Optimization of integrated care in trauma and COVID-19 patients: similar approaches
Authors:   , Berkeveld Eva 
Published: January 2024

This dissertation has focused on optimization strategies in the acute integrated care. Current insights into the effects of time and triage in early trauma care were evaluated. Additionally, from a capacity perspective, the processes in integrated care related to meeting the high demand in trauma and COVID-19 care were examined. Directly after traumatic injury, receiving the appropriate care as swiftly as possible can be crucial. Chapter 2 describes a comprehensive statistical analysis of the early phase after severe injury (Injury Severity Score (ISS) ≥ 16). A retrospective observational study focusing on severely injured patients who were directly presented to a level-1 trauma center after having received prehospital care by (H)EMS (n=342) did not demonstrate a correlation between time and mortality. An average prehospital time of 45.2 minutes was identified. Nonetheless, the data does not exclude that individual patients may benefit from short prehospital times. In Chapter 3 a retrospective cohort study involving over 18,000 HEMS dispatches observed a cancellation rate of 54.5%. The most common reason for cancellation was the physiologically and neurologically stable condition of the patient, with no expected deterioration within an hour (76.1%). Trauma-related dispatches were most frequent (65.2%), with dispatches for reasons such as ‘assault with a blunt object’ (64.1%), ‘undefined traumatic incident’ (59.9%), or ‘strangulation’ (58.6%) showing the highest cancellation rates. Despite these dispatches could being considered overtriage, most involved a primary HEMS dispatch. Due to the short flight time until cancellation (median five minutes), the simultaneous unavailability for other calls in case of a canceled flight remains minimal. Chapter 4 analyzes the undertriage of trauma patients who potentially could benefit from level-1 trauma. Trauma patients meeting at least one of the following criteria—ISS ≥ 16, direct ICU admission, emergency intervention (< 24 hours), or death (< 24 hours), and who are being directly presented at a level-2 or -3 trauma center—were included. An undertriage of 17.3% was demonstrated for patients who could potentially benefit from level-1 trauma care. Specifically, for patients with an ISS ≥ 16 an undertriage percentage of 22.9% was shown. Chapter 5 examines the effect of the presence of a clock in the trauma resuscitation room in a prospective observational double-cohort study conducted in a level-1 trauma center. Median resuscitation times were found to be non-significantly different at 40.3 minutes and 44.3 minutes, respectively, without (n=50) and with the clock (n=50). Severely injured patients showed median resuscitation times of 54.6 minutes and 46.0 minutes, respectively, without (n=9) and with the clock (n=8). Chapter 6 describes a retrospective cohort study on the care demand of prehospital and inhospital integrated trauma care after merging two academic level-1 trauma centers in Amsterdam. In total, 462 patients were considered severely injured (ISS ≥ 16). There were 702 emergency interventions performed (< 24 hours), and 442 patients were admitted to the ICU. The sum of healthcare demand resulted in an expected increase post-merger of 167.4% for trauma patients and 151.1% for severely injured patients. Chapter 7 describes the experience of a novel established task force in coordinating the distribution of COVID-19 patients in region Noord-Holland Flevoland. Building upon an existing acute trauma care network (Regionaal Overleg Acute Zorgketen (ROAZ)), regional collaboration was enhanced, and the novel crisis task force was established. Together, the task force and local crisis coordinators formed a regional collaborative framework for COVID-19 patient distribution in which 130 COVID-19 patient transfers were coordinated intra- and interregionally during the first COVID-19 wave. Chapter 8 outlines the process improvement strategies undertaken by the regional task force. Processes were standardized, new strategies were implemented and the decision tree was continuously evaluated.