Background: Using patient outcomes to monitor medical centre performance has become an essential part of modern health care. However, classic league tables generally inflict stigmatization on... Show moreBackground: Using patient outcomes to monitor medical centre performance has become an essential part of modern health care. However, classic league tables generally inflict stigmatization on centres rated as "poor performers", which has a negative effect on public trust and professional morale. In the present study, we aim to illustrate that funnel plots, including trends over time, can be used as a method to control the quality of data and to monitor and assure the quality of trauma care. Moreover, we aimed to present a set of regulations on how to interpret and act on underperformance or overperformance trends presented in funnel plots. Methods: A retrospective observational cohort study was performed using the Dutch National Trauma Registry (DNTR). Two separate datasets were created to assess the effects of healthy and multiple imputations to cope with missing values. Funnel plots displaying the performance of all trauma-receiving hospitals in 2020 were generated, and in-hospital mortality was used as the main indicator of centre performance. Indirect standardization was used to correct for differences in the types of cases. Comet plots were generated displaying the performance trends of two level-I trauma centres since 2017 and 2018. Results: Funnel plots based on data using healthy imputation for missing values can highlight centres lacking good data quality. A comet plot illustrates the performance trend over multiple years, which is more indicative of a centre's performance compared to a single measurement. Trends analysis offers the opportunity to closely monitor an individual centres' performance and direct evaluation of initiated improvement strategies. Conclusion: This study describes the use of funnel and comet plots as a method to monitor and assure high-quality data and to evaluate trauma centre performance over multiple years. Moreover, this is the first study to provide a regulatory blueprint on how to interpret and act on the under- or overperformance of trauma centres. Further evaluations are needed to assess its functionality. Show less
Background Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of... Show moreBackground Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time. Methods All severely injured patients (Injury Severity Score [ISS] >= 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008-2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS. Results The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63-74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC. Conclusion Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital. Show less
Annually around 5 million people die as a consequence of injuries and many more suffer from livelong disabilities. Although implementation of trauma care systems and structured trauma training has... Show moreAnnually around 5 million people die as a consequence of injuries and many more suffer from livelong disabilities. Although implementation of trauma care systems and structured trauma training has led to decreased mortality and disability in several countries, controversies remain to exist. The awareness of the current trauma burden and its expected increase has led to new initiatives for scientific research in an attempt to eventually improve trauma care worldwide. Despite the improvements there is room for further optimization of care. The primary aim of this thesis is to analyze the presence and structure of trauma systems, evaluate specific care-delivery processes, and focus on patient-centered and clinically important parameters and outcomes. The second aim is to evaluate one of these parameters, the role of the nutritional status in the outcome of polytrauma patients. Show less
Background Many factors of trauma care have changed in the last decades. This review investigated the effect of these changes on global all-cause and cause-specific mortality in polytrauma patients... Show moreBackground Many factors of trauma care have changed in the last decades. This review investigated the effect of these changes on global all-cause and cause-specific mortality in polytrauma patients admitted to the intensive care unit (ICU). Moreover, changes in trauma mechanism over time and differences between continents were analyzed. Main body A systematic review of literature on all-cause mortality in polytrauma patients admitted to ICU was conducted. All-cause and cause-specific mortality rates were extracted as well as trauma mechanism of each patient. Poisson regression analysis was used to model time trends in all-cause and cause-specific mortality. Thirty studies, which reported mortality rates for 82,272 patients, were included and showed a decrease of 1.8% (95% CI 1.6-2.0%) in all-cause mortality per year since 1966. The relative contribution of brain injury-related death has increased over the years, whereas the relative contribution of death due to multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, and sepsis decreased. MODS was the most common cause of death in North America, and brain-related death was the most common in Asia, South America, and Europe. Penetrating trauma was most often reported in North America and Asia. Conclusions All-cause mortality in polytrauma patients admitted to the ICU has decreased over the last decades. A shift from MODS to brain-related death was observed. Geographical differences in cause-specific mortality were present, which may provide region-specific learning possibilities resulting in improvement of global trauma care. Show less
