Injury, Int. J. Care Injured 45S (2014) S89–S92
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
TraumaNetzwerk DGU1: Optimizing patient flow and management Steffen Ruchholtz a,*, Ulrike Lewan a, Florian Debus a, Carsten Mand a, Hartmut Siebert b, Christian A. Ku¨hne a a b
Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg GmbH, Marburg, Germany German Trauma Society, Berlin, Germany
A R T I C L E I N F O
A B S T R A C T
Keywords: Quality of trauma care Trauma network Whitebook Trauma centres
Purpose: Caring for severely injured trauma patients is challenging for all medical professionals involved both in the preclinical and in the clinical course of treatment. While the overall quality of care in Germany is high there still are significant regional differences remaining. Reasons are geographical and infrastructural differences as well as variations in personnel and equipment of the hospitals. Methods: To improve state-wide trauma care the German Trauma Society (DGU) initiated the TraumaNetzwerk DGU1 (TNW) project. The TNW is based on five major components: (a) Whitebook for the treatment of severely injured patients; (b) evidence-based guidelines for the medical care of severe injury; (c) local auditing of participating hospitals; (d) contract of interhospital cooperation; (d) TraumaRegister DGU1 documentation. Results: By the end of 2013, 644 German Trauma Centres (TC) had successfully passed the audit. To that date 44 regional TNWs with a mean of 13.5 TCs had been established and certified. The TNWs cover approximately 90% of the country’s surface. Of those hospitals, 2.3 were acknowledged as Supraregional TC, 5.4 as Regional TC and 6.7 as Lokal TC. Moreover, cross border TNW in cooperation with hospitals in The Netherlands, Luxembourg, Switzerland and Austria have been established. Preparing for the audit 66% of the hospitals implemented organizational changes (e.g. TraumaRegister DGU1 documentation and interdisciplinary guidelines), while 60% introduced personnel and 21% structural (e.g. X-ray in the ER) changes. Conclusions: The TraumaNetzwerk DGU1 project combines the control of common defined standards of care for all participating hospitals (top down) and the possibility of integrating regional cooperation by forming a regional TNW (bottom up). Based on the joint approach of healthcare professionals, it is possible to structure and influence the care of severely injured patients within a nationwide trauma system. ß 2014 Elsevier Ltd. All rights reserved.
Trauma care in Germany Every year 7–8 million accidents occur in the Federal Republic of Germany [1]. Current assessments expect 33,000–38,000 severely injured patients (ISS 16) per year [2,3]. Moreover, a similar number of patients suffer from less severe trauma (ISS < 16) but still require treatment in the Emergency Room (ER) due to the preceding injury mechanism or a temporary impairment of the vital signs. Thanks to the well-organized rescue system and the commitment of all participating medical dis-
* Corresponding author at: Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043 Marburg, Germany. Tel.: +49 6421 5866216. E-mail address: [email protected] (S. Ruchholtz). http://dx.doi.org/10.1016/j.injury.2014.08.024 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
ciplines the reputation of trauma care in Germany is excellent. Nonetheless, controversies discussing individual cases as well as a number of scientific studies indicate that the quality of trauma care is comparatively heterogeneous in our country [3–8]. According to the data of the Federal Bureau of Statistics the rate of mortal traffic injuries varies widely between the federal states of Germany. Mortality after traffic accident in states such as Mecklenburg-Western Pomerania for example amounts to 2.7%, more than double the rate of North Rhine-Westphalia (1.1%). In city – states like Berlin, it is only 0.5% [26]. Data from TraumaRegister DGU1 demonstrate significant differences between the participating hospitals [6,7] as well. There are two main reasons leading to the cited quality variations. Firstly, there are geographic and infrastructural differences between the federal states and secondly, treatment concepts, organization and equipment in the participating hospitals differ.
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Analysing care areas per hospital there is a great range when comparing the federal states. A hospital in Mecklenburg-Western Pomerania is responsible for an area of 4634 km2, an area about nine times larger than the care areas in North Rhine-Westphalia (541 km2). Air rescue systems and highway coverage per state also differ substantially [3]. A survey conducted in 51 hospitals participating in TraumaRegister DGU1 in 2004 revealed that 14% of the hospitals lacked radiographic and 23% sonographic diagnostics in the ER [9]. Differences in the treatment of severely injured patients can amount to significant outcome variations. Biewener et al. [5] conducted a study analyzing the quality of trauma care in relation to the level of the designated hospital. A significant increase in mortality after severe trauma (41% vs. 16% at comparable injury severity) resulted for patients treated in community hospitals. In university trauma centres also treatment quality variations resulting in altered mortality after severe trauma may be detected both in internal quality management systems and in external controls [7,8]. In order to develop a nationwide, long-lasting, optimum system of care for severe trauma the TraumaNetzwerk DGU1 project of the German Trauma Society was initiated in 2006. TraumaNetzwerk DGUW Background The outcome of severely injured patients closely correlates with the quality of the trauma system. An immediate transport to a hospital with adequate treatment competence is of paramount significance. Studies on the quality of clinical care for severe trauma from the final decades of the 20th century have indicated that the implementation of regionalized trauma centres has reduced the rate of preventable deaths in the treatment of severe injuries by 50% in the USA [10–15]. Mortality after severe trauma decreased by 15–20% [13,16–19]. Obviously the risk of death has been diminished by 25% in a system transporting the patient to a trauma centre [20]. In Germany a trauma system exclusively based on maximum level trauma centres was discussed at the beginning. The approximately 100 pre-existing hospitals with the highest level of care would then have to treat 300–400 patients per year to cover the treatment of 35,000 severely injured patients. The following reasons speak clearly against this conception: a) High level care hospitals are not distributed homogenously in the territory. Ground transportation of severely injured patients would cost important losses of time in the sparsely populated regions. b) Due to legal and economical reasons air transportation by helicopter is permitted only during daytime in Germany. c) Calculating that the intensive care time of a severely injured patient averages 11 days (annual report of TraumaRegister DGU1 2012; 6) the care for 300 patients per year would require 9–10 intensive care places per institution. The provision of such a high number of ICU places is not possible for many maximum care hospitals due to economical and organizational reasons.
In order to address these problems a conception of certified hospitals with different levels of care working together on a regional trauma network was recognized. The project TraumaNetzwerk DGU1 (TNW) was developed by medical professionals (trauma surgeons) under the patronage of the German Trauma Society. The project was established in 2006 and was based mainly on the following five elements.
1. Whitebook – Medical Care of the Severely Injured [21,22]: Herein, the standards for the structure and organization of trauma centres and their interaction within regional inter-hospital networks are described. The first version of the Whitebook was published in 2006, after review and agreement among the medical societies involved in the treatment of severely injured patients (e.g., trauma surgery, anesthesiology, neurosurgery, etc.). In 2012, the Whitebook was revised regarding the evidence-based Guidelines for the Treatment of the Severely Injured (see below) and the experience gained during the process of establishing the TNW. 2. Evidence-based Guidelines for the Treatment of the Severely Injured [23]: Herein, recommendations for the prehospital and clinical treatment of the severely injured are provided. The guidelines, published in 2011, are evidence-based, and they were developed in cooperation with the medical societies involved in the treatment of severely injured patients. 3. Audit: For TNW trauma centres, compliance with the Whitebook personnel and structure requirements is assessed via local visits performed by specially trained auditors. According to the audit results, hospitals are classified as supra-regional (STC), regional (RTC) or local (LTC) trauma centres. STCs represent the highest level of treatment and are generally located in university or major city hospitals, where all of the medical disciplines are available. In most cases, RTCs are situated in urban hospitals. The availability of acute neurosurgical care is an important determinant for this category, in contrast to the LTC. LTCs are smaller urban or rural hospitals that provide all of the prerequisites for the acute stabilization of a bleeding patient. The audit is repeated every 3 years. The certification of the TCs and the regional TNW is performed by an independent company (DIOcert GmbH; Mainz, Germany). 4. Contract of cooperation: The TCs in a region organize a regional TraumaNetzwerk (TNW) with a minimum of five audited TCs, including one STC. To achieve optimal treatment in a defined region, the trauma centres work together based on a contract of cooperation, which consists of rules for the admission and transfer of trauma patients, biannual quality circle meetings and annual educational meetings. 5. TraumaRegister DGU1: Documentation of all of the relevant data in TraumaRegister DGU1 is mandatory for every injured patient who is admitted to hospital via emergency room with subsequent ICU/ICM care or reach the hospital with vital signs and die before admission to ICU. Comprehensive pre-hospital, emergency room and ICU treatment data are continuously entered into a central TraumaRegister DGU1 server via a Web-based portal.
Cooperation in a TNW A maximum of 30 min transportation time from scene of accident to TC admission is the goal to work for in the regional TNW. The severely injured patient should be transferred directly to a regional or supraregional TC. If transportation time exceeds 30 min the patient should be admitted to a local TC. The TNW coordination and cooperation is based on a contract between the TCs regarding all relevant procedures in a regional TNW. The cooperative initiative and maintenance of regional TNW corresponds to the spokesman of a supraregional trauma centre. The common goals of a regional TNW are 1. Quality optimization in the treatment of severe injury by better communication, consented standards in care and qualityoriented cooperation. 2. Increasing efficiency by use of existing resources and cooperation of hospitals.
S. Ruchholtz et al. / Injury, Int. J. Care Injured 45S (2014) S89–S92
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Table 1 Measures established by the hospitals to pass successfully the audit (evaluation after 435 audits). Organizational changes
Personnel changes 1
Documentation in the TraumaRegister DGU Establishment of a quality circle Written Interdisciplinary Guidelines Structured Communication with the Rescue System Trauma phone Trauma room merge call
66% 60% 55% 53% 45% 34%
Structural changes
ATLS-education Interhospital Neuro-trauma Cooperation On Call Trauma Specialist Service
3. Regulation of the financial aspects of interhospital transfers in accordance to the German Diagnosis Related Group system. 4. Cooperation in a joint system of continuing education. Characteristic elements of TNWs are: 1. Defined admission criteria from the scene to a trauma centre according to the evidence based S-3 guidelines for the treatment of severely injured of the German Trauma Society. 2. Standardized personnel, structural and organizational requirements (i.e. equipment of the ER) according to the Whitebook. 3. Consented treatment procedures and transfer criteria in the early care phase according to the S-3 guidelines [23]. 4. Professional medical qualification via mandatory attendance of special educational programmes (i.e. ATLS1; [24,25]; www.atls.de). 5. Participation in internal and external quality assurance programmes (e.g. intrahospital quality circle) and documentation of all severely injured patients in TraumaRegister DGU1 of the German Trauma Society (www.TraumaRegister.de). 6. Prehospital and interhospital telecommunication systems for the rescue teams and hospitals.
61% 30% 17%
Emergency Surgery Tray Teleradiological cooperation Ultrasound in the Trauma Room Warm touch Blood storage X-Ray in the trauma room New CT-scan in the ED department
26% 18% 16% 16% 10% 10% 6%
important structural changes like the implementation of special trays for emergency operations (26%) or ultrasound (16%) in the ER. According to the Whitebook of the DGU all physicians in the ER need to have passed the Advanced Trauma Life Support (ATLS) course or similar qualification. The first audit required at least one ED physician with the relevant qualification. In 2013, 1558 physicians received ATLS training. Certified TNWs By December 2013 a total of 44 TraumaNetworks have been completely certified (Fig. 1). 588 of the originally registered hospitals received the certification as a trauma centre in one of the three levels. 29.8% of the originally registering hospitals stopped the process of certification mainly because they were not able to comply with the criteria of the Whitebook.
Quality management The quality of trauma care is continuously documented in TraumaRegister DGU1. TraumaRegister DGU1 offers an online quality report for the TC and the TNW that can be downloaded at any time. These data are analyzed and discussed two times per year at the meetings of the TNW quality circle that is composed by responsible physicians of the participating TCs and leading personnel of the rescue services TNW. The current status Audits By December 2013, 644 hospitals have passed the audit. After a successful visitation the changes that were introduced by the hospital to pass the audit are documented [26]. Analysing the measures taken in 435 hospitals preparing for the certification process it became clear that many relevant reforms concerned changes in organization, personnel and structure (Table 1). There were many organizational changes such as the establishment of written multidisciplinary clinical guidelines, in 55% not existing before. In 45% of the hospitals an emergency telephone answered 24/365 by a physician authorized to take the necessary decisions was installed for the rescue services or the other TCs. Also important changes in personal training (ATLS; 61%) or specialist support (i.e. neurosurgical background for regional TC 30%) were documented. Furthermore, the hospitals initiated
Fig. 1. 44 Regional TNWs in Germany (December 2013). Supra-regional TCs = red dots; Regional TCs = blue dots; Local TCs = green dots; Audited TCs waiting for integration in a regional TNW = yellow dots. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
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A typical TNW at the moment consists of 13.9 (5–29) hospitals with 2.3 (0–6) supraregional, 5.4 (1–9) regional and 6.7 (2–14) community trauma centres. International cooperation Based on pre-existing cooperations a number of TNWs transgressing the German frontiers has been established. The foreign hospitals in The Netherlands, Luxembourg, Switzerland and Austria have allowed auditing according to the criteria in the Whitebook of the DGU. Furthermore, the Rashid Trauma Centre in Dubai was audited and certified as supraregional TZ in 2011. Conclusion The TNW project combines the control of common standards of care for all participating hospitals (top down) and the integration of local competence and cooperation by forming a regional TNW (bottom up). STCs represent the core of the TNWs, providing excellent care for severely injured patients. Smaller hospitals (LTCs) can be integrated to cover sparely populated areas. They can provide an average level of care if they fulfil the basic criteria for the treatment of severely injured patients and are integrated into a regional TNW. Through this joint approach of all participating health care professionals and organizations in TraumaNetzwerk DGU1, it is possible to implement successfully a nationwide trauma system that positively influences the quality of trauma care. Conflict of interest There are no competing interests in relation to this study from following authors: Ulrike Lewan, Florian Debus, Carsten Mand, Hartmut Siebert, Christian A. Ku¨hne, Steffen Ruchholtz are the speakers of the Working Group on the Implementation of the TraumaNetwork of the German Society for the Surgery of Trauma but did not receive any compensation for the preparation of this work. Acknowledgments The TraumaNetzwerk DGU1 is managed by the AKUT Steering Committee. In addition to the authors of this manuscript (C. Ku¨hne, S. Ruchholtz, H. Siebert), Prof. Dr. Johannes Sturm (Mu¨nster) and Annette Pries (Mainz) were also members of the steering committee. References [1] Statistisches Bundesamt; 2010, Internet: http://www.destatis.de/. [2] Haas NP, von Fournier C, Tempka A, Sudkamp NP. Trauma center 2000. How many and which trauma centers does Europe need around the year 2000? Unfallchirurg 1997;100:852–8. [3] Ku¨hne CA, Ruchholtz S, Buschmann C, Sturm J, Lackner CK, Wentzensen A, et al. Status report. Unfallchirurg 2006;109:357–66.
[4] Liener UC, Rapp U, Lampl L, Helm M, Richter G, Gaus M, et al. Incidence of severe injuries. Results of a population-based analysis. Unfallchirurg 2004;107:483–90. [5] Biewener A, Aschenbrenner U, Rammelt S, Grass R, Zwipp H. Impact of helicopter transport and hospital level on mortality of polytrauma patients. J Trauma 2004;56:94–8. [6] Lefering R, AG Polytrauma der DGU (2012) Jahresbericht fu¨r das Jahr 2010. to purchase from Dr. Thomas Paffrath, Lehrstuhl fu¨r Unfallchirurgie/Orthopa¨die Universita¨t Witten-Herdecke Klinikum Ko¨ln-Merheim Ostmerheimer Str. 200 51109 Cologne, Germany. [7] Ruchholtz S. AG-polytrauma. The Trauma Registry of the German Society of Trauma Surgery as a basis for interclinical quality management. A multicenter study of the German Society of Trauma Surgery. Unfallchirurg 2000;103:30–7. [8] Ruchholtz S, Waydhas C, Lewan U, Piepenbrink K, Stolke D, Debatin J, et al. A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers. Intensive Care Med 2002;28:1395–404. [9] Beck A, Bischoff M, Gebhard F, Huber-Lang M, Kinzl L, Schmelz A. Diagnostic apparatus in the shock trauma room. Unfallchirurg 2004;107(10):862–70. [10] Cales RH, Ehrlich F, Sacra J, Cross Jr R, Ervin ME. Trauma care system guidelines: improving quality through the systems approach. Ann Emerg Med 1987;16:464. [11] Shackford SR, Hollingworth-Fridlund P, Cooper GF, Eastman AB. The effect of regionalization upon the quality of trauma care as assessed by concurrent audit before and after institution of a trauma system: a preliminary report. J Trauma 1986;26:812–20. [12] Shackford SR, Hollingsworth-Fridlund P, McArdle M, Eastman AB. Assuring quality in a trauma system – the Medical Audit Committee: composition, cost, and results. J Trauma 1987;27:866–75. [13] Zulick LC, Dietz PA, Brooks K. Trauma experience of a rural hospital. Arch Surg 1991;26:14–9. [14] Champion HR, Sacco WJ, Copes WS. Improvement in outcome from trauma center care. Arch Surg 1992;127:333–8. [15] Mullins RJ, Mann NC. Population-based research assessing the effectiveness of trauma systems. J Trauma 1999;47:59–66. [16] West JG, Cales RH, Gazzaniga AB. Impact of regionalization. The Orange County experience. Arch Surg 1983;118:740–4. [17] Shackford SR, Mackersie RC, Hoyt DB, Baxt WG, Eastman AB, Hammill FN, et al. Impact of a trauma system on outcome of severely injured patients. Arch Surg 1987;122:523–7. [18] Kane G, Wheeler NC, Cook S, Englehardt R, Pavey B, Green K, et al. Impact of the Los Angeles County trauma system on the survival of seriously injured patients. J Trauma 1992;2:576–83. [19] Hulka F, Mullins RJ, Mann NC, Hedges JR, Rowland D, Worrall WH, et al. Influence of a statewide trauma system on pediatric hospitalization and outcome. J Trauma 1997;2:514–9. [20] Mackenzie EJ, Rivara FP. A national evaluation of the effect of trauma center care on mortality. N Eng J Med 2006;354:4. [21] The German Society for Trauma Surgery (Deutsche Gesellschaft fu¨r Unfallchirurgie) Whitebook ´ Medical Care of the Severely Injured´ Available at www.dgu-online.de. Berlin: Langenbeck-Virchow-Haus Luisenstraße 58/59, 10117; 2006. [22] The German Society for Trauma Surgery (Deutsche Gesellschaft fu¨r Unfallchirurgie) Whitebook ´ Medical Care of the Severely Injured´ 2. Revised and Updated Edition Available at www.dgu-online.de. Berlin: LangenbeckVirchow-Haus Luisenstraße 58/59, 10117; 2012. [23] The German Society for the Surgery of Trauma (Deutsche Gesellschaft fu¨r Unfallchirurgie). S3 Guidelines for the treatment of severely injured patients Available at www.dgu-online.de/http://www.awmf.org/. Berlin: LangenbeckVirchow-Haus Luisenstraße 58/59, 10117; 2011. [24] Bouillon B, Kanz KG, Lackner CK, Mutschler W, Sturm J. The importance of Advanced Trauma Life Support (ATLS) in the emergency room. Unfallchirurg 2004;107:844–50. [25] Sturm JA, Lackner CK, Bouillon B, Seekamp A, Mutschler WE. Advanced Trauma Life Support (ATLS). Unfallchirurg 2002;105:1027–32. [26] Mand C, Muller T, Ruchholtz S, Kunzel A, Kuhne CA. Organizational, personnel and structural alterations due to participation in TraumaNetwork DGU: the first stocktaking. Unfallchirurg 2012;115:417–26.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
TraumaNetzwerk DGU1: Optimizing patient flow and management Steffen Ruchholtz a,*, Ulrike Lewan a, Florian Debus a, Carsten Mand a, Hartmut Siebert b, Christian A. Ku¨hne a a b
Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg GmbH, Marburg, Germany German Trauma Society, Berlin, Germany
A R T I C L E I N F O
A B S T R A C T
Keywords: Quality of trauma care Trauma network Whitebook Trauma centres
Purpose: Caring for severely injured trauma patients is challenging for all medical professionals involved both in the preclinical and in the clinical course of treatment. While the overall quality of care in Germany is high there still are significant regional differences remaining. Reasons are geographical and infrastructural differences as well as variations in personnel and equipment of the hospitals. Methods: To improve state-wide trauma care the German Trauma Society (DGU) initiated the TraumaNetzwerk DGU1 (TNW) project. The TNW is based on five major components: (a) Whitebook for the treatment of severely injured patients; (b) evidence-based guidelines for the medical care of severe injury; (c) local auditing of participating hospitals; (d) contract of interhospital cooperation; (d) TraumaRegister DGU1 documentation. Results: By the end of 2013, 644 German Trauma Centres (TC) had successfully passed the audit. To that date 44 regional TNWs with a mean of 13.5 TCs had been established and certified. The TNWs cover approximately 90% of the country’s surface. Of those hospitals, 2.3 were acknowledged as Supraregional TC, 5.4 as Regional TC and 6.7 as Lokal TC. Moreover, cross border TNW in cooperation with hospitals in The Netherlands, Luxembourg, Switzerland and Austria have been established. Preparing for the audit 66% of the hospitals implemented organizational changes (e.g. TraumaRegister DGU1 documentation and interdisciplinary guidelines), while 60% introduced personnel and 21% structural (e.g. X-ray in the ER) changes. Conclusions: The TraumaNetzwerk DGU1 project combines the control of common defined standards of care for all participating hospitals (top down) and the possibility of integrating regional cooperation by forming a regional TNW (bottom up). Based on the joint approach of healthcare professionals, it is possible to structure and influence the care of severely injured patients within a nationwide trauma system. ß 2014 Elsevier Ltd. All rights reserved.
Trauma care in Germany Every year 7–8 million accidents occur in the Federal Republic of Germany [1]. Current assessments expect 33,000–38,000 severely injured patients (ISS 16) per year [2,3]. Moreover, a similar number of patients suffer from less severe trauma (ISS < 16) but still require treatment in the Emergency Room (ER) due to the preceding injury mechanism or a temporary impairment of the vital signs. Thanks to the well-organized rescue system and the commitment of all participating medical dis-
* Corresponding author at: Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043 Marburg, Germany. Tel.: +49 6421 5866216. E-mail address: [email protected] (S. Ruchholtz). http://dx.doi.org/10.1016/j.injury.2014.08.024 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
ciplines the reputation of trauma care in Germany is excellent. Nonetheless, controversies discussing individual cases as well as a number of scientific studies indicate that the quality of trauma care is comparatively heterogeneous in our country [3–8]. According to the data of the Federal Bureau of Statistics the rate of mortal traffic injuries varies widely between the federal states of Germany. Mortality after traffic accident in states such as Mecklenburg-Western Pomerania for example amounts to 2.7%, more than double the rate of North Rhine-Westphalia (1.1%). In city – states like Berlin, it is only 0.5% [26]. Data from TraumaRegister DGU1 demonstrate significant differences between the participating hospitals [6,7] as well. There are two main reasons leading to the cited quality variations. Firstly, there are geographic and infrastructural differences between the federal states and secondly, treatment concepts, organization and equipment in the participating hospitals differ.
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Analysing care areas per hospital there is a great range when comparing the federal states. A hospital in Mecklenburg-Western Pomerania is responsible for an area of 4634 km2, an area about nine times larger than the care areas in North Rhine-Westphalia (541 km2). Air rescue systems and highway coverage per state also differ substantially [3]. A survey conducted in 51 hospitals participating in TraumaRegister DGU1 in 2004 revealed that 14% of the hospitals lacked radiographic and 23% sonographic diagnostics in the ER [9]. Differences in the treatment of severely injured patients can amount to significant outcome variations. Biewener et al. [5] conducted a study analyzing the quality of trauma care in relation to the level of the designated hospital. A significant increase in mortality after severe trauma (41% vs. 16% at comparable injury severity) resulted for patients treated in community hospitals. In university trauma centres also treatment quality variations resulting in altered mortality after severe trauma may be detected both in internal quality management systems and in external controls [7,8]. In order to develop a nationwide, long-lasting, optimum system of care for severe trauma the TraumaNetzwerk DGU1 project of the German Trauma Society was initiated in 2006. TraumaNetzwerk DGUW Background The outcome of severely injured patients closely correlates with the quality of the trauma system. An immediate transport to a hospital with adequate treatment competence is of paramount significance. Studies on the quality of clinical care for severe trauma from the final decades of the 20th century have indicated that the implementation of regionalized trauma centres has reduced the rate of preventable deaths in the treatment of severe injuries by 50% in the USA [10–15]. Mortality after severe trauma decreased by 15–20% [13,16–19]. Obviously the risk of death has been diminished by 25% in a system transporting the patient to a trauma centre [20]. In Germany a trauma system exclusively based on maximum level trauma centres was discussed at the beginning. The approximately 100 pre-existing hospitals with the highest level of care would then have to treat 300–400 patients per year to cover the treatment of 35,000 severely injured patients. The following reasons speak clearly against this conception: a) High level care hospitals are not distributed homogenously in the territory. Ground transportation of severely injured patients would cost important losses of time in the sparsely populated regions. b) Due to legal and economical reasons air transportation by helicopter is permitted only during daytime in Germany. c) Calculating that the intensive care time of a severely injured patient averages 11 days (annual report of TraumaRegister DGU1 2012; 6) the care for 300 patients per year would require 9–10 intensive care places per institution. The provision of such a high number of ICU places is not possible for many maximum care hospitals due to economical and organizational reasons.
In order to address these problems a conception of certified hospitals with different levels of care working together on a regional trauma network was recognized. The project TraumaNetzwerk DGU1 (TNW) was developed by medical professionals (trauma surgeons) under the patronage of the German Trauma Society. The project was established in 2006 and was based mainly on the following five elements.
1. Whitebook – Medical Care of the Severely Injured [21,22]: Herein, the standards for the structure and organization of trauma centres and their interaction within regional inter-hospital networks are described. The first version of the Whitebook was published in 2006, after review and agreement among the medical societies involved in the treatment of severely injured patients (e.g., trauma surgery, anesthesiology, neurosurgery, etc.). In 2012, the Whitebook was revised regarding the evidence-based Guidelines for the Treatment of the Severely Injured (see below) and the experience gained during the process of establishing the TNW. 2. Evidence-based Guidelines for the Treatment of the Severely Injured [23]: Herein, recommendations for the prehospital and clinical treatment of the severely injured are provided. The guidelines, published in 2011, are evidence-based, and they were developed in cooperation with the medical societies involved in the treatment of severely injured patients. 3. Audit: For TNW trauma centres, compliance with the Whitebook personnel and structure requirements is assessed via local visits performed by specially trained auditors. According to the audit results, hospitals are classified as supra-regional (STC), regional (RTC) or local (LTC) trauma centres. STCs represent the highest level of treatment and are generally located in university or major city hospitals, where all of the medical disciplines are available. In most cases, RTCs are situated in urban hospitals. The availability of acute neurosurgical care is an important determinant for this category, in contrast to the LTC. LTCs are smaller urban or rural hospitals that provide all of the prerequisites for the acute stabilization of a bleeding patient. The audit is repeated every 3 years. The certification of the TCs and the regional TNW is performed by an independent company (DIOcert GmbH; Mainz, Germany). 4. Contract of cooperation: The TCs in a region organize a regional TraumaNetzwerk (TNW) with a minimum of five audited TCs, including one STC. To achieve optimal treatment in a defined region, the trauma centres work together based on a contract of cooperation, which consists of rules for the admission and transfer of trauma patients, biannual quality circle meetings and annual educational meetings. 5. TraumaRegister DGU1: Documentation of all of the relevant data in TraumaRegister DGU1 is mandatory for every injured patient who is admitted to hospital via emergency room with subsequent ICU/ICM care or reach the hospital with vital signs and die before admission to ICU. Comprehensive pre-hospital, emergency room and ICU treatment data are continuously entered into a central TraumaRegister DGU1 server via a Web-based portal.
Cooperation in a TNW A maximum of 30 min transportation time from scene of accident to TC admission is the goal to work for in the regional TNW. The severely injured patient should be transferred directly to a regional or supraregional TC. If transportation time exceeds 30 min the patient should be admitted to a local TC. The TNW coordination and cooperation is based on a contract between the TCs regarding all relevant procedures in a regional TNW. The cooperative initiative and maintenance of regional TNW corresponds to the spokesman of a supraregional trauma centre. The common goals of a regional TNW are 1. Quality optimization in the treatment of severe injury by better communication, consented standards in care and qualityoriented cooperation. 2. Increasing efficiency by use of existing resources and cooperation of hospitals.
S. Ruchholtz et al. / Injury, Int. J. Care Injured 45S (2014) S89–S92
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Table 1 Measures established by the hospitals to pass successfully the audit (evaluation after 435 audits). Organizational changes
Personnel changes 1
Documentation in the TraumaRegister DGU Establishment of a quality circle Written Interdisciplinary Guidelines Structured Communication with the Rescue System Trauma phone Trauma room merge call
66% 60% 55% 53% 45% 34%
Structural changes
ATLS-education Interhospital Neuro-trauma Cooperation On Call Trauma Specialist Service
3. Regulation of the financial aspects of interhospital transfers in accordance to the German Diagnosis Related Group system. 4. Cooperation in a joint system of continuing education. Characteristic elements of TNWs are: 1. Defined admission criteria from the scene to a trauma centre according to the evidence based S-3 guidelines for the treatment of severely injured of the German Trauma Society. 2. Standardized personnel, structural and organizational requirements (i.e. equipment of the ER) according to the Whitebook. 3. Consented treatment procedures and transfer criteria in the early care phase according to the S-3 guidelines [23]. 4. Professional medical qualification via mandatory attendance of special educational programmes (i.e. ATLS1; [24,25]; www.atls.de). 5. Participation in internal and external quality assurance programmes (e.g. intrahospital quality circle) and documentation of all severely injured patients in TraumaRegister DGU1 of the German Trauma Society (www.TraumaRegister.de). 6. Prehospital and interhospital telecommunication systems for the rescue teams and hospitals.
61% 30% 17%
Emergency Surgery Tray Teleradiological cooperation Ultrasound in the Trauma Room Warm touch Blood storage X-Ray in the trauma room New CT-scan in the ED department
26% 18% 16% 16% 10% 10% 6%
important structural changes like the implementation of special trays for emergency operations (26%) or ultrasound (16%) in the ER. According to the Whitebook of the DGU all physicians in the ER need to have passed the Advanced Trauma Life Support (ATLS) course or similar qualification. The first audit required at least one ED physician with the relevant qualification. In 2013, 1558 physicians received ATLS training. Certified TNWs By December 2013 a total of 44 TraumaNetworks have been completely certified (Fig. 1). 588 of the originally registered hospitals received the certification as a trauma centre in one of the three levels. 29.8% of the originally registering hospitals stopped the process of certification mainly because they were not able to comply with the criteria of the Whitebook.
Quality management The quality of trauma care is continuously documented in TraumaRegister DGU1. TraumaRegister DGU1 offers an online quality report for the TC and the TNW that can be downloaded at any time. These data are analyzed and discussed two times per year at the meetings of the TNW quality circle that is composed by responsible physicians of the participating TCs and leading personnel of the rescue services TNW. The current status Audits By December 2013, 644 hospitals have passed the audit. After a successful visitation the changes that were introduced by the hospital to pass the audit are documented [26]. Analysing the measures taken in 435 hospitals preparing for the certification process it became clear that many relevant reforms concerned changes in organization, personnel and structure (Table 1). There were many organizational changes such as the establishment of written multidisciplinary clinical guidelines, in 55% not existing before. In 45% of the hospitals an emergency telephone answered 24/365 by a physician authorized to take the necessary decisions was installed for the rescue services or the other TCs. Also important changes in personal training (ATLS; 61%) or specialist support (i.e. neurosurgical background for regional TC 30%) were documented. Furthermore, the hospitals initiated
Fig. 1. 44 Regional TNWs in Germany (December 2013). Supra-regional TCs = red dots; Regional TCs = blue dots; Local TCs = green dots; Audited TCs waiting for integration in a regional TNW = yellow dots. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
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A typical TNW at the moment consists of 13.9 (5–29) hospitals with 2.3 (0–6) supraregional, 5.4 (1–9) regional and 6.7 (2–14) community trauma centres. International cooperation Based on pre-existing cooperations a number of TNWs transgressing the German frontiers has been established. The foreign hospitals in The Netherlands, Luxembourg, Switzerland and Austria have allowed auditing according to the criteria in the Whitebook of the DGU. Furthermore, the Rashid Trauma Centre in Dubai was audited and certified as supraregional TZ in 2011. Conclusion The TNW project combines the control of common standards of care for all participating hospitals (top down) and the integration of local competence and cooperation by forming a regional TNW (bottom up). STCs represent the core of the TNWs, providing excellent care for severely injured patients. Smaller hospitals (LTCs) can be integrated to cover sparely populated areas. They can provide an average level of care if they fulfil the basic criteria for the treatment of severely injured patients and are integrated into a regional TNW. Through this joint approach of all participating health care professionals and organizations in TraumaNetzwerk DGU1, it is possible to implement successfully a nationwide trauma system that positively influences the quality of trauma care. Conflict of interest There are no competing interests in relation to this study from following authors: Ulrike Lewan, Florian Debus, Carsten Mand, Hartmut Siebert, Christian A. Ku¨hne, Steffen Ruchholtz are the speakers of the Working Group on the Implementation of the TraumaNetwork of the German Society for the Surgery of Trauma but did not receive any compensation for the preparation of this work. Acknowledgments The TraumaNetzwerk DGU1 is managed by the AKUT Steering Committee. In addition to the authors of this manuscript (C. Ku¨hne, S. Ruchholtz, H. Siebert), Prof. Dr. Johannes Sturm (Mu¨nster) and Annette Pries (Mainz) were also members of the steering committee. References [1] Statistisches Bundesamt; 2010, Internet: http://www.destatis.de/. [2] Haas NP, von Fournier C, Tempka A, Sudkamp NP. Trauma center 2000. How many and which trauma centers does Europe need around the year 2000? Unfallchirurg 1997;100:852–8. [3] Ku¨hne CA, Ruchholtz S, Buschmann C, Sturm J, Lackner CK, Wentzensen A, et al. Status report. Unfallchirurg 2006;109:357–66.
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