Dan Bieler1, Anna Hörster2, Rolf Lefering2, Axel Franke3, Christian Waydhas4,5, Stefan Huber-Wagner6, Markus Baacke7, Thomas Paffrath8, Jan Wnent9, Ruth Volland10, Barbara Jakisch11, Felix Walcher12, Martin Kulla13. 1. Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery, Burn Medicine, Armed Forces Central Hospital Koblenz, Ruebenacher Strasse 170, 56072, Coblenz, Germany. dr.dan.bieler@t-online.de. 2. Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Ostmerheimer Str. 200 House 38, 51109, Cologne, Germany. 3. Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery, Burn Medicine, Armed Forces Central Hospital Koblenz, Ruebenacher Strasse 170, 56072, Coblenz, Germany. 4. Department of Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, 44789, Bochum, Germany. 5. Medical Faculty of the University Duisburg-Essen, Bürkle-de-la-Camp Platz 1, Hufelandstr. 55, 45137, Essen, Germany. 6. Department of Trauma Surgery, Klinikum rechts, Isar Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany. 7. Department of Trauma and Reconstructive Surgery/Emergency Department, Krankenhaus der Barmherzigen Brüder Trier, Nordallee 1, 54292, Trier, Germany. 8. Department of Trauma and Orthopaedic Surgery, Faculty of Health, School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany. 9. Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, Haus 808, 24105, Kiel, Germany. 10. AUC, Academy for Trauma Surgery GmbH, Wilhelm-Hale-Straße 46b, 80639, Munich, Germany. 11. Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, Haus 808, 24105, Kiel, Germany. 12. Department of Trauma Surgery, University Magdeburg A.ö.R, Leipziger Str. 44, 39120, Magdeburg, Germany. 13. Department for Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Armed Forces Hospital Ulm, HEMS "Christoph 22", Oberer Eselsberg 40, 89081, Ulm, Germany.
Abstract
BACKGROUND: The TraumaRegister DGU® (TR-DGU) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) enables the participating hospitals to perform quality management. For that purpose, nine so-called audit filters have existed, since its foundation, which, inter alia, is listed in the Annual Report. The objective of this study effort is a revision of these quality indicators with the aim of developing pertinent new and reliable quality indicators for the management of severely injured patients. MATERIALS AND METHODS: Apart from indicators already used at national and international levels, a systematic review of the literature revealed further potential key figures for quality of the management of severely injured patients. The latter were evaluated by an interdisciplinary and interprofessional group of experts using a standardized QUALIFY process to assess their suitability as a quality indicator. RESULTS: By means of the review of the literature, 39 potential indicators could be identified. 9 and 14 indicators, respectively, were identified in existing trauma registries (TR-DGU and TARN), 17 in the ATLS® training concept, and 57 in the S3 guideline on the treatment of polytrauma/severe injuries. The exclusion of duplicates and the limitation to indicators that can be collected using the TR-DGU Version 2015 data set resulted in a total of 43 indicators to be reviewed. For each of the 43 indicators, 13 quality criteria were assessed. A consensus was achieved in 305 out of 559 individual assessments. With 13 quality criteria assessed and 43 indicators correspond this to a relative consensus value of 54.6%. None of the indicators achieved a consensus in all 13 quality criteria assessed. The following 13 indicators achieved a consensus in at least 9 quality criteria: time between hospital admission and WBCT, mortality, administration of tranexamic acid to bleeding patients, use of CCT with GCS <14, time until first emergency surgical intervention (7-item list in the TR-DGU), time until surgical intervention for penetrating trauma, application of pelvic sling belt (prehospital), capnometry (etCO2) in intubated patients, time until CCT with GCS < 15, time until surgery for hemorrhagic shock, time until craniotomy for severe TBI, prehospital airway management in unconscious patients (GCS < 9), and complete basic diagnostics available. Two indicators achieved a consensus in 11 criteria and thus represent the maximum consensus achieved within the group of experts. Four indicators only achieved a consensus in three quality criteria. 17 indicators had a mean value for the 3 relevance criteria of ≥ 3.5 and were, therefore, assessed by the group of experts as being highly relevant. CONCLUSION: Not all the key figures published for the management of severely injured patients are suitable for use as quality indicators. It remains to be seen whether the quality indicators identified by experts using the QUALIFY process will meet the requirements in practice. Prior to the implementation of the assessed quality indicators in standardized quality assurance programs, a scientific evaluation based on national data will be required.
BACKGROUND: The TraumaRegister DGU® (TR-DGU) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) enables the participating hospitals to perform quality management. For that purpose, nine so-called audit filters have existed, since its foundation, which, inter alia, is listed in the Annual Report. The objective of this study effort is a revision of these quality indicators with the aim of developing pertinent new and reliable quality indicators for the management of severely injured patients. MATERIALS AND METHODS: Apart from indicators already used at national and international levels, a systematic review of the literature revealed further potential key figures for quality of the management of severely injured patients. The latter were evaluated by an interdisciplinary and interprofessional group of experts using a standardized QUALIFY process to assess their suitability as a quality indicator. RESULTS: By means of the review of the literature, 39 potential indicators could be identified. 9 and 14 indicators, respectively, were identified in existing trauma registries (TR-DGU and TARN), 17 in the ATLS® training concept, and 57 in the S3 guideline on the treatment of polytrauma/severe injuries. The exclusion of duplicates and the limitation to indicators that can be collected using the TR-DGU Version 2015 data set resulted in a total of 43 indicators to be reviewed. For each of the 43 indicators, 13 quality criteria were assessed. A consensus was achieved in 305 out of 559 individual assessments. With 13 quality criteria assessed and 43 indicators correspond this to a relative consensus value of 54.6%. None of the indicators achieved a consensus in all 13 quality criteria assessed. The following 13 indicators achieved a consensus in at least 9 quality criteria: time between hospital admission and WBCT, mortality, administration of tranexamic acid to bleedingpatients, use of CCT with GCS <14, time until first emergency surgical intervention (7-item list in the TR-DGU), time until surgical intervention for penetrating trauma, application of pelvic sling belt (prehospital), capnometry (etCO2) in intubated patients, time until CCT with GCS < 15, time until surgery for hemorrhagic shock, time until craniotomy for severe TBI, prehospital airway management in unconscious patients (GCS < 9), and complete basic diagnostics available. Two indicators achieved a consensus in 11 criteria and thus represent the maximum consensus achieved within the group of experts. Four indicators only achieved a consensus in three quality criteria. 17 indicators had a mean value for the 3 relevance criteria of ≥ 3.5 and were, therefore, assessed by the group of experts as being highly relevant. CONCLUSION: Not all the key figures published for the management of severely injured patients are suitable for use as quality indicators. It remains to be seen whether the quality indicators identified by experts using the QUALIFY process will meet the requirements in practice. Prior to the implementation of the assessed quality indicators in standardized quality assurance programs, a scientific evaluation based on national data will be required.