In this Delphi study, a representative national expert panel achieved consensus on a set of guidelines describing the optimal process of care in the Netherlands for severely injured trauma patient.
According to the guidelines, the time interval between the call to the dispatch nurse until the moment that the patient leaves the trauma room of a level 1 trauma centre should not exceed 60 min. Critical actions in this time frame include the dispatch of an ambulance in conjunction with an MMT, ABCDE stabilisation, formulation of a provisional diagnosis, transportation to a level 1 trauma centre, complete trauma team presence at the ED when the patient arrives, and a complete trauma series of X-rays to confirm or adapt the provisional diagnosis. The Delphi panel indicated that the patient should be cared for by competent teams, as assessed by novel flow charts. Moreover, the perception of cooperation, communication and feedback within and between all team members should be judged as satisfactory.
An inherent limitation of our design is that studies based on expert opinion are low in the ranking of scientific evidence. The relation between the developed process guidelines and functional outcome or mortality should be established in later validation studies. This approach has been applied in the USA, where a national panel of trauma experts reached consensus on 28 criteria to evaluate prehospital trauma care . Subsequently, two of the proposed audit filters were validated, and only one of these filters was associated with increased mortality .
A second limitation is that consensus was based on a national study, reflecting the unique aspects of the Dutch setting (including densely populated cities and relatively short distances between hospitals). However, the Dutch trauma system operates according to international standards and many core results might be transferred to trauma systems working with similar processes in a similar structure. Furthermore, some of the guidelines may be generically applicable, as the anatomic and physiological damage resulting from injuries are similar worldwide. However, to assess which of the guidelines may be generalisable to all trauma systems, an international expert panel study is recommended.
A third limitation of our study is that the response rates dropped from 87% in the first round to 48% in the final 5th round; however, the sensitivity analysis did not reveal any selective withdrawal by occupation or by setting. Moreover, the 61 respondents that filled out all 5 questionnaires did not answer questions differently from the 66 respondents that filled out questionnaires 1 to 4 only. This implies that response bias is minimal and that the results of this study can be interpreted as a national consensus among all professions involved in Dutch regional trauma care.
Although national consensus was reached, more research is needed to elucidate the possible connection between time intervals and outcome in the trauma patient. Some authors reported that mortality increased with increasing time spent out of hospital [27, 28] whereas others did not find this association [10, 29–31]. Authors that studied timeliness in the ED setting could not establish a relation with outcome [10, 32]. Our Delphi panel stated that critical limits for the time spent on scene are only relevant for patients in whom a ‘scoop and run’ strategy is applied as this is the subgroup of trauma patients where time is expected to be most crucial; these subgroups include patients with traumatic brain injury and penetrating injuries. Studies on prehospital time intervals in these subgroups could not establish a relation with outcome [22–24].
Although our Delphi study identified many ‘action filters’ that are already addressed in the ACSCOT and ATLS, we also found a filter not yet mentioned in the literature, i.e. formulating a provisional diagnosis in the prehospital setting.
Two of the action guidelines as proposed by our panel are related to the organisation of trauma care: dispatch of an ambulance in conjunction with an MMT and transport to a level 1 trauma centre. Dispatch of an MMT in addition to an ambulance brings a physician to the scene. It is reported that mortality decreases when patients are treated on scene by a physician in conjunction with a nurse [33, 34]. Transportation of a severely injured trauma patient to a level 1 trauma centre is in line with the current international standards [9, 32, 35, 36]. In contrast, the establishment of a provisional diagnosis is, as far as we know, never mentioned and/or investigated as a relevant aspect of trauma care. The expert panel agreed on the establishment of a provisional diagnosis as a guideline for quality of trauma care for the prehospital setting and the ED setting. Further research is needed to evaluate the possible value of the provisional diagnosis as a process guideline.
Available evidence on the education and experience of a prehospital or ED team is scarce and inconclusive. Some found a contribution of the surgeon’s experience on outcome of the trauma patient [37, 38], whereas others found no effect [39–41]. Available studies were unable to show any effect of trauma courses on the outcome of severe trauma patients [15, 16]. No studies were found that combined the competencies of several team members. Future studies should establish whether being treated by competent teams, as assessed with our novel flow charts, offers an advantage in terms of survival and/or functional outcome in the severe trauma patient.
Our panel defined one interdisciplinary process guideline which lies on largely unexplored terrain; its validity in trauma care practice has yet to be established. However, the interdisciplinary process guideline is in accordance with current international standards on medical specialty training that place emphasis on cooperation and communication skills .
The results of this study can be seen as a new field standard for quality in trauma care in the Netherlands. The standards are based on a national consensus among all professionals involved in regional trauma care; this should facilitate the acceptance of the guidelines by all stakeholders. Additional steps are required before the set of guidelines can be validated and implemented. First, a thorough analysis of the availability and reliability of the data needed to assess the guidelines is required in order to monitor and improve the performance of a trauma system. Future research needs to determine whether adherence to specific guidelines (or the set as a whole) is associated with improved survival and/or functional outcome of the severe trauma patient.