Are pre-hospital time and emergency department disposition time useful process indicators for trauma care in Italy?

Di Bartolomeo, Stefano; Valent, Francesca; Rosolen, Valentina; Sanson, Gianfranco; Nardi, Giuseppe; Cancellieri, Francesco; Barbone, Fabio

doi:10.1016/j.injury.2006.10.005

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Volume 38, Issue 3 , Pages 305-311, March 2007

Are pre-hospital time and emergency department disposition time useful process indicators for trauma care in Italy?

Stefano Di Bartolomeo
- Unit of Hygiene and Epidemiology, DPMSC-School of Medicine, University of Udine, Via Colugna, 40-33100 Udine, Italy
- Corresponding author. Tel.: +39 0432 547241; fax: +39 0432 478349.
Francesca Valent
- Unit of Hygiene and Epidemiology, DPMSC-School of Medicine, University of Udine, Via Colugna, 40-33100 Udine, Italy
Valentina Rosolen
- Unit of Hygiene and Epidemiology, DPMSC-School of Medicine, University of Udine, Via Colugna, 40-33100 Udine, Italy
Gianfranco Sanson
- Accident & Emergency Department, United Hospitals, Trieste, Italy
Giuseppe Nardi
- Shock & Trauma Unit, S. Camillo-Forlanini Hospital, Roma, Italy
Francesco Cancellieri
- Intensive Care Unit & Emergency Services, ‘Ospedale Maggiore’ Hospital, Bologna, Italy
Fabio Barbone
- Unit of Hygiene and Epidemiology, DPMSC-School of Medicine, University of Udine, Via Colugna, 40-33100 Udine, Italy

Accepted 17 October 2006.

Summary

Background

It is recommended that process indicators (PI) for trauma-care be validated in the setting where they are applied for quality assurance (QA) and quality improvement (QI). In a pilot attempt at trauma QA and QI, we evaluated pre-hospital time (PT) and emergency department disposition time (EDt) as possible PIs in three Italian trauma-referral hospitals.

Methods

We used registry data on all the 753 major (ISS>15) trauma cases admitted to the participating hospitals between the 1 July 2004 and the 31 June 2005. The distribution of PT and EDt in the hospitals was investigated together with the performances of the hospitals. The performances were evaluated in terms of patient outcome with multivariate regression models. Outcome measures were trauma death, Euroqol 5-D (EQ5D), and Glasgow Outcome Score (GOS). The possible PIs were then evaluated as independent predictors of outcome.

Results

In the hospital with the best outcome-measures (Hospital A) PT and EDt were also the shortest. The differences in PT and EDt were significant (p<0.05) versus Hospital B and Hospital C, respectively. However, at the patient level, longer PT and EDt were not independently associated with bad outcome. Neither a threshold could be found that indicated higher risks of bad outcome. EDt>120min was paradoxically associated with lower mortality.

Conclusion

Although PT and EDt were significantly shorter in the hospital with best outcome performances, we could not confirm at the patient level their expected independent association with outcome. More evidence is needed before these indicators can be validated as standard tools for system analysis in our setting.

Keywords: Wounds and injuries, Quality assurance (health care), Quality indicators (health care), Trauma centers, Time factors, Outcome assessment (health care), Process assessment (health care), Emergency medical services, Trauma severity indices, Registries