Hrev_master [Emergency Care Journal 2016; 12:5359] [page 1] Defining criteria to choose appropriate destination hospital for trauma patients: Piacenza Local Health Authority’s Piacenza trauma algorithm protocol Fabio Mozzarelli,1 Stefano Nani,1 Enrica Rossi,1 Mario Pizzamiglio2 1Ambulance Emergency Service, Piacenza Local Health Authority, Piacenza; 2Emergency Department, Guglielmo Da Saliceto Hospital, Piacenza, Italy Abstract Ambulance crew’s choosing of appropriate destination hospital for trauma patients can affect survival and morbidity outcomes. Aim of the present study is to devise a decision-mak- ing algorithm in order to allow the best choice of destination hospital for trauma patients and to apply it on an electronic device able to facil- itate the decision made by ambulance staff. The method used was analysis of literature data, context and workload with a retrospective observational study. A comparison between the destination hospitals actually chosen and those that could have been chosen with the Piacenza trauma algorithm has been applied. The data shows a 9.5% (P>0.10) more advan- tageous change in appropriateness in the choice of medical facility and a 1.4% increase in admissions to the Emergency Department of the provincial hospital. The creation and use of a medical protocol and its consequent installa- tion on an electronic device (tablet) that can be shared over a computer platform could help medical staff make appropriate pre-hospital choices as regards the destination hospital for trauma patients. Introduction The prehospital organization and manage- ment of trauma patients represents a very important challenge for emergency medical services. In the Western world, trauma injury represents the first cause of death and invalid- ity in subjects up to 44 years of age and the third cause amongst the general population.1 Starting in the 1990s, a number of intra- and extra-hospital systems known as trauma sys- tems was introduced in the United States, Canada and various European countries to improve trauma patient care. These organiza- tional-management systems are based on trau- ma centers, highly-specialised hub centers serving large catchment areas.2 The epidemio- logical data available for Italy indicate that the establishment of a trauma center requires a workload of 450 severe traumas per year per million inhabitants and no less than 250 cases per year are required to maintain the skill sets of the medical teams.3 This introduces the issue of avoidable death, i.e. those trauma patients who would have had greater chances of survival if they had been assessed and treat- ed correctly and, above all, sent to the most appropriate hospital facility. In line with the findings of the American College Surgeons Committee on Trauma, certain research stud- ies conducted in Italy have calculated that the percentage of potentially avoidable deaths to be somewhere between 32 and 40% and the percentage of certainly avoidable deaths has been estimated at between 11 and 18%.4,5 Correct identification of the severity of the patient’s condition, consequent medical treat- ment and the most advantageous choice of hospital given the injuries sustained are, in addition to transfer times, the main variables impacting the survival and morbidity of trauma patients. The emergency medical system must abide by the golden hour concept and the THREE Rs – get the right patient to the right hospital in the right time – are particularly apt. A number of articles were identified during the literature search, including one French paper highlight the importance of transferring severe trauma patients, identified using spe- cially-devised triage schemes, straight to the hub trauma center.6 Some authors of scientific publications specified that in accidents occur- ring in rural settings patients are taken to trauma centers in between 5 and 10% of cases, and that the greatest proportion of deaths for severe trauma occur in decentralized emer- gency departments.7,8 Some researchers claim that anatomical and physiological criteria can be used to identify with greater appropriate- ness those patients with severe injuries, in order to allow a more adequate use of the resources available.9,10 One interesting article on the situation in Italy focused on the central- ization of major trauma by analysing the injury mechanism. The research was conducted at the Emergency Department of Florence’s Ospedale Careggi and reported that many of the patients defined as having major trauma according to physiological or anatomic criteria presented a higher degree of criticality than those referred according to the event dynamics mechanism alone (odds ratio 30.35, 95% confi- dence interval 21.09-43.65, P<0.0001).11 Conversely, one research article that conflicts with those mentioned so far, suggests not underestimating the dynamics criterion, espe- cially for falls from a height12 and one analysis conducted in Australia, as suggested by the American College of Surgeons Committee on Trauma, revealed that in road accidents the longer time required to remove patients from the vehicle is statistically significant for severe injury.13 Studies have also been conducted on the difference between rapid transfer of poly- trauma patients directly to trauma centers and transfer to medical facilities with less-special- ized resources that are closer to the event. The authors point out that subjects who were sent to less-specialized hospitals had higher mor- tality rates and that their involvement in the trauma system network can be detrimental.14 The aims of this paper are to analyze the pathways for the appropriate hospitalization of trauma patients and to devise a complexity-ori- ented decision-making algorithm. Furhter, we aim to compare the devised protocol with the information present in scientific literature. A final goal is to implement the decision-making algorithm using a telemedicine system that can help medical staff choose the most suit- able facility given the criticality of the patient’s condition and the resources available. Materials and Methods Figure 1 summarizes the approach chosen to allocate injured patients within the local area to the hospital facility best suited to the injuries sustained. The medical protocol was developed using epidemiological data and workload data for recent years considering the orographic and demographic characteristics of the province of Piacenza, the local and inter- Emergency Care Journal 2016; volume 12:5359 Correspondence: Fabio Mozzarelli, Emergency Department, Piacenza Hospital, via Antonio Anguissola 15, Piacenza, Italy. Tel/Fax: +39.0523.301111. E-mail: fabio.mozzarelli@gmail.com Key words: Algorithm; Trauma; Piacenza; Triage; Hospitalization. Contributions: FM took care of data processing and drafting of the article; SN collected data; MP and ER critically evaluated the process. Conflict of interest: the authors declare no poten- tial conflict of interest. Received for publication: 9 June 2015. Revision received: 26 October 2015. Accepted for publication: 26 October 2015. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright F. Mozzarelli et al., 2016 Licensee PAGEPress, Italy Emergency Care Journal 2016; 12:5359 doi:10.4081/ecj.2016.5359 Non co mmerc ial us e o nly [page 2] [Emergency Care Journal 2016; 12:5359] provincial hospitals available and the approaches used in literature such as those proposed by advanced trauma life support,15 prehospital trauma life support,16 Piacenza Local Health Authority prehospital triage,17 trauma team activation by Ulleval University Hospital,18 trauma triage criteria,9 Centers for Disease Control of Atlanta,19 and the Ferrara ambulance service centralization criteria.20 This instrument also considers certain hos- pitals outside the province, as according to the hub and spoke system, Major Hospital of Parma is the hub Trauma Center also for Piacenza and Reggio Emilia, whereas Major Hospital of Cremona is the first level trauma center neighbouring the province of Piacenza, in an area that has always been devoid of its own medical facilities. In the Piacenza trauma algorithm flow chart, the choice of hospital follows the approach of triage based on a series of indices to be meas- ured and/or observed. Each assessment set is allocated one or more hospitals. Therefore, if a patient criterion or characteristic is observed for the first item it is not necessary to proceed further as the chart suggests the destination hospital. Conversely, if no index coincides with the injured patient being observed, the user moves on to the next assessment block. The first set dedicated to physiological crite- ria includes the alteration of certain values such as a Glasgow coma scale (GCS) score of less than 9 points, severe hypotension, signifi- cant respiratory rate alteration and burns involving the airways. The above indices can be used both individually and jointly; however, the alteration of just one is sufficient to direct the patient to the hub trauma center, which, in the case of the province of Piacenza, is Major Hospital of Parma and the transfer is usually by helicopter. When the aircraft cannot be used, injured patients are transferred to the provincial trauma center. The second item listing anatomical injuries refers to open injuries of the head, neck, chest and limbs, crush injuries, skin-stripping injuries and limb mutilation or amputation. It also includes suspected fracture of two or more long bones or a hip, neuromotor deficits or sensory alterations (with a GCS score of between 9 and 13) and, last but not least, and burns covering more than 20% of the body’s surface area. Again, just one criterion is suffi- cient to direct the injured patient to the hub trauma center or, if this is not possible, to the provincial facility. The third slot contains two special situa- tions – patients who are more than 20 weeks pregnant and children under 10 years of age – in which, given the special condition of the subjects and as gynaecology and paediatric specialists are only present at Piacenza Hospital, the patient must be taken to this facility (or Cremona Hospital if closer). The last section lists the event mechanisms characterized by a high-energy exchange between the individual and the injuring agent. The list includes falls from a height or, for road accidents, crushing of the vehicle, death of other passengers in the crash and suspicion of vehicles travelling at high speed. In the case of pedestrians and motorcyclists or cyclists it is necessary to look for clues sug- gesting high-energy collisions. In the absence of other anatomical/physiological evidence, the major dynamics mechanisms described sug- gest the patient should be transferred to local first aid services or the closest hospital, as recent evidence published in international guidelines has reduced the emphasis placed on this kind of criterion.21 However, if effica- cious airway management is not obtained at the local facility or if the injured patient pres- ents severe haemodynamic instability, the individual can be taken to the closest hospital as all of Piacenza’s hospital facilities have a life support specialist on duty around the clock. The fleet of vehicles used by Piacenza Local Health Authority’s emergency service is fitted with the Ortivus MobiMed Smart™ telemedi- cine system (Ortivus, Danderyd, Sweden), which allows data transmission and sharing over a dedicated virtual network (Figure 2). This appliance makes it possible to exchange information, clinical data and vital parameters whilst also authorizing the management of clinical documentation such as the drafting of the patient’s medical records, the consultation Article Figure 1. Method used to allocate injured patients within the local area to the hospital facility best suited to the injuries sustained. Non co mmerc ial us e o nly [Emergency Care Journal 2016; 12:5359] [page 3] and filling out of certain assessment schemes, scores and scales and also allows the user to consult clinical protocols, diagnostic, thera- peutic and care pathways and guidelines. The instrument also contains algorithms that facil- itate decision-making concerning case severi- ty and complexity. The Piacenza trauma algo- rithm was installed on the device in checklist mode to offer local emergency nursing crews the possibility of consulting it as an aid to deci- sion-making as to the most suitable medical facility, limiting the degree of subjectivity of the individual operator and guaranteeing homogeneity in care behaviour. The appropriateness of injured patient allo- cation was explored in a retrospective study to evaluate how patients would have been distrib- uted in 2013 had the Piacenza trauma algo- rithm been used. Patients transferred to med- ical facilities outside the province, with the exception of Major Hospital of Parma and Major Hospital of Cremona, were excluded from the analysis. All trauma injury patients treated by professional ambulance crews and subsequently transferred to the various emer- gency services were included. For greater con- sistency, the study only involved patients who were injured in municipalities belonging to the province in which access to the emergency Department could involve both a local hospital and the provincial trauma center in Piacenza (Cremona or Parma), and therefore excluded patients injured in urban, suburban and even extra urban areas who, regardless of the sever- ity of the event, would only have been taken to Piacenza Hospital, as it was both the closest and the best equipped facility. To improve the analysis, a random caseload was created from which a sample of 345 units was obtained. The selected patients were eval- uated using the patient record filled out by the local emergency system staff for each patient, the computerized record used by the ambu- lance call center when receiving and managing callouts, engineering 118@NET the regional computer platform, Dedalus healthcare systems group the electronic record used in emergency services, the injury severity score (ISS), meas- ured using the information collected from the emergency record for critical patients (yellow and red codes) alone and only for injured patients transferred to hospitals in the Piacenza area. By studying these instruments and compar- ing them with the Piacenza trauma algorithm we obtained the information needed to com- pare the actual destination of trauma patients with that which could have been chosen in 2013. The sample size was calculated using Raosoft software, by setting a power value of 90%, a confidence interval of 95% and a preva- lence index of 50%. Randomization was per- formed using a table created with the random number generation system provided on the Emilia-Romagna Regional Authority website. The data was collected and processed using a Microsoft® Office Excel 2007 spreadsheet. The χ2 test was used for statistical comparisons. Differences were considered statistically sig- nificant when P>0.05. Results The analysis of the data collected in the observational study showed that 9.5% of patients (P>0.10) would have been sent to a different destination hospital than that which was actually chosen. Of injured patients classi- fied as having low criticality, 5.4% were trans- ferred to the hub trauma center in Piacenza, despite the fact that they could have been taken to a local emergency Department. Of injured patients identified as having an inter- mediate complexity, 3.8% were taken to peripheral emergency services but should have been taken to the hub trauma center and 0.3% of high severity patients who should have been taken to the city hospital or, better still, to the Parma trauma center were taken to a local hos- pital (Figure 3). Another conclusion that can be drawn concerns the impact of patient distri- bution to the various emergency services had the criteria of the new algorithm been adopted. By applying the appropriate proportions there would have been a 1.4% increase in admis- sions to Piacenza Emergency Department (Figure 4). Discussion The aim of the Piacenza trauma algorithm and its installation on Ortivus MobiMed Smart™ was to direct the professional to a rea- soned, homogeneous and appropriate choice of destination hospital in trauma patients in the province of Piacenza. The corresponding flow chart was devised taking into account the orographic and demographic characteristics of the province of Piacenza, considering the arrangement of its hospital facilities and those of the greater Western Emilia area, as well as the regional organization of the trauma sys- tem, on the basis of papers published in scien- tific literature, the best and most up-to-date scientific evidence and information concern- ing the workload and analysis of the data obtained from the retrospective study. The limitations of this study could be the decision to adopt an algorithm characterized by triage criteria, which may lead to over-or underestimation. The increase in patients directed to Piacenza Emergency Department was estimated in quantitative terms (1.4%); however, the caregiving weight and clinical commitment that these new patients would generate was not studied. Patients with low criticality injuries repre- sented over 90% of total caseload; in the light of this data new organizational measures should be taken to dedicate greater attention to this type of patient in emergency depart- ments. Literature has consistently shown that Article Figure 2. Ortivus MobiMed Smart™. Non co mmerc ial us e o nly [page 4] [Emergency Care Journal 2016; 12:5359] the choice of hospital facility can impact sur- vival indices and invalidating outcomes. Use of the Piacenza trauma algorithm could provide professionals with valid support when choos- ing destination hospitals. The observational research showed that certain choices concern- ing the destination hospital did not comply with the criteria suggested by the algorithm. Despite not being statistically significant, this portion, which is equal to 9.5%, can be improved. With a view to the future develop- ment of the pre-hospital management of trau- ma patients, the conduct of a observational (cohort, case-crossover, before/after) study could provide an opportunity to further investi- gate the validity of the Piacenza trauma algo- rithm, to ascertain with more suitable instru- ments the care workload and clinical complex- ity of the majority of patients who would be admitted to Piacenza Emergency Department. Conclusions The creation of the Piacenza trauma algo- rithm and its application on the Ortivus MobiMed Smart™ telemedicine system will make it possible to choose the destination hos- pital for trauma patients provided by the regional and provincial hospital network with greater accuracy and uniformity. Moreover, the device stores the decision-making steps select- ed by the professional for potential future ver- ification and analysis. References 1. Chiara O, Cimbanassi S, Fava A, Vesconi S. 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Available from: www.cdc.gov/mmwr/ PDF/rr/rr5801.pdf Article Non co mmerc ial us e o nly