1. Trauma care importance
According to the experts’ perspective, owing to the significance of trauma care, function and evaluation of trauma care performance can be considered from two perspectives:
A. The involved Individuals’ being young and productive
Most traumatic accidents, such as car accidents and occupational accidents, show an increasing trend across the world. Most of the trauma-affected people are young. Indeed, they are at production and activity age. Trauma results in the death or disability of these young people. They may lose their life due to the lack of adequate information or no timely and appropriate interventions in the accident scene or in emergency centers. The secondary disabilities will be very costly as well. They actually will need expensive rehabilitation services in order to return to their normal life.
B. Effectiveness of trauma care
Experts believed that the interventions that can be considered as trauma care have been clearly defined. Trauma patients are patients with acceptable prognosis. This means that the more the patients are provided with care services, the higher the curing chance is. Providing timely cares improves therapy, makes it effective and decreases inpatient bed occupancy rate. Trauma patients are not chronic patients. Therefore, if their problems are managed accurately, they will be treated. On the other hand, most traumas are latent and need timely diagnosis and treatment because they may seriously damage other organs.
2. Trauma care indicators
According to the experts’ comments, indicators of different phases of trauma should be determined in order to identify and evaluate whether trauma care services are provided acceptably. Then, by comparing current procedures with relevant standards, judgments may be made on current trauma services. The experts have outlined the indicators of three areas: pre-hospital indicators, in-hospital indicators, and post-hospital indicators.
A. Pre-hospital indicators
Many interventions of pre-hospital phase are crucial and vital. Generally, at accident scenes and during the transportation of patients to hospital, there is little information about the status of patients, especially in developing countries where there is a weak documentation system. On the other hand, patients’ status at this stage can affect their next condition in hospital. The experts argued that there are always questions about the quality of services. The first questions are as follow: when did they contact the medical center? By what means was the patient taken to hospital? How long did it take to take the patient to hospital? How was the injured patient removed from the accident scene? How and when was the patient immobilized? When was serum and drug therapy initiated? How was the ambulance operator knowledge? What was the equipment of the ambulance?
Generally, all guidelines and instructions including the instructions concerning immobilization, bleeding control, and safe air ways, should be followed correctly. The adequacy of explanations provided by the technician in charge is of high importance in the continuity of care services. The experts believed that all mentioned items should be considered through the definition of appropriate indicators. Such indicators highlight the importance of the completeness of assessing and- stabilization of patients in pre hospital phase.
B. In-hospital indicators
The specialists held that care service indicators should be derived from clinical guidelines. Clinical guidelines are algorithms used to initiate patient evaluation, administer treatment, complete treatment process, define care key points, evaluate treatment trend, and measure the patient's recovery rate. The specialists asserted that all principles of care service can be defined as an indicator.
The experts asserted providing timely and accurate medical and nursing services are considered as the determinants of these operations. At the arrival, patients are triaged considering injury degree. It is essential that considering their damage level, the patients be triaged and prioritized accurately. The interval between the entrance of patient to hospital and doctor’s visit is of high importance because patients are treated in accordance with the doctor’s decisions. Active trauma team and their timely presence beside patients facilitate and accelerate such decisions. Accurate decision making decreases hospitalization period and, as a result, cuts hospital costs.
The experts believed that the time required to transport patients to Para clinical wards, including radiology and computed tomography scan wards, is very important and determines the ultimate time required for patient deposition. Waiting time between patient’s depositions to hospitalization or transportation time, taking patient to surgery room, or waiting times in the main surgery room are of high important.
According to the experts’ viewpoint, timing indicators are beneficial and can be calculated. These indicators were first determined by an expert panel. Later, they were determined based on clinical evidence. During in-hospital period, patients have the highest prognosis level. These times cannot be accurately extracted from patients’ documents. However, online systems eliminate this problem. In such systems, any person involved in patients’ care services and evaluation process registers their start-end service time in the system.
GCS (Glasgow Coma Scale) is another important indicator, according to the specialist’s comments. GCS is a scale used to determine depth and intensity of the decreased levels of consciousness in people aged >5. This indicator is typically used in brain damages, or other consciousness-disturbing factors, and determines the type of cares to be provided. The fall of GCS after transporting the patient to clinical centers, or after a couple of days from accident, is considered as an important outcome indicator and the relevant cause shall be certainly assessed.
Based on the experts’ views, calculating injury severity using some scales such as ISS (Injury Severity Score), GAP (Glasgow Coma Scale, Age, and Systolic Blood Pressure score), RTS (Revised Trauma Score) and TRISS (Trauma and injury severity score) , and calculating survival probability by adjusting injury severity score are among factors demonstrating the quality of services provided to trauma patients. The indicators are being used across the world. On the other hand, mortality itself is among the simplest outcome indicators. However, the quality of services cannot be judged according to this indicator alone because it is influenced by many other factors including visit time, duration of assessment, and service processes. Mortality and morbidity indicators are routinely collected. Although they are easily collected, they rarely are compared with real facts. Correct processes lead to appropriate consequences.
The experts held that input is always the first-rank priority and to provide appropriate services minimal degrees should be determined. For instance, determining the number of service centers and the time required to access them is vital. The adequacy of service centers affect access time. Moreover, the adequacy of human resource and physical space are important in facilitating care services. Some hospitals are old and suffer inappropriate design and cannot admit and treat trauma patients in a large scale. Inappropriate appearance and malfunctioning equipment create a stressful environment for patients, their family, and personnel.
The specialists argued that some indicators might be important at national level where they are collected throughout the country (Iran). Therefore, adopting these indicators in trauma cares may be beneficial. One of these indicators of outcome is the frequency of unwilling injury occurrence, or centinal event, which is an important consequence indicator. This indicator is collected for trauma patients who are injured within the first 24 hours and, then, are assessed in mortality committee in order to find the cause of accident and to prevent its re-occurrence. The other indicator that The Ministry of Health and Medical Education insists on collecting it is successful CPR of trauma patient’s indicator, which is collected separately. Also, occurrence of hospital infections is collected for all patients and can be provided separately for trauma patients. According to the experts’ view, air way, bedsore and post-surgery cares, and creating appropriate feeding ways are of important factors that should be assessed and performed correctly after hospitalization too.
C. Post-hospital indicators
The experts opined that many patients become disabled due to trauma and they should be continuously checked by physiotherapists and at times be referred to rehabilitation centers. Assessing the individual’s quality of life, returning him/his to previous normal life and obtaining acceptable functioning status are other dimensions of such assessments. In the simplest case, in-clinic checkups and the rate of re-reference of patients to hospitals show the extent of curing. GOS (Glasgow Outcome Score) is another important indicator demonstrating the functional status of patients after being discharged from hospital.
Following trauma, a patient may suffer from mental problems, even depression, besides physical problems. Services provided by social workers, referring to patients’ home and even the assistance of volunteer people could assist patients and prevent further damages and costs.
3. Stages of trauma care evaluation
After they pointed to the indicators, the experts claimed that after the above mentioned indicators are determined, it is possible to measure trauma care services in accordance with defined stages. These stages included: evaluation prerequisites, finalization of indicators prior to evaluation, determining evaluation time scope, determining evaluation dimensions, monitoring and evaluation and use of evaluation results.
A. Evaluation prerequisites
All evaluations need a qualified leader. In addition, prior to evaluations, all service providers should be informed of the evaluation procedure and learn how to use the obtained results and yield to its results. The issue that the experts pointed to was that trauma care evaluations should be made in accordance with the level of facilities and the nature of activities.
The specialists believed that data are the key elements of evaluations. Selecting a certain person for collecting raw data for evaluation is of high importance. On the other hand, the higher the reliance on online and computer-aided systems, the lower is the likelihood of human error. Indeed, using in-system data assists the evaluation process provided that they are registered accurately.
B. Finalizing indicators prior to evaluation
In order for the indicators to be used, they should be primarily assessed. Indeed, the indicators, themselves, need to be monitored. This monitoring includes investigating if the indicators can be used and are necessary at different time periods. The revision of indicators prevents time waste, human resource and money waste. Hence, certainly in the following evaluations different indicators will be available.
According to the experts’ view, prior to initialization of evaluation process, consensus should be achieved as to the studied indicators. The indicators should be evidence-based and should be in connection with outcomes.
C. Evaluation time scope
The specialists argued that the more an indicator is related to mortality, they should be studied within shorter intervals. Indeed, indicators should be prioritized. The first priority belongs to the indicators that have a direct relationship with death. Depending on indicators, evaluations may be practiced on a daily, weekly, monthly or annual basis. Therefore, consensus should be achieved about evaluation time scope prior to initializing evaluation.
D. Dimensions of evaluation
The experts believed that evaluations should have broad dimensions and any given problem should be studied from different angles. Indicators may be defined at the first step and, then, comparisons may be made with ideal values. Assessment of awareness, knowledge, attitude and skill of service providers is another step of evaluation. This issue aids to realize whether staffs know how to perform their tasks and how they should perform them ideally. The assessment and use of service receivers’ opinion is important too. Therefore, it should certainly be evaluated in the framework of patient’s satisfaction measurement.
E. Monitoring and evaluation
The experts asserted that external evaluations are generally performed by auditor organizations, such as accreditation organizations, and this may be very beneficial. Principally, it is better to select out-organization auditors because they are not a stakeholder of the studied system. In addition, cares should be monitored during therapy process. For on-job evaluations, it is better to use in-organization employees, who are familiar with the processes of the provided services but do not individually benefit from the procedure.
According to the experts’ comments, modern trauma care monitoring techniques are currently being used. For example, the interventions on trauma patients are recorded by cameras and then, judgments are made concerning the accuracy and adequacy of the interventions.
F. Use of evaluation results
Experts believe that establishing a relationship between evaluation results and disease outcome leads to the primary, secondary and tertiary preventions and reduces trauma-induced effects. It is better to investigate evaluation results within hospital committees in order to follow up relevant feedbacks through relevant clinical groups. Then, they should be submitted to relevant authorities. Eventually, both positive and negative results along with promotion outcomes should be made public through media. It is probable that out-hospital and out-clinical causes are identified after evaluations.
4. Improvement of trauma care
The experts believed that in addition to the assessment and elimination of weaknesses and drawbacks, extra-organizational dimensions and the provision of necessary facilities and information should be taken into account in order to enable the improvement of trauma care. Problems should be reported just as they occur. Managers tend to refuse many problems and to show positive dimensions, instead. If the culture of finding the faulty person is put aside and the concepts of improvement and promotion are put ahead, this will be beneficial to the whole health system. Experts said some intervention improve trauma care. These interventions were balancing workload in trauma centers, enhancement of information system, considering extra-organizational dimensions in trauma care and empowerment of trauma care providers.
A. Balancing workload of trauma centers
The experts declared that although the shortage of trauma care centers is a challenge in providing trauma care services, the most important problem in Iran is the lack of binding to referring system which, in turn, leads to increased workload and inappropriate services. Some trauma centers may be overloaded where some patients may not need the services of these centers. Conversely, some centers may experience no reference, and consequently, face inefficiency problem.
B. Enhancement of information systems
Experts insisted that improvement of trauma cares requires improvement of information system. Data are the improvement resources of any system. The incorrect attitude towards data collection is that it is a time-consuming and in vain process. However, if the benefits of utilizing data are explained properly, this will facilitate the process of collecting data about indicators, and consequently will promote the quality.
The specialists stated that, unfortunately, trauma registry system has not been defined in Iran. Building a trauma registry system can aid the improvement of trauma cares. If all data of trauma patients are fed into the system and then analyzed, in addition to helping make judgments on the quality of services, they will assist doctors to make proper decisions in future.
C. Extra-organizational dimensions in trauma cares
According to the experts’ views, trauma care improvement depends on the reduction of faults and human errors. On the other hand, it at times turns into a social and extra-organizational problem. Trauma indicators are broad social indicators where even an education-oriented behavior may affect trauma incidence. It needs to develop people information and cooperation of many organizations in society. This is a conventional problem of the 3rd world countries.
D. Empowerment of trauma care providers
The promotion of trauma cares needs fully specialized staff in medicine and nursing sectors. Providing therapies and cares in accordance with relevant protocols, and educating employees based on such protocols will always improve trauma cares. Particular trainings are necessary for trauma care providers and, in turn, improve such cares. Experts argued that wherever the subject of education is introduced, it results in changes.
The experts were sure that consistency of evaluations is a success factor by itself and it converts decisions to actions. Monitoring improves performance almost by 20%. There is a proper infrastructure due to the availability of some programs such as quality improvement, clinical governance and evaluation departments, the development of which enhances individuals’ knowledge on the issues of quality and patients’ safety.