International emergency medicineEvaluation of Trauma Care Applying TRISS Methodology in a Caribbean Developing Country
Introduction
Deaths due to a traumatic injury have been steadily increasing in many countries all over the world. The Centers for Disease Control (CDC) of the United States of America reported in 2002 that trauma was the leading cause of death for the 15–24-year-old age group in the population (1). Ten million Americans were estimated to be disabled by trauma during that year—400,000 of them permanently—and there were over 150,000 fatalities. The United Kingdom reported similar findings. Traumatic injuries kill 40 people per day or 14,500 per year (2). Furthermore, over 7 million attend Accident and Emergency (A&E) Departments for treatment annually, and 620,000 patients are admitted to hospitals after injury (2).
The financial impact of trauma on a nation's economy is also devastating. In 1985, The Medical Commission on Accident Prevention in England estimated that road traffic accidents alone would cost the British economy 2.8 billion dollars (2). The cost of caring for victims in 1987 exceeded 64 billion dollars of the total personal health care spending in the USA (1).
In recent years, Trinidad and Tobago have experienced a surge in crime. There was an increase of serious criminal and violent acts, such as murder and manslaughter (excluding traffic accidents) (3). Trauma-related deaths and injuries increased by 10.3% from 1998 through 2002. The risk of deaths due to motor vehicle accidents increased from 5.9 per 1000 accidents in 1998 to 11.2 in 2003 (3). It is imperative, therefore, that Trinidad and Tobago be equipped with adequate infrastructure and resources in the public hospitals to appropriately manage the increasing influx of patients.
Major trauma causes both morbidity and mortality. To assess the severity of a patient's injuries, scoring systems are widely used internationally. In the 1980s, the Trauma Injury Severity Score (TRISS) was developed to predict patient outcomes after trauma using physiological and anatomical criteria. It combined the earlier developed Revised Trauma Score (RTS) and the Injury Severity score (ISS) (4, 5). TRISS methodology was proposed to assess the degree of injury, calculate the chances of a patient's survival (for identification of cases for peer review), and compare the death rates to survival rates of patient populations in different hospitals (6). Despite further advancements in trauma care and identification of numerous limitations of TRISS, this methodology continues to be the most commonly used tool for monitoring trauma outcomes and assessing trauma unit performance (7, 8).
With this background, this study attempted to evaluate trauma care applying the TRISS methodology in the major public hospitals of Trinidad. There have been studies from the Caribbean reporting the improvisation of trauma care after Advanced Trauma Life Support (ATLS) training courses to the personnel who care for trauma victims (9, 10, 11, 12, 13). To our knowledge, there is no published report applying the TRISS methodology to evaluate trauma care in the Caribbean.
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Study Setting
Trinidad and Tobago comprise a twin-island nation of the Caribbean that is English-speaking, with a population of 1.3 million. In 2003, the per capita gross national income was US$7260, thus making Trinidad and Tobago one of the richest countries in the West Indies (3). In the same year, the Government allocated US$210 million toward the health sector; the per capita expenditure being US$1754 (3). There are three major public hospitals in Trinidad: Eric Williams Medical Sciences Complex, San
Results
Of the 326 patients enrolled in the data set, 279 patients were adults and 47 were children (≤ 12 years of age). Demographic data, mean waiting time in the A&E Department, and type of trauma for all of the patients is presented in Table 1. The age of patients and the waiting time in the A&E Department did not have statistically significant differences between hospitals.
The mean predicted survival according to the TRISS methodology in adults was 98.5 (0.1 SD). This implies that the predicted
Discussion
The major finding of the present study is the disparity between the observed and predicted outcomes when TRISS methodology was applied to predict outcomes of trauma patients. The M statistic for the present study was 0.98, which may imply that the case-mix of the present study is similar to that of the Major Trauma Outcome Study database. However, the Z statistic was positive, which may imply that the TRISS methodology underestimated mortality in the patients enrolled in the study. The Z
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