trends in the german trauma system registry, …...trends in the german trauma system registry,...
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Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Trends in the German
trauma system
Registry, Network, Outcome
Rolf Lefering
Institute for Research in Operative Medicine (IFOM)
University Witten/Herdecke
Cologne, Germany
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
German Trauma Society DGU (Deutsche Gesellschaft für Unfallchirurgie)
TraumaNetzwerk DGU®
TraumaRegister DGU®
P.A.R.T.Y. Injury Prevention
TKmed ®
AltersTraumaZentrum DGU®
ATLS Courses
Sektion NIS
of DGU
Rolf Lefering
Scientific
Leadership
Cooperation / Service Owner
of the data
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Trends ….
• TraumaRegister DGU®
• Regional trauma networks
• Number of trauma patients
• Trends in trauma care
• Better survival (?)
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
254 395 688 616 844 1066 15482465 2782 3098 3269 3279 3843
51566745 6711
10141
16985
24688
29998
34878
3804639346
0
5.000
10.000
15.000
20.000
25.000
30.000
35.000
40.000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Annual Number of Patients
Working group
‚Polytrauma‘
founded
National
research
grant
Online data
collection
introduced
Obligatory tool for quality
assessment in regional
trauma networks
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
TR-DGU Patients 2015
100%
89%
66%
78%
9%
55%
45%
26%
12%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Paffrath et al, Injury 2014, 45S: S64-S69
Berlin
definition
Isolated
trauma
Severely
injured
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
5 Hospitals
Working Group „Polytrauma“ No Networks 1993
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
657 participating hospitals 52 certified networks 2016
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
2005
Participation in the registries of DGU
is obligatory.
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
2012
The TraumaRegister DGU® is the basis for
quality assessment in trauma care.
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Trauma Networks in Germany
• Managed by Trauma Society / AUC GmbH
• Audit in each hospital (re-audit every 3 years)
• Three levels of care defined: local / regional / supra-regional trauma center
• Network contract of cooperation
• Regular meetings
• Registry participation obligatory
• Costs: 5000€ /audit; 650€ /year for registry
Ruchholtz et al. “TraumaNetzwerk DGU®: Optimizing patient flow
and management“ Injury 2014, 45 (Suppl. 3) S89-S92
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
14.04.2010: Zertifikatsübergabe für die TraumaNetzwerke
Südhessen, Mittelhessen und Osthessen in Wiesbaden
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Number of Trauma Patients
Is there a general incease / decrease?
How many patients should be treated in a local
/ regional / supra-regional trauma center?
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Three different approaches:
1. Hospital method
2. State method
3. Network method
TraumaRegister DGU® / AKUT
Year 2012: 450 hospitals
17 certified netwerks
ISS ≥ 16
Debus et al,
Ärzteblatt Int. 2015, 112: 823–9
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
1. Hospital method
Patientes with ISS≥16 in …
Supra-regional Trauma Centers
85 /year
Regional Trauma Centers
25 /year
Local Trauma Centers
3,5 /year
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Hospital
method
State
method
Netzwork
method
No. of patients with
ISS 16+ 16.558 16.514 16.554
Estimated under-
reporting (10%) 18.214 18.165 18.209
Number of Trauma Patients
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Trends in Trauma Networks
• Is there a shift from smaller to larger hospitals?
• Improved infrastructure?
• Adequate sample size per center?
• Is there a difference in outcome?
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Trends in Trauma Networks
• Is there a shift from smaller to larger hospitals?
Partially, from level 3 to level 1/2
• Improved infrastructure?
Level 3 hospitals improved most
• Adequate sample size per center?
None / 20 / 40 (ISS 16+)
• Is there a difference in outcome?
Maybe
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Trauma Patients and Level of Care 2013-15
29588
53571
9412Level 3 (local)
Level 2 (regional)
Level 1 (supra-regional)
32% 58%
10%
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Zacher et al.,
Br. J. Surg. 2015,
102: 1213-1219
Number of
Patients and
Outcome
ISS 16+
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Ruchholtz et al. J. Trauma,
2014; 76: 1456-61
Level of Care
and Outcome
Patients:
- Year 2012
- Germany
- Certified trauma center
- ICU treatment (or death)
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Letalität – Prognose im Zeitverlauf
RISC: n = 1.206
RISC II:
n = 30.866
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU® RISC II - Second draft
Variable Value Coefficient
Sex female + 0,2 male / ??? 0
ASA 1-2 + 0,3 pre-trauma 3 / ??? 0 4 - 1,3
Mechanism blunt / ??? 0 penetrating - 0,6
GCS motor normal + 0,6 function directed / ??? 0 non-directed - 0,4 none - 0,8
Systolic BP < 90 - 0,7 on admission 90-110 / ??? 0 111-150 + 0,3 > 150 0
CPR nein / ??? 0 ja - 1,8
Coagulation: < 1,2 + 0,6 INR 1,2 - 1,4 + 0,2 1,4 - 2,4 / ??? 0 > 2,4 - 0,4
Blood: 12,0 + 0,4 Hemoglobin 7,0-11,9 / ??? 0 <7,0 - 0,5
Acidosis: < 6 +0,3 Base deficit 6-9 / ??? 0 9-15 - 0,4 15+ - 1,5
Variable Value Coefficient
Constant + 3,6
Worst AIS 3 - 0,5 injury AIS 4 - 1,3 AIS 5 - 1,7 AIS 6 - 2,9
Second AIS 0-2 + 0,2 worst AIS 3 0 injury AIS 4 - 0,6 AIS 5 - 1,4
Head AIS 0-2 0 injury AIS 3/4 - 0,2 AIS 5/6 - 0,8
Age 1-5 + 1,4 6-10 + 0,6 11-54 0 55-59 - 0,5 60-64 - 0,8 65-69 - 0,9 70-74 - 1,2 75-79 - 1,9 80-84 - 2,4 85+ - 2,7
Pupil brisk + 0,2 reactivity sluggish/??? 0 fixed - 1,0
Pupil normal + 0,2 size anisocoric/??? 0 bilat. dilated - 0,5
RISC II
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Level of Care and Outcome
Annual Report 2016
Years 2013-15 combined
TraumaRegister DGU; Annual Report 2016
available at: www.auc-online.de
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Trends in Trauma Care
• Age
• Whole-body CT
• Intubation
• Volume
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
0%
10%
20%
30%
40%
50%
30
35
40
45
50
55
1993-99
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Pa
tie
nts
ag
ed
60
or
old
er
(%)
Me
an
ag
e (
ye
ars
)
mean age
60 years or older (%)
Age
TraumaRegister DGU® 1993-2012; Germany; ISS 16+; n=49,801
Lefering et al., Injury 2014
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Whole-Body CT
• There is a survival benefit for WB-CT Huber-Wagner, Lancet 2009
• Even patients in shock
benefit from WB-CT Huber-Wagner, PLOS one 2013
• Location near the
emergency room Huber-Wagner, Injury 2014
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Whole-body CT
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
CT
WB-CT
x-ray thorax
TraumaRegister DGU®; Germany 2000-2013; primary admitted;
ISS 9+ and intensive care; n=81.210
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Preclinical Volume & Intubation
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1993-99
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Pre
-ho
sp
ital
inte
rven
tio
n p
erf
orm
ed
(%
)
Intubation with GCS 9-15
Intubation with GCS 3-8
Volume > 1000 ml
TraumaRegister DGU® 1993-2012; Germany; ISS 16+; n=49,801
Lefering et al., Injury 2014
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Coagulation status on hospital admission Thromboplastin Time (Quick‘s value)
73,6 73,374,3
75,9
77,5 77,877,3
76,2
78,4
79,9
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Mean
vo
lum
e (
ml)
66
68
70
72
74
76
78
80
82
preclinical volume
Quick (%)
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Coagulation status on hospital admission Hemoglobin
10,911,1 11,0
11,4 11,5 11,5 11,6 11,712,0
12,3
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Mean
vo
lum
e (
ml)
9
10
11
12
13
preclinical volume
Hemoglobin
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Blood Transfusion until ICU
0%
10%
20%
30%
40%
50%
60%
1993-99
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Pati
en
ts w
ith
tra
nsfu
sio
n (
%)
blood transfusion
massive transfusion
TraumaRegister DGU® 1993-2012; Germany; ISS 16+; n=49,801
Lefering et al., Injury 2014
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
Prehospital
Tranexamic
Acid
258 pairs matched
by propensity score (ADAC air rescue service)
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
• Successful implementation of nation-wide
networks in Germany
• Improved outcome but causal proof is difficult
(interaction of multiple effects)
• Trauma registration is mandatory
Summary
Institut für Forschung in der
Operativen Medizin (IFOM)
TraumaRegister DGU®
• Injury scoring & definitions
• Update of quality indicators
• Cross-border comparisons
• Primary admission versus transfer
• Quality of Life: Outcome beyond the
acute care
• Data quality
Future Tasks