Pre-hospital and in-hospital parameters and outcomes in patients with traumatic brain injury: A comparison between German and Australian trauma registries
Introduction
Traumatic brain injury (TBI) is the leading cause of death and disability in young people in Western industrialised society. TBI is also an increasing cause of death and disability in the elderly.10, 12, 13, 21
Several factors have been shown to substantially contribute to impaired outcomes after TBI, the most significant secondary insults being hypotension and hypoxia, resulting in higher morbidity and mortality.5, 13, 14, 16 Many of these secondary insults occur prior to the arrival of the patient in the hospital trauma bay during the pre-hospital phase of care in which patients are managed by emergency medical service (EMS) systems.20 Comparisons of EMS systems around the world show great differences with regard to qualification of staff, management, logistics and infrastructure.8, 13, 18, 22
Roudsari et al.19 provided insights into the international variability in patient mix, processes of care, and performance of different pre-hospital trauma care systems worldwide; however, the analysis was not TBI-specific. Germany's EMS is an example of a system where physician-operated advanced life support (DOC-ALS) EMS run the majority of pre-hospital acute trauma care and are utilised more frequently as compared to other developed countries.18, 24 In contrast, in Anglo-American emergency medical systems such as Australia, an alternative EMS has developed in which highly trained paramedics are deployed on road and air for acute trauma care at the scene and for transport. Within this system, emergency physicians rarely leave the hospital for patient care at the scene and if so, only on very special occasion or upon specific request.
The Brain Trauma Foundation (BTF) issued specific guidelines for the pre-hospital management of TBI patients in 1996 with an up-date in 2000,2 but did not suggest a one system preference as there is no class I evidence. Furthermore, the frequency of secondary insults and clinical outcomes from these different systems for TBI patients is still unclear.
The availability of two large population-based trauma registries, from Germany (Trauma Registry of the German Society of Trauma Surgery/TR-DGU) and the Australian State of Victoria (Victorian State Trauma Registry/VSTR) enabled a comparison between EMS models to be undertaken with respect to patients with TBI. The aim of the present investigation was to present and characterise: (i) patient profile, (ii) pre-hospital management, and (iii) outcomes of patients with a principal diagnosis of TBI that were cared for by two different EMS systems.
The Human Research Ethics Committees of all participating institutions and Monash University granted ethics approval for VSTR. The TR-DGU is approved by the review board of the German Society of Trauma Surgery (DGU) and is in compliance with all institutional and ethical requirements.
Section snippets
Setting
The Australian state of Victoria has a population of 5.3 million, a large urban population of 3.7 million people in Melbourne and is serviced by three Melbourne-based major trauma centres (2 adult, 1 paediatric). Germany has a population of 82.2 million, with several major trauma centres concentrated mainly in the larger cities. Both populations use transport by helicopter frequently.
Study design
A comparative review of prospectively collected data (2002–2007) from (1) the Victorian State Trauma Registry
Profile of cases
Overall, 10,183 trauma cases were reviewed as part of this study. Of these, 5665 (55.6%) were recorded by the TR-DGU and 4518 (44.4%) by the Australian VSTR registry. The patient profile is provided in Table 1.
The distribution of gender was similar between German and Australian cohorts. There were more 16–34 years old and over 65 years in the VSTR and less people aged 35–64 years. However, there was no statistically significant difference in median age (z = −1.9, p = 0.057). The registries differed
Discussion
This study is the first intercontinental comparison of TBI patient characteristics and outcomes across countries with paramedic and physician based EMS systems. Roudsari et al.18, 19 showed great heterogeneity between EMS systems and countries in multitrauma patients, but did not investigate patient subgroups, including patients with and without TBI. Tagliaferri et al.23 investigated the epidemiology of TBI in Europe, but did not examine pre-hospital observations and processes between
Conflicts of interest
Authors are unaware of any conflicts of interest. The Victorian State Trauma Registry is a Department of Human Services and Victorian Trauma Foundation funded and approved initiative. The Trauma Registry of the German Society of Trauma Surgery is an initiative of the German Society of Trauma Surgery – Polytrauma Section.
Acknowledgements
The authors wish to thank Edward Chow and Rolf Lefering for their assistance with extraction of the data from VSTR and TR-DGU. The authors also thank the VSTR and TR-DGU Steering Committees, participating health services and data collectors. An overview of contributing centres and hospitals that actively send data to the TR-DGU can be found on www.traumaregister.de. Information about the VSTR can be found on http://www.med.monash.edu.au/epidemiology/traumaepi/traumareg.html.
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These authors contributed equally to this work.