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%
• Implementation AIS2008
• Patient characteristics and care process
• Outcome evaluation
Highlights registry data 2015
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
s
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
mb
er
adm
itte
d t
rau
ma
pat
ien
ts
Age (per year)
males females
The Dutch Trauma Registry: Patient characteristics and care process
0
100
200
300
400
500
600
700
66 95+
Nu
mb
er
adm
itte
d t
rau
ma
pat
ien
ts x
10
.00
0
males females
Age x gender admitted trauma patients (incidence rate x 10.000) (2015)
The Dutch Trauma Registry: Patient characteristics and care process
Injury cause admitted trauma patients (2015)
The Dutch Trauma Registry: Patient characteristics and care process
All Severely injured (ISS>15)
Transport admitted trauma patients (2015)
The Dutch Trauma Registry: Patient characteristics and care process
31%
15%
1% 6%
10%
3%
25%
47%
5%
Pe
rce
nta
ge o
f p
atie
nts
Injury distribution admitted trauma patients (2015)
20% hip fracture
The Dutch Trauma Registry: Patient characteristics and care process
Hospital stay – admitted* trauma patients (2015)
The Dutch Trauma Registry: Patient characteristics and care process
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)
The Dutch Trauma Registry: Patient characteristics and care process
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
The Dutch Trauma Registry: Patient characteristics and care process
Glasgow Outcome Score at discharge - survivors (2015)
Preliminary results (31% missing)
The Dutch Trauma Registry: Patient characteristics and care process
• Implementation AIS2008
• Patient characteristics and care process
• Outcome evaluation
Highlights registry data 2015
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
200
250
300
350
400
450
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)
Outcome: expected versus observed mortality
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)
Outcome: expected versus observed mortality
Psurvival distribution (PSNL15) (2015)
77.027
4.816 1.147 491 178 149
21% 25%
59%
80% 84% 87%
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
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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ge t
reat
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at
Trau
ma
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Nu
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pat
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PSurvival (PSNL15)
Total % trauma center
Outcome: expected versus observed mortality
SMR Funnelplot
Standardized Mortality Ratio (SMR): observed/expected : indirect comparison
Outcome: expected versus observed mortality
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)