcome?

Maybe




Trauma Patients and Level of Care 2013-15

29588

53571

9412Level 3 (local)

Level 2 (regional)

Level 1 (supra-regional)

32% 58%

10%




Zacher et al.,

Br. J. Surg. 2015,

102: 1213-1219

Number of

Patients and

Outcome

ISS 16+




Ruchholtz et al. J. Trauma,

2014; 76: 1456-61

Level of Care

and Outcome

Patients:

- Year 2012

- Germany

- Certified trauma center

- ICU treatment (or death)




Letalität – Prognose im Zeitverlauf

RISC: n = 1.206

RISC II:

n = 30.866



TraumaRegister DGU® RISC II - Second draft

Variable Value Coefficient

Sex female + 0,2 male / ??? 0

ASA 1-2 + 0,3 pre-trauma 3 / ??? 0 4 - 1,3

Mechanism blunt / ??? 0 penetrating - 0,6

GCS motor normal + 0,6 function directed / ??? 0 non-directed - 0,4 none - 0,8

Systolic BP < 90 - 0,7 on admission 90-110 / ??? 0 111-150 + 0,3 > 150 0

CPR nein / ??? 0 ja - 1,8

Coagulation: < 1,2 + 0,6 INR 1,2 - 1,4 + 0,2 1,4 - 2,4 / ??? 0 > 2,4 - 0,4

Blood: 12,0 + 0,4 Hemoglobin 7,0-11,9 / ??? 0 <7,0 - 0,5

Acidosis: < 6 +0,3 Base deficit 6-9 / ??? 0 9-15 - 0,4 15+ - 1,5

Variable Value Coefficient

Constant + 3,6

Worst AIS 3 - 0,5 injury AIS 4 - 1,3 AIS 5 - 1,7 AIS 6 - 2,9

Second AIS 0-2 + 0,2 worst AIS 3 0 injury AIS 4 - 0,6 AIS 5 - 1,4

Head AIS 0-2 0 injury AIS 3/4 - 0,2 AIS 5/6 - 0,8

Age 1-5 + 1,4 6-10 + 0,6 11-54 0 55-59 - 0,5 60-64 - 0,8 65-69 - 0,9 70-74 - 1,2 75-79 - 1,9 80-84 - 2,4 85+ - 2,7

Pupil brisk + 0,2 reactivity sluggish/??? 0 fixed - 1,0

Pupil normal + 0,2 size anisocoric/??? 0 bilat. dilated - 0,5

RISC II




Level of Care and Outcome

Annual Report 2016

Years 2013-15 combined

TraumaRegister DGU; Annual Report 2016

available at: www.auc-online.de

http://www.auc-online.de/






Trends in Trauma Care

• Age

• Whole-body CT

• Intubation

• Volume




0%

10%

20%

30%

40%

50%

30

35

40

45

50

55

1993-99

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Pa

tie

nts

ag

ed

60

or

old

er

(%)

Me

an

ag

e (

ye

ars

)

mean age

60 years or older (%)

Age

TraumaRegister DGU® 1993-2012; Germany; ISS 16+; n=49,801

Lefering et al., Injury 2014




Whole-Body CT

• There is a survival benefit for WB-CT Huber-Wagner, Lancet 2009

• Even patients in shock

benefit from WB-CT Huber-Wagner, PLOS one 2013

• Location near the

emergency room Huber-Wagner, Injury 2014




Whole-body CT

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

CT

WB-CT

x-ray thorax

TraumaRegister DGU®; Germany 2000-2013; primary admitted;

ISS 9+ and intensive care; n=81.210




Preclinical Volume & Intubation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1993-99

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Pre

-ho

sp

ital

inte

rven

tio

n p

erf

orm

ed

(%

)

Intubation with GCS 9-15

Intubation with GCS 3-8

Volume > 1000 ml






Coagulation status on hospital admission Thromboplastin Time (Quick‘s value)

73,6 73,374,3

75,9

77,5 77,877,3

76,2

78,4

79,9

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Mean

vo

lum

e (

ml)

66

68

70

72

74

76

78

80

82

preclinical volume

Quick (%)




Coagulation status on hospital admission Hemoglobin

10,911,1 11,0

11,4 11,5 11,5 11,6 11,712,0

12,3

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Mean

vo

lum

e (

ml)

9

10

11

12

13

preclinical volume

Hemoglobin




Blood Transfusion until ICU

0%

10%

20%

30%

40%

50%

60%

1993-99

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Pati

en

ts w

ith

tra

nsfu

sio

n (

%)

blood transfusion

massive transfusion






Prehospital

Tranexamic

Acid

258 pairs matched

by propensity score (ADAC air rescue service)




• Successful implementation of nation-wide

networks in Germany

• Improved outcome but causal proof is difficult

(interaction of multiple effects)

• Trauma registration is mandatory

Summary




• Injury scoring & definitions

• Update of quality indicators

• Cross-border comparisons

• Primary admission versus transfer

• Quality of Life: Outcome beyond the

acute care

• Data quality

Future Tasks

trends in the german trauma system registry, …...trends in the german trauma system registry,...

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