Eric Mercier: Prehospital care of severely injured patients

INTRODUCTION AND RATIONALE

The establishment of regionalised trauma systems have led to temporal improvements in outcomes for trauma patients in Canada and other countries.(1-4) However, the contribution and added value of each trauma system component still lack good quality evidence and not all components have been subjected to the same scrutiny.(5, 6) In fact, most trauma studies are oriented towards in-hospital rather than out-of-hospital care.(7) Nevertheless, a well-coordinated continuum of care that includes quality prehospital care is important as inclusive system designs have consistently been linked to a significant decrease in mortality and morbidity for the severely injured patients.(6)

While the overall trauma-related deaths have decreased, the proportion of fatalities occurring during the prehospital phase has risen.(8) About half of trauma-related deaths now occurs prior to hospital arrival(9) and many fatalities are still considered preventable or potentially preventable.(10, 11) For instance, in-hospital mortality associated with motor vehicles accidents (MVA) has decreased by 58% over a period of 36 years and prehospital deaths now represents 56% of all MVA-related deaths.(12) The disproportionate reduction of in-hospital fatalities likely illustrates the effectiveness of trauma centres and the in-hospital quality of care delivered but also demonstrates the need to focus on prehospital care. Considering that trauma remains the leading cause of death and disability in children, adolescent and young adults, research aiming at optimising prehospital care to improve outcomes for severely injured patients is crucial.(13-23)

Unfortunately, little is known about the epidemiology, the injuries sustained, the preventable mortality and the care delivered to patients that have died in the prehospital setting.(7) Particularly worrying, this topic has been poorly addressed in our Canadian setting. One of the key element that could improve prehospital care is the development of accurate triage protocols used to determine the severity of the injuries and subsequently the appropriate destination hospital to where the patient should be transported. Current triage protocols have been insufficiently accurate with frequent over- and underestimation of the injuries’ severity.(22, 23) While underestimation of the injuries’ severity is a frequent error that contributes to preventable trauma deaths,(30) overestimation leads to unnecessary procedures and contributes to trauma centre overcrowding.(5) No studies have adressed the accuracy of the current trauma triage protocols in the Canadian setting and their potential association with preventable early trauma-related deaths. Since inadequate assessment of injuries’ severity remain frequent and has been associated with unfavorable outcomes, studies dedicated to assessing trauma triage protocols and analysing preventable mortality must be prioritized.(24)

OBJECTIVES

Evaluation and optimization of the care provided to severely injured patients before reaching the hospital constitute the central theme of this research program. During the upcoming years, this research program will focus towards identification and evaluation of prehospital criteria/protocols used in triaging injured patients as well as the prehospital care delivered to the most severely injured patients in terms of preventability, identification of areas for improvement and potential role for novel interventions. This research program is divided into four phases. A multidisciplinary and experienced team will be involved during the progression of this research program.

This research program has six main objectives:

  1. To synthetize and to compare the prehospital care delivered to severely injured patients across Canada
  2. To identify research priorities regarding prehospital trauma triage protocols and the care delivered to severely injured patients in Canada
  3. To determine the optimal methodological approach to reviewing prehospital trauma deaths in order to assess preventable mortality using a multicentre pilot study
  4. To determine the accuracy of the triage protocol currently used in the Province of Quebec to identify severely injured patients, namely the Échelle québécoise de triage préhopsitalier en traumatologie (EQTPT)
  5. To compare the accuracy of the triage protocols used in Canada to determine the injuries’ severity
  6. To review traumatic out-of-hospital cardiac arrest (OHCA) in order to assess preventability of death, to identify areas for improvements and to evaluate the potential role for novel interventions to improve outcomes for seriously injured trauma patients using a Province-wide study

PHASE 1A. Overview of the prehospital care delivered to severely injured patients current Canadian situation

(Objective 1) 

The prehospital care and the system activated following a traumatic event have developed differently across Canada. Variables such as the paramedic level of training, EMS treatment protocols and EMS triage protocols are inconsistent.(25, 26) These variations are likely to affect outcomes of the most severely injured patients. Little is known about regional and provincial standards of care delivered to severely injured patients. This lack of a wider country picture precludes comparisons between the prehospital structures and the contribution of each component to improve outcomes. In order to fill that knowledge gap, EMS protocols used across Canada will be retrieved and compared. A framework proposed by the World Health Organization (WHO) will be used to determine the prehospital components that will be extracted. The main aim will be to compare the trauma triage protocols used to determine the injuries’ severity and the destination hospital following a trauma.

Specific actions:

  1. To perform an environmental scan of the protocols used to guide prehospital care of severely injured patients across Canada. EMS triage protocols, EMS level of training, prehospital definition of a major trauma, EMS treatment protocols including traumatic OHCA management, available on-site interventions, transport destination decision making process, availability of first responders, physician-on call availability, activation criteria for in-hospital trauma response team and quality-of-care monitoring activities will be extracted and compared.

PHASE 1B.   Identification of prehospital trauma care research priorities

(Objective 2)

There is a need for the determination of research priorities regarding the Canadian prehospital care of severely injured patients as well as the elements that should be prioritized in regard to in-field trauma triage protocols studies. A discussion followed by a consensus between Canadian trauma experts would allow the development of a research agenda aligned with the perceived priorities.

Specific actions:

  1. Using the modified Delphi method, which will be administered to a panel of Canadian trauma experts, to determine 1) the variables that should be prioritized regarding in-field trauma triage protocols studies; 2) the research priorities regarding the prehospital care delivered to severely injured patients and 3) the areas for improvement of prehospital trauma care in Canada and where standard of care should be established.

PHASE 2.     Preventability of death assessment using a pilot study of prehospital trauma death case review (Objective 3)

Reviewing trauma death cases is a core component of trauma research.(10, 17) In addition to assessing the quality of clinical care delivered in relation to a standard of care, reviewers can also assess preventable mortality and potential areas for improvement.  Furthermore, analysis of deaths may be used as a performance indicator, a measure of health service quality, and may help identify new strategies to improve clinical care, injury prevention and implementation of novel technologies.(11) A multicentre pilot study will be conducted to determine the optimal methodological approach to reviewing prehospital trauma deaths with the aim to examine preventable mortality following prehospital traumatic OHCA. This is the pilot study of a Provincial study presented in phase 4. Accordingly, the objectives of the main study and a summary of the methods are presented in phase 4. Objectives specific to this pilot study are: 1) to determine the inter-panel reliability between panel groups regarding the preventability assessment; 2) to determine the inter-rater reliability regarding the survivability assessment; 3) to establish the optimal functioning of the expert panel case review meeting; 4) to assess the evaluation of areas for improvement during expert panel review meetings and 5) to establish a list of potential novel prehospital tools and interventions that could be useful to improve the care of severely injured patients. Similar prehospital trauma death studies aiming to assess preventable mortality have been used with success but none in the Canadian setting.(7, 11) The methods used and the study reporting are have been heterogeneous and no standardized methods exist.(11) The pilot study will focus on implementation and practicality and is essential to refine the methods to ensure optimal progression of a larger study.(27, 28)

Specific actions:

  1. To perform a pilot study of prehospital trauma death case review in two administrative regions.

PHASE 3.      Prehospital identification and triage of injured patients (Objectives 4-5)

Recently, the EQTPT has been introduced in the Province of Quebec but its accuracy has not been studied. Other important aspects of the EQTPT such as the rate of over- and under-triage and the EMS adherence to the protocol would also benefit being examined. As for most prehospital trauma triage protocols,  EQTPT is based on an assessment of the patient’s physiologic status including the vital signs, the anatomic localisation of injuries, the mechanism of the trauma sustained and other considerations such as the age and the patient’s regular medication.(29)

Specific actions:

  1. To assess EQTPT’s accuracy and EMS provider adherence by reviewing all EMS transports for injured patients in two administrative regions within the Province of Quebec using prehospital and in-hospital data.
  2. With the data extracted, to compare the accuracy of the EQTPT in identifying severely injured patients with the other Canadian prehospital triage protocols retrieved during the environmental scan (phase 1A).

PHASE 4.     Preventability of death assessment using a pilot study of prehospital trauma death case review (Objective 4)

This will be a retrospective review of prehospital and early in-hospital (<24 hours) deaths following traumatic OHCA that were attended by paramedics during the period of 2010 to 2015. Eligible patients will be identified through the prehospital records and data will be linked with the in-hospital medical records and the coronial files when available. The main aim of this study will be to examine the preventability of death following traumatic OHCA. The study will be undertaken in four phases: 1) survivability assessment; 2) preventability assessment; 3) identification of potential areas for improvement; and 4) identification of potentially useful novel technologies. For patients who have not sustained unsurvivable injuries, a multidisciplinary experts panel review will be conducted to assess the preventability as well as the identification of potential areas for improvement and potential usefulness of novel technologies. The methods used during this study will be based on the pilot study’s conclusions. A Province-wide study will allow a population-based capture of traumatic OHCA and help guide injury prevention programs, establish strategies to reduce preventable deaths and determine main areas for improvements of prehospital care.

Specific actions:

  1. To perform a Province-wide study of prehospital trauma death case review.

TIMELINE

RELEVANCE, PERSPECTIVES AND CONCLUSION

Focusing on prehospital care delivered to severely injured patient should be a research priority considering the fact that it carries the greatest potential to reduce trauma-related mortality and morbidity. This research program will create a comprehensive overview of the current Canadian situation as well as a deep understanding of preventable mortality and the accuracy of in-field trauma triage protocols.

Notably, performing a Province-wide study will allow the acquisition of an accurate epidemiologic profile of prehospital trauma fatalities both in rural and urban regions using a population-based capture. This will be a unique opportunity to improve the trauma systems components involved in the care of trauma patients before they reach the hospital and their individual contribution to outcomes.

Finally, the evaluation of potentially novel interventions by a panel of experts will help identify potentially beneficial interventions during prehospital care, guide the development and future implementation of innovative measures, inform on prehospital research priorities, promote research collaborations and inform the development of injury prevention programs.

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