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Background: The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS).Methods: Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC.Results: Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times.Conclusions: Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements. (C) 2021 Elsevier Ltd. All rights reserved.

Background: Adequate pre-hospital trauma triage is crucial to enable optimal care in inclusive trauma systems. Transport of children in need of specialised trauma care to lower-level trauma centres is associated with adverse patient outcomes. We aimed to evaluate the diagnostic accuracy of paediatric field triage based on patient destination and triage tools. Methods: We did a multisite observational study (P2-T2) of all children (aged

Objective:To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands. Summary Background Data:Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome. Methods:A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period).Results:During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012). Conclusions:The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.

BACKGROUNDThe Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of >= 3 in >= 2 body regions (2AIS >= 3) combined with the presence of >= 1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR). METHODSThe evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS >= 3, Injury Severity Score (ISS) of >= 16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS >= 3 patients were compared with those from the Deutsche Gesellschaft fur Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS >= 3-DNTR patients and compared with those with an ISS of >= 16. RESULTSThe DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of >= 16, and 6,263 patients had suffered a 2AIS >= 3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS >= 3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS >= 3 and ISS >= 16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group. CONCLUSIONThis study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS >= 16 and 2AIS >= 3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate.

Introduction: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National Trauma Registry (DNTR) to evaluate epidemiology, patient distribution, resource use and quality of care. In this study we describe the DNTR, the incidence and main characteristics of Dutch acutely admitted trauma patients, and evaluate the value of including all acute trauma admissions compared to more stringent criteria applied by the national trauma registries of the United Kingdom and Germany.Methods: The DNTR includes all injured patients treated at the ED within 48 hours after trauma and consecutively followed by direct admission, transfers to another hospital or death at the ED. DNTR data on admission years 2007-2018 were extracted to describe the maturation of the registry. Data from 2018 was used to describe the incidence rate and patient characteristics. Inclusion criteria of the Trauma Audit and Research (TARN) and the Deutsche Gesellschaft fur Unfallchirurgie (DGU) were applied on 2018 DNTR data.Results: Since its start in 2007 a total of 865,460 trauma cases have been registered in the DNTR. Hospital participation increased from 64% to 98%. In 2018, a total of 77,529 patients were included, the median age was 64 years, 50% males. Severely injured patients with an ISS=16, accounted for 6% of all admissions, of which 70% was treated at designated RTCs. Patients with an ISS= 15were treated at non-RTCs in 80% of cases.Application of DGU or TARN inclusion criteria, resulted in inclusion of respectively 5% and 32% of the DNTR patients. Particularly children, elderly and patients admitted at non-RTCs are left out. Moreover, 50% of ISS >= 16 and 68% of the fatal cases did not meet DGU inclusion criteriaConclusion: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,0 00 inclusions annually, the DNTR has become one of the largest trauma databases in Europe The registries strength lies in the broad inclusion criteria which enables studies on the burden of injury and the quality and efficiency of the entire trauma care system, encompassing all trauma-receiving hospitals. (C) 2020 Elsevier Ltd. All rights reserved.

Background: Measuring patients' experiences to determine health-care performance and quality of care from their perspective can provide valuable evidence for international improvements in the quality of care. We compare patients' experiences in Accident & Emergency departments (A&E) in England and the Netherlands and discuss the usefulness of this comparison. Methods: A cross-sectional survey was conducted among patients attending A&Es aged 18 years and older. In England, 134 A&Es were surveyed. In the Netherlands, nine hospitals participated in the study. Main outcome measures were patients' experiences represented by six domain scores aggregated on the country level or on the A&E level. Results: In England, 43 892 completed questionnaires were received (40%). In the Netherlands, 1865 completed questionnaires were received (42%). Three of six domain scores were significantly higher for patients in the Netherlands: 'waiting time' [mean scores of 73.8 (NL) versus 67.2 (ENG)], 'doctors and nurses' [mean scores of 85.7 (NL) versus 80.6 (ENG)] and 'your care and treatment' [mean scores of 82.6 (NL) and 80.2 (ENG)]. The variance among the English A&Es was large. The best and worst practices on five domains were English. Conclusions: The mean quality of care in the A&E appeared to be better in the Netherlands on three domains, but the best practices were English A&Es. The within-country differences between A&Es were much larger than differences between countries. Healthcare performance in the A&E can be compared between countries by surveying patients' experiences, and there seems much to learn across A&Es both within and among countries.

Objective To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency department (ED) to a general practitioner (GP) based on the Manchester triage system (MTS). Methods All self-referred patients in the evening, night and weekends were included in this prospective observational study. Patients were triaged by an ED nurse according to the MTS and allocated to a GP or the ED according to a predefined care scheme. For patients treated by the GP, assessments were made of safety as measured by hospitalisation and return to the ED within 2 weeks, and efficiency as measured by referral to the ED. Results In 80% of cases allocation of the self-referrals to the ED or GP was according to a predefined scheme. Of the 3129 low urgent self-referred patients triaged to the GP, 2840 (90.8%) were sent home, 202 (6.5%) were directly referred to the ED, 36 (1.2%) were hospitalised. Within a random sample of low urgent patients sent home by the GP (222 of 2840), 8 (3.6%) returned to the ED within 2 weeks. Against the agreed MTS scheme, the ED also directly treated 664 low urgent patients, mainly for extremity problems (n=512). Despite the care agreements, 227 urgent patients were treated by the GP, with a referral rate to the ED of 18.1%, a hospitalisation rate of 4.0% and a 4.5% return rate to the ED within 2 weeks. Conclusions Low urgent self-referrals, with the exception of extremity problems, were shown to be treated efficiently and safely by a GP. A selected group of more urgent patients also seem to be handled adequately by the GP. Triage of low urgent patients with extremity problems and reasons for nurses not following a predefined triage allocation scheme need further elaboration.

Objective Pain is one of the six general discriminators of the Manchester triage system (MTS). The frequency of pain assessments conducted at triage with the MTS, and patient, nurse and triage characteristics associated with pain assessments were studied. Also, nurses9 reasons for not assessing pain at triage were studied. Methods The study consisted of two parts. In part 1, nurses from two emergency departments (ED) registered patient characteristics and the process of triage for every presenting patient during 1 week in May 2009. The characteristics of triage nurses were registered on a second form. In part 2 of the study, 13 nurses were interviewed about reasons for not assessing pain at triage. Results According to the MTS guidelines, pain assessments should have been conducted in 86.1% of the patient presentations. It was only assessed in 32.2% of these patients. Characteristics associated with conducting pain assessments were children under 12 years of age, patients referred by others than a general practitioner or ambulance service, intake of medication before an ED visit, experience of the nurse with the MTS and the duration of triage. Reasons for not assessing pain according to the guidelines included the thought of triage nurses that pain assessments result in overtriage. Conclusions Pain assessments at triage are conducted infrequently because of insufficient education, conducting activities at triage that are not necessary for estimating urgency and a lack of clarity in the MTS guidelines. Changes in these areas are necessary to improve the reliability and validity of pain assessments and the MTS.

Since 1999, the Dutch trauma care has been regionalized into ten trauma systems. This study is the first to review such a trauma system. The aim was to examine the sensitivity of prehospital triage criteria [triage revised trauma score (T-RTS)] in identifying major trauma patients and to evaluate the current level of trauma care of a regionalized Dutch trauma system for major trauma patients. Major trauma patients (n=511) (June 2001–December 2003) were selected from a regional trauma registry database. The prehospital T-RTS was computed and standardized W scores (Ws) were generated to compare observed vs expected survival based on contemporary US- and UK-norm databases. The T-RTS showed low sensitivity for the prehospital identification of major trauma patients [34.1% (T-RTS≤10)]. Nevertheless, 78.0% of all major trauma patients were directly managed by the trauma center. These patients were more severely injured than their counterparts at non-trauma-center hospitals (p

Objectives: To examine children's reports of their health-related quality of life (HRQoL) following paediatric traffic injury, to explore child and parental post-traumatic stress, and to identify children and parents with adverse outcomes. Design: Prospective cohort study. Assessments: shortly after the injury, three months and six months post injury. Setting: Department of Traumatology, University Hospital. Subjects: Fifty-one young traffic injury victims aged 8-15 years. Main measures: TNO-AZL Children's Quality of Life questionnaire and the Impact of Event Scale. Results: Short-term adverse changes in the child's HRQoL were observed for the child's motor functioning and autonomy. At three months, 12% of the children and 16% of the parents reported serious post-traumatic stress symptoms. Increased stress at three months, or across follow-up, was observed among hospitalized children, children with head injuries, and children injured in a motor vehicle accident. Parental stress was related to low socioeconomic status and the seriousness of the child's injury and accident (hospitalization, head injury, serious injury, motor vehicle involved, others injured). Conclusions: The children reported only temporary effects in their motor functioning and autonomy. Post-traumatic stress symptoms following paediatric traffic injury were not only experienced by the children, but also by their parents.

Background Assessment of patients’ views are essential to provide a patient-centred health service and to evaluating quality of care. As no standardized and validated system for measuring patients’ experiences in accident and emergency departments existed, we have developed the Consumer Quality index for the accident and emergency department (CQI A&E). Methods Qualitative research has been undertaken to determine the content validity of the CQI A&E. In order to assess psychometric characteristics an 84-item questionnaire was sent to 653 patients who had attended a large A&E in the Netherlands. Also, fifty importance questions were added to determine relevance of the questions and for future calculations of improvement scores. Exploratory factor analysis was applied to detect the domains of the questionnaire. Results Survey data of 304 (47%) patients were used for the analysis. The first exploratory factor analysis resulted in three domains based on 13 items: ‘Attitude of the healthcare professionals’, ‘Environment and impression of the A&E’ and ‘Respect for and explanation to the patient’. The first two had an acceptable internal consistency. The second analysis, included 24 items grouped into 5 domains: ‘Attitude of the healthcare professionals’, ‘Information and explanation’, ‘Environment of the A&E’,’Leaving the A&E’ and ‘General information and rapidity of care’. All factors were internal consistent. According to the patients, the three most important aspects in healthcare performance in the A&E were: trust in the competence of the healthcare professionals, hygiene in the A&E and patients’ health care expectations. In general, the highest improvement scores concerned patient information. Conclusions The Consumer Quality index for the accident and emergency department measures patients’ experiences of A&E healthcare performance. Preliminary psychometric characteristics are sufficient to justify further research into reliability and validity.

Objective Patients triaged in category 5 of the Emergency Severity Index (ESI) do not need any resources before discharge from the emergency department (ED). We studied the characteristics of these patients and focused on those who were admitted or sent to the outpatient department after their ED visit. Methods A retrospective observational study was conducted on 117 740 patient presentations. Patients were included in the study when they were triaged with the ESI and presented to one of the two EDs under study between 1 September 2004 and 1 June 2006. Results Overall, 22.2% of the patients were triaged in ESI 5. Patients aged less than 40 years, women, and self-referred patients were most likely triaged in ESI 5, as well as patients presenting with complaints such as 'checkup appointments at the ED' and 'complaints of the skin'. Patients triaged in ESI 5 who were admitted or sent to the outpatient department were most likely elderly (aged above 65 years) and referred patients. They were also more likely to present with complaints such as 'postoperative complications, wound care problems, and plaster problems' and 'complaints of the genitourinary system'. Conclusion Although younger patients and women were more likely triaged in ESI 5, patients within this category who were admitted or sent to the outpatient department were more likely elderly and referred patients. Being admitted or sent to the outpatient department and triaged in ESI 5 indicates undertriage. Revision of the system is required to properly account for these patient groups.

Prehospital triage is aimed at getting the right patient to the right hospital. Evaluations on the performance of prehospital triage tools are scarce. This study examines the ability of the American College of Surgeons' Committee on Trauma (ACSCOT) triage guidelines to identify major trauma patients in a European trauma system. Furthermore, this study evaluates the predictive power of other prehospital measurements. Prehospital data of 151 minor (Injury Severity Score (ISS) 1–15) and 151 major trauma patients, (ISS > 15) treated at a Dutch trauma center, were collected. Logistic regression analysis was used to identify predictors of major trauma patients. The major trauma patients particularly incurred severe head injuries (45.7%) and severe thorax injuries (21.9%). The ACSCOT guidelines had a sensitivity of 84.1% and a specificity of 77.5%. A new prehospital trauma triage model was constructed including nine predictors of major trauma. This model identified more major trauma patients than the ACSCOT (sensitivity 92.1%, p = 0.023) and resulted in a comparable specificity (79.5%; p = 0.711). The new triage model outperforms the ACSCOT triage guidelines in identifying major trauma patients in the prehospital setting. The new triage guidelines may improve patient outcomes but needs to be validated in a prospective study.

Sturms LM, van der Sluis CK, Groothoff JW, ten Duis HJ, Eisma WH. Young traffic victims' long-term health-related quality of life: child self-reports and parental reports. Arch Phys Med Rehabil 2003;84:431-6. Objectives: To describe the long-term health-related quality of life (HRQOL) reported by young traffic injury victims and to assess the child-parent agreement on the child's HRQOL. Design: Cohort study with a mean follow-up of 2.4 years. Setting: Traumatology department in a university hospital in The Netherlands. Participants: All traffic injury victims treated at the traumatology department in 1996[ndash ]1997 and aged 8 to 15 years at follow-up (N = 254). The data of 157 child-parent pairs were available for analysis (mean follow-up age, 12[plusmn]2.4y; 57% boys; 24% hospitalized). Interventions: Not applicable. Main Outcome Measure: TNO-AZL Children's Quality of Life parent and child questionnaires. Results: Young traffic injury victims reported a significantly lower HRQOL in the motor and autonomy scales compared with contemporaries in the reference group. The child-parent agreement ranged from low to moderate (intraclass correlations, .35[ndash ].67). A comparison made between the children and their parents found that the children were more negative regarding the physical complaints and the motor, autonomy, and positive-emotion scales. Conclusions: Young traffic injury victims reported a reasonably good long-term HRQOL, and, surprisingly, few psychologic problems were revealed. Physicians who rely only on parental reports may overestimate the child's HRQOL, especially when assessing the physical functioning. The child's own reports should not be neglected in the assessment of a comprehensive picture of the child's HRQOL. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objective: To describe the health-related quality of life (HRQoL) of young traffic victims and to identify those children who are at high risk of a reduced HRQoL. Methods: Retrospective analysis of data obtained from a registration system and from questionnaires completed by 211 parents of young traffic victims who attended the department of traumatology in 1996 and 1997. Results: The overall group of young traffic victims experienced a lower HRQoL sumscore compared with the reference population (p = 0.001). A total of 48 parents (23%) attributed their child's reduced HRQoL specifically to the traffic accident. The socioeconomic status (SES) of the father (p = 0.018) and the Injury Severity Score (p

Objectives and Background Measurements of patients9 perceptions have been recognised as an important part of evaluations of the quality of care. However, in the Netherlands a standardised and validated instrument to systematically measure how patients experience the healthcare delivered in an emergency department (ED) is lacking. Therefore, we developed the Consumer Quality Index for the Emergency Department (CQI ED). Methods The CQI ED was developed according to the national CQI guideline. First, qualitative research was used to construct the CQI ED. Second, to assess psychometric characteristics the 84-item CQI ED, temporarily extended with 50 important questions, was sent to 653 patients who attended a large-sized ED in the Netherlands in January 2010. Exploratory factor analyses were used to determine the domains of the questionnaire. Improvement scores were computed by multiplying the importance scores with the percentages to the negative answering categories of the experience questions. Results Survey data of 304 (47%) patients were used for analyses. The first exploratory factor analysis resulted in 15 items grouped in three internally consistent domains: Attitude of the healthcare professionals, environment and impression of the ED and respect and explanation towards the patient. The second analysis, ignoring the general CQI guidelines, included 27 items and resulted in 5 domains: Attitude of the healthcare professionals, information and explanation, environment of the ED, leaving the ED, and general information and rapidity of care. The three most important aspects in healthcare performance at the ED were: trust in the competence of the healthcare professionals, hygiene at the ED and received care as expected. The highest improvement scores were mostly about informing patients. Conclusions The CQI ED is a reliable instrument to measure patients9 experiences with care at the ED and seems applicable for local quality improvement. Preferring a construct of three or five domains depends on the choice for a between-ED or within-ED comparison.