The Alfred Hospital Trauma Centre Evaluation Study

THE ALFRED HOSPITAL TRAUMA CENTRE EVALUATION STUDY

Phase 1 : Baseline data of trauma management before the Alfred Hospital Trauma Centre commenced operations

B.N. Fildes F.T. McDermott W.M. McKenzie A.F. Norman J. E. Ozanne-Smith A.P. Vulcan

March 1993

Report No. 33

MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE REPORT DOCUMENT PAGE

Report No. Report Date ISBN Pages

33 March 1993 073260026 X 72

Title and sub-title

ALFRED HOSPITAL TRAUMA CENTRE EVALUA TION STUDY

Phase 1: Baseline data of trauma management before the Alfred Hospital Trauma Centre commenced operations

Author(s)

FILDES RN., McDERMOTT F.T., McKENZIE W.M, NORMAN A.F., OZANNE-SMITH lE., and VULCAN A.P.

Sponsoring Organisation

Transport Accident Commission 222 Exhibition Street Melbourne Victoria 3000

Abstract:

The Trauma Centre and Helipad at the Alfred Hospital were established as part of a program to improve the management of major road trauma in Victoria. The Monash University Accident Research Centre were commissioned to conduct a study to evaluate the effects of these changes. A "before" and "afier" study design was chosen involving the Alfred Hospital and eight other hospitals in its traditional catchment area to monitor these changes.. "In addition, the Royal Melbourne Hospital was also included as a "control" to assess state-wide changes in trauma management apartfrom the Trauma Centre. To date, nine months of "before" study data has been collected involving 1480 road trauma patients. These data have been presented to demonstrate the wealth of data available and the types ~f comparisons possible once the "after"study data has been assembled The report concludes with a recommendation for additional.funding to complete the evaluation study. In the meanwhile, there would be merit in providing extra resources to analyse these data more thoroughly to gain a clearerpicture of trauma management in this state.

KeyWords: * Disclaimer: (IRRS except when marked This report is disseminated in the interests of information exchange. The views expressed are those of the author, and not necessarily those of Monash University.

Reproduction of this page is authorised. 11 ACKNOWLEDGEMENTS

A study of this magnitude could not have been undertaken without the help of co-operation of a great number of people. The authors are particularly indebted to the Transport Accident Commission in particular and other baseline sponsors C?f the Centre for their continued sponsorship of this project.

The efforts of the stqff of the ten study hospitals in allowing us access to the patient records and in providing additional services as required were especially appreciated. Our thanks to the staff of the Alfred Hospital, the Royal Melbourne Hospital, Dandenong and District Hospital, Traralgon Hospital, Monash Medical Centre, Prince Henry's Hospital, Frankston Hospital, Warrigal Hospital, Bairnsdale Hospital, and Sale Hospital for their continued support and assistance.

The effort of the Consultative Committee of this project was also very much appreciated, especially during the formulative stages of the work. The authors wish to thank Dr. Frank Archer, Dr. Chris Athns, Professor Steven Cordner, Mr. Rodney Judson, Dr. Anne D'Arcy, Mr. Gavin Robins, and Mr. Gordon Trincafor their efforts during the course ~!the pr~iect.

The committed and thoroughly pr~!essional approach taken in data collection by the four study Nurse/Researchers, namely Srs Robbie Debney, Kate Hodge, Angela Muir, and Judith Salvadore deserves a special mention. In addition, the efforts ~!Professor Chris Selby• Smith and M<;. Rosemary Roberts in attempting a cost effectiveness analysis, albeit unsuccessfully in the end, was also greatly appreciated.

The Ambulance Service ~!Victoria were especially helpful in allowing us access to their records, both in Metropolitan Melbourne and country Victoria. The Victorian Coronial Services, too, were always willing to provide i1?!ormation on fatal cases for which we are grateful.

The Transport Accident Commission and The A(fred Hospital's Road Trauma Services, too, were particularly helpful and our thanks to the Director, Dr. Ian McVey, Ms. Vicki Campbell and other stafffor their kind assistance throughout the pr~iect.

Dr. William Sacco, Tri-Analytics Inc. contributed substantially in helping shape our thinking about this project during 2 visits to this country for which we are eternally grateful.

Last (but not least) we are also indebted to Mrs. Janette Muddle, Ms. Jennie Oxley, Ms. Christina Leong and others at the Monash University Accident Research Centre for their excellent preparation of the final report.

Table of Contents

EXECUTIVE SUMMARy ...... •. (i)

1. INTRODUCTION ...... 4 1.1 BACKGROUND ...... 4 1.2 PROJECT OUTLINE ...... 4 1.3 PROJECT ADVISORY COMMITTEE AND STUDY TEAM 5 1.4 AIMS 5 1.5 OUTCOME MEASURES 7 1.6 'BEFORE' AND 'AFTER' RESEARCH DESIGN 7 1.7 THIS REPORT 8 2. METH0 DS 9 2.1 SAMPLE HOSPITALS 9 2.2 TIME FRAME 9 2.3 DEVELOPMENT OF THE DATA COLLECTION FORM 9 2.4 PILOT STUDY 9 2.5 TRAINING OF DA TACODERS 10 2.6 CODING PROCEDURES AND OPERATIONAL DEFINITIONS 10 2. 7 DATA COLLECTION PROCEDURES 10 3. RESULTS , 11 3.1 DATA ANALYSIS PROCEDURES 11 3.2 DESCRIPTION OF SAMPLE 11 3.3 PATIENT INFORMATION 12 3.3.1 Patient Sex 12 3.3 .2 Patient Age Distribution 12 3.4 INCIDENT INFORMATION 12 3.4.1 Velocity of Impact 12 3.4.2 Type of Road User 12 3.4.3 Type of Other Vehicle or Fixed Object.. 12 3.4.4 Impact Direction to Patient's Vehicle 12 3.4.5 Ejection and Entrapment 12 3.4.6 Ambulance Officers' Diagnosis 12 3.4.7 Number of Victims 17 3.5 TRIAGE AND TRANSFER 17 3.5.1 Types of Transfer to Hospital... 17 3.5.2 Medical Retrieval Team Usage 17 3.5.3 Time between Accident and Patient Arrival at Hospital 17 3.5.4 Time between Accident and Arrival With and Without Transfer 17 3.5.5 Transfer Status 17 3.5.6 Transfer by Injury 17 3.5.7 Time between Accident and Arrival by Injury Severity 25 3.5.8 Transfer by Patient Age 25 3.5.9 Transfer by Injury Severity 25 3.5.10 Transfer by Trauma Score 25 3.6 TREATMENTS RECEIVED PRE-HOSPIT AL 25 3.6.1 Pre-Hospital Treatment Required 25 3.6.2 Surgical Procedures (Referring Hospital) 25 3.7 TRAUMA SCORES AND SURVIVAL OUTCOMES 25 3.7.1 Trauma Score by Hospital Type 31 3.7.2 Initial Trauma Score by Survival 31 3.7.3 Admission Trauma Score by Survival... 31 3.7.4 Post-Admission Trauma Score by Survivals 31 3.7.5 Trauma Score Changes 31 iii 11 3.8 EMERGENCY ROOM ASSESSMENT AND TREATMENT 31 3.8.1 Cardio-Pulmonary Resuscitation 31 3.8.2 Adequacy of Airway on Arrival 37 3.8.3 Emergency Airway Treatment.. 37 3.8.4 Computerised Tomography (CT) Scans 37 3.8.5 Type and Result ofCT Scan 37 3.8.6 CT Scan by Transfer 37 3.8.7 CT Scan by Body Region Injured 37 3.8.8 Diagnostic Peritoneal Lavage (DPL) 37 3.8.9 DPL by Injury Severity 37 3.8.10 DPL by II1iury 37 3.8.11 Dispatch from Emergency Department 37 3.8.12 Time Spent in the Emergency Department... 44 3.9 INJURIES SUSTAINED 44 3.9.1 Body Region Injured by Severity 44 3.9.2 Multiple Injuries and Age Effects 44 3.9.3 Pairing of Multiple Body Regions Injured 44 3.10 SURGICAL PROCEDURES PERFORMED 52 3.10.1 Initial Surgery 52 3.10.2 Time to Surgery after Admission 52 3.10.3 Referring Hospital Surgery Time 52 3.11 ICU AND ADMISSION DURATION 52 3.11.1 Intensive Care Treatment... 52 3.11.2 ICU by Patient Age 52 3.11.3 ICU by Minimum Trauma Score 52 3.11.4 ICU by Patient Injury 52 3. I 1.5 Total Hospital Stay 52 3.11.6 Hospital Stay by Age 57 3.11. 7 Hospital Stay by Trauma Score 57 3.11.8 Hospital Stay by Patient Injury 57 3.12 OUTCOME AND DISCHARGE DETAILS 57 3.12.1 Survival Outcome 57 3.12.2 Associated Fatality 57 3.13 DISABILITY AT DISCHARGE 57 3.13.1 Primary Mode of Locomotion 57 3.13.2 Ability to Express 57 3.13.3 Disability Score 64 3.14 COMPLICATIONS , 64 3.14.1 Pulmonary Complications 64 3.14.2 Non-Pulmonary Infections 64 3.14.3 Cardio- Vascular Complications 64 3.14.4 Renal Complications 64 3.14.5 Neurologic Complication 64 3.14.6 Haematologic Complications 64 3.14.7 G.1. COlnplications 64 3.14 .8 Vascular Complication 64 3.14.9 Hepatic-Biliary Complications 64 4. DISCUSSION 69 4.1 OVERVIEW 69 4.2 POSSIBLE ADDITIONAL ANALYSES 70 4.3 EV ALUA TING THE IMPACT OF THE ALFRED HOSPITAL TRAUMA CENTRE 71 4.3.1 Changes in Trauma Care Delivery 71 4.3.2 Changes in Patient Management 71 4.4 CONCLUSIONS AND RECOMMENDATIONS 72 4.4.1 Recommendations 72

EXECUTIVE SUMMARY

INTRODUCTION

The Trauma Centre and Helipad at the Alfred Hospital were established as part of an overall program to improve the management ~fmqjor road trauma in Victoria. The Transport Accident Commission (TAC) commissioned the Monash University Accident Research Centre (MUARC) to evaluate the effects of the Trauma Centre and Helipad at the Alfred Hospital and to identify ways tofurther improve road trauma management in this state.

THE EVALUATION STUDY

A "before" and "after" design was adoptedfor this research project and comprehensive data were collected on patient management from the scene to discharge from hospital. This design included changes in the system on a statewide basis, the gathering of detailed information on management of major trauma up to admission at the ten study hospitals, and a comprehensive assessment of changes in the severity of road trauma, stages of treatment, and outcomes once the patient had been admitted

This Phase 1Report presents a descriptive analysis of outcome and management of trauma patients within the traditional Alfred Hospital catchment area 'before' the establishment C?f the Alfred Trauma Centre. These data form the baseline against which the impact of the Alfred Hospital Trauma Centre can be evaluated

DATA COLLECTION STRATEGY

Data were collected for all road trauma patients admitted to the Alfred Hospital and nine other urban and rural hospitals between 1st September 1988 and 31st May 1989. With the exception C?l the Royal Melbourne Hospital which was included as a control, all hospitals were within the Alfred Hospital's traditional "catchment area". A total of 1,480 road trauma patients were admitted to the study h05pitals during the specified time.frame.

INDEPENDENT VARIABLES

The data collected provided a detailed description C?l aspects of patient characteristics and trauma care deliveryfrom accident scene through to hospital discharge. 7hese included:

· Incident information · Triage and Transfer information · Pre-hospital treatment · Trauma scores · Emergency room assessment and treatment · Injuries sustained (including AIS and ISS assessments) · Surgical procedures performed · Complications. · Hospital and ICU bed usage · Survival outcome · Discharge details · Disability at discharge

RESULTS TO DATE

The overall impression from these data is that the system for trauma care delivery, as it existed during the study period, was generally working well. This conclusion is supported by comparatively low mortality rates and usually effective pre-hospital treatment. Nevertheless, some aspects of pre-hospital and hospital management give cause for concern and a sign~ficant proportion of patients required inter-hospital transfer.

UNIQUENESS OF THE STUDY

The study performed here was quite unique in that there have only been two Us. studies previously reported in the literature that involved a detailed scientific evaluation of changes to a trauma care system of a similar kind to that reported here. Given the large amounts ~f resources involved in establishing Trauma Centres of this kind, detailed evaluation studies are imperative to assess their effectiveness.

ADDITIONAL ANALYSES

Because C?fthe comprehensive nature C?fthese data collected during Phase 1C?fthe prC?iect, there is an opportunity for analysis far beyond the scope of the original aims of the study. An indication C?fthe types C?fanalyses and potential uses is given in Chapter 4.

These analyses have the potential to increase considerably our understanding of the effectiveness C?ftrauma care delivery in Victoria and how it may be improved It is quite likely however, that the establishment of the Trauma Centre has had wide ranging effects and the system as it exists today may be sign?ficantly different from that which existed in 1988 and 1989.

RECOMMENDA TIONS

It is recommended that funding be made available for the 'qfter' phase C?fthe study to complete the evaluation of the impact C?ftheAlfred Hospital Trauma Centre and Helipad' ff funds for continuation of the study are not immediately available, perhaps additional resources might befoundforfurther in-depth analysis of existing data.

1. INTRODUCTION

1.1 BACKGROUND hospital, method of transport to hospital, inter• hospital transfers etc.

The Trauma Centre and Helipad at the Alfred Hospital were established as part of aprogram to LEVEL 2 was designed to provide the bulk of improve the management of major road trauma, the detailed information on management of major involving changes in various procedures from trauma required to meet the aims of the study. It the roadside through to discharge from hospital. involved all patients with major trauma The Transport Accident Commission (TAC) (hospitalised or died in hospital) admitted to the commissioned the Monash University Accident Alfred Hospital, the Royal Melbourne Hospital, Research Centre (MUARC) to conduct a study and the major hospitals in the Alfred's traditional to evaluate the effects of these changes; to catchment area (Dandenong, Frankston, explore the cost-effectiveness of the overall Moorabbin, Sale, and Central Gippsland, East system; and to identify ways offurther improving Gippsland and West Gippsland.) trauma management after the Trauma Centre had been established. Additional data was collected from the ambulance report and from the patient's medical The study was designed to take into account record. This enabled the severity oftrauma to be improvements in trauma management that are quantified interms ofT rauma Score, Abbreviated taking place progressively throughout the State Injury Scale (AIS), and Injury Severity Score as well as any changes in the nature of trauma (ISS). Times for each stage of the process from cases treated at the Alfred, and other hospitals accident to completion of hospital management within the Alfred's traditional catchment area, were also recorded and analysed. after the commencement of the Trauma Centre's operation. Extraction of the data from the medical records and coding was done by research assistants 1.2 PROJECT OUTLINE visiting each hospital. The data items recorded at this level are set out in Attachment 1. The study involved analysis of data before establishment of the Centre and at various periods LEVEL 3 In order to enable a more after establishment. Three levels of detailed comprehensive assessment of the changes in data were collected for this purpose. severity of road trauma, stages of treatment, and outcomes, very detailed data were collected at LEVEL 1 was designed to monitor changes in the Alfred Trauma Centre, the Royal Melbourne, the system over time on a Statewide basis. It and Dandenong and District Hospitals. This involved all motor accident patients admitted to involved collection of data not previously hospital in Victoria, but was limited to data recorded by the hospitals. available through existing computerised records. The primary source was the TAC records, Initially, a costing study comparing the cost of supplemented where necessary by the hospital treatments pre- and post- Trauma Centre morbidity file, the Police Accident Reports, and operation was proposed as part ifthis study. On the Ambulance Services Records. investigation, it was found that systems for detailed hospital costings are not yet in place at This would allow the monitoring of overall the Alfred Hospital, therefore it was not possible changes in indicators such as the numbers to undertake this analysis. However, a admitted to hospital, the duration of hospital preliminary analysis of 6000 statewide stay, and total treatment costs, disaggregated by hospitalization claims for road trauma was location of accident, type of accident, level of conducted using TAC records. Results from 1 1. To evaluate the effect on outcome for road this analysis have been presented elsewhere (see Roberts, 1989). accident casualties with major trauma of establishment of the Trauma Centre and 1.3 PROJECT ADVISORY Helipad at the Alfred Hospital. The COMMITTEE AND STUDY TEAM evaluation should take into account any associated changes in procedures involving ambulance services, In order to obtain a wide range of advice and communications, triage, inter-hospital support for the study, a project Advisory transfers and emergency room procedures. Committee was established. The Committee An attempt should also be made to measure includes representatives of: benefits in relation to the relevant costs.

Institute for Forensic Pathology 2. To identify ways in which the mangement Royal Australian College of Surgeons of major road trauma can be improved. Royal Melbourne Hospital Transport Accident Commission Specific Victorian Ambulance Directorate A number of specific aims were also identified. plus key project staff and consultants These are listed below, together with the to the project. associated research hypotheses. The Principal Investigators for the project were Dr. Brian Fildes, Senior Research Fellow at the Accident Research Centre, and Associate 1. To measure outcomes (e.g. in terms of survival, complications, disability, Professor Frank McDermott, Department of duration of hospital and ICU stay, Surgery, Monash University and an Associate of the Monash University Accident Research controlled for injury severity and patient age) in relation to differences in the time Centre. Other persons involved with the project included: intervals between the accident, emergency department arrival and initial operation.

Dr. Peter Vu/can, Director, HYPOTHESIS: That outcome in terms Monash University Accident Research of survival, complications, hospital stay, Centre,responsible for overall co• disability and costs is related to the pattern ordination of the project. and severity ofinjury and patient age and, in addition, to geographic distribution of Dr. Joan Ozanne-Smith, hospitals with appropriate level of Senior Research Fellow, Accident facilities, delays in availability of Research Centre, responsible for data emergency, ambulance/helicopter. collection, training, and AIS scoring. 2. To assess the patterns and severity of Professor Chris Se/by-Smith, injury and emergency management in Consultant Health Economist to the relation to time of death and possibility of project. preventing death.

1.4 AIMS HYPOTHESIS: That place of death (accident site, in emergency transport en The aims of the evaluation study as stated in the route to hospital, emergency department, research proposal were as follows: operating theatre, intensive care unit, ward, in emergency transport during General interhospital transfer) will be related to injury pattern and severity, time intervals in relation to times of accident, ambulance

11 arrival at scene, departure from accident HYPOTHESIS: That the computer scene, of transit, of receiving appropriate conversion program provides a reliable treatment (e.g.' operation for control of index of injury severity by comparison major haemorrhage within one hour of with coding directly from the Medical arrival in emergency department), and of Records. transfer to hospital with appropriate facilities. 6. To evaluate the frequency ofCT scanning at the hospital of initial referral and its 3. To identify the specific injuries where an usefulness in determining the need for additional benefit is gained by immediate operative intervention, and management within a trauma centre. rapid transfer to a hospital with more appropriate facilities. 4. To assess the extent to which casualties are managed at hospitals with the 7. To evaluate the frequency of Diagnostic appropriate level of facilities. Peritoneal Lavage (DPL) in assessment of abdominal trauma and its value in HYPOTHESIS 1: That geographic site determining the need for laparatomy, and of the accident will influence outcome lessening the interval between arrival time since delays in transportation of the and commencement of the first operation. casualty to hospital are likely when the 8. To evaluate the need and use ofIntensive crash occurs at a site remote from ahospital with appropriate facilities. In addition, Care Unit management and the duration delays in management will be increased in oflCU care required in relation to injury instances where casualties require patterns and severity. interhospital transfer to a hospital with appropriate facilities for the injuries 9. To identify changes in recording sustained. procedures and integration which would assist trauma mangement and associated HYPOTHESIS 2: More preventable research. This could also assess whether deaths and increased morbidity will occur the centralised data collection and storage in casualties initially managed in a hospital systems established for the project should withinappropriate facilities for the injuries be maintained in the interests of general sustained. hospital and medical administration improvements. HYPOTHESIS 3: That preventable mortality rates will not differ significantly Comment in casualties treated at any facility irrespective of whether it be a trauma It should be remembered that these aims centre, metropolitan teaching hospital or generally refer to the full evaluation study and country base hospital, provided the facility require both before-study and after-study data is appropriate for the severity of trauma. to provide definitive answers.

5. To evaluate the reliability of a computer The aims of the before-study alone were to program for conversion of International provide baseline data against which the effects Classification of Diseases (ICD9 CM) to of establishing the Alfred Hospital Trauma Abbreviated Injury Score (AIS) data by Centre could be properly assessed. There were comparison of AIS results obtained from no other aims or objectives of the before study direct coding of medical records injury vs beyond this. While some of these preliminary computer conversion. data might offer hints towards testing hypotheses, they were not intended and should not be expected to provide definitive resultsof the

3 effectiveness of the Alfred Hospital Trauma Time from injury until first operation Time until death Centre on trauma management in this State. Rate of CT scans and positives before and after establishment of the trauma 1.5 OUTCOME MEASURES centre Mode of arrival at hospital Evaluation of the trauma centre will eventually Rates ofinter-hospital transfers; reason be made on the basis of performance on various for transfer outcome measures. These were grouped Inter-facility interventions according to patient health status criteria, using Rates of over- and under-triage both direct and indirect indicators. Changes in the distribution of trauma patients between hospitals, including Patient Outcome Measures changes in population and patient mix, and injury type and severity levels Trauma patients with comparable levels of injury Changes in pre-hospital triage criteria severity, before and after the establishment of Changes to the hospital by-pass system the Alfred Hospital Trauma Centre. Organs harvested

Direct Measures The data were collected from a variety of sources including hospital records, TAC, and ambulance Death/S urvi val service records. Disability on Discharge - mode of locomotion, feeding, expression 1.6 'BEFORE' AND 'AFTER' Destination on Discharge RESEARCH DESIGN Level of medical follow-up Return to work - applies only to those The research design adopted for the project was employed a 'before' and 'after' quasi-experimental design Level and period of financial support with a comparison group. Typically, this design Long term disability/impairment involves at least two measurements over time of the centre under evaluation and involving a Indirect Measures centre of similar characteristics as a control. Both rates of change and amount of change Number of days in hospital between the two centres are then compared. Number of days in ICD This design enables researchers to assess how Complications much of the observed change is due to the Death where probability of survival intervention under evaluation and how much is predicted at greater than 50% (calcu• due to other factors, such as changes in road lated from trauma score and injury trauma. The major difficulty with this approach severity score and compared with is ensuring that the comparison and participant relevant norms) groups have similar characteristics. Even if the two groups are different, if the differences are Trauma Management measured they can be controlled for, thus enabling a credible comparison to be made. Time forretrieval- from time of incident until hospital admission The current evaluation study examines trauma Change in trauma score between care management in the traditional catchment incident and arrival at hospital area of the Alfred Hospital 'before' and 'after' Change in trauma score between the establishment ofthe Alfred Hospital Trauma admission to and discharge from the Centre. The Royal Melbourne Hospital was emergency department used as the comparison, or control, hospital.

" The Alfred Hospital Trauma Centre was officially opened for use on the 10th May, 1990. 'The following twelve months constituted the "start-up" period where operational procedures were refined and any difficulties encountered with its operation were resolved. The "after• study" period could therefore commence any time after this period, although a longer stabilising period would be preferable to ensure consistency in the data.

1.7 THIS REPORT

This Phase 1 report presents the results of a descriptive analysis of level 2 data only, describing outcome and trauma management of patients within the traditional Alfred Hospital Catchment area 'before' the establishment of the Alfred Trauma Centre. These data are the baseline data against which the impact of the trauma centre can be evaluated. The data provide a valuable description of the outcome and management of trauma care in Victoria. Level 1 and Level 3 data will be presented in the final report to be presented after analysis of data collected after the Trauma Centre commenced operation.

As noted earlier, this analysis cannot address many of the aims and objectives of the full evaluation study. It is presented mainly to indicate the wealth of baseline data available and to demonstrate the types of comparisons possible in the main study.

5 2. METHODS 2.3 DEVELOPMENT OF THE DATA COLLECTION FORM

2.1 SAMPLE HOSPITALS The data collection forms used in this study were based on those used in the ongoing Major Approval to collect data in the following ten Trauma Outcome Study (MTOS) which hospitals was generously provided by these commenced in the D.S. in the mid 1980s. The organisations: MTOS instrument was expanded to include additional information required to address the The Alfred Hospital specific aims of Alfred Trauma Centre study. More detailed information was needed to The Royal Melbourne Hospital Dandenong & District Hospital understand the management of road trauma Central Gippsland (Traralgon Hospital) patients, in particular information regarding the Monash Medical Centre accident, triage, pre-hospital treatment, multiple Prince Henry's Hospital trauma and in-hospital management. The trauma Frankston Hospital admission form used at the Westmead Hospital in N.S.W. was also used as a reference. West Gippsland (Warrigal Hospital) East Gippsland (Bairnsdale Hospital) Sale Hospital The data collection form was developed in consultation with members of the Advisory These hospitals are all within what is considered Committee in order to take full advantage of the to be the Alfred Hospital's traditional catchment breadth of experience and expertise of committee area; the exception was the Royal Melbourne members. A copy of the Level 2 data collection which was included as the comparison hospital. form is included in Attachment 1. Moorabbin Hospital was excluded from the study because it handled only a small number of 2.4 PILOT STUDY trauma cases. A pilot study was undertaken initially to assess Formal agreement to participate in the study the completeness and accuracy of information was sought from each hospital individually available at the hospitals and to test the adequacy through the hospital's ethics committee. All of the data collection form. The pilot study was hospitals were assured of the confidentiality of undertaken during June 1988. the data collected and no information identifying individual patients was collected. Results from the pilot study revealed that the 2.2 TIME FRAME information available at the hospitals was sufficient for the needs of the study. A few minor deficiencies were found in the data Level 2 and 3 data was collected retrospectively collection forms and these were amended as and included all road trauma patients, as defined appropriate. For instance, there was some by the TAC, admitted to one ofthe study hospitals confusion in the definition of blunt and in the nine months from 1st September 1988 to penetrating injuries and it was agreed that the 31st May 1989. It was anticipated that' after' V.S. definition was most suited. data would be collected over a similar time frame at an appropriate. time after the Alfred The researchers experienced excellent co• Hospital Trauma Centre had opened and stabilised. operation from the participating hospitals during all phases of the data collection.

11 2.5 TRAINING OF DATACODERS LEVEL 2 AND 3 The majority of data was extracted retrospectively from patient medical A review of the literature on AIS coding and records and back-up sources of information on• inter-rater reliability indicated that research site at the participating hospitals. Missing data assistants involved in the data collection needed was collected directly from the Centre/ to have a number of pre-requisite skills and Department involved. experience. Four research assistants with a nursing background and research experience Research assistants were instructed in the use of were subsequently employed and underwent a AIS-85 and ICD9-CM codes for coding and thorough training program including hands-on verification purposes. Unresolved questions experience, discussion of operational definitions regarding data collection were discussed at and provision of written guidelines and regular meetings throughout the data collection procedures. period.

An extensive inter-rater reliability study was Further specific data collection instructions were conducted at the end of the training periods to provided in the document "Operational ensure data reliablility and consistency (see Definitions" referred to earlier. Ozanne-Smith, 1989 for further details). Formal data collection was not commenced until inter• and intra-rater reliability scores were at acceptable levels of reliability (minimum 70% agreement).

2.6 CODING PROCEDURES AND OPERATIONAL DEFINITIONS

At the outset, it was acknowledged that the validity ofthe study required the consistent use of appropriate operational definitions among the data coders. These were developed by the principaltesearchers in consultation with the Steering Committee based on ICD9-CM codes, AIS scores, and appropriate coding procedures.

Written operational definitions and coding guidelines were supplied to research assistants involved in data collection. This document is included in Attachment 2.

2.7 DATA COLLECTION PROCEDURES

LEVEL 1 The primary source for this data was existing computerized records of the Transport Accident Commission, supplemented where necessary by Hospital Morbidity Records, Police Ambulance Reports and Ambulance Records.

7 3. RESULTS

3.1 DATA ANALYSIS PROCEDURES 3.2 DESCRIPTION OF SAMPLE

There were 1,480 road trauma patients admitted to Data analysis of the baseline data was not intended to achieve the aims of the project. Rather, the the sample hospitals during the study period. TAC records show that throughout the state there was a analysis set out to describe relevant aspects of the total of 4,476 cases of road trauma involving a data and to provide an overview of trauma hospital admission during this period. Thus, the management in the traditional Alfred Hospital study sample represents approximately one third of catchment area prior to the opening of the Trauma Centre. the total population.

On the basis of age, sex and road user type the study An extensive database was constructed from the sample shows a very similar profile to that of the data collection forms for use on the Monash total population. Both groups show an over• University main frame computer. These data were representation of male versus female and younger structured in fixed format for analysis using the versus older patients. The statewide TAC data Statistical Package for the Social Sciences (SPSS• shows a slightly higher proportion of patients who X) analysis package. As this analysis was primarily were vehicle occupants than the study sample. A descriptive in nature, there was little need for the comparison of the two patient groups is shown in widespread use of tests of significance on these Table 3.1 compansons. TABLE3.1 COMWAmSONOFSTUDYSAMWLE~THSTATE~ETACDATA

Study Data 46563583%171459Sample 6914411180205951 TAC TYPE PATIENT /CLAIMANT (n=1,480) AGEOtherBicyclist55yrsFemaleMotorPedestrianSEXroadorCyclistmoreuser (n=4,500)% MaleLessVehiclethan Occupant55yrs

11 3.3 PATIENT INFORMATION For patients admitted following a vehicle crash, 71 per cent were from cars, 2 per cent from trucks, 16 3.3.1 Patient Sex percent from motorcycles, 7per cent from bicycles, and 4 per cent from tram, bus and other vehicle Sixty-five per cent of patients (n=960) were male types. and 35 per cent (n=519) female. (Not known = 1) The distribution of road user by hospital category Sex distributionofpatientsadmitted to cityteachIDg, is shown in Figure 3.4. Motorcyclist casualties city non-teaching and rural hospitals is detailed in were relatively more common at rural hospitals Figure 3. 1. Similar sex distributions were observed while pedestrians were more frequent at city across all hospital categories with a slightly higher hospitals. tendency for female patients to be treated at city 3.4.3 Type of Other Vehide or Fixed non-teaching hospitals. Object

3.3.2 Patient Age Distribution Another car was involved in more than half the vehicle crashes (56%) and a fixed object in 22 per Eighty-three per cent of patients were aged under cent. A small number of collisions involved 55 years and I 7 per cent aged 55 years or more. The motorcycles, bicycles, trams, buses, pedestrians, age distribution found at the different types of and animals. hospital is detailed in Figure 3.2, showing approximately equal age distribution across all Crashes which did not involve another vehicle or hospital categories. collision with a fixed object were more common in rural accidents (Figure 3.5). 3.4 INCIDENT INFORMATION 3.4.4 Impact Direction to Patient's 3.4.1 Velocity of Impact Vehicle

The velocity of vehicle impact assessed by the Frontal collisions were the most common (55%), ambulance officers was available in 1071 instances. followed by impacts to the left or right side (26%), The impact was of high velocity (more than 80 rollovers (15%), and rear end (4%). kilometres per hour) in 43 per cent, medium (40• 80km per hour) in 46 per cent and low (less than Rollovers were over-involved and frontal collisions 40km per hour) in only 11 per cent of cases. It is under-involved in rural hospital admissions, as not known how accurate this assessment was. shown in Figure 3.6.

The impact velocities by the different hospital 3.4.5 Ejection and Entrapment types are detailed in Figure 3.3. Low impacts were significantly more frequent and high impacts less For vehicle occupants, 6 per cent were ejected and frequent in rural hospitals compared with city 20 per cent entrapped as assessed by ambulance hospitals. officers. Figure 3.7 shows that ejection was more 3.4.2 Type of Road User common amongst rural casualties and entrappment over-involved in city teaching hospital admissions.

The majority of patients were car occupants (59%), 3.4.6 Ambulance Officers' Diagnosis followed by pedestrians (17%), motor cyclists (14%), bicyclists (6%), and otherroad users (4%). Almost all patients (99%) were diagnosed as having Drivers comprised 62 per cent, front passengers 25 sustained a blunt injury . Only ~patients sustained per cent, and rear passengers 13 per cent of car a penetrating injury and three suffered amputations. occupants.

9 70 --- 117

50 T - I 1~ I • Total

40 .1. _ I ---1~ ~._ ~ I 0 City Teaching PERCENTAGE . FPATIENTS 1- I ~ ~ I ~CityNon-teachlng o 30

~Rural 20 \. IW. ~.

o MALE FEMALE

SEX OF PATIENT

Figure 3.1 Sex of the patient.

90 1231 794 297 80

60 • Total

PERCENTAGE 50 o City Teaching

OF PATIENTS 40 El City Non-teaching

30 ~ Rural

20 10

o <55 years >54 years AGE OF PATIENT

Figure 3.2 Patient age distribution.

" ~ Rural • Total ~"'II"'A_,UUUI ~UIUII'.~UUIUU' __ _~·'##rlr##n_ uuuuurlllll",#> .-I § City Non-teaching50 ~.LowMedium 123 .- r:-I ..•0 City Teaching_ 3015 I-18 IMPACT VELOCITY High (>80km) PERCENTAGE250 1111 •• .- 45 1040355 - OF PATIENTS 20 ~• •

Figure 3.3 Velocity of impact.

• Total 25 o City Teaching PERCENTAGE 20 OF PATIENTS ~ City Non-teaching

15 ~ Rural

o Driver Front Rear Motorcyclist Bicyclist Pedestrian Other Passenger Passenger TYPE OF ROAD USER

Figure3A Type of road user.

11 Figure 3.5 Type of other vehicle or fixed object.

293 60 • Total

D City Teaching 50 ~ City Non-teaching

~ Rural 40

PERCENTAGE 30 OF PATIENTS

Frontal R H Side Rear L H Side Rollover IMPACT TO PATIENT'S VEHICLE

Figure 3.6 Impact direction to patient's vehicle.

12 I %of12 - 14 I 134 Cases 6 108

r 1 • Total

o City Teaching

~ Cny Non Teaching

~ Rural 4

o Ejection Entrapped EJECTION & ENTRAPMENT (Vehicle Occupants)

Figure 3.7 Ejection and entrapment of vehicle occupants.

I 3 1061710 246 105 1 100.00 PERCENTAGE OF PATIENTS 50.00 90.00 30.0020.0070.0060.0080.0010.000.00 40.00

• Total

o City Teaching § City Non-teaching III Rural

651 0

Amputation Blunt Injury Penetrating AMBULANCE DIAGNOSIS OF INJURY TYPE

Figure 3.8 Ambulance officers' diagnosis of injury type. 13 Figure 3.8 shows practically no difference in these presenting themselves at a considerably later time proportions across the various hospital categories . than the accident and also to patients representing .atanother hospital after initial treatment elsewhere. 3.4.7 Number of Victims Timedurations were significantly longer inpatients In 66 per cent of all cases there was only a single admitted to ruralthan city hospitals (p=O.O 18). The victim involved in the crash. A further 19 per cent cumulative arrival time for the different hospital of cases involved two victims, 8 per cent involved categories are given in Figure 3.12. three victims, 3 percent involved four victims, and 4 per cent involved five or more victims. 3.5.4 Time between Accident and Arrival With and Without Figure 3.9 shows practically no difference in the Transfer number ofvictims across the three different hospital categories. Figure 3.13 shows that the majority (90%) of non• transferredpatientswereadmitted within two hours. 3.5 TRIAGE AND TRANSFER Only 18 per cent of transferred patients were admitted to the final hospital within 4 hours. The 3.5.1 Types of Transfer to Hospital greatest proportion (40%) were admitted within 4• 8hrs,althoughanumberofthese werenottransferred Transportation to hospital of1480 patients involved for several days. 2073 providers. Road ambulance transport comprised three-quarters ofthese transports (74%), 3.5.5 Transfer Status Mica ambulance 11per cent, helicopter 5 per cent, and self-transport 8 per cent. Details are given in Seventeen per cent of all patients required transfer Figure 3.10. from another hospital (see Figure 3.14). Patients transferredwithsimilarfrequencyfrom cityteaching Self transport was more frequent for patients andruralhospitals andless often from non-teaching presenting at rural hospitals and police helicopter hospitals. use predominated at city teaching hospitals. Mica ambulance transport was confmed exclusively to Figure 3.15 shows that where transfer reasons city hospital patients. were stated, appropriate consultants were unavailable in 60 per cent of cases, ICD transfers 3.5.2 Medical Retrieval Team Usage wereinvolvedin 17percentofcases,andunavailable investigations comprised 16 per cent of transfer A medical retrieval team was used in the pre• reasons. Appropriate consultant unavailability was hospital care and transport of only three patients, especially noted in transfers from rural hospitals. one from a city-teaching and two from city-non• teaching hospitals. 3.5.6 Transfer by Injury

3.5.3 Time between Accident and Tables3.2and3.3 showthe breakdown oftransferred Patient Arrival at Hospital cases by decisive body region injured and AIS level. In general, most cases involved either ahead! 1bree-quarters (76%) of patients arrived at the neck, extremity, or chest injury with a distribution hospital within two hours of the accident and a of injury severities, ranging from minor (AIS 1)to further 9 per cent were admitted 2 to 4 hours after major (AIS 5). the accident. The time distribution between the accident andhospital admission forthe entirepatient Table 3.4 further shows the breakdown of body group is given in Figure 3.11. regioninjuredbytransferreasonforthesetransferred cases. Consultants unavailable and re-presentations The longer time intervals in a small proportion of forthe same injury were predominant among head! patients were partly related to these patient 14

" 70

• Total

60 o City Teaching

E3 City Non-teaching 50 ~ Rural

40 PERCENTAGE OF PATIENTS 30

27 16 7 4 27 17 5 5 o no. involved 2 3 4 5 6+ NUMBER OF VICTIMS

Figure 3.9 Number of victims in crashes.

80 • Total D City Teaching 70 § City Non-Teaching 60 ~ Rural

PERCENTAGE 50

OF PATIENTS 40

45 20

10 87 90 o 21 19 0 2 2 1 980 1 o Road MICA Fixed Wing Police Other Self Other Ambulance Ambulance Air Helicopter Helicopter Transport AMBULANCE TYPE

Figure 3.10 Types of transfer to hospital.

15 • Total 90

80 o City Teaching ~ City Non-teaching 70 11 Rural 60

PERCENTAGE 50

OF PATIENTS 40

13 13 0 0 12 8 3 1 o

0-2 2-4 4·8 8 - 12 12 • 1 - 2 2-4 5-7 hours hours hours hours 24 days days days hours

TIME BETWEEN ACCIDENT AND E.D. ARRIVAL BY HOSPITAL TYPE

Figure 3.11 Time between accident and patient arrival at hospital by hospital type.

60 1 10hour1-2184·52·36~5-66-73-43 ~ --{J--- City non-teaching CitydaysTeaching//~;/hours~-=:::==1~10050 hoursT hoursdays hours • PERCENTAGE hours 4030 OF PATIENTS 0 -+-- Rural 90 + 70 20100 -~~ CUMULATIVE80 + y?

CUMULATIVE TIME FROM ACCIDENT TO HOSPITAL

Figure 3.12 Cumulative time from accident to hospital arrival.

16 • Total

o Non-transferred

11 Transferred

5-7 days

TIME BETWEEN ACCIDENT AND E.D. ARRIVAL

Figure 3.13 Time between accident and hospital arrival with and without transfer.

314 90.00 f • Total

80.00 o City Teaching

70.00 ~ City non-teaching ~ Rural 60.00

PERCENTAGE 50.00 OF PATIENTS 40.00

30.00

20.00

10.00

0.00 NO TRANSFER TRANSFER PATIENT'S TRANSFER STATUS

Figure 3.14 Patient's transfer status.

17 40 PERCENTAGE OF PATIENTS 30

10 o 3 3 0 0 220 o

By-pass Spinal Injury Test Consultant ICU Transfer Paediatric Unavailable Unavailable

REASONS FOR INTER-HOSPITAL TRANSFER

Figure 3.15 Reasons for inter-hospital transfer.

50 .18S<15 PERCENTAGE 40 OF PATIENTS o ISS> 15 30

10 25 9 16 8 o 10 3 8 4

o - 2 2 - 4 4 - 8 8 - 12 12 - 24 1 - 2 2 - 4 5 - 7 hours hours hours hours hours days days days TIME TAKEN FROM ACCIDENT TO E.D. BY ISS

Figure 3.16 Time between accident and hospital arrival by injury severity.

11 I ;1 TABLE 3.2 INTER-HOSPITAL TRANSFER BY DECISIVE BODY REGION INJURED

BODY REGION 3.4%30.9%31.5%20.8%4.0%9.4%PERCENTFREQUENCY 4746311465

Abdomen ExternalFaceChestExtremityHead/Neck

NB: There were 18patients for which a decisive body region injured was unknown.

TABLE 3.3 INTER-HOSPITAL TRANSFER BY AIS LEVEL

AIS LEVEL25.6%22.3%3.0%43.0%6.1%PERCENTFREQUENCY 2181301131531

5423(Severe)1 (Minor)

NB: Multiple injuries per patient are included in this analysis.

19 TABLE 3.4 INTER-HOSPITAL TRANSFER REASON BY BODY REGION INJURED

- IPaediatricCD transfer 1RANSFER 41584- ABOOMEN179621812rnrsrEXIREMITY834211-EXIERNAL-1645TOTALHFAD 561007 - TestRe-presentunavailable(same)unavailable (new) (1%)(5010)(?I/o)C7%)7151275!NECK 3 (31%) 9 Other REASON 32183 (23%)FACE (23%)119 J5 10fAL Re-presentConsultant 412 16 12 4

NB: Patients could be transferredfor more than one reason. Thejigures above are the total transfer reasons observed

11 11 I TABLE 3.5

TIME FROM ACCIDENT TO HOSPITAL

DeviationStandard1284Number11170.810.600.890.820.551.502.111.481.212.232.441.162.171.931.45800328771346689156127301Patients16711180298727 of4.323.694.074.261.113.591.231.161.171.42Mean4.021.561.191.821.43 Population188>15TransferNo188<15TransferNo188>15For188<15transfertransferEntire (hrs) RuralTransfer CityCityTeachingNon-teaching No Transfer

21 neck and extremity injuries.ferred cases. Consultants 3.6 TREATMENTS RECEIVED PRE• HOSPITAL unavailable and re-presentations for the same injury were predominant among head/neck and extremity IDJunes. 3.6.1 Pre-Hospital Treatment Required

3.5.7 Time between Accident and On average there were 2.5 pre-hospital treatments Arrival by Injury Severity given per patient. Figure 3.22 shows that fewer pre• hospital treatments were given for city non-teaching

The proportion of patients arrival at final hospital and rural hospital patients than city teaching hospital within 2 hours was slightly less for those with patients. severe injuries (ISS >15) as shown in Figure 16. This is probably confounded by the more frequent Figure 3.23 shows that the order of frequency of instance of transfer in seriously injured patients, pre-hospitaltreatments included oxygen (51%), resulting in late arrival. This is evident in Table 3.5 drugs (30%), splints (28%), IV fluids (24%), C• when comparing transferred and non-transferred Collar (20% ), pressure bandage (19%), backboards mean times for low and high ISS Scores. (6%). Nineteen percent of patients received no pre• hospital treatment at all.

3.5.8 Transfer by Patient Age Assisted ventilation was only given to 3 per cent of Figure 3.17 shows that slightly fewer patients aged patients, achesttubeorneedlethoracostomy inserted 55 years or more were transferred, compared with in 2 per cent, and a mast suit fitted to 1.5 per cent. their younger counterparts (16% c.f. 17%). Cardio-pulmonary Resuscitation (CPR) was administered to only four patients out of a total of 3.5.9 Transfer by Injury Severity 1444.

Transfers were more common in patients with higher The corresponding frequencies of pre-hospital ITyll1)' severity scores (ISS> 15),shown in Figure 3.18. treatment by hospital categories are given in Figures This is further confirmed in Figure 3.19 which shows 3.24 to 3.26. The patterns of frequency of use are that transfer frequency generally increased (except for not too dissimilar across the three hospital categories. the most severe category) as the maximum abbreviated injury score (MAIS) increased. 3.6.2 Surgical Procedures (Referring Hospital) 3.5.10 Transfer by Trauma Score Fifteen percent of patients transferred had undergone Roughly half(56% )ofthepatients who were transferred surgery at the referring hospital. Body regions had a nonnal trauma score (IR=13) atthe scene of the operated on most frequently were the extremities, accident. Figure 3.20 further shows that the likelihood abdomen, and external regions. Figure 3.2 7 shows ofbeing transferred increased asthe initialtrauma score details of the body area operated on by hospital at the scene fell (from 13% to 19%). category. The small numbers involved here do not pennit any meaningful comparisons of these data. Comparing transfer by minimum trauma score group (the lowest of the 4 trauma scores collected for each 3.7 TRAUMA SCORES AND patient), however, is less clear as shown in Figure 3.21. SURVIVAL OUTCOMES There is little evidence of any relationship between likelihood of transfer and minimum trauma score. Almost two thirds (61%) had a normal minimum trauma score (the lowest trauma score obtained before and after admission). Nineteen percent had minimum scores of 12, and 21 per cent were 11 or less.

I 90 201 1173 972 • Total 80 0<55 years 70 ~ >54 years 60

PERCENTAGE 50

OF PATIENTS 40

20 204

o NO TRANSFER TRANSFER PATIENT'S TRANSFER STATUS

Figure 3.17 Transfer status by patient age.

90 T 814 • Total 80 o ISS <15 70 § ISS >15 60

PERCENTAGE 50 OF PATIENTS 40

o NO TRANSFER TRANSFER PATIENT'S TRANSFER STATUS

Figure 3.18 Transfer status by injury severity (ISS scores).

23 2 .' TRANSFER 100 TRANSFER OF PATIENTS 40NO PERCENTAGE 20705060803010900 PATIENT'S TRANSFER STATUS

• Total

o MAIS 1

8 MAIS2

11 MAIS3

[] MAIS4

III MAIS 5

~ MAIS6

Figure 3.19 Transfer status by injury severity (MAlS scores).

527 90 T 153 I Trauma Score 80

70 • 13 (normal)

60 012

El <=11 PERCENTAGE 50 OF PATIENTS 40

30 35 20 10

o NO TRANSFER TRANSFER PATIENT'S TRANSFER STATUS RELATED TO INITIAL PRE-HOSPITAL TRAUMA SCORE

Figure 3.20 Transfer status related to initial pre-hospital trauma score. 24

i I I 3

2.5

Average No. of 1.5 Treatments

0.5

o __.+_ l'///////////////////////////////J -+-__ All City City Non- Rural Hospitals Teaching Teaching Hospital Type

Figure 3.22 Number of pre-Iwspital treatments by hospital type.

60 741 50

PERCENTAGE 30 OF PATIENTS

o -IDCl)Dl=> (j)>- ID .=>':J-IDx"0'"0'"Dlc .0en'"'" :;if.'" Ca;a'"ena.0-IDID0 u> 15 CID > '" uen'"u(;" cs z0C <{ en cL ~E ±;! en

Figure 3.23 Frequency of types of pre-hospital treatments. 25 169 50 45 40 35

30 87 PERCENTAGE 25 I 84 OF PATIENTS 20 15 10

Cl>>- CLell co 5 "0""Cl>co:;,cQ)(.):;, r. - co co~:;(fJQ)(,)"0c~'"ell'" D ccIr.I2:;, co Q) x ~"'~:;,'0(,)u:ICLu;0CQiQ)erCl>0 ~rf)(fJ1-coc ~> :0 ~ (.) ell :§0Q.12:; 0 0 co co0 (,) z ~0 I "0 o PRE-HOSPITAL TREATMENTS(CITY NON-TEACHING)

Figure 3.25 Frequency of pre-hospital treatments (city non-teaching) hospitals.

50 77 45 40 35 30 PERCENTAGE 25 OF PATIENTS 20 15 10 5 o

"0""-CfJ::J(/)c:en::J Cl. Cl)«l::Jc:rID e;;::J Cl) >- '0«l (/) u ..: e;;~CS.maE ~.£l z ce;;~ ~ ~ PRE-HOSPITAL TREATMENT (RURAL)

Figure 3.26 Frequency of pre-hospital treatments (rural) hospitals. 26

11 _11 4 8 t II1II Rural I 6 126 18 ~ I I• 0TotalCity Teaching - I § c,ty NOO-leachio9 PERCENTAGE 4 -i- ,I - OF PATIENTS 10 + (Transferred)

Head/Neck Face Abdomen Extremity External BODY REGION OPERATED ON (Referring Hospital)

Figure 3.27 Frequency of body area operated on by hospital type.

4 100.00

90.00

80.00

70.00 • All Hospitals

PERCENTAGE 60.00 City Teaching OF PATIENTS 50.00 WHO DIED ~ City Non Teaching 40.00 III Rural 30.00

20.00

10.00

0.00 Normal Abnormal INITIAL PRE-HOSPITAL TRAUMA SCORE FOR THOSE WHO DIED

Figure 3.30 Mortality rates by pre-hospital trauma score.

27 3.7.1 Trauma Score by Hospital Type treatment (0.08% c.£ 1%). Conversely, a higher proportion of those who still had an abnonnal1rauma Abnormal minimum trauma scores were more score after ED. treatment subsequently died (17% c.£ likely in city teaching than either city non-teaching 12%). Moreover, the proportion of non-suMvors or rural hospitals (not illustrated here). This may in increased substantially as their post-admission trauma part reflect transfer patterns between the various score decreased, shown in Figure 3.32. hospital types. 3.7.5 Trauma Score Changes Death occurred to 4 per cent of patients overall in this study. Less than 1 per cent of those with a Figure 3.33 shows the percentage of abnormal normal minimum trauma score subsequently died trauma scores by hospital type for the pre-hospital, in hospital compared with 9 per cent of those who admission, and post-admission phase. The had an abnormal minimum trauma score. percentage of abnormal trauma scores decreased from the scene to the Emergency Department and 3.7.2 Initial Trauma Score by Survival more markedly after hospital admission.

Sixty-two percent of patients had normal trauma Most strikingly, the percentage of abnormal trauma scores at the scene of their accident and 1 per cent scores at the scene was greatest for rural hospital of these patients died. Of those who had an casualties but reduced markedly on arrival at the abnormal trauma score (3 8%), death occurred in 10 emergency department. per cent of cases.

Figure 3.34 further shows that the majority of all Figure 3.30 shows that there were no cases of death survivors (68%) had no change between their among casualties with a normal initial trauma score admission and initial trauma scores, compared to at rural hospitals. The mortality rate for casualties with an abnormal initial trauma score was lower in only 16% of non-survivors. Except for this there was little appreciable change in the pattern of city non-teaching hospitals than other hospital increases and decreases in trauma score between types. those who survived and those who died. There were too few number to compare changes in trauma 3.7.3 Admission Trauma Score by Survival scores between patients who lived or died across the various hospital types.

Seventy-fivepercentofpatientshadanormaladmission The majority of patients (survivors, 82% and non• traumascorewhentheyarrivedathospitaland I percent survivors, 56%) had no change in their trauma of them subsequently died. Of the 25 percent abnormal score between first and final evaluations in the E.D. patients, 12 per cent died after arrival. as shown in Figure 3.35. Twenty-one percent of non-survivors showed a decrease and 24% an Figure 3.31 shows that the mortality rate was increase in their trauma score, compared with 4% highest among those with normal admission trauma and 13%for survivors. Againtherewereinsufficient scores but lowest for casualties at rural hospitals with an abnormal admission trauma score. cases to compare trauma score changes by hospital type.

3.7.4 Post-Admission Trauma Score by 3.8 EMERGENCY ROOM Survivals ASSESSMENT AND TREATMENT

The number of patients with a normal post-admission 3.8.1 Cardio-Pulmonary Resuscitation trauma score increased following Emergency Department (E.D.) treatment (82% c.f. 75%). In Onlyonepercentofpatientsrequiredcardio-pulmonary addition, the death rate also decreased amongst those resuscitation (CPR). Figure 3.40 shows that CPR was with normal post-admission trauma following ED. more frequent in rural hositals than city hospitals.

11 i I I I 90.00 33 80.00

70.00

60.00 • All Hospitals PERCENTAGE 50.00 OF PATIENTS o City Teaching WHO DIED 40.00 ~ City Non- Teaching 30.00 § Rural

20.00

10.00

0.00 Normal Abnormal

ADMISSION TRAUMA SCORE FOR THOSE WHO DIED

Figure 3.31 Mortality rates by hospital admission trauma scores.

90 1173 118 80

60 • TOTAL PERCENTAGE 50 ALIVE 22 o OF PATIENTS 40 ~ DEAD 30

10 20 8 10

11011011011010132151 o 1 2 3 4 5 6 7 8 9 10 11 12 13 POST-ADMISSION TRAUMA SCORE BY SURVIVAL

Figure 3.32 Survival and death rates by post-hospital admission trauma scores 29 280 60 T • Total •45 withTraumaAbnormalScoreInitial30 %50PatientsI 20 ~ City Teaching 40 100 ~ City Non-Teaching

o Rural

Admission Post Admission

Trauma Score Sequence

Figure 3.33 Percentage of abnormal trauma scores by hospital type for pre-hospital, admission and post-admission phases.

% of 40 ---Alive total patients 30 --0- Dead

10 ~ ''', .~~.~ "'0// o , r I ----,-- -4 -3 -2 -1 0 1 2 3 4 5 TRAUMA SCORE CHANGE (Pre-admission - Admission)

Figure 3.34 Trauma score change (pre-admision to admission) for suvivors and non-survivors. 30

I i I i I '1'-1'0 ------0-' 90 '-2 ,/- I

'-3(+) cases80o 2 % of 6020705010 4030

-- ALIVE

-D-- DEAD

'2 '3 '4+ TRAUMA SCORE CHANGE (Admission - Post Admission)

Figure 3.35 Trauma score change (admission to post-admission) for survivors and non-survivors.

946.-~~- 353 100 OF PATIENTS 40 PERCENTAGE 6030207050100 • Total 90 80 o City Teaching

~ City non-teaching

III Rural

9 16 6

ePR NOT ePR ADMINISTERED ADMINISTERED CARDIO-PULMONARY RESUSCITATION

Figure 3.40 Frequency of cardio-pulmonary resuscitation. 31 9341445 345 100 - • Total 7080OF PATIENTS 40 90 PERCENTAGE 20506030100 o City Teaching

IS City Non-teaching

III Rural

7 34 18 9

AIRWAY AIRWAY ADEQUATE INADEQUATE

ADEQUACY OF AIRWAY ON ARRIVAL IN E.D.

Figure 3.41 Adequacy of airway on hospital arrival.

100 OF PATIENTS 40 PERCENTAGE 80607020305010900 • Total

o City Teaching

~ City Non-teaching

III Rural

7 6 5 0 1 24 17 6 1 15 B 0 7 3 o

No Treatment Nasallntubation Oral Intubation Oropharyngeal Other AIRWAY MANAGEMENT IN E.D.

Figure 3.42 Frequency of emergency airway treatment by hospital type. 32

11 i .1 • Tolaf

o City Teaching

I§ City Non-teaching

III Aural

NO CT CT SCAN SCAN CT DURING E.D. TREATMENT

Figure 3.43 Frequency of Computerised Tomography (CT) scans by hospital type.

Note: Shaded areas represent positive CT scans

90.0% 27 80.0% 128 98 ~ 70.0% uCQ I-UJ 60.0% ~o 50.0% g 40.0% E 8. 30.0% E a. 20.0%

••.•_ ,_.~ unu.~ 1r'''''''A_~0...... _._..".,--~.. r-~..._-,~ "".'/.I'A •... er:L.Jo~-c._ E::===!- CD .~ c0>CD IIIIII CD :t:._z..c>-Ill>-cc'0>0._0>G:lQCD Ier:;:)Q) -•...IIIco >-.~ III •... 111OI-c01-._:r:~0C)Qc;:) z~0._Ci20I 'IccCier:;:)•...2l-- OI-l-:r: 0 l- •... l- CD z..c 10.0%~g.=~~ i"1II!II~.fz~I- I-~er:~III ~0~>-~ cc VI I I L.J cc0 I->- C:~~g>g zC.§~~~g> ii.~ t! 5 ~ HgADCT S~INALABOMENc1iESTP~i.VIC CTCTCT 0.0% Ci

TYPE AND RESULT OF CT SCAN

Figure 3.44 Type and result of eT scans. 33 3.8.2 Adequacy of Airway on Arrival Table 3.7 further shows the breakdownofCT scans by time of arrival for positive Head/Neck scans. The airway was inadequate on arrival at E.D. in two More than half these procedures (54 %) were percent of patients. An inadequate airway was performed on patients who arrived at the treatment observed more often in rural compared with city hospital less than two hours after their crash. The hospitals (see Figure 3.41). longer times most likely represent transferred patients from a previous hospital. 3.8.3 Emergency Ainvay Treatment 3.8.8 Diagnostic Peritoneal Lavage

F our percent of patients required airway (DPL) management in E.D. Figure 3.42 shows that oral intubation and oropharyngeal treatments were most Diagnostic peritoneal lavage (DPL) was perfonnedon common treatments, the latter particularly in rural 5percentofpatients. Figure3.46showsthatitwasmore hospitals. frequently perfonned in city teaching (5%) and non• teaching (4%) than runU (0.6%) hospitals. 3.8.4 Computerised Tomography (CT) Scans Positive results were obtained in 58 per cent of patients tested with practically no difference found

eT Scans were performed on 14 per cent of patients across the various hospital types. DP Lavage was in E.D. They were twice as commonly performed generally performed within 90 minutes after the in city teaching hospitals (16%) than in city non• patient's arrival at hospital. teaching (8%) or rural (9%) hospitals (see Figure 3.43). 3.8.9 DPL by Injury Severity

DPL was perfonned infrequently in patients with an 3.8.5 Type and Result of eT Scan ISS lessthan 15(1.4% )comparedwiththosewhoseISS was greater than 15(10%), as shown in Figure 3.47. A Figure 3.44 shows the body region scanned and the positive result was more common amongst the higher percentage with positive fmdings. Most scans were ISS group (63%) than those less injured (36%). performed on the head (70%), abdomen and spine (12% each). In general, roughly three-quarters of Of some interest, DPL was not performed at all at~ all tests were positive, independent of body region scanned. There were no marked differences in of the rural hospitals and two of the city hospitals. positiveornegative outcome ofCT scan by hospital 3.8.10 DPL by Injury type.

3.8.6 CT Scan by Transfer Table 3.8 shows the DPL test by body region injured and IAS severity level. Testswereperforrned The type and outcome of CT scan for those generally for injuries to all body regions, although transferred or not is shown in Figure 3.45. CT scans slightly more frequently for external injuries which were also the more common injuries recorded by of the head and spine were slightly more frequent patients. Tests tended to be performed for lower in transferred than non-transferred patients and there was a marginally higher likelihood of a severity injuries « AIS 3). positive result among these cases. 3.8.11 Dispatch from Emergency Department 3.8.7 CT Scan by Body Region Injured

The majority of patients (59%) were dispatched to Table 3.6 shows the CT scan performed by body a general ward from the E.D., as shown in Figure region injured. The vast majority ofCT Scans (73 3.55. A further 19 per cent were dispatched to an percent) were performed to the HeadlNeck region, operating theatre and 8 per cent to an intensive care while 11 percent were for spinal injuries. unit(ICU). City hospital patterns were quite similar 34 whileruralpatientsweremorelikelytobedispatched 80.0% 24 Note: Shaded areas represent positive eT scans 121. 97 70.0%

~ 60.0% o(1:l o~ 50.0% .•... o 40.0% c: o

~c. 30.0% o ~ 20.0%

IfJ~..IfJ ~.. f0-en0f0-e:lU~ene: lUlU z00 1iilUI-CD0lU1iilU~I-IfJCDee:IfJCD I-lUI-lU SPINALABDOMENCHESTPELVICCTCTCT f0- z 10.0%22.02.02 0 I-lU~0 HEAD CT TYPE OF CT SCAN BY TRANSFER STATUS en 0.0%

Figure 3.45 Type of eT scan by transfer status.

172 8 >-- 38 29 0 ~1 100 OF PATIENTS~ 40 00 ~, 14 PERCENTAGE 302060708050 90 10 I_

I.Total

I 0 City Teaching 1 S City Non-teaching

fill Rural

DPL NOT DPL DPL DONE PERFORMED POSITIVE DIAGNOSTIC PERITONEAL LAVAGE

Figure 3.46 Frequency of Diagnostic Peritoneal Lavage (DPL) by hospital type. 35 TABLE 3.6

CT SCAN BY BODY REGION INJURED

BODY REGION11.5%2.2%2.9%10.8%72.6%PERCENTFREQUENCY 101151643 ChestSpinePelvisAbdomen HeadlNeck

TABLE 3.7

CT SCAN BY TIME OF ARRIVAL (POSTIVE HEAD INJURY)

TIME INTERVAL13.0%16.7%31.5%22.2%9.2%7.4%PERCENT 17129754 Above4321--- 4832 HRHR8 HR FREQUENCY

0- 1 HR

11 I ;·'1 I 100 962

60 • TOTAL PERCENTAGE 50 OF PATIENTS o ISS < 15 40 ~ ISS > 15

20 52 10 33 38 5 o Not Done DPL Performed DPL Positive DIAGNOSTIC PERITONEAL LAVAGE

Figure 3.47 Frequency of DPL by injury severity.

80 127 • Total 70 o City Teaching 60 El City Non-teaching

50 III Rural

PERCENTAGE 40 OF PATIENTS

20 43 10 9 8 0 1 o ICU Operating Morgue Trauma General Home Other Theatre Ward Ward PLACE PATIENT DISCHARGED TO

Figure 3.55 Place of dispatch from emergency department. 37 TABLE 3.8

D. P. LAVAGE TEST BY BODY REGION AND AIS LEVEL

22493219- Total1410.31332033902922297453801624.1%43916.3%-1419.2%15.3%15.8%-Percent569.4%1316100% 144191041- AIS LEVEL Region ChestAbdomenExtremityFaceExternalTOTAL Body HeadlNeck

11 I I_I 72 • Total 45 o City Teaching 40 § City Non-teaching 35 11 Rural 30

PERCENTAGE 25 OF PATIENTS 20

Ul~(\lUlNUl . 0301 31 L:(\l\0CX)0~NL:\00(\l~L:0 0

TIME SPENT IN EMERGENCY DEPARTMENT BY HOSPITAL TYPE

Figure 3.56 Time spent in emergency department by hospital type.

"" I TRANSFER I • NO TRANSFER 72 8hours6-84-6hours2-412-1616-20hours- 123 40431T 0 0 68 _1 ~ I I hours OF 338PATIENTS0-2I 30 TIME SPENT IN E.D. BY TRANSFER STATUS •I- 11 15 PERCENT AGE 2520105 • 35 t

Figure 3.57 Time spent in emergency department by transfer status.

39 2 • ISS < 15 7 82-44-6hours6-820-24hours16-2012-16- 12l~ 184 "A" 40 T I 96 hours 0 PERCENT AGE 20 t IIIl~III TIME SPENT IN E.D. BY ISS SCORE OFIIIPATIENTSI 0-2 5 I DISS>152510 30 35 t I15 1.7

Figure 3.58 Time spent in emergency department by injury severity scores.

50 T

I 678 45

40 35

30 431

PERCENTAGEOF PATIENTS 25 20 15 10 5 15 o

None Head/Neck Face Chest Abdomen Extremity External INITIAL SURGERY - PATIENT'S BODY REGIONS UNDERGOING SURGERY

Figure 3.59 Initial surgery - body regions operated on. 40

11 I1 j ,·1 to a general ward and less likely to an operating were external (33%), extremity (20%) and head theatre. injuries (19%) and AIS 3 or less (95%). There was an especially low effectiveness rate (survivors' 3.8.12 Time Spent in the Emergency injuries over total injuries) for severe HeadlNeck Department injuries (25%) and chest injuries (65%) showing the greater likelihood of these particular injuries Figure 3.56 shows the time distribution spent in the leading to death. Emergency Department. Eighty-one percent of patients spent less than 6 hours, 4 per cent less than 3.9.2 Multiple Injuries and Age Effects 4 hours, and 15percentless than 2 hours. Agreater proportion of patients in rural hospitals spent less Table 3.10 shows the frequency of body regions than 4 hours in the emergency department than injured by the Major Abbreviated Injury Severity those in city hospitals. (MAIS) category for surviving patients. Almost three-quarters of these patients substained injury in Agreaterproportionofpatients who were transferred 3 or less body regions, although this varied spent less than2 hours intheEmergency Department depending on whether the MAIS was less than 3 of the admission hospital (see Figure 3.57),retlecting (87%) or 3 or more (61 %). a tendency for these cases to have urgent definitive treatment. Table 3.11 shows the multiple Injury Severity Score (ISS) for minor (ISS < 15) and major (ISS > Figure 3.58 shows that patients with high injury 15) injury cases by survival rates and patient age severity scores (ISS> 15) more commonly spent categories. Sixty-nine percent of patients had a less than 2 hours in the emergency department minor ISS which was marginally higherforyounger compared to thosewithlowseverityscores(ISS<15). patients (71 %) than those aged 45 years of above 1bis confirms that those seriously injured are more (61%). likely to receive urgent treatment. However, a sizeable proportion of these patients did, in fact, Survival rates were generally high overall for this still spend a considerable amount of time in the sample of patients (97%) and higher for minor Emergency Department before being discharged. (99%) than major (91 %) injury cases. Again, survival rates were better for those aged less than 45 3.9 INJURIES SUSTAINED years (98%) than older patients (92%) and was especially poor for elderly patients sustaining severe One of the most valuable aspects of these data injuries (84%). collected was the categorisation ofinjuries sustained in terms of body region and seriousness of injury 3.9.3 Pairing of Multiple Body Regions using the Abbreviated Injury Severity (AIS 85) Injured system of the Association for the Advancement of Automotive Medicine. 1bis enabled a number of It was possible to demonstrate the pattern of single interesting injury comparisons to be performed and pairs of body regions injured when comparing including the consequences of multiple injuries the most severe injuries sustained by each patient. through the use of the Injury Severity Score (ISS). These patterns are illustrated in Tables 3.12 to 3.14 While these measures have been criticised as being for varying levels of injury severity too general, they do nevertheless provide detailed analysis of management by injury sustained, not Table 3.12 shows the frequency and days previously possible. hospitalised for single and multiple injuries where no injury was greater than AIS 2. Single minor 3.9.1 Body Region Injured by Severity injuries predominantly occurred in external body regions, and generally resulted in less than 1week's Table 3.9 shows the pattern ofinjuries by AIS level stay in hospital. The most common pairs of minor for the total number of patients and those surviving injuries were external with head/neck (221 cases), patients (in parenthesis). The majority of injuries 41 external with extremity (165 cases), external with There appears to be a marked increase in the chest (109 cases) and extremity with head/neck (88 average days spent in hospital for these cases cases). compared to the lesser severity cases inthe previous Table.

Table 3.13 shows a similar pattern of single and Finally, Table 3.14 shows the pattern of single and paired injuries where at least one injury was AIS 3 paired injuries where both injuries were AIS 3 or or greater. The predominance of single external injurieshasdisappeared here and extremity injuries greater. The single injury pattern is the same as in are now the most common single injury. However, Table 3.13(AIS 3or greatersingleinjury). However, external with extremity and head/neck injuries there were some notable changes in the pattern of were still frequent (presumably the external injury severe paired injuries, especially the increased was the less severe in these cases) as were external proportion of chest with extremity and Head/neck with head/neck, chest, and face injuries. injuries Noteworthy, too, was the further.increase

TABLE 3.9

BODY REGION INJURED BY INJURY SEVERITY FOR TOTAL AND SURVIVING PATIENTS (n=1480)

BODY 0110130 28385472172232382472913962592943580564(100.0%)313240237396(100.0%)398325TOTAL10013601340(100.0%)AIS498(94.8%)(97.2%)(97.1(97.6%)98(99.5%)(98.0%)(98.8%)(97.3%)34508(98.5%)(97.0%)(96.4%)(96.3%)33530639082314(97.4%)2347AIS(25.0%)(100.0%)(63.3%)45(84.4%)(97.6%)(92.7%)381510297.5%)4241727084556(98.0%)541(97.3%)7377(98.0%)419(100.%)(65.2%)(88.9%)129876 23AIS45%) 446857113813071403239 TOTALEXTERNALABDOMENEXTREMITYCHEST (100.0%)(96.9%0(98.0%)(96.9%)(97.5%)4371261328363171 REGION NECKFACEHEAD/ (95.7%)(97.5%)

TOP figure is for total injuries, INTERMEDIATE figure is for surviving patients injuries, while the figure in parenthesis is the EFFECTIVENESS rate (the percentage of survivors to total patients).

42 TABLE 3.10

NUMBERS OF MULTIPLE BODY REGIONS INJURED BY ABBREVIA TED INJURY SEVERITY LEVEL

BODY REGIONS 17137104211065TOTAL35828927157AIS1855519176152 > 3 AIS 487206132<83541131 TOTAL62534 1

NB: Data in this table is based on a sub-set of patients (approximately 70 per cent)

TABLE 3.11a

MULTIPLE INJURY SEVERITY SCORE BY SURVIVAL RATE AND PATIENTS' AGE GROUP

PATIENT100.092.995.095.895.981.1100.087.557.991.797.294.797.990.090.690.994.197.798.8100.095.499.396.891.4FREQ1079SURVIVORSSURVIVORS4912143391074913132767180335319301621429125E.R.27723014114323104851046820947131045360397713776333273546FREQ360740138473334773912 ISS<15 TOTALISS>15 45-5425-3465-7484+TOTAL35-4455-6475-840-24 AGE

NB: ER is the EFFECTIVENESS RATE which refers to the percentage of survivors to total patients. ISS is the INJURY SEVERITY SCORE which is the sum of the 3 most severe injury AIS scores squared Data in this table is based on a sub-set of patients (approximately 70 per cent)

43 TABLE 3.11B FREQUENCY AND SURVIVAL RATES FOR DIFFERENT LEVELS OF INJURY SEVERITY FOR YOUNG AND OLD PATIENTS

100.0%42.9%33.3%50.0%60.0%100.0%12.%%0.0%62.5%0.0%75.0%80.0%33.3%93.4%0.0%62.5%0.0%87.5%85.0%97.5%03021412125311512852172403571 FREQ.80.0%71.4%100.0%60.0%78.9%96.9%98.5%85.7%94.1%85.0%70.6%87.5%92.3%94.9%100.0%98.8%88.9%75.0%95.2%0.0%75.0%99.4%Data99.7%99.6%96.6%93.9%95.2%95.8%88.9%94.9%92.3%85.7%100.0%96.3%93.0%88.2%0.0%60.0%100.8%100.7%100.4%110.4%98.4%FREQ99.7%99.6%99.3%S.RATS.RATESURV.4879(78)(134)314465(225)4015(40)228161130(12)(291)286(1)(3)3(46)(224)2275(8)161039(4)(17)1(15)(0)(94)94(16)(28)42(270)(60)(271)351270271(48)(21)21(18)(162)(351SURV.1718FREQ.8(352)(162)(271)(273)229130286228(18)in(99)(24)(0)(52)(21)(8)22935242208016217(63)(49)(29)(48)(24)(9)1056(4)(1)(5)2724227144099245210195)this(5)326621071 table is based AGEon a subsetTOTAL>= 55ofYRS.patientsP=O.89164(approximately(FOR 70SURV.Epercent)CASES) TOTAL61-7041-5036-4051-6071+ (0)(20)( (4)(3)17) LEVEL26-3031-3506-1011-1518-2021-25 (133)(223)(289)(224)(48)(81(20)) 00-05 (EXP.VAL) P=0.39270 (FOR ALL CASES) NB: ISS AGE<55YRS

11 11 I .1 TABLE 3.12

FREQUENCY AND AVERAGE DAYS IN HOSPITAL FOR SINGLE AND MULTIPLE BODY REGION INJURIES FOR CASES WHERE NO INJURY WAS GREATER THAN 2

REGION ABDOMENCHEST2056(11.4%)(4.1%)396.75.75.428FACE185(7.9%)EXTREMITY(7.7%)(17.9%)38(2.2%)5.7(5.7%)6.57.034(14.3%)11(22.2%)(18.1%)11.2(37.7%)221109288.48.5(5.7%)88(6.9%)9.039(7.9%)(45.0%)5.28.8896.45.870EXTERNAL5.4(1.8%)HEAD9 4 2 3 8 57 /NECK EXTERNALEXTREMITYABDOMENFACECHEST/NECK 1.6 (0.8%)2.0 (0.4%)6.5 (0.6%)1.0 HEAD(1.6%)7.1 (11.6%)5.5

NB: TOP figure is for frequency of single (diagonal) or multiple (matrix) injury. Figure in parenthesis is the percentage of total cases while the LOWERjigure represents average days spent in hospital. Data in this table is based on a sub-set of patients (approximately 70 per cent).

45 TABLE 3.13

FREQUENCY AND AVERAGE DAYS IN HOSPITAL FOR SINGLE AND MULTIPLE BODY REGION INJURIES FOR ALL CASES WHERE AT LEAST ONE INJURY WAS AIS 3 OR GREATER

, : REGION, ABDOMEN171118CHEST(20.0%)(29.0%)(12.2%)7218.712520.447921.318.559(30.7%)(20.8%)18112318.1(10.0%)18.4FACE(21.2%)EXTREMITY12724521.028622.520.8414172(70.2%)(32.0%)(29.2%)18922.821.4(27.3%)161(48.5%)(21.5%)19.518.019.817.5EXTERNA(0.3%)HEAD2 0 6 L 18 , 3 1 EXTERNAL (41.5%) (81.2%) , /NECKABDOMENEXTREMITYFACECHEST 10.5/NECK (0.0%)0.0(1.0%) 15.3(0.5%) 15.0 (3.1%)14.2 (0.2%)6.0 HEAD

NB: TOP figure is for frequency of single (diagonal) or multiple (matrix) injury. Figure in parenthesis is the percentage of total cases while the LOWERfigure represents average days spent in hospital. Data in this table is based on a sub-set of patients (approximately 70 per cent).

11 11, 1,1 I TABLE 3.14

FREQUENCY AND AVERAGE DAYS IN HOSPITAL FOR SINGLE AND MULTIPLE BODY REGION INJURIES FOR CASES WHERE ALL INJURIES WERE AIS 3 OR GREATER

REGION ABDOMEN15CHEST32.018(2.7%)123425.326.72038(6.1%)FACE(0.9%)19.0(3.2%)(1.6%)EXTREMITY(0.7%)433.7(18.354032.039.527.6(0.2%)(0.7%)(0.0%)26.9(6.8%)(2.2%)(3.6%)(7.2%)9EXTERNA(0.2%)0.04000.0%)1HEAD1 0 6 3 L 17 0 EXTREMITYABDOMEN/NECKEXTERNALCHESTFACE 20.0/NECK (0.0%)0.0 (1.1%)15.3 (0.5%)15.0 (3.1%)14.6 (0.0%)0.0 HEAD

NB: TOP jigure isfor frequency of single (diagonal) or multiple (matrix) irljury. Figure in parenthesis is the percentage of total cases while the LOWERjigure represents average days spent in hospital. Data in this table is based on a sub-set 'afpatients (approximately 70 per cent).

47 60

• Total

40 o City Teaching

§ City Non-teaching PERCENTAGE 30 OF PATIENTS 11 Rural

Head/neck Face Chest Abdomen Extremity External TOTAL BODY REGIONS OPERATED ON

Figure 3.60 Total body regions operated on by hospital type.

30 • Total

o City Teaching 25 46 ~ City Non-teaching

m Rural 20

PERCENTAGE 15 OF PATIENTS 64 10

o 0-1 1 - 3 3-6 6 - 12 12 - 24 1 - 2 3-7 1 - 2 Over 2 hour hours hours hours hours days days weeks weeks TIME BETWEEN ADMISSION TO FINAL HOSPITAL AND SURGERY

Figure 3.61 Time to surgery after admission by hospital type. 48

11 11 I ,·1 in average.... days spent in hospital for these more 3.10.3 Referring Hospital Surgery Time severe Injury pamngs.

There were only ~ instances of prior surgical 3.10 SURGICAL PROCEDURES treatment in patients referred to the study hospitals PERFORMED (6%). Among these cases, most (62%) had surgery within 24 hours of arriving at the referring hospital 3.10.1 Initial Surgery and prior to transfer (Figure 3.63).

Fifty-four percent of the patients admitted to the 3.11 ICU AND ADMISSION DURATION study hospitals after road trauma received surgery to at least one body region. Figure 3.59 shows the 3.11.1 Intensive Care Treatment breakdown of initial surgery by first body region operated on. Extremity Pelvic girdle was the most Fifteen percent of patients admitted at one of the frequent region (54% ),followed by external (15%), study hospitals after road trauma required ICV and the chest was the least common body area treatment. Figure 3.64 shows that two-thirds of operated on (2%). them were admitted for 5 days or less and that this proportion was much lower in rural (52%) than city The 802 initial operations involved surgery to 1499 hospitals (69 or 70%). body regions (roughly 1.9 body regions per operation). Figure 3.60 shows that city teaching 3.11.2 ICV by Patient Age hospitals were over-represented in all body regions operated on except for extremity injuries. In Patients aged 65 years or more were over-represented particular surgery to the head/neck, face, and chest among those with stays longer than 14days, compared was more frequent at city teaching hospitals where to their younger counterparts (Figure 3.65). facilities for these operations would be more 3.11.3 ICV by Minimum Trauma Score comprehensive.

Relatively fewer patients with a normal tramna 3.10.2 Time to Surgery after Admission score spent more than 5 days in leD whereas abnormal patients more frequently spent longer Approximately one-half ofthepatients who underwent times in ICD (Figure 3.66). surgery entered the operating theatre within twelve hours from admission. Figure 3.61 shows the time 3.11.4 ICV by Patient Injury between admission and surgery for the three hospital types. Ingeneml, there were slightly more patients who The duration of stay in ICD was longer in patients had their surgery within 12hours at rum1and city non• with progressively higher Maximmn AlS, shown teachinghospitalsthancityteachinghospitals,although in Figure 3.67. There were no instances where ruml hospitals tended to have slightly longer times to patients with MAIS 1 stayed longer than two days surgery ovemll. inICD.

By contrast, only 36 percent of transferred patients This pattern was consistent, too, for patients with had their surgery within 12 hours at the admission lower and higher iJUury severity scores, shown in hospital (Figure 3.62). This varied from 32 percent Figure 3.68. Low severities were associated with at city teaching, 44 per cent at city non-teaching, shorter stays in ICD than were higher severities. and 47 per cent at rural hospitals. This reflects the fact that many patients were transferred for reasons 3.11.5 Total Hospital Stay other than immediate surgery needs.

Figure 3.69 shows that the majority of patients (59%) were admitted to one of the study hospitals for less than 10 days, 20 per cent for 10 to 19 days, 9 percent between 20 and 29 days, and the remaining 49 • Total 45 11 o City Teaching 40 7 ~ City Non-teaching 35 III Rural 30

PERCENTAGE 25

19 OF PATIENTS 20

10 7

o . 2 2 . 3 3 - 6 6 - 12 12 . 24 1 . 2 3 • 7 1 . 2 Over 2 hours hours hours hours hours days days weeks weeks TIME BETWEEN ADMISSION TO FINAL HOSPITAL AND SURGERY IN TRANSFERRED PATIENTS

Figure 3.62 Time to surgery after admission for transfe"ed patients by hospital type.

40 I35 3 OF PATIENTS 2 25 1 15 PERCENT AGE 20 300105 --

0- 3 hours 6 - 12 hours 12 - 24 hours 1 - 2 days 1 ·2 weeks TIME BETWEEN ARRIVAL AND OPERATION AT REFERRING HOSPITAL

Figure 3.63 Time between arrival and operation at referring hospital. 50

11 11 I ,'. I 50 45 OF PATIENTS68 05 I 20 PERCENTAGE 302540351015

• TolaJ

o City Teaching

~ City Non-teaching

II1II Rural

1 - 2 days 3-5days 6-9days 10-14 days 15-21 days 21 + days INTENSIVE CARE UNIT STAY (DAYS)

Figure 3.64 Intensive care unit (ICU) treatment - number of days.

45 ~ 97 76 1 - 2 days • Total 1003035OF5 PATIENTS 20 PERCENT AGE 4025 15 0< 55 Years

El 55 + Years

3 - 5 days 6 - 9 days 10-14 days 15-28 days 28 + days DAYS IN ICU BY AGE

Figure 3.65 ICU treatment by patient age.

51 70 22 Trauma Score 60 • Total

50 0<= 11

~ 12 40 PERCENTAGE OF PATIENTS 30

o o

1 - 2 days 3·5 days 6 - 9 days 10-14 days 15-28 days 28 + days ICU DAYS BY MINIMUM TRAUMA SCORE

Figure 3.66 ICU treatment by minimum trauma score.

42 2 22 ~ MAIS3MAIS2 10-143615-2828-- 59+daysdaysdays 19 ~ MAIS4 o 20 ,. NI 100 I ~ MAIS5 OF PATIENTS ~1R DAYS IN ICU BY MAXIMUM40 AIS (MAIS) 3010900 1 - 2 days PERCENTAGE 506070 • ~ r:MAIS 1 80

Figure 3.67 ICU by patient injury.

11 I 25 days283-5days6-928days15-10-14+ 80 T 0188<1511188>15 days days I 97 Total DAYS SPENTPERCENTIN ICU AGEBY ISS40 OF PATIENTS1 - 2 I. 6070 30 50 20100

Figure 3.68 Days spent in fCU by injury severity scores.

13580 ~ OF PATIENTS0- 9 days • Total 30 PERCENT70 AGE 20405060100 o City Teaching 8 City Non-teaching

10-19days 20-29 days 30-50 days Over 50 days TOTAL DAYS IN HOSPITAL:.

Figure 3.69 Total days in hospital by hospital type. 53 12 per cent for 30 days or more; the median infatalityrate by hospital type. Fatalityratesamongst admission duration period was 5 days (not shown). the severely injured (ISS> 15) by age group and Hospital staysofl 0 days or more were less frequent hospital type is shown in Figure 3.77. The fatality in rural than city hospitals. rate overall was higher for those aged 55 years or more than for younger patients (20% c.f. 9%). 3.11.6 Hospital Stay by Age There was amarked increaseinfatalityrates amongst the aged (and conversely a lower fatality rate for Patients older than 54 years tended to have longer younger victims) for city non-teaching than other stays in hospital than younger patients (Figure hospitals. 3.70). This was especially noteworthy among those whose hospital stays were 50 days or more. Fatality rate by ISS and Minimum trauma score is shown in Figure 3.78. The majority of fatalities 3.11.7 Hospital Stay by Trauma Score occurred to patients with severe injuries (ISS> 15) and abnonnal trauma score «13). Three patients Patients with abnormal pre-hospital trauma scores with minor injuries (lSS<15) who had a normal were more likely to have longer stays in hospital trauma score subsequently died whereas no patient than normal pre-hospital trauma score patients, with minor injuries and an abnormal trauma score particularly for stays of 20 days or more (Figure died. 3.71). 3.12.2 Associated Fatality 3.11.8 Hospital Stay by Patient Injury There were 83 crashes where a vehicle occupant Figure 3.72 shows that patients with injuries of was admitted to hospital while another occupant of higher MAIS spent longer in hospital than those the same vehicle had been killed. with lower MAIS. Practically all patients admitted for 20 days or more had injuries of MArS 3 or The rate of other occupant death amongst vehicle greater severity. occupants was higher for city non-teaching (13% ) than

other hospital types (<)010 city teaching and 6% rural). Similarly, those with higher injury severity scores (ISS> 15) were more likely to have longer periods 3.13 DISABILITY AT DISCHARGE in hospital than those with lower ISS. Two-thirds of severely injured patients were admitted for 10 3.13.1 Primary Mode of Locomotion days or more, as shown in Figure 3.73.

3.12 OUTCOME AND DISCHARGE Eighty -eight per cent of patients were able to walk DETAILS out of hospital (with or with-out assistance) on discharge. Five per cent required a wheel chair and 3.12.1 Survival Outcome 8% continued to require bed rest (see Figure 3.80). Figure 3.81 shows the breakdown of disability at discharge by the degree of disability. For As noted earlier, 4 per cent of patients who were locomotion, 53% of patients were completely hospitalised from a road crash at one of the study independent, 35% moderately independent, 4% hospitals subsequently died at that hospital during moderately dependent, while 8% were completely treatment. Ninety-five percent of these fatalities dependent on discharge. had an ISS greater than 15, as shown in Figure 3.74. The probability of death increased for those with a 3.13.2 Ability to Express higher ISS (11 % c.£ 0.3%). The relationship between ISS and fatality rate is shown further in Figure 3.75. Again, most of the patients (93%) were able to express themself clearly on discharge from hospital. Three per cent were moderately independent, two This is further broken down by hospital type in Figure 3.76. where there were no marked differences percent moderately dependent, and two per cent 54

I I I I I ~,• I 739 60

AGE

50 • < 55 years

0>= 55 years 40

PERCENTAGE 30 OF PATIENTS

30 29 10

1 - 9 days 10-19 days 20-29 days 30-49 days 50 + days TOTAL DAYS IN HOSPITAL BY AGE

Figure 3.70 Total days in hospital by age.

60 360 Trauma Score

• <=11 50 012

40 S 13

PERCENTAGE 30 OF PATIENTS

1 - 9 days 10-19 days 20-29 days 30-49 days 50 + days TOTAL DAYS IN HOSPITAL BY INITIAL PRE-HOSPIT AL TRAUMA SCORE

Figure 3.71 Total days in hospital by initial pre-hospital trauma score. 55 ~ MAIS4 1 OOT 63 I I ~ MAIS5 So MAIS2MAIS 3 OF PATIENTS 468 80 40 PERCENTAGE 5060 _ 2030100 I- MAIS 1 gall7°1

1 - 9 days 10-19 days 20-29 days 30-49 days 50 + days TOTAL DAYS IN HOSPITAL BY MAXIMUM AIS (MAIS)

Figure 3. 72 Total days in hospital by MAIS score.

80 699 70 OF PATIENTS I 1 - 9 days 30 PERCENT AGE 40602050100 ISS

• ISS < 15

o ISS > 15

10-19 days 20-29 days 30-49 days 50 + days TOTAL DAYS IN HOSPITAL BY ISS

Figure 3.73 Total days in hospital by injury severity score. 56

11 11 f 'if 100 54 OF0 PATIENTS 40 PERCENT AGE 8030206070501090

• TOTAL

o ALIVE

§ DEAD

155<15 155>15 SURVIVAL BY ISS SCORE

Figure 3.74 Survival outcome by injury severity score.

4 4080 0 % Rate303 Fatality I 1 - 14 2050607010

16 - 24 25 - 34 35 - 44 45 - 54 55 +

INJURY SEVERITY SCORE (ISS)

Figure 3.75 Fatality rate by injury severity score.

57 42 I Rural ~~l § I 0 City Teaching % 54 I WJ City Non Teaching-• Rate 86+ 10 • Total 11 4 12 t- Fatality j

3 2 o o

ISS<15 ISS> 15

INJURY SEVERITY SCORE (ISS)

Figure 3.76 Fatality rate by injury severity score and hospital type.

6 30

20 • Total

Fatality o City Teaching Rate 15 % ~ City Non Teaching

10 § Rural

Less than 55yrs 55yrs or more PATIENT'S AGE GROUP

Figure 3. 77 Fatality rates of the severely injured by age group and hospital type. 58

11 11 1 1·1 j 51 I I 0I 2 I 80 I •03IIISS <> 15 I I I I 40 90 0 I 53 3 I I l 207030 I I - OF PATIENTS I PERCENT AGE 50 6010t t 100 t

Total Normal Abnormal Tffiuma Trnuma Score Score (13) «13) FATALITIES BY ISS AND MINIMUM TRAUMA SCORE

Figure 3.78 Fatality rate by [SS and Minimum trauma score.

90 1226

PERCENTAGE 50 OF PATIENTS 40

10 110 53 10 o

Walking Part Wheelchair Wheelchair Not· out of bed PRIMARY MODE OF LOCOMOTION

Figure 3.80 Disability at discharge - primary mode of locomotion. 59 211 2727_ 37100 , - I- -- 24 1312 0 90 -L 1230 OF PATIENTS 50 I • Complete Independence PERCENTAGE 70 80 20603010 40 o Moderate Independence

~ Moderate Dependence

III Complete Dependence

729

FEEDING EXPRESSION LOCOMOTION

DISABILITY WHEN DISCHARGED FROM HOSPITAL

Figure 3.81 Disability at discharge by the degree of disability.

... DISABL'D146--1375891011 4 50%.--4109 ,- 0% a.~I-zet 20%25% -- NORMALI - 45% ~4 Cl) 40%35%10%30%5%15%

Figure 3.82 Distribution of disability scores. 60

I f I ,'I were unable to communicate more than half the 3.14.3 Cardio-Vascular Complications time or to express theirbasic need despite prompting, when discharged from hospital. The most common type of cardio-vascular complications were shock (36%) and arrhythmia 3.13.3 Disability Score (30%), followed by cardiac arrest (12%) as shown in Table 118. The number of registered cases of To provide information on multiple disabilities at shock is likely to be conservative, given that this discharge, a disability score was constructed condition is not always stated in the patientmedica1 comprising all three disability measures. For each file. measure, the values ranged from I (complete independence) to 4 (complete dependence). Thus, 3.14.4 Renal Complications the disability score (DS) could range from 3 to 12. Renal failure was the most frequent (95% ), followed

Forty-seven per cent of patients had absolutely no by AIN (11%) and drug reactions (5%) among disability whatsoever on discharge (DS = 3), while patients who recorded renal complications (see only I% were completely dependent on all measures Table 3.19). (DS = 12). Figure 3.82 shows the distribution of disability scores for all patients. 3.14.5 Neurologic Complication

3.14 COMPLICATIONS Of individual neurologic complications, deterioration of original complaint was most Table 3.15 shows that pulmonary complications common (19%), followed by brain death (12%), as comprised 19% of all complications experienced shown in Table 3.20. by patients following their road trauma. Non• pulmonary infections were the next most frequent 3.14.6 Haematologic Complications type of complication (12%), cardio-vascular complications (9%), renal (8%), psychological Table 3.21 shows that Coagulopathy was more (8%), and neurologic (7%). common (78%) amongst Haemotologic complication patients, compared to Disseminated 3.14.1 Pulmonary Complications Intravascular Coagulation (26%).

Table 3.16 shows the different types of pulmonary 3.14.7 G.!. Complications complications occurring in these patients. It should be remembered that a patient can have more than Amongst patients with defined G.!. complications, one type of pulmonary complication. the single most common complication was small bowel obstruction (16%). Upper G.!. haemorrhage Atelectasis was the most frequent pulmonary and peritonitis each accounted for 5% of cases complication (53%), followed by pleural effusion recorded (see Table 3.22). (28%) and pneumonia (25%). ARDS and pulmonary embolism comprised 9% and 5% of 3.14.8 Vascular Complication pulmonary complications respectively. Nerve inj ury was the most frequent type ofvascular 3.14.2 Non-Pulmonary Infections complication (47%), followed by other (33%), and DVT - lower extremity (28%), as shown in Table Table 3.17 shows that wound infection was the 3.23. most common type of non-pulmonary infection (54%). Septicaemia occurred in only 4%, sepsis• 3.14.9 Hepatic-Biliary Complications like syndrome in 3%, and fungal sepsis in only 2% of non-pulmonary infected patients. Table 3.24 shows that defmed hepatic-biliary complications consisted of liver failure (33%) and acalculous cholecystitis (15%). 61 TABLE 3.15

PATIENT COMPLICATIONS ASSESSED DURING HOSPITALIZATION

Complication 0.6%22.4%6.7%5.1%4.0%12.4%19.3%8.1%8.0%9.1%Percent Frequency325280132179117118597458979 VascularGastrointestinal NeurologicPsychologicalHepatic-HaematologicalRenalCardiovascularNon-pulmonaryPulmonaryOtherBiliary

n = 1448 complications

TABLE 3.16

TYPES OF PULMONARY COMPLICATIONS

Pulmonary 0.4%28.3%25.1%2.0%3.6%53.4%5.3%4.9%9.3% Percent Frequency1326270231312591 EmpyemaLun~PneumothoraxHaemothoraxAspirationFatPulmonaryARDSPleuralPneumoniaEmbolusComplicationAbscessEffusionOedemaEmbolus Atelectasis

n=338 complications

11 I1 I ,'·f I TABLE 3.17

TYPES OF NON-PULMONARY INFECTIONS

Infection 0.52.82.30.936.03.753.5Percent Frequency1157885261 Other Menin~tisFungalOsteomyelitisSepsis-likeIntra-abdominalSepticaemiaWoundsepsissyndromeInfectionabscess

n = 216 complications

TABLE 3.18

TYPES OF CARDIO-V ASCULAR COMPLICATIONS

Complication 0.64.535.712.336.41.39.1 Percent Frequency56551419721 FailureCardiac Arrest Low flow MyocardialCongestiveOtherArrhythmiaShock HeartInfarction

0=154 complications

TABLE 3.19

TYPES OF RENAL COMPLICATIONS

Complication 10.594.75.3 Percent Frequency1821 DrugAcuteRenalreactionsTubularfailureNecrosis

n=21 complications

63 TABLE 3.20

TYPES OF NEUROLOGIC COMPLICATIONS

Complication 70.13.118.612.4 Percent Frequency6812183 StrokeAnoxiccomplaintEncephalopath Brain Death DeteriorationOther of original

n=l04 complications

TABLE 3.21

TYPES OF HAEMOTOLOGICAL COMPLICATIONS

Complication Frequency Percent 18 78.3 6 26.1

n=104 complications

TABLE 3.22

TYPES OF G.!. COMPLICATIONS

Complication 4.815.91.668.3 Percent Frequency431031 AnastomosisFistulaPancreatitisSpleenicUpperPeretonitisSmallOtherG.I.BowelInjuryHaemorrageLeakOhs.

n=63 complications

I 11 11' I'f I I TABLE 3.23

TYPES OF VASCULAR COMPLICATIONS

Complication 32.827.65.246.6 Percent Frequency2719163 GraftThrombosis/embolusOtherinfection DVT(Lowerextrenrity)Nerve injury

n=68 complications

TABLE 3.24 TYPES OF HEPATIC-BILIARY COMPLICATIONS

Complication 55.633.314.8 Percent Frequency531 Liver failure AcalculousOther cholecystitis

n=8 complications

TABLE 3.25 TYPES OF OTHER COMPLICATIONS

Complication 2.225.511.711.41.258.54.9 Percent Frequency1903837831647 TransfusionRetum to O.T.reaction AnaestheticPost-oP.MissedSub.-DelayOtherspecialtyinhaemorragediagnosisDiagnosiscomp.comp.

n=379 complications

65 4. DISCUSSION rural hospitals indicating that people involved in rural accidents are not clearly disadvantaged in this respect. 4.1 OVERVIEW For all hospital types, trauma scores on admission The primary objective of the 'before' study was to to the Emergency Department were higher than at provide baseline data for the evaluation of the the accident scene which is generally consistent Alfred Hospital Trauma Centre, and its impact on with effective pre-hospital resuscitation. road trauma care in Victoria. The data generated provides a valuable picture in itself of the nature of The time intervals between admission and surgery trauma care delivery in Victoria. The overall were also similar for the different hospital types. impression from the data is that the system for trauma care delivery, as it existed in late 1988 and The data higWighted some possible areas for early 1989, was generally working well. The concern: following indicators support this conclusion: Pre-Hospital Management

For any given Injury Severity Score OSS) the mortality rate at the different hospital types for Intravenous fluid resuscitation was considerably young and older age groups compared favourably less frequently provided to casualties admitted to with those reported in the United States ofAmerica. rural hospitals although some ambulance transportation times were considerably lengthier The mortality rate did not attain 2.5 per cent until than for city casualties. the ISS exceeded 24. Only 11 per cent of patients The first priority in trauma managment is had an ISS exceeding 24. establishment of an adequate airway. However, this was not achieved before hospital arrival in 34 MICA ambulances attended 15per cent of accident patients. A higher proportion of patients admitted scenes. Giventhatonly 11per cent of patients have toruralhospitalshad inadequatepre-hospital aitway an ISS exceeding 24 and mortality rates exceeding control. 2.5 per cent, there appeared to be an adequate number of MICA ambulances for pre-hospital management of serious (ISS > 24) casualties. Inthe CT scanning was less frequently used for diagnosis United States itis generally considered that patients in rural and non-teaching hospitals which may with an ISS exceeding 15 should be taken to a suggest under usage. In addition, diagnostic trauma centre or equivalent because the mortality peritoneal lavage was infrequently used in rural rate approximates 10 per cent once an ISS of 15 is hospitals. exceeded. Thirty one per cent of our patients' ISS Inter-Hospital Patient Transfers were in excess ofl 5but the mortality rate ofISS 16• 24 was only 2.3 per cent. Approximately 15-20 per cent of patients required inter-hospital transfer because of insufficient Further analysis would reveal whether MICA and specialist expertise or facilities. The main reasons air ambulances attended the appropriate types of for transfer included: injured patients. The appropriate types are defmed in the Guidelines of Triage used at the Alfred lack of an appropriate specialist, Hospital Trauma Centre (based on those of the particularly in rural hospitals (more Trauma Committee, American College of Surgeons). than two thirds of transfer cases). lack ofICU facilities at the hospital of The time interval between accident and arrival at initial admission accounted for almost the Emergency Department was generally similar 10% of the transferred patients. forthe city teaching and non-teaching hospitals and

, t I unavailability of a diagnostic 5. Evaluation of outcomes in casualties with investigation accounted for another 5 head injury related to the Glasgow Coma to 10%. Scale «8,8-12, 13-14), head AIS score, The majority of transferred patients had Injury transfer status, performance of cranial! Severity Scores greater than 15 and relatively intra-cranial operation. lower trauma scores on admission to the referring 6. Evaluation of outcomes in high risk hospital. Transfer ofpatients with severe injuries is groups: preferably avoided, provided that the appropriate management isavailable atthe hospital ofthe initial patients requiring more than 6 units of admission. blood

Inter-hospital transfers can be reduced by more systolic blood pressure less than 90mm/ frequent direct triage to a trauma centre or by hg on admission upgrading multi-trauma care at regional hospitals respiratory rate less than lO/minute or and providing additional specialist services, ego more than 29/minute on admission neurosurgery . AIS 3 or more abdominal injuries 4.2 POSSIBLE ADDITIONAL ISS exceeding 15 and an abnormal ANALYSES trauma score

The wealth of data collected during the 'before' pelvic fractures with hypovolaemic shock. phase of the study presents the opportunity for considerable in-depth analysis, beyond the scope 7. Other evaluations such as specific injuries, of the original aims of the study. An indication of e.g. liver trauma, major vessel trauma, the type of anaysls that can be conducted isdetailed aortic rupture, haemoperitoneum with below: shock.

1. Establishment of the 50% survival 8. Specific analyses of major concern to probability line required for TRISS those responsible for patient treatment analysis using the total 1480 patient group and management such as: to obtain Australian national norms. This would provide a baseline for future rate of head injuries comparative studies and secular trends time to CT and surgery for those with and for comparison with overseas results. head injuries CT head scans and transfer rates 2. Multivariate analyses to reveal which variables are the major determinants of crash details and subsequent outcome patient outcome (survival, complications, time to hospital by outcome days in hospital and ICU, disability at discharge, etc). Identification of the time to hospital by body region injured significant independent variables may lead closer examination of Ist two hours to improvements in the trauma care system treatment and individual management protocols. close examination of survival rates by 3. Influence of pre-existing disease on post-hospital trauma scores. outcomes.

4. Outcomes related to transfer status, body region injury and severity, and reasons for transfer.

67 4.3 EVALUATING THE IMP ACT OF hospital, and definitive operation THE ALFRED HOSPITAL timeat final hospital. TRAUMA CENTRE DOCUMENTATION OF MEDICAL RECORDS: Data collected in the "before" study provide a baseline against which possible changes following Medical records without trauma scores the establishment of the Alfred Hospital Trauma Medical records without Glasgow Centre can be assessed. Changes are likely to occur Coma Scores in head injury patients. both in the system of trauma care delivery and inthe clinical management of individual patients. HOSPITAL SERVICE UTILISATION

4.3.1 Changes in Trauma Care Delivery Hospital days

lCD days The following before and after comparisons will identify changes in the system of trauma care operations performed delivery: CT usage.

PRE-HOSPITAL PROVIDERS: 4.3.2 Changes in Patient Management

Utilisation of MICA ambulances and The following comparisons will identify changes air ambulance helicopters. in regard to patient management and outcomes:

Utilisation can be measured in regard Patient survival in relation to Trauma to its appropriateness according to Score, Injury Severity Score, and age established triage criteria and by the (TRISS). retrospective criterion of the Injury Severity Score. Outcomes (hospital stay, lCU stay, complications, disability) related to Changes in helicopter utilisation: injury type and severity. transport patients from the accident scene direct to hospital versus inter• Pre-hospital treatmement hospital transfer of patients. - airway adequacy on hospital Changes in time intervals between admission accident and hospital arrivals. - ventilatory adequacy on hospital INTER HOSPITAL TRANSFERS: admission - intravenous fluid use in resuscitation Changes in the frequency of inter• - trauma score changes hospital transfers related to the three hospital types. - complications of pre-hospital treatment. Changes in the reason for inter hospital transfer related to hospital types. Outcomes related to specific high risk Frequency of inter-hospital transfers injuries as detailed previously. for head injuries and cranial/intracranial Effectiveness of management related surgery related to time intervals to MAIS 1-5 injuries and to different between accident, admission to initial body region AIS 1-5 injuries. The full equation is shown below.

Effectiveness = No. survivors with AIS 4-5 chest injuries Total No. chest injuries AIS 4-5

11 11 I (_I Audit filter success rate. cannow be made WITH the results ofintemational Application of audit filters established studies of trauma management. It is quite likely, by the Consultative Committee on Road however, that the establishment of the Trauma Trauma Fatalities. Centre has had wide ranging effects and the system asitexiststoday may be significantly different from Time intervals between hospital that which existed during the Phase 1study period. admission and operation with specific InJury. A significant investment has been made into the Analysismay be undertaken to evaluate . development of data collection fonns, training of trauma management in survivors and data coders, and the development of coding fatalities with comparable injury type procedures and operational definitions. There is no and severity. need for this investment to be duplicated, thus the time frame for Phase 2 should be significantly Similar case control analyses could be shorter than Phase 1. undertaken in regard to other outcome

differences, e.g. prolonged hospital or 4.4.1 Recommendations reu stay.

4.4 CONCLUSIONS AND It is recommended thatfurther funding be made RECOMMENDA TIONS available for continuation of the project and completion of Phase 2 of the study so that the The data generated from Phase I (the "before" evaluation of the impact of the Alfred Hospital phase) of this study represents the fIrst time a Trauma Centre may be made. However, ilfunds systematic assessment has been made of trauma for the continuation of the study are not care delivery in Victoria. The calculation ofInjury immediately available, it is recommended that Severity Scoresandcollection ofthe necessarydata additional resources bemade availablefor further to conductTRISS analysesmeansthat comparisons in-depth analysis of existing data.

REFERENCES

Ozanne-Smith,1. (1989) Evaluation of the effects of the Alfred Hospital Trauma Centre: Inter• rater reliability. Unpublished M.P.H. Dissertation, Monash Univerity Department of Social & Preventive Medicine, Melbourne, Australia.

Roberts, R.F. (1989) Cost effectiveness of the Alfred Hospital Trauma Centre. Unpublished M.B.A. Dissertation, Monash University Graduate School of Managerment, Melbourne, Australia.

69 11 11 I ATTACHMENT 1

THE ALFRED HOSPITAL TRAUMA CENTRE EV ALUATION STUDY

LEVEL 2 DATA COLLECTION FORM. I'

" 1I I TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 1

HOSPITAL 0 ODD STUDY NUMBER CASE NOOOOO WORKCARE CLAIM - Yes or No UR NUMBER 000000 WORKCARE NUMBER TAC FILE NUMBER DDDDDD

------6 1. PATIENT INFORMATION

CITY/SUBURB ------POST CODE DODO DATE OF BIRTH / / _ AGE (years) DD

SEX OF THE PATIENT ------0 1 = Male 2 = Female 9 = Unknown

------2. INCIDENT INFORMATION INCIDENT LOCATION ------POSTCODE DDDD INCID~T DATE D ODD DD INCID~ TIME DDDD EXTERNAL CAUSE OF INJURY (refer E-code manual) --DDDDD MECHANISM OF INJURY (select up to 2)

----06 1 = Fall 4 = Entrapment 2 = Ejection 5 ~ Knocked down Other (specify) 3 ~ Occupant death 9 ~ Unknown 0

NATURE OF INJURY - AMBULANCE DIAGNOSIS (select up to 2)

6 ~ Head -0 1 ~ Amputation 4 ~ Penetrating 2 = Blunt injury 5 = Other (specify) 9 = Unknown o 3 ~ Spine

VELOCITY OF IMPACT ------0 1 - High (>80K) 2 ~ Medium (40-80K) 3 ~ Low «40K) 9" Unknown

PATIENT'S VEHICLE ------00 01 ••None 07050608 •.•=~ TramBicycleTrainBus 09 •.•Other (specify) 020304 •.•= CarTruckMotorcycle 99 •.•Unknown TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 2

OTHER VEHICLE OR OBJECT1199120907100608 == AnimalUnknownOtherPedestrianTramFixedTrainBus object(specify)(specify) 0402 ""= MotorcycleCar 0305 = TruckBicycle 01 = None ---DD

IMPACT TO PATIENT'S VEHICLE 0 1 = Not relevant 5 = LH side 8 = Other (specify) 2 = Frontal 6 = Rollover 3 = RH side 7 = Fixed object 9 = Unknown 4 = Rear

PROTECTIVE DEVICES USED ------0 1 = Seat belt 3 = Child restraint 5 = None used 2 = Helmet 4 = Air bag 9 = Unknown

CASUALTY CATEGORY ------00 01 = Driver 06 = LH rear 11 = Other (specify) 02 = C front 07 = Motorcyclist 03 = LH front 08 = MIC pillion 99 = Unknown 04 = RH rear 09 ""Bicyclist 05 = C rear 10 = Pedestrian ~~~~~~~ DD ------3. PRE-HOSPITAL PROVIDERS

TRANSPORT FROM SCENE (up to 5 rigs as detailed below)

1 = Road Ambulance 4 = Police helicopter -0 7 = Other (specify) 2 - MICA Ambulance 5 ""Other helicopter D 3 -= Fixed wing air 6 = Self transport 9 ""Unknown D TRANSPORT FROM SCENE D RIG 1-----CASE No ------D RIG 2-----CASE No ------DATE OF D:rSPATCR D000 [ RIG 3 CASE No _ TIME 1ST lUG D:rSPATCBED OODO :rNTER-HOSP:rTALTRANSFER l.STlUG AT SCENE DOOO RIG 4 CASE No _ PATIENT DEPARTED SCENE 0000 J RIG 5 CASE No . I PAT:rENT AT DEST:rNAT:rON 0000 DATE OF ARRIVAL AT DEST:rNAT:rON0000 [

MEDICAL RETRl:EVAL TEAM USED ------1 = No D 2 -= Yes 9 Unknown TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 3

4. DESTINATION AND PRE-HOSPITAL TRANSFER DETAILS

INI~IAL HOSPI~AL DES~INA~ION (~AC allocated number) I~ER-HOSPI~AL ~RANSFER REASONS ------DODO 01 = No transfer 05 = Spinal 09 = Paediatric DD 02 = Bypass 06 = Test Unavailable 10 '"Other (specify) 03 '"Burns 07 = Consultants Unavail

04 = Multivictim 08 '" ICU transfer 99 0= Unknown

FINAL HOSPITAL DESTINATION (TAC allocated number)

UR NUMBER (REFERRING HOSPITAL) DODO

5. TREATMENT RECEIVED PRE-HOSPITAL

TREATMENTS0102 = NoneAsst VentilationPRE-HOSPITAL (seJ.ectup to11 •.•6)Oxygen 0B. 0403 = BackboardC-Collar 1213 •.•= SplintsSand bag DD 0506 = ChestCPR tube 1514 •.•= PressureTourniquetbandage DD 0708 = DefibrillationDrugs 1716 •.•OtherIV fluids(specify) DD 0910 = MASTNeedlesuitthoracostomyfitted 99 ""Unknown DD

CRYSTALLOID FLUl:DS COLLOID FLUIDS :::BBBB TOTAL FLUIDS (ml)OOOO SURGICAL PROCEDURES (REFERRINGHOSPITAL) ---0 1 •.•None 5 ""Abdomen/Pelvic content 8 ""Other (specify) 2 - Head/neck 6 ""Extremity/pelvic girdle 3 •.•Face 7 -= External 9 ""Unknown 4 ""Chest

DATE OFSTARTPROCEDURET:rMEOOOO000000 END T:rMEOOOO 4 TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM

6. ASSESSMENT

TRAUMA SCORE COMPUTATION

------

ADMISS POST-ADM ITEM PRE-HOSP PRE-HOSP (Initial) (Final) ------

RESPIRATORY RATE 4 = 10-24 per min 3 = 25-35 per min 2 = >36 per min 1 = 1-9 per min o = None

SYSTOLIC BLOOD PRESS. 4 = >90mm Hg 3 - 70-89mm Hg 2 = 50-69mm Hg 1 = 0-49mm-Hg o = None

EYE OPENING 4 = Spontaneous 3 = To voice 2 = To pain 1 = None

VERBAL RESPONSE 5 = Oriented 4 = Confused 3 = Inappropriate words 2 = Incomprehensible words 1 = None

MOTOR RESPONSE 6 = Obeys commands 5 = Localizes pain 3 = Withdraw (pain) 3 = Flexion (pain) 2 - Extension (pain) 1 = None

TOTAL (Trauma scores)

------

TRAUMA SCORE (INITu.L PRE-HOSPITAL) DD TRAUMA SCORE (ADMISSION)(FINAL PRE-HOSPITAL) TRAUMA SCORE (POST-ADMISSION) BB TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 5

APACHE 2 - PRE-EXISTING DISEASES (select up to 3) _

01 ••.None 05 = Renal DD 09 ••.Immuno (postsplen) 02 = Liver 06 •••Diabetes 10 ••.Other (specify) 03 ••C'vascular DD 07 ..•Immuno (therapy) 04 ••.Respiratory 08 ••.Immuno (disease) 99 ..•Unknown DD

PRE-EXISTING IMPAIRMENTS (select up to 3)------'00 01 ••None 02 = Brain dysfunction 09 ••.Orthopaedic conditions 03 •••Other neurological 04 ..•Paraplegia 081110 •••••...•PainOtherCongenitalsyndromesdisablementsdeformities DB 05 •.•Quadralplegia 0 06 ••.Limb amputation 99 •.•Unknown 07 •.•Arthritis

IN'l'OBATION (PRE-HOSPITAL) ------0 IN'l'OBATION (ADMISSION) -----0 IN'l'OBATION (POST-ADMISSION) -----0 1 ••Not intubated 2 •.•Intubated 9 ••.Unknown VENTILATOR (PRE-HOSPITAL) -----0 VENTILATOR (ADMISSION) -----0 VENTILATOR (POST-ADMISSION) -----·0 1 = No ventilator 2 •••Ventilator 9 ••.Unknown

7. EMERGENCY ROOM TREATMENT DATE OF TRFATMENT 000000 TIME OF ATTENDANCE DODO CPR ADMINISTERED ------0 1 = Not administered 2 = Administered 9 = Unknown

AIRHAY MANAGEMENTON ARRIVAL ------0 1 ••.Adequate 2 ••.Inadequate 9 ••.Unknown EMERGENCYAIRHAY TREATMENT ------o 1 ••.No treatment 4 •.•Surgical 7 •••Other (specify) 2 •.•Nasal intub. 5 •••Oropharyngeal 3 ••Oral intub. 6 •••Cricothyroidotomy 9 •••Unknown

EMERGENCYROOMRESUSCITATION INITIATED ------0 1 •••Yes 2 •••No 9 ••.Unknown 6 TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM eT SCAN D 9 ••.Unknown 1 ••.Done 2 ••.Not done DIAGNOSTIC PERITONEAL RESULTS D 3 ••.Not done 9 ••.Unknown 1 ••.positive 2 ••.Negative

6 ...TOTALOther CRYSTALLOID(specify) FLUIDS (mll ODD 0 TOTAL9 = UnknownBLOOD PRODUCT OUANTITY (mll 0 0 DD 5 = Fresh-frozen plasma HAEMACELDOTHERTOTALFLUIDSCOLLOIDSCOLLOID(ml)SPPS(mll(ml)ODDFLUIDSDODODODO(ml) ODD0 0 DODO D DOOOOJ[

BLOOD PRODUCTS ADMINISTERED

1 ••.None 2 = Packed cells 3 ••.Whole blood 4 = Platelets

DATE OF ER FINAL DEPARTURE

TIMEOF ER FINALDEPARTURE DISPATCHEDTO

1 = ICU 4 •••Trauma ward 7 •••Other (specify) 2 •••OR 5 ••Gen. adm 3 - Morgue 6 •.•Home 9 - Unknown

------8 . SURGICAL PROCEDURES PERFORMED

FIRST MAJOR OPERATING PROCEDURE

SURGICAL CODES (ICD9-CM) DATEFIRST PROCEDUREDOOO [ STARTTIMEDDDD ENDTIMEDDDD BLOODUNITS (ml)DDDD TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 7

ARREST ------0 1 = Arrest 2 = No arrest 9 = Unknown

BODY AREA OPERATED ON (select up to S} 0 1 = Head/neck 4 = Abdomen/pelvic content 9 = Unknown 2 = Face 5 = Extremity/pelvic girdle o 3 = Chest 6 ••External 8 o

RE'l'URNED TO O.R. WITHIN 48 HOURS ------0 1 = Yes 2 = No 9 = Unknown

9. FINAL DISPOSITION

DAYS SPENT IN INTENSIVE CARE UNIT DD DATE OF DISCHARGE ODDDDD TIME OF DISCHARGE DODO TOTAL DAYS SPENT IN HOSPITAL DD D

DISCHARGE STATUS ------0 1 = Alive 2 ••Dead 9 = Unknown

DISCHARGED TO ------DD 01 ••Extended care 05 ••Psych unit 09 ••Other (specify) 02 = Home (no assist) 06 ••Rehabilitation 03 ••Home (assist) 07 ••Other hosp. 99 ••Unknown 04 ••Morgue 08 ••Out of State DISCHARGE HOSPITAL TAC NUMBER ------

MEDICAL FOLLOW-UP REQUIRED ------0 1 ••Yes 2 ••No 9 ••Unknown

FINAL ANATOMICAL DIAGNOSIS SOURCE ------0 1 ••Autopsy 4 •• MRI 7 ••Other (specify) 2 ••CT 5 ••Radiographs 3 •• Surgery 6 = Clinical 9 ••Unknown TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 8

10. DISCHARGE DIAGNOSIS TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 9

ADDITIONAL INJURIES NOT-CODED

AISICD9 ISS l. 2.7.5.3.8.4.6.

HEAD/NECK INJURIES (ISS Body Regions) ______---'maximumus D FACE INJURIES (ISB Body Region) ______maximum AIS D CHEST INJURIES (ISS Body Region)

ABDOMEN & PELVIC CONTENT (ISS Body Region) _____ maximummA y~ 1'\UJ'Q US D0 EXTREMITY & PELVIS (ISS Body Region) maximum AIS 0 EXTERNAL INJURIES (ISS Body Region) ______maximum AIS 0

FINAL DIAGNOSIS DECISIVE INJURY ------0 1 = Blunt 2 = Penetrating 3 = None 9 = Unknown DECISIVE INJURY LOCATION (up to 2 most decisive regions) o 1 = Head/neck 4 = Abdomen/pelvic content 9 = Unknown 2 = Face 5 = Extremity/pelvic girdle D 3 = Chest 6 = External

11. COMPLICATIONS PRE-HOSPITAL COMPLICATIONS (select up to 2) D 1 = None 6 = Fluids 2 = Oesophageal intubation 7 = Other (specify) D 3 = Extubation unintentional 4 = Mainstream intubation 9 = Unknown 5 = Drugs CARDIOVASCULAR COMPLICATIONS (select up to 2) --00 01 = None 07 = MI 08 = Shock 02 = Arrhythmia DD 03 = Cardiac arrest 09 = Other (specify) 04 = Cardiogenic shock 05 = CHF 99 = Unknown 06 = Low flow (decreased C.O.) 10 TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM

08 pancreatitis 0912111099 =••OtherUnknownPeritonitisSBOSplenic(specify)injury GI COMPLICATIONS (select up to 2) DD 0403 = Dehis/EvisFistula 07 ••Enterotomy DD 05 = 02 = Anastomosis leak 06 ••= Haemorrhage (upper(lower GI) 01 = None

HAEMATOLOGIC COMPLICATIONS (select up to 2) 59 ••= UnknownOther--0(specify) 1 = None 4 ••Haemorrhage 3 = DIC o 2 = Coagulopathy

HEPATIC/BILIARY COMPLICATIONS (select up to 2) 8679 ••= UnknownOtherLiverRetainedfailure(specify)--0stone 1 = None 243 = AcalculousBiliaryBile ductstrictureinjurycholecystitis 5 = Hepatitis D

NEUROLOGIC COMPLICATIONS (select up to 2)------0 5 = Stroke 1 = None 6 ••Other (specify) 2 = Anoxic encephalopathy o 3 = Brain death 9 •• Unknown 4 = Prog of original complaint PULMONARY COMPLICATIONS (select up to 2) DD 01 = None 10 ••Pneumonia -02 = ARDS 11 = Pneumothorax (barotrauma) DD = 03 Aspiration 12 pneumotrauma (iatrogenic) 04 ••Atelectasis 13 = pulmonary oedema 05 ••Empyema 14 ••Pulmonary embolus 06 ••Fat embolus 15 ••Other (specify) 07 Haemothorax/Hydrothorax 08 •• Lung abscess 99 - Unknown 09 = Pleural effusion

PSYCHOLOGICAL COMPLICATIONS ------0 1 ••Absent 2 ••Present 9 - Unknown

RENAL COMPLICATIONS (select up to 2}------00 08090799 ••= OtherUnknownUTIUrine retention 01 ••None (specify) 04 ••Perinephric060302 = UretheralDrugATNabscessreactionsinjury 05 ••Renal failure DD , ,

TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM 11

VASCULAR COMPLICATIONS (select up to 2) DD 0102 ••AnastomosisNone haemorrhage 0807 ••Thrombosis/embolusNerve injury DD 03 ••CVA 09 ••Other (specify) 04 ••DVT (lower extremity) OS •• DVT (upper extremity) 99 ••Unknown 06 ••Graft infection

NON-PULMONARY INFECTIONS (select up to 2)------00

0102 ••NoneIntraabdominal abscess 0807 ••FungalSepsis-likesepsissyndrome DD 03 ••Meningitis 09 ••Other (specify) 04 ••Osteomyelitis OS •• Septicaemia 99 ••Unknown 06 ••Wound infection

OTHER COMPLICATIONS (select up to 2)------00 0102 ••NoneAnaesthetic complication 0708 ••TransfusionSub-specialtyRxcomplication DD 03 ••Delay in Dx 09 ••Other (specify) 04 ••Missed Dx 05 ••Post-operative haemorrhage 99 ••Unknown 06 ••Return to OR

12. DISABILITY AT DISCHARGE (ADULT PATIENTS ONLY)

FEEDING 34 ••EquallyNot9 ••outUnknowncapableof bed49 ••- CompleteUnknown dependence 2 ••Wheelchair23 ••- Moderate dependencedep.endenceindependence DD 11 ••••CompleteWalkingComplete independenceindependence EXPRESSIONLOCOMOTIONPRIMARY MODE OF LOCOMOTION • t

12 TRAUMA CENTRE STUDY - LEVEL 2 DATA FORM

13. NARRATIVE SUMMARY

------15. CODING DIFFICULTIES ATTACHMENT 2

THE ALFRED HOSPITAL TRAUMA CENTRE EVALUATION STUDY

OPERATIONAL DEFINmONS I, I1 INDEX

PAGE

General Information

1.0 Study document 2.0 Confidentiality 3.0 Patient Population Selection Criteria 4.0 Data Forms 5.0 Data Collection 6.0 Personal Records 7.0 Alphabetical Listing of Medical Abbreviations

Level 3 Data Forms

1.0 Patient Information 2.0 Incident Information 3.0 Pre-Hospital Providers 4.0 Destination and Pre-Hospital Transfer Details 5.0 Treatment Received Pre-Hospital 6.0 Surgical Procedures at Referring Hospital 7.0 Assessment 8.0 Initial Hospital Treatment 9.0 Laboratory Orders & Fluids Administered in ED 10.0 Other Laboratory Orders & Fluids Pre-Theatre 11.0 Hospital Diagnosis on Admission 12.0 Surgical Procedures Performed 13.0 ICU Procedures 14.0 Final Disposition Details 15.0 Discharge Diagnosis 16.0 Complications 17.0 Disability at Discharge 18.0 Narrative Summary 19.0 Coding Difficulties

Level 2 Data Forms

1.0 Emergency Room Procedures 2.0 Operating Procedures I'

" 1

GENERAL INFORMATION

1.0 STUDY DOCUMENT

The document, Monash University Accident Research Centre, "Evaluation of Effect of Establishing the Alfred Hospital Trauma Centre, and Identification of Methods to Improve Trauma Management in Victoria", April 1988, provides an overview of the study and its aims. It is required that this be read prior to undertaking the data collection.

2.0 CONFIDENTIALITY

Care is to be taken to ensure full confidentiality. Neither the name of the patient nor the persons attending the patient are to be published. Likewise, hospitals are to be coded to ensure confidentiality.

3.0 PATIENT POPULATION SELECTION CRITERIA

3.1 Road trauma victims 3.1.1 All admissions to hospital 3.1.2 All deaths pronounced in hospital, ego in Emergency Department 3.1.3 All transfers to the facility including all Accident & Emergency and Inpatient transfers. 3.1.4 ICD-9-CM. E Codes - E810 to E819 and E824. 3.1.5 Omit Non-Victorian patients who were involved in Non-Victorian accidents.

4.0 DATA FORMS

4.1 Level 2 Data Forms (Contains less data than Level 3 Form)

Used for the following hospitals: East Gippsland (Bairnsdale) Frankston Gippsland Base (Sale) Monash Medical Centre Moorabbin Prince Henry's West Gippsland (Warragul)

Yellow-coloured forms are to be used for the "Before establishment of Trauma Centre" study.

Blue-coloured forms are to be used for the "After esablishment of Trauma Centre" study. 2

4.2 Level 3 Data Forms - Appendix I (Comprehensive data)

Used for the following hospitals:

Alfred Central Gippsland (Traralgon) Dandenong Royal Melbourne

Green-coloured forms are to be used for the "Before establishment of the Trauma Centre" study.

Pink-coloured forms are to be used for the "After establishment of the Trauma Centre" study.

5.0 DATA COLLECTION

5.1 The majority of the data is to be collected restrospectively from the patient's Medical Record

5.2 Missing data is to be collected from the Centre/Department concerned. The "Letter of Authorization" is to be produced on initial contac~ by way of introduction.

5.3 The book, "The Abbreviated Injury Scale", American Association for Automotive Medicine, 1985 Revision (AIS-85) is to be used for coding A.I.S. Scores.

5.4 A copy of ICD9-CM codes is to be used for verification purposes.

5.5 Data collected from a 'sending' facility is to be linked with that of the 'receiving' facility.

5.6 Unresolved questions regarding data collection ar~ to be discussed at the regular Trauma Study meetings. This will include all items under 19 CODING DIFFICULTIES.

5.7 Each section of the form must have information coqed into boxes ..

5.8 When coding a 1, 2 or 3-digit number into 4 boxes enter zeros in the preceding boxes.

For example, when entering the

numeral 5, code as 0 50

numeral 50, - " 0 " numeral 500, - 3

5.9 Decimal points are not to be entered in boxes. Thus

provided.24.3 is coded as LJLJlJLJ~ where 4 boxes are

5.10 When coding

5.10.1 'unknown' values/information, use the numeral 9 (or 9's as appropriate)

5.10.2 known to be none - code o's 5.10.3 - "- not done - code o's

5.11 Every effort is to be made to collect the data indicated in the Operational Definitions by an asterisk * Critical Data.

5.12 If there is a delay in a specific area of data collection, leave the boxes blank until the information is entered.

5.13 Endeavour not to make entries in the margins of the forms. Relevant information is to be entered in either No. 18 NARRATIVE SUMMARY, 0 r No. 19 CODING DIFFICULTIES.

5.14 Pre Hospital data ...may be transferred from Level 2 to Level 3 forms in order to complete Sections 1-4.

5.15 Clinical data ...is not to be transferred from Level 2 to Level 3 forms.

5.16 Discharges at own risk and patients on day leave who are re-admitted within 48 hours are to be considered as a continuation of their initial admission.

6.0 PERSONAL RECORDS

Research Assistants are to maintain records of the following information for each case:

6.1 Case number allocated by RA 6.2 Patients UR Number 6.3 Julian Date) Nominated by the 6.4 Case Number) Ambulance Service 6.5 Incident date 6.6 Missing data 6.7 Coding difficulties 6.8 Problems 6.9 Police number (if available) 4

7.0 ALPHABETICAL LISTING OF MEDICAL ABBREVIATIONS

ARDS - Acute Respiratory Distress Syndrom ATN - Acute Tubular Necrosis C- (COLLAR) - Cervical (collar) (DECREASED) C.O. - Cardiac Output C.H.F. - Congestive Heart Failure C.P.R. - Cardio-pulmonary Resuscitation CT SCAN - Computerized axial Tomography CVA - Cerebro-vascular accident CVP (line) - Central Venous Pressure DEHIS/EVIS - Dehiscence/Evisceration DIC - Disseminated Intravasular Coagulation DP (LAVAGE) - Diagnostic Peritoneal DVT - Deep Vein Thrombosis ET (INTUBATION) - Endotracheal ICP - Intra-Cranial Pressure IVP - Intra-Venous Pyelogram MI - Myocardial Infarction MRI - Magnetic Resonance Imaging PA CATHETER - Pulmonary Artery Catheter UTI - Urinary Tract Infection

j' 5

LEVEL 3 DATA FORM (See Appendix I)

HOSPITAL: A 4-digit code number assigned by T.A.C. (see Appendix 11, "Transport Accident Commission, Hospital Codes"). For example, the Alfred Hospital is 0003.

CASE NUMBER: A 4-digit number assigned by the Research Assistant (RA) using the following guide:

R.A. A. "Before" study:• 0001 - 0499 5000 - 5999 "After" study:- 200030004000 - 299939994999 1500 - 1999 10000500 - 14990999 R.A. B. "Before" study: "After" study: D.c. "After" study: R.A.

R.A.

Care must be taken not to duplicate study numbers.

UR NUMBER: A 6-digit number taken from the individual Medical Record. For example UR 850724.

TAC FILE NUMBER:Assigned by the T.A.C. after the claim is made.

This may appear on the Medical Record as 88/10317 and is to be coded using the final 6 digits ie 810317.

If no number is available, leave blank. It will be entered later in the course of the study.

WORKCARE CLAIM:Circle either "Yes" or "No".

WORKCARE NUMBER:Assigned by Workcare. This number is to be entered later in the course of the study.

1. PATIENT INFORMATION

CITY / SUBURB : Enter the City/Suburb only. Use the present address of the patient. For example, if the patient is a tourist, use his/her current city/suburb

POSTCODE: Enter 4-digit number used by Australia Post "Postcode" pamphlet, Issue No. 15 [PM41 (June 88)]. 6

DATE OF BIRTH: Enter 2 digits in each section day/month/year. For example, a birth date 10 January 1971 would be entered as 10/01/71.

A~ (years) : If the patient is less than one year of age, code a$ 00.

SEX OF THE PATIENT: As defined on the Study Form.

I I I I I I I ~ '. 7

2. INCIDENT INFORMATION

This information is gained primarily from the Ambulance Service record of the incident. Follow-up at the appropriate Ambulance Service Branch may be necessary to complete data collection.

If Ambulance transport was not used, much of the information may be gained from the histories taken by the Admitting Medical Officer, Nursing staff, Police information (if available), etc.

INCIDENT LOCATION: Enter all information known to be correct. If incorrect, for example, the suburb is recorded as Toorak, 3142, but is known from the given location to be South Yarra, 3141, enter the latter.

If information is given as "•..near Benalla" - code 3672 (Benalla district postcode) " in the bush" - code 9999 " in N.S.W." - code 9999

POSTCODE: Enter 4-digit code as before.

INCIDENT DATE: *Enter day/month/year.

INCIDENT TIME: *Use 24 hr. clock.

Conversion Table lAM 0100 IPM 1300 2AM 0200 2PM 1400 3AM 0300 3PM 1500 4AM 0400 4PM 1600 5AM 0500 5PM 1700 6AM 0600 6PM 1800 7AM 0700 7PM 1900 8AM 0800 8PM 2000 9AM 0900 9PM 2100 lOAM 1000 10PM 2200 l1AM 1100 IlPM 2300 12Noon 1200 12Midnight 2400

Example: If the patient was injured at 9:23PM, the Injury Time entered would be 2123 hrs. If patient was injured at 12:30AM, the time entered would be 0030 hrs.

If a range of times is supplied, use the median time. For example, if the patient was injured between 1600 hrs and 1800hrs and the ambulance service was not used, enter 1700 hrs.

If the ambulance dispatch time has been coded but an accurate incident time is unknown - code 9999.

EXTERNAL CAUSE OF INJURY: A coded number is assigned by the Medical Records Administrator using the ICD9-CM code for the most significant injury. 8

This is to be substantiated using the copy of the ICD9-CM codes provided. If it is found to be incorrect, use the information available to define the appropriate code and enter it on the Study Form and a note made of this under NO. 19. CODING DIFFICULTIES.

Do not alter the code in the Medical Record.

MECHANISM OF INJURY (select up to 2)

2 = Ejection includes partial ejection.

3 = Occupant death - that is, any occupant deaths at scene.

6 = Entrapment - to be coded if evidence is provided that: a) the patient has been entrapped in or by the vehicle, b) entrapment is assumed to have contributeq to the mechanism of injury, , c) entrapment has caused significant delay ~n extrication, or b) the Ambulance Officer used the term "entrapped".

This does not normally include minor delays d$e to doors jamming, etc.

NATURE OF INJURY - AMBULANCE DIAGNOSIS (select up to 2)

This is to be coded only if an Ambulance record or doctor's letter is filed in the Medical Record, otherwise code 9 = Unknown.

Note:lf there are more than two causes of injury, select those which caused the most severe injury.

2 = Blunt - injury resulting from the applicatio~ of a diffuse force ..

3 = Spine - includes spinal injury (excludes "whiplash", "neck sprain"). Also code 2 = Blunt if appropriate.

4 = Penetrating - injury resulting from tissue penetration or perforation by an object. Th~s is only coded if there is clear evidence of penetration.

5 = Other (specify) - includes fractures reporte by Ambulance Officer. Also code 2 = Blunt i appropriate.

11 11 t •.• 9

6 = Head - includes L.O.C., amnesia, fractured skull. Also code 2 = Blunt if appropriate.

VELOCITY OF IMPACT

This is generally recorded by the Ambulance Officer as either 'high' or 'low'. If there is no record of impact, the following range of indicators may be used if a speed has been recorded.

1 = High > 80 kph 2 = Medium 41-79 kph 3 = Low < 40 kph.

However, if the velocity is reported as

a) "High - travelling at 70 kph" - code using the speed. Thus it would be coded as 2 = Medium.

b) "Speeding around the corner" - code 9

c) "High speed police chase" - code 1.

PATIENT' S VEHICLE

02 = car - includes report of "M.V.A." but no other evidence of type of vehicle.

OTHER VEHICLE OR OJECT

10 = Fixed Object - includes stationary car.

12 = Other (specify) - includes "the road" if the patient falls off cycle. - includes instances where 2 or more objects involved ego another car and a telephone pole.

IMPACT TO PATIENT'S VEHICLE

Frontal - forward of the windscreen.

Rear - rear of the back window.

Code according to that which appears to have been the primary damage.

1 = Not relevant - includes pedestrian, bicyclist, motor cyclist.

6 = Rollover - includes rolling onto side. 10

8 = Other (specify) - includes instances where vehicle impacted in more than one area ego Hit from the rear into a pole in the front.

PROTECTIVE DEVISES USED

5 = None used - includes pedestrian.

CASUALTY CATEGORY

Code using the description/diagram given by the Ambulance Officer.

11 = Other (specify) - includes "rear seat", "front seat" when exact position unknown.

NUMBER OF VICTIMS INVOLVED:

This is usually coded on the Ambulance form. For example, 6 people involved in an accident may be coded:

21 person" = PT26 (BLS ambulance) 1 231 @E]=3 people " 2 2 = ALIOI (- -) 1I " MZ01 (ALS ;

However, all will have the same ambulance Case Number.

Case Numbers change at midnight.

Example of Case Number:

Julian date Area Patient No's. 0598 111 1 1

Only enter the number of victims known to be involved, including - deaths - those who attend the Emerge~cy Department for care (regardle~s of which hospital they presen at) .

11 I·f I I" I' 11

3. PRE-HOSPITAL PROVIDERS

TRANSPORT FROM SCENE

1 = Road Ambulance= MZAL •••••••••••= PT •••••Ambulance Service assigns AltonaFrankstonan e.g.alphaPrestonprefix,=City- EachFTBLS.....=branchBasic ofLifetheSupport

Road Ambulances are numbered within the range 09 to 137.

Hence a Road Ambulance may bear the code PT26.

Country cars may add 2 digits, ego

Q) en t1 ("'t" (")en I ~.t1e: (")

2 = "MICA" Ambulance ("'t" ALS - Advanced Life Support

Mobile Intensive Care Ambulance

These are assigned the prefix "z" and are numbered within the range 01 - 08. However, MICA Ambulance Officers may be assigned to any MICA ambulance. Hence MICA ZOl Ambulance Officers may be assigned to Z08 or Z04 ambulance.

3 = Fixed Wing Air - Air Ambulance 985 - Usually uses call no's VHBUS or VHRED

4 = Police Helicopter Air 495 or A495 or Q0001 Used for the city & suburban areas Crewed by. pilot - pOlice officer Observer -" - " MICA Ambulance Officer

5 = Other Helicopter National Safety Council of Australia (N.S.C.A.) helicopter Helimed I. 7 = Other - includes boat - Used for country areas. 12

TRANSPORT FROM SCENE Rigs 1, 2 and 3

INTER -HOSPITAL TRANSFER Rigs 4 and 5

If more than 2 rigs were used to transport the patient, code the 2 most significant, ego the ALS ambulance and the Helicopter. Note this under 19 CODING DIFFICULTIES.

NB. Rig numbers are listed in the same sequence as the box numbers.

RIG INFORMATION

"Rig" refers to the particular type of transport ego ALS or BLS Ambulance. Thus the appropriate ambulance code number is entered under RIG 1, RIG2, etc.

CASE NO. Enter the case number allocated by the . Ambulance Service. This is to be precede~ by the Julian Date for follow-up purposes!. For example,

Julian Date 0569 + Ambulance Case No. 1121 = Coding Case no. 0569-112

NB. The case no. on the Ambulance form ils usually shortened from 6 digits to 3 digits.

Example: RIG 1. PT 76 CASE NO. 05 6 9 - 11

DATE OF DISPATCH day/month/year.

TIME 1ST RIG DISPATCHED 24 hour clock.

1ST RIG AT SCENE 24 hour clock.

PATIENT DEPARTED SCENE 24 hour clock.

PATIENT AT DESTINATION 24 hour clock. * That is, the first hospital the patient arrives at. Includes self-transported patients.

DATE OF ARRIVAL AT DESTINATION- day/month/year.

* Missing data ~~ to be collected from the ambulance centre concerned.

MEDICAL RETRIEVAL TEAM USED This is only to be coded when a fully constituted Medical Retrieval Team is involved. Thus a Medical Officer escorting a patient would not be coded.

i, •• I , , 13

4. DESTINATION AND PRE-HOSPITAL TRANSFER DETAILS

This entire section is to be completed for all patients.

For example, should the INITIAL HOSPITAL DESTINATION be the same as the FINAL HOSPITAL DESTINATION, code in the following manner:

INITIAL HOSPITAL DESTINATION (TAC allocated number) 0003 INTER-HOSPITAL TRANSFER REASONS 01 FINAL HOSPITAL DESTINATION (TAC allocated number) 0003 UR NO. (Referring Hospital) leave blank

INITIAL HOSPITAL DESTINATION

If the patient is transferred from a Medical Centre, Doctors Rooms, etc., code "INITIAL HOSPITAL DESTINATION" using the TAC no. of the admitting hospital.

That is, "INITIAL HOSPITAL DESTINATION" is the first hospital with a TAC No. that the patient arrives at - even if he/she is not admitted to that hospital.

Cases transferred from an interstate hospital to a Victorian hospital are to be coded 8888.

INTER-HOSPITAL TRANSFER REASONS

07 = Consultants unavail. - use this code only when stated as the reason.

10 = Other (specify) - includes social reasons.

11 = Re-presentation at same hospital.

12 = Re-presentation at different hospital leading to a hospital admission.

INITIAL HOSPITAL DESTINATION - 0020 i.e. Code for original presentation even if not a hospital in the study ego Box Hill Hospital. INTER-HOSPITAL TRANSFER REASONS 12 FINAL HOSPITAL DESTINATION 0003 i.e. where coding conducted ego Alfred Hospital.

FINAL HOSPITAL DESTINATION

The hospital where the particular coder is extracting data.

OR NUMBER (REFERRING HOSPITAL)

If unavailable or not relevant, leave blank. 14

5. TREATMENTRECEIVED PR! HOSPITAL

AIRWAY 'rREA'rMENT:

1 = Cricothyroid - Cricothyroidotomy

4 = Natural - If information regarding the airway treatment has not been recorded, yet all other reports indicate that the patient did not experience any difficulty in breathing, the assumption can be made that the patient was breathing naturally.

- Includes oxygen by mask

5 = Oropharyngeal - for example, Guedel's airway

6 = Surgical - for example, tracheostomy

If more than one treatment was provided, e.g. on transfer of the patient, it is to be coded and an entry made umber 18. ~T~S~Y.

TREATMENTS PRE-HOSPITAL (That is, all treatment before the final hospital destination. )

Codes 01 to 17 - refer to treatment given by Ambulance Officers or others (including simple hospital interventions) prior to attendance at the initial hospital.

08 = Drugs - include inhalation anaesthetic, for example, Penthrane.

09 = ~f suit filled - i.e. inflated

13 = Splints - do not include triangular bandage.

17 = Other (specify) - includes minor additional treatments.

For all pre-hospital treatments not identified by the codes 01-17, code as 88. Then, using the guid~ provided below, list the appropriate codes under 1~. NARRAfIVE SUMMARY.

18 = CT scan (head)(abdomen)(unknown)(chest)(pelvis)(spine) 222124231920 = DPCT lavagescan 28252726 = PACystogramICPIVP catheter 15

29 = Urethrogram 30 = Angiogram 31 = Pericardial Aspiration 32 = Blood gases 33 = X-Rays 34 = ICU management - includes ventilation 35 = Blood Chemistry 36 = Haematology 37 = ECG 38 = Consultations - Resident Staff 39 = Consultation - Consultants 40 = Surgical procedures conducted under Local Anaesthetic ego Suturing, Local Wound Exploration, etc. ego LAMP 41 = Urinary catheterization 42 = Naso-gastric intubation 43 = POP

Surqical Procedures conducted under a General Anaesthetic at either a "Referring Hospital" or pre-hospital, will be coded under 6. S~I~ PROCEDURES AT REFERRING HOSPITAL, eg. GAMP.

Collect information from the coder of the linking hospital wherever possible.

IV FLUIDS

No fluids administered - Code 0000 Fluids administered but data massing - Code 9999 Unknown if fluids administered - Code 9999 Fluids administered < 9998 ml - Code as appropriate > 9998 ml - code 9998

Crystalloid Colloid

· Hartmann's (Ringer's) Solution · Dextran · Hartmann's with 5% Dextose · Manodex · Normal Saline · Rheomanodex · D5% in Saline · Haemacel D4% in Saline · Plasmanate · Mannitol Include the following if relevant: · Whole blood · Packed cells · SPPS · FFP · Albumin 16

6. SURGICAL PROCEDURES AT REFERRING HOSPITAL

Enter the codes for the major operation performed prior to transfe into the first set of boxes. (This will relate to corresponding information provided in the transferring Level 2 data.)

~~TI~~SaupTI~:Enter the desciption of the operation/s as recorded by the surgeon. This does not include minor procedures conducted elsewhere, for example intercostal catheter insertions in the ED.

DATEOFVISIT: Day/month/year

STARTTIME:) Enter the times indicated by the Anaesthetist on ENDTIME: ) the anaesthetic form in the Medical Record. If no accurate times are available, enter proxies and note this under No. 19 CODINGDIFFICULTIES.

BLOOD(ML)

~ST i.e. Cardiac arrest. Code 2 if no operation performed

BODYAREAOP~TED ON (select up to 5)

These body areas are consistent throughout the formi and refer to the Injury Severity Score (I.S.S.) BodV regions, as defined in the AIS 85 coding book.

SURGICALCODES(ICD9-CH)

These codes are assigned by the Medical Records Administrator and are to be entered as given. However, should they be found to be incorrect or omitted when verifying them against the ICD9-CM codes provided, corrected codes should be entered the coding boxes. A note of this is to be made under No. 19 CODING DIFFICULTIES.

Subseauest visits to the Operating Theatre are to be entered wher~ relevant.

7. ASSESSMENT*

TRAUMA SCORE COMPUTATION

P~-BO~I~ (Initial) - First set of observations taken at the scene of the incident.

P~-BOSPI~ (Final) - Last set of observations taken prior to admission to the final receiving (coder's) hospital.

The above information is generally available from the Ambulance form. If data is omitted, and is not available

, ,I I' 17

from the ambulance centre concerned, code as 99 and note under 19 CODING DIFFICULfIES.

No score assumptions are to be made for pre-hospital data where the patient self-presents or is unco-operative due to alcohol or language problems.

Code children 9 unless information available.

ADMISSION -The first full set of observations taken in the Emergency Department of the receiving hospital when patient to be admitted.

POST-ADMISSION - The last full set of observations taken in the Emergency Department. If only one set of observations was taken in the Emergency Department prior to dispatch, code the first full set of observations taken in the ward/department.

If there is clear evidence in the medical record that the observations would be the same, code them as such. If no head injury observations have been taken but there is clear evidence that the the patient is "conscious and alert", or "oriented to Time, Place, Person", attribute the highest coding score on the Glasgow Coma Scale sections of 'Eye Opening', 'Verbal Response' and 'Motor Response' .

If there are missing/no observations, leave the sections blank and note this under No. 19 CODING DIFFICULTIES. However, should the observations be stable for some time in the Emergency Department, use these as proxies.

VENTILATED PATIENTS: MTOS convention

INTUBATED & VENTILATED: Respiration: score at ventilatory rate If paralyzed: score nil response for eye opening, motor response, verbal response. Not paralyzed: score as appropriate for eye opening, motor response, and assign nil for verbal response. EYE OPENING: If the verbal and motor response is normal and there is no evidence of other C.N.S. damage.

VERBAL RESPONSE: a} Babies and small children b} Non-English speaking persons Code 1 = None - if appropriate Code 3 = Inappropriate - for any other.

MOTOR RESPONSE: 6 = Obeys commands - includes cases where it is assumed that the patient would normally have this response, ego fractured limbs, weakness of one hand, etc. 18

CALCULATION OF TOTAL ('l'RA0Ml SCORES)

a) Establish the total Glasgow Comas Scale (GCS) point using the Medical Record data.

b) Convert these to the single digit number using the following table

Total GCS Points

14 - 15 5 11 - 13 4 8 - 10 3 5 - 7 2 3 - 4 1

c) Add the single digit number to the Respiratory Ratei and Systolic Blood Pressure scores.

Example

Respiratory Rate 4 Systolic Blood Pressure 4 Eye Opening 4 G.C.S. Verbal Response 5 ie. 15 = 5 Motor Response 6

Total (Trauma Score) 13

Z~O'S are never to be used as a Total (Trauma Score).

N/R99 546 N/R-N/R99PREFINALHOSP TOTAL ExamRle ADMISS VERBALEYEMOTORBP - -- INITIAL RESP PRE HOSP ADMISS POST

4 N/R 4 4 4 N/R 5 N/R 6 N/R

13 13

Explanation of Coding for the Example Given

PRE HOSP - INITIAL. The BP was not recorded because "the patient's clothing was too bulky" and there was "a language problem".

As no assumptions can be made on pre-hospita1 data, th total trauma score was coded as 99 and a note made under 19. CODJ:NG DJ:FFJ:CULTJ:ES.

I '1C·,,,t,j·¥.\ 19

PR! BOSP - FINAL. No further observations were recorded by the Ambulance Officer, thus for the reason given above, the total trauma score was coded as 99 and a note made under 19. CODING DIFJl'ICUL~IES.

~mss. All observations were recorded, thus the trauma score was coded as 13.

p~T~mss. Only the blood pressure and pulse were recorded on the last set of observations taken in the Emergency Department prior to the patient's dispatch to a general ward. However, the patient had several sets of observations taken in Emergency Dept., all of which clearly indicated that she was stable, alert and oriented in time, place and person. Thus, assumptions were made regarding the missing data and the total trauma score was coded as 23 and a note made under 19. CODINGDIFJl'ICULT~.

99.Where scores areJ~1 unknown TRAUMASCOREfromEnterScores)code (INITIALtheasrelevant. TOTALPRE-aOSPI~AL)(Traumascores

TRAUMASCORETRAUMA(ADMISSION)SCORE (POST-ADMISSION)TRAUMASCORE (FINAL PRE-aOSPITAL)

APACHE 2 - PRE-EXISTING DISEASES:

Based on Apache 11 definitions for chronic disease history with the addition of diabetes and post splenectomy.

Chronic Organ Insufficiency must have been evident prior to this hospital admission and conform to the following criteria:

~: Biopsy-proven cirrhosis and documented portal hypertension, or episodes of past upper GI bleeding attributed to portal hypertension; or prior episodes of hepatic failure/encephalopathy/coma.

cumI~C~: New York Heart Association Class IV, i.e., angina or symptoms at rest or minimal exertion, e.g. getting dressed or self care.

RESP~roRY: Chronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction, i.e., unable to climb stairs or perform household duties; or documented chronic hypoxia, hypercapnia, secondary pOlycythemia, severe pulmonary hypertension ( 40 mmHg), or respiratory dependency.

RENAL: Re.:iving chronic hemo- or peritoneal dialysis. 20

DDUm~S: Insulin dependent.

IMMUNO-COMPROMISED BOST

Definition: The immuno-compromised state must have been evident prior to this hospital admission and conform to the following criteria:

1. Therapv: The patient has received therapy that suppresses resistance to infection, e.g. immuno• suppression, chemotherapy, radiation, long-term low dose steroids (during 30 days prior to hospitalisation) or recent high dose steroids ( 15 mg/Kg for five or more days)

2. Disease: The patient has a disease that is sufficiently advanced to suppress resistance to infection, e.g., leukemia, lymphoma, AIDS, documented diffuse metastatic cancer, ARC (AIDS Related Complex) .

3. Post Splenectomy Splenectomy prior to this hospita~ I admission.

Ref. "Data Collection Form: Operational Definitions", American College of Surgeons Committee on Trauma, Major Trauma Outcome Study, Washington (October, 1988) •

PRE-EXISTING IMPAIRMENrS

Minor impairments are irrelevant - code only if performance affected.

10 = Pain syndrome - include spondlylolisthesis

11 = Other disablements - Specify these e.g. patie~t

known to be an alcoholic (chronic or acute), j drug addict, epileptic. Also make note of this under No. 18 ~TJ:VES~Y especially if patien~ affected at time of incident. :INTUBAT:ION" (PRE-HOSPITAL) " (ADMISSION) As defined on Study Form (POST-ADMISSION)

VENTJ:LATOR" (PRE-HOSPITAL) " (ADMISSION) As defined on Study Form (POST-ADMISSION)

• I·~ I i l',~••. Hf I I 21

LOSS OF CONSCIOUSNESS

When coding this section, use evidence given by the Ambulance Officer's report.

1 = None 2 = Transient - terms used may be - "brief amnesia" "momentary LoC" "doesn't remember incident" - reliable bystander's evidence of LoC will be accepted as transient

3 = 5 min 4 = 1 hr Enter these codes only when clear 5 = 1 hr J evidence available

6 = Unspecified - Patient known to have been unconscious but length of time unspecified 9 = Unknown - Unknown whether the patient has or has not lost consciousness.

8. INITIAL HOSPITAL TREATMENT That is, treatment commenced within several hours of Admission to study hospital.

DAm OF ~nmN~: Day/Month/Year

~IME OF A~mNDANCE: 24 hour clock It may be noted at this point that there are discrepancies regarding Ambulance arrival time, ED observations time and Time of Attendance. These times are nevertheless to be recorded, even where small discrepancies occur. However, larger anomalies are to be noted under 18 NARRA~IVE SUMMlUtY.

PUCE ~A~mNDANCE: 5 = Outpatient Department

9 = Unknown - includes other places of attendance.

E • D • CONSUL~AN~IONS (RESIDEN~ S~AFF - list up to 7):

Code only those Registrar & Senior R.M.O. Consultants:

a) not attached to the Emergency Department

b) consulted within the first 3 hours of the patient's admission 22

B.D. CONSULTATIONS (CONSULTANTS - List up to 5)

If there is no clear indication that anyone has bee consulted, code 01 = None.

E.g. If the patient has been sent to the Operating Theatre for Orthopaedic surgery, it cannot be assumed (unless otherwise recorded) that an orthopaedic surgeon and/or anaesthetist was consulted.

Consultations made over the telephone (d/w • discussed with) are to be included.

CPR ADMINISTERED: As defined on Study Form.

AIRWAY MANAGEMEN~ ON ARRIVAL: (That is, upper airway treatment). If airway management is not stipulated on reports but clear evidence indicates that it is "adequate", code as 1 = Adequate.

1 = Adequate - includes 02 by mask, ETT in situ on arrival

EMERGENCY DEPARTMEN~ AIRWAY TREA~MEN~: (That is, upper airway treatment)

1 = No treatment - includes 02 by mask, ETT in sit, .on arrival.

DIAGNOS~IC PROCEDURES (list up to 9):

12 = Other - includes ECG, ETOH.

RADIOGRAPHIC PROCEDURES (list up to 8):

05 = Extremities - includes hip and shoulder X-Rays 10 = Other - includes facial X-Rays

ADDITIONAL SUPPORTIVE PROCEDURES (list up to 15):

10 = Splinting of Fx - includes all means of immobilizing fractures. E.g. use of sandbags or collars for cervical fractures, triangular bandage for bone and/or joint fractures.

CT SCAN :RESULTS: + = positive - pathology found = negative - no pathology found

DA'l'E (BEAD ) = day/month/year) Code even if patient i TIME (BEAD) 24 hour clock.) in a ward/unit. Includes Facial Bones and Orbit DIAGNOSTIC PERITONEAL :RESULTS:

Code as Reported. However, should a comment be made indicating that the result may have been a false positive, this should be noted under 18. ~TIVES~Y.

, It" 11 I·~ ;' •. I, id,lf , 'I , 23

INVESTIGATIONS PERFOIUmD OUTSIDE E. D. :

That is, investigations conducted in another facility.

DATE OF DISPATCH: Day/month/year fIME OF DISPAfCH: 24 hour clock If no definite time is recorded but known to be between two times, ego 1600 hrs and 1800hrs, code the median time, 1700hrs.

DISPATCHED TO: Dispatch information refers to the patient's destination upon being discharged from the Emergency Department. Do not include X-Ray, eT, special procedure rooms, etc. 24

9. LABORATORY ORDERS AND FLUIDS ADMINISTERED IN Z.D.

TIME OF BLOOD CBE!aSTRY TESTS: Taken within first 6 hours no matter which Ward/Dept.

TIME OF ARTERIAL BLOOD GAS TESTS - Base deficit, Code 00 - if not coded Code 99 - if conducte4 (regardless of result)

OXYGENADMINISTERED DURING BLOOD GAS fiST - as defined on Study Form.

TIME OF ADDITIONAL BLOOD TESTS - Taken within first 6 hours no matter which Ward/Dept.

Haematocrit entry - Example. If Haematocrit result reported as 0.40, enter as .40 in the 2 boxes provided.

If test requests made by the Medical Officer are listed in the Medical record but no results are available, please contact the Department concerned e.g. Biochemstry Lab., before entering code.

TOTAL CRYSTALLOID FLUIDS (ml) (In Emergency Department)

'rIPE OF BLOOD PRODUCTS ADMINISTERED (in Emergency Department)

2 = WholePlateletsFreshPacked blood60frozencells-mltakeperplasma- takeaspack490-astakeml190permlaspackper270 packml per pack 5 = 4 = 3 = - include"partiallybloodCross-Matched"reported as

TOTAL BLOOD PRODUCT QUANTITY (ml) (in Emergency Department)

10. OTHER LABORATORY ORDERS & FLUIDS PRE-THEATRE

(Only record additional amounts given between ED and Theatre with~n 24 hours from time of arrival at hospital (i.e. not admission to ! hospital)

NB This section refers only to those patients who actually attehd the Operating Theatre.

TIM!!: OF BLOOD CBBMISTRY TESTS

TIM!!: OF ARTERIAL BLOOD GAS TESTS

TIM!!: OF ADDITIONAL BLOOD TESTS

TOTAL CRYSTALLOID FLUIDS (ml)

TOTAL COLLOID FLUIDS ( " )

I !··I ! v· j I j 25

mE OF BLOOD PRODUCTS ADMINISTERED

TOTAL BLOOD PRODUCT QUANTITY (ml)

11. HOSPITAL DIAGNOSIS ON ADMISSION

NATURE OF MOST SEVERE INJURY 5 = Other - includes burns.

BURNS SUPERFICIAL

BURNS DEEP

B.S.A. Body Surface Area

12 • SURGICAL PROCEDURES PERFORMED

This section is to be coded as defined under Section No. 6, and is to include all surgical procedures performed during the patient's admission to hospital.

13. ICO PROCEDURES That is, ICO-type procedures.

DATE OF ADMISSION: Day/month/year

TIME OF ADMISSION: 24 hour clock

DAYS SPENT IN ICU: If admitted and(1 day)discharged- code ason appropriatethe0099 same day If noadmittedtime inoneIfICUdaymoreunknown&thandischarged1 day the next - code as 01

PROCEDURE CHOICE: As defined on Study Form

14. FINAL DISPOSITION DETAILS

DATE OF DISCHARGE: Day/month/year

Admissions interrupted by less than 48 hours (eg. discharge at own risk) are considered to be continuous.

Transfer to Rehabilitation Ward within the same hospital is to be treated as a discharge from that hospital. 26

TIME OF DISCHARGE: 24 hour clock

Deceased Patients - code time patient was pronounce dead by Medical Officer ie. regardless of when organs were/were not harvested.

TOTAL DAYS SPENT IN HOSPITAL:

Enter the total number of days spent in hospital until discharge including the Ieu days. If admitted and disCharged/died on the same day code as 001 (i.e. 1 day) If admitted one day and discharged/died the next - code as 001 (i.e. 1 day) If admitted for more than one day - code as appropriate, counting nights, including those spent in Emergency Department. Days/nights spent "on leave" are to be included in the total.

DISCHARGE STATUS: As defined on the Study Form

DISCHARGED TO: 02 = Home (no assist) - the patient's (or a significant other's) home without professional: assistance. includes (a) a family member or friend. assisting with nursing ca~e e.g. dressings (b) a child or a baby

03 = Home (assist) - the patient's (or a significant other's) home with assistance. That is, care or therapy provided by a professional. For example, a visiting Registered Nurse, Physiotherapist, Occupational Therapist.

06 = Rehabilitation - a facility whose goal it is tio return the patient to the highest functional level possible.

DISCHARGE HOSPITAL TAC NUMBER: Where a patient is transferred to another facility, code the TAC number if available (not in boxes) .

MEDICAL FOLLOW-UP REQUIRED: As defined on Study Form. For example, Outpatient Department review, Local M.O., etc.

FINAL ANATOMICAL DIAGNOSIS SOURCE: That is, the final definitive anatomical diagnosis source.

- includes tests which eliminate major diagnoses. All deceased patients have an autopsy.

DECEASED DONATION STATUS: As defined on the Study Form

O~SDONA~D (select up to 3 organs): As defined on the Study Form.

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15. DISCHARGE DIAGNOSIS (I.S.S. Body Regions)

From the Medical Records, please list all injuries diagnosed by:

1. Physician examination e.g. abrasions, lacerations, contusions.

2. Documented X-ray reports or computerized axial tomography (CT/CAT Scan) or magnetic resonance imaging (MRI/NMR).

3. Operative findings

4. Autopsy results.

DEFINITIONS

Abrasion: A wound caused by rubbing or scraping the skin or mucous membrance e.g. "skinned knee", "friction rub".

Contusion: An injury to tissues without breakage of skin: a bruise.

Laceration: A wound produced by tearing of body tissue as distinguished from a cut or incision.

Code the most severe of the above. Limit the cOding of these to a maximum of three injuries.

The injuries should be recorded only when the diagnosis is certain or where the treatment regime is consistent with a definitive diagnosis. They should be checked at discharge or death prior to submitting the form. FOllow-up X-Rays from Outpatient's Department sometime provide a more definitive diagnosis of the original problem.

Please include the following when describing injuries:

1. Record the size of all abrasions and contusions, as well as their location on the body. The area is determined by multiplying the length by the breadth.

2. Indicate the length of all lacerations (both external and internal) and their locations and whether they extend into subcutaneous tissue.

3. Indicate the area of the skull for fractures, as well as:

a) open, dura torn, depressed b) if the skull fracture is depressed, indicate minimal or severe. 28

4. Record all brain injuries from eT scan reports when possible. Do not state multiple cerebral contusions but state where.

Example: (R) frontal, (L) parietal, (L) occipital cerebral contusions.

5. Indicate side and region of brain for all intracranial injuries. 6. Record duration of loss of consciousness for ALL head injuries.

7. Utilise term "closed head injury" only if no other information is available.

8. Indicate for all fractures whether right, left, bilateral, open, displaced or comminuted.

9. Indicate rib fractures by side and which rib:

a) Note total number of ribs.

10. Name vessels injured and state whether lacerated, intimal tear, transected or ruptured.

11. State volume of blood and side(s) of occurrence fo~

haemothoracies. I

12. State side for pneumothoracies.

13. Record abdominal organ injuries as contusion, laceration, perforation (number), rupture, etc.

14. Indicate volume of haemoperitoneum in mls if possible. 15. Indicate the sites of all missiles.

16. Indicate the location in which the missile was lodged.

17. Indicate spinal cord injury as contusion or laceration of cord:

Include extent of injury

Example:injury withQuadriplegia,motor and/orparaplegia,sensory loss,incomple~ewhether permanent or transient.

Detailed injury descriptions will enable accurate coding of injury severity.

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