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    • br Materials and methods We revised

    2018-11-12


    Materials and methods We revised a set of criteria for TPA to include (1) Glasgow Coma Scale (GCS) score ≤13, (2) systolic blood pressure (BP) ≤90 mmHg, (3) fall of more than 6 m in height, and (4) head, neck, or torso gunshot wound (Table 1). When an injured patient meets the TPA criteria, the triage nurse should initiate a trauma code. The surgeon in charge of trauma care can also activate a trauma code if it is felt necessary. Once a trauma code is activated, the patient is brought to a designated trauma bay area and cared for by a team according to Advanced Trauma Life Support (ATLS) principles. All the consultants required are alerted and they are expected to present in the emergency room (ER) within 30 minutes. Trauma patients take priority over other ER patients for portable X-ray examinations or CT scans. Data are expressed as mean ± SD. Comparisons among groups were performed using analysis of variance or a Student t test for parametric data and a χ2 test for categorical data. Significance was set to a value of p < 0.05.
    Results During the first 10 months of the study kainate receptors between October 1, 2010, and July 31, 2011 (Phase I), there were 2988 trauma admissions for which 281 trauma codes were activated. Of these, 181 (64.4%) patients were designated TPA according to the protocol and 100 did not meet the criteria for activation. The most common reason for TPA was GCS score ≤13, followed by systolic BP ≤90 mmHg. In comparison, among 204 patients who fulfilled at least one TPA criterion, 23 (11.3%) were not designated TPA. Thus, the TPA accuracy during Phase I was 95.9% (Table 2). Subsequent analysis for these 23 patients not designated TPA revealed that 12 patients had a GCS score of 13, one patient had systolic BP of 90 mmHg, nine patients had an injury resulting from a fall of >6 m, and one patient had sustained a gunshot wound to the torso that was missed on arrival. To improve TPA accuracy, we redesigned the computer program to prompt triage nurses to initiate a trauma code when abnormal GCS and BP data were entered into the hospital computer. We also educated all medical personnel to improve familiarity with the TPA criteria and appropriate evaluation of trauma mechanisms within the scope of quality management. During the next 3 months, between August 2011 and October 2011 (Phase II), the NA rate decreased from 11.3% to 2.8%. The FA rate also decreased from 35.6% to 14.6% (Table 2). We next compared TPA patients to patients who should have been designated TPA. As shown in Table 3, TPA patients had significantly lower GCS scores and were more likely to be admitted to the intensive care unit (ICU). Both groups had similar age and sex distributions, systolic BP on arrival at the ER, ISS, mortality rate, and length of stay. We examined the data for patients who were later found to have ISS ≥ 16 but did not initially meet our TPA criteria on arrival to the ER. The most common causes were motorcycle crashes and ground floor falls, accounting for 73% of the injuries. The distribution of injured body regions is shown in Fig. 1. Some 135 (72%) patients had a significant head injury with AIS–Head ≥2. Among these patients, 23.7% (32/135) had no complaints on arrival to suggest head trauma and the remaining 103 patients had at least one symptom among headache, dizziness, vomiting, and loss of consciousness. We compared the outcome for brain injured patients between TPA and non-TPA groups. TPA patients were significantly younger (46.7 ± 21.5 years vs. 51.9 ± 23.6 years, p < 0.05) but the sex distribution was similar between the two groups. In addition, ISS, AIS–Head scores, and overall mortality rate were significantly higher for TPA patients (Table 4).
    Discussion Emergency care for trauma patients in Taiwan follows the same pattern as for other disease entities. The EMS is still in its infancy and care provided at the scene is quite limited. There are also scarce on-line supports for EMS personnel. Severely injured patients are frequently transported to nearby hospitals even if the receiving hospital might not have adequate facilities or personnel to care for them. In addition, many patients with minor trauma are transported by the EMS or private vehicles to trauma centers, which can potentially disrupt the care of severely injured patients. On arrival, trauma patients are first examined and managed by ER physicians in most hospitals, and surgical consultations are then arranged when necessary. This trauma care pattern cannot provide a continuum of care, and potential delays in care may occur at each step between the accident scene to the hospital and transfer between hospitals. Clearly, the trauma care system in Taiwan is inadequate and should be further developed to improve the outcome for trauma patients.