Original Article
Analysis of the Result of Survey on Trauma Systems: The Neglected Disease of the Modern Society
Análisis de los resultados de una encuesta sobre los sistemas de trauma en España: la enfermedad abandonada de la sociedad moderna
David Costa Navarro
, Montiel Jiménez Fuertes, José Ceballos Esparragón, Soledad Montón Condón, José María Jover Navalón, Fernando Turégano Fuentes, Salvador Navarro Soto
Corresponding author
Sección de Politraumatizados y Cuidados Intensivos Quirúrgicos, Asociación Española de Cirujanos, Madrid, Spain
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Even minor trauma is associated with a high rate of morbidity and mortality in the elderly.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In some countries, the magnitude presented by the problem of trauma has led to the development of cost-effective systems to manage this type of patients, which help minimize the morbidity and mortality impact of this disease. These healthcare systems are called trauma care systems, and trauma centers are at their nucleus.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In Europe, the first trauma system was organized in Germany in 1972.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Nowadays in most European cities, trauma care is organized and coordinated by general surgeons, acting as emergency surgeons or acute care surgeons.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> More recently created but much more advanced, homogenous and widespread is the trauma system used in the United States. In 1922, there started to be interest in developing a trauma system; the <span class="elsevierStyleItalic">American College of Surgeons</span> (ACS) created at that time the <span class="elsevierStyleItalic">Committee on Treatment of Fractures</span>, which is currently the <span class="elsevierStyleItalic">Committee on Trauma</span> (ACSCOT). This committee has provided the lead for conceptualizing and creating the trauma systems that were initiated in the US in 1966 with the publication of the National Academy of Sciences and the National Research Council: <span class="elsevierStyleItalic">Accidental Death and Disability: The Neglected Disease of Modern Society</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Afterwards, in 1976, hospital categorization was begun by ACSCOT and the first guidelines were published for trauma care.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In 1980, the Advanced Trauma Life Support (ATLS) courses were standardized, and in 1987 the consultation/verification program was integrated into the trauma center formal designation process, defined in guidelines published by the ACS, and called <span class="elsevierStyleItalic">Resources for the optimal care of the injured patient</span>,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> which are periodically reviewed and modified. The impact of the implementation of trauma systems by the ACS has been analyzed in multiple publications and has been demonstrated to be a system that positively influences the survival of these patients, the quality of care provided, as well as costs.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,12–22</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although there is evidence that some European countries have organized trauma care, it is quite heterogeneous.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In the case of Spain, the training of general and gastrointestinal surgeons does not specifically contemplate mandatory training in polytrauma. Nor is there a national trauma register in order to determine what is really happening in our country. As a consequence, we also do not know what level we are at in accordance with optimal care standards and to what extent we can improve quality of care while reducing medical expenses resulting from the care of these patients. Thus, the objective of the present study is to analyze the results of a survey on the organization of trauma care in our country.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A survey was created with 14 questions on the organization of trauma care and the training of doctors in specific aspects of polytrau ma patient treatment. The survey was posted in the news section of the Spanish Association of Surgeons website (<a href="http://www.aecirujanos.es/secciones/politraumatizados/encuesta_stae.php">http://www.aecirujanos.es/secciones/politraumatizados/encuesta_stae.php</a>) for a period of nine months (July 2011 to March 2012). All members of the association were also invited to participate on 2 separate occasions during this period by e-mail. The survey questions referred to aspects about the organization of polytrauma patient treatment, all of which were close-ended (yes/no or similar) except for 2 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The responses were collected in Access 97 and analyzed descriptively with the SPSS 9.0 statistical package.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 190 responses were received from 110 different hospitals. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the distribution of the participation by autonomous communities (Spanish provinces): participants from Catalonia turned in 56 surveys, from Valencia 32, Madrid 27 and Andalusia 21. The responses were sent by the following personnel at the different hospitals: 3 nurses, 14 directors of clinical services, 14 department heads, 21 residents and 138 attending physicians. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the specialties of these staff members. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> compiles the results of the responses about polytrauma care organization and the training of the participating personnel. Of these, we should highlight that in 67.3% of the hospital centers (74) there were protocols in place for polytrauma care, 81.1% of which are based on the ATLS guidelines, and 53 centers (48%) have a multidisciplinary polytrauma team, with a corresponding protocol for activation in 46 of these. Furthermore, in the centers that have trauma teams, they are multidisciplinary and made up of doctors from at least 2 different specialties. The team leader is usually the anesthetist in 7 centers, the general surgeon in 5, the intensive care specialist in 15 and the ER physician in 7; in the remaining 19 centers, the team is usually led by the member of the trauma team that has the most experience in each situation. Thirty-nine centers (35%) have a Committee for Polytrauma Care that is in charge of generating the protocols and controlling the quality of care for these patients, as well as the correct application of the protocols. Twenty-seven centers (24%) have an intrinsic training system in polytrauma care for their personnel. 24.5% of the hospitals have a rehabilitation program or center for polytrauma patients. Out of the 190 people who responded to the survey, 138 had completed the ATLS course and 74 (38.9%) had completed the DSTC course.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Properly organized and protocolized trauma care has been demonstrated to be beneficial for patients. It reduces the time used in reanimation and reduces delays before surgical intervention if indicated, especially in penetrating trauma, which improves morbidity and mortality rates. Along these lines, Petrie et al. concluded that the severest patients (those with an ISS above 12) have clearly better results when treated in a trauma team activation system.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> In our survey, we have found that only 67.3% of the hospitals surveyed have a polytrauma treatment protocol, although 81.1% of these are based on ATLS guidelines. Only 62.2% of the centers with protocols declare having a trauma team activation plan,<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a> which would be the best case scenario according to the evidence.</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand, 72.6% of those surveyed declare having completed the ATLS course, which is not a bad result when we considered that the course is not mandatory (not even as part of the residency program) for any other specialties represented. The ATLS method was initiated by James Styner and a training course was developed for the treatment of polytrauma patients, which was later adopted by the <span class="elsevierStyleItalic">American College of Surgeons Committee on Trauma</span>, and the ATLS course began in 1978.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,26</span></a> This method, which is now standardized and taught by the course in 50 countries, was established in Spain in the year 2000 through the Spanish Association of Surgeons<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> with the aim to improve the knowledge and abilities of our professionals and, above all, to provide a common language.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> As has been mentioned, the ATLS course is not mandatory during training, although the effectiveness of the ATLS method has been demonstrated by several studies in different settings.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28–31</span></a> For example, Ali et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> demonstrated that the ATLS program improved the results of polytrauma patients by reducing mortality from 68% to 34% after completing the course. With all this, it would seem that the ATLS course should be mandatory training for hospital personnel that are involved in one way or another with trauma patients. In many countries, it is required to have a valid ATLS certificate to be able to work in contact with trauma patients. Almost three-quarters of the survey participants declared having completed the course, which is not a bad result. We believe that, in time, this percentage will get closer to 100%, which would be ideal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">When faced with a polytrauma patient in a surgical setting, the concepts of damage control and operative management offered by the DSTC or ATOM courses are equally useful.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32–34</span></a> The DSTC course (established by the IATSIC) is a more recent development in Spain and is specifically directed at surgeons, which is demonstrated by the lower percentage of staff that had completed the course (38.9%).</p><p id="par0045" class="elsevierStylePara elsevierViewall">In trauma systems, the trauma center is the nucleus of the system. Depending on the functioning characteristics and the population area covered, this center should meet a series of characteristics. The ideal trauma center should include training for its personnel and ensure that the protocols are properly followed in morbidity and mortality sessions.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> It should also verify the level of knowledge and clinical effectiveness of the personnel treating these patients, and carry out a continuous audit of the care of these patients using a trauma register.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,24</span></a> Among the centers surveyed, 24.5% reported having a training system for their staff, 32.7% declared having a register or database of polytrauma patients and 35.5% declared having a committee in charge of evaluating the clinical efficiency of the management of these patients (Trauma Committee) or morbidity and mortality sessions of polytrauma patients. Likewise, one of the functions that a trauma system should perform is the rehabilitation of injured patients after having recovered from their acute problems.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,24,35</span></a> According to the result of the survey, in Spain this only happens in 24.5% of the centers surveyed. All these characteristics are essential conditions for a hospital to meet the requisites to be accredited as a trauma center in the US system of accreditation and verification, which, given its proven efficacy,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,8</span></a> should be considered the gold standard. Based on the results of the survey, very few Spanish centers would meet all the requisites to be accredited as a trauma center with the American criteria. It is true, however, that in some Spanish autonomous communities it is starting to become compulsory by law to meet minimum requirements, such as having an activation system for the trauma team and protocols for treating polytrauma patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In contrast, what is striking is the good general development that we have detected in the coordination of prehospital polytrauma care (57.3% stated having prehospital care integrated in the center, and 81% of the centers have a trauma care protocol and trauma team, with a trauma team activation protocol in 81% of the cases). Nonetheless, we should not be tempted to consider that an excess of polytrauma patient assistance is synonymous with improved quality.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> On many occasions, there continues to be a lack of early communication between the prehospital assistance provider and the receiving hospital. As many centers do not have a trauma register, it is not possible to get any feedback about the quality of care in either of the two trauma care settings.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The present paper has a very obvious bias: the participants who answered the survey either have a personal interest in trauma care, or at the hospital where they work relevance is given to the care of this type of patients. Meanwhile, those who did not answer the survey may possibly lack this interest. This bias would over-interpret the reality of trauma assistance. In spite of this, we believe that although the interest in trauma care may have grown in our country in recent years, it still has a long way to go to reach the level of other countries such as the United States, Australia, Israel, Germany or Austria.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In this function of improving and implementing trauma care, the Polytrauma Section of the Spanish Association of Surgeons plays a very important role, as it has demonstrated up to the present time. But, it is also necessary to accompany this effort with large doses of enthusiasm and motivation from the professionals who, at each particular hospital, would promote this development. What is also needed is greater involvement of the local, regional and national government, providing greater specific funding and a legal framework that would promote more and better development of polytrauma patient treatment, concentrating cases of severe trauma in specially designed and accredited hospitals.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The number of these centers would logically be proportional to the number of inhabitants in each province or public healthcare region, following well-known recommendations and studies. Necessary and essential conditions would be the initiation of a mandatory trauma register in each of these hospitals, the organization of integral care for these patients and the creation of the figure of hospital trauma coordinator, who would unite these organizational efforts.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres297368" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec281109" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres297369" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec281108" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-05-06" "fechaAceptado" => "2012-07-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec281109" "palabras" => array:4 [ 0 => "Trauma systems" 1 => "Trauma education" 2 => "Trauma centers" 3 => "Multiple injuries" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec281108" "palabras" => array:4 [ 0 => "Sistemas de trauma" 1 => "Educación en trauma" 2 => "Centros de trauma" 3 => "Politrauma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A questionnaire was prepared consisting of 14 questions regarding aspects of the trauma care organization and trauma education. It was posted on the web site of the Spanish College of Surgeons and all members were encouraged to participate.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">One hundred and ninety questionnaires from 110 different hospitals were received. More than two-thirds (67.3%) of the centers had protocols for treating trauma patients, with 81% of them based on ATLS guidelines. Almost three-quarters (72.6%) of the doctors had completed the ATLS course, and 38.9% the DSTC course. There was a specific education program in trauma in 24.5% of the centers, and 35.5% had a Trauma Committee. There was a rehabilitation program in 24.5% of the centers.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Very few of the participating centers would fulfill the requirements of the American College of Surgeons accreditation for trauma centers. Trauma care in Spain has improved a lot in the recent years, but there is still a lot to do to reach the level of that in the United States of America.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las lesiones por trauma representan la principal causa de pérdida de años de vida en la población mundial. El objetivo es conocer qué grado de organización de la asistencia al paciente politraumatizado tenemos en España.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se confeccionó una encuesta con 14 preguntas acerca de la organización de la asistencia al trauma y sobre la formación en aspectos de la atención al politraumatizado y se colgó en la web de la AEC, notificándolo por <span class="elsevierStyleItalic">e-mail</span> a todos los asociados.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se recibieron un total de 190 respuestas de 110 hospitales diferentes. El 67,3% de los centros encuestados tiene una protocolización de la asistencia al politraumatizado basada en el 81,1% en las directrices del ATLS. El 72,6% de los encuestados ha realizado el curso ATLS y el 38,9% el curso DSTC. De los centros encuestados, el 24,5% tiene un sistema formativo para su personal, el 32,7% tiene un registro o base de datos de enfermos politraumatizados, el 35,5% posee un Comité de Politraumatizados. El 24,5% de los centros facilita la rehabilitación y reinserción sociolaboral del paciente.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Muy pocos centros nacionales reunirían los requisitos completos para poder acreditarse como centro de trauma con los criterios americanos. La asistencia al trauma, si bien en los últimos años ha mostrado un creciente interés que se ha acompañado de un mayor desarrollo, todavía tiene un largo camino que recorrer hasta que lleguemos al nivel de implantación y desarrollo que poseen países como los Estados Unidos de Norteamérica.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Costa Navarro D, Jiménez Fuertes M, Ceballos Esparragón J, Montón Condón S, Jover Navalón JM, Turégano Fuentes F, et al. Análisis de los resultados de una encuesta sobre los sistemas de trauma en España: la enfermedad abandonada de la sociedad moderna. Cir Esp. 2013;91:432–437.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2629 "Ancho" => 3250 "Tamanyo" => 605202 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Survey about trauma systems in Spain.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1213 "Ancho" => 1573 "Tamanyo" => 101998 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of the number of surveys answered (number of participants) per <span class="elsevierStyleItalic">autonomous community</span> (Spanish provinces).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Specialty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Participation \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General and Gastrointestinal Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">171 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thoracic Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anesthesiology and Reanimation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orthopedic and Trauma Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Emergency Medicine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intensive Medicine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pediatric Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Otorhinolaryngology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nursing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab433877.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Specialties of the Survey Participants.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Answer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Yes (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Are there protocols for polytrauma patient management at your hospital? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 (67.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (32.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. If so, are they based on ATLS guidelines?<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (81.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (18.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Is there a trauma team activation protocol for patients that meet certain severity characteristics?<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 (62.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (37.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Is prehospital trauma care integrated with your hospital for polytrauma patient management? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 (57.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 (42.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Is there a trauma team activation protocol that can be activated by the prehospital care providers?<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (81) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6. Have you completed the ATLS course? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">138 (72.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 (27.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">190 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7. Have you completed the DSTC course or its equivalent (ATOM, etc.)? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 (38.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">116 (61.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">190 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8. Is there an training program at your hospital for trauma patient care with either clinical sessions or a specific course? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (24.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83 (75.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9. Does your hospital have at least a minimal polytrauma patient register or database? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (32.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 (67.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11. At your hospital, is there a committee in charge of creating trauma patient management protocols and/or evaluating trauma care through morbidity and mortality committee, etc.? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 (35.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 (64.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12. In your work area, is there a rehabilitation/social integration center (or a reference center that is relatively close) where polytrauma patients can be referred under a protocol? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (24.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83 (85.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab433876.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Answers 2 and 3 are conditioned by the response to question 1. The answer to question 5 is conditioned by the response to 4.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Responses to the Questionnaire on the Organization of Trauma Systems in Spain.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Celso" 1 => "J. Tepas" 2 => "B. Langland-Orban" 3 => "E. Pratch" 4 => "L. Papa" 5 => "L. 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| 2024 November | 5 | 0 | 5 |
| 2024 October | 21 | 15 | 36 |
| 2024 September | 19 | 11 | 30 |
| 2024 August | 24 | 15 | 39 |
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| 2024 April | 56 | 12 | 68 |
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| 2024 February | 12 | 6 | 18 |
| 2024 January | 54 | 2 | 56 |
| 2023 December | 36 | 5 | 41 |
| 2023 November | 19 | 4 | 23 |
| 2023 October | 11 | 8 | 19 |
| 2023 September | 32 | 4 | 36 |
| 2023 August | 15 | 2 | 17 |
| 2023 July | 15 | 5 | 20 |
| 2023 June | 36 | 3 | 39 |
| 2023 May | 83 | 7 | 90 |
| 2023 April | 69 | 9 | 78 |
| 2023 March | 53 | 6 | 59 |
| 2023 February | 34 | 12 | 46 |
| 2023 January | 43 | 4 | 47 |
| 2022 December | 52 | 12 | 64 |
| 2022 November | 43 | 16 | 59 |
| 2022 October | 36 | 15 | 51 |
| 2022 September | 31 | 7 | 38 |
| 2022 August | 36 | 22 | 58 |
| 2022 July | 36 | 13 | 49 |
| 2022 June | 38 | 29 | 67 |
| 2022 May | 33 | 21 | 54 |
| 2022 April | 24 | 8 | 32 |
| 2022 March | 40 | 10 | 50 |
| 2022 February | 37 | 11 | 48 |
| 2022 January | 70 | 14 | 84 |
| 2021 December | 47 | 15 | 62 |
| 2021 November | 33 | 5 | 38 |
| 2021 October | 40 | 27 | 67 |
| 2021 September | 42 | 11 | 53 |
| 2021 August | 38 | 11 | 49 |
| 2021 July | 17 | 14 | 31 |
| 2021 June | 19 | 14 | 33 |
| 2021 May | 33 | 9 | 42 |
| 2021 April | 61 | 34 | 95 |
| 2021 March | 24 | 6 | 30 |
| 2021 February | 21 | 8 | 29 |
| 2021 January | 18 | 6 | 24 |
| 2020 December | 17 | 15 | 32 |
| 2020 November | 26 | 4 | 30 |
| 2020 October | 18 | 4 | 22 |
| 2020 September | 26 | 16 | 42 |
| 2020 August | 25 | 8 | 33 |
| 2020 July | 31 | 12 | 43 |
| 2020 June | 14 | 3 | 17 |
| 2020 May | 32 | 17 | 49 |
| 2020 April | 29 | 8 | 37 |
| 2020 March | 17 | 5 | 22 |
| 2020 February | 19 | 10 | 29 |
| 2020 January | 19 | 9 | 28 |
| 2019 December | 13 | 8 | 21 |
| 2019 November | 13 | 7 | 20 |
| 2019 October | 13 | 5 | 18 |
| 2019 September | 14 | 3 | 17 |
| 2019 August | 10 | 8 | 18 |
| 2019 July | 14 | 18 | 32 |
| 2019 June | 12 | 7 | 19 |
| 2019 May | 49 | 16 | 65 |
| 2019 April | 39 | 17 | 56 |
| 2019 March | 21 | 8 | 29 |
| 2019 February | 13 | 3 | 16 |
| 2019 January | 14 | 5 | 19 |
| 2018 December | 13 | 5 | 18 |
| 2018 November | 30 | 1 | 31 |
| 2018 October | 33 | 3 | 36 |
| 2018 September | 22 | 6 | 28 |
| 2018 August | 29 | 3 | 32 |
| 2018 July | 12 | 7 | 19 |
| 2018 June | 12 | 5 | 17 |
| 2018 May | 7 | 6 | 13 |
| 2018 April | 28 | 6 | 34 |
| 2018 March | 14 | 1 | 15 |
| 2018 February | 14 | 1 | 15 |
| 2018 January | 19 | 2 | 21 |
| 2017 December | 13 | 1 | 14 |
| 2017 November | 11 | 3 | 14 |
| 2017 October | 20 | 1 | 21 |
| 2017 September | 12 | 2 | 14 |
| 2017 August | 21 | 6 | 27 |
| 2017 July | 23 | 5 | 28 |
| 2017 June | 28 | 2 | 30 |
| 2017 May | 34 | 8 | 42 |
| 2017 April | 30 | 5 | 35 |
| 2017 March | 23 | 22 | 45 |
| 2017 February | 19 | 1 | 20 |
| 2017 January | 13 | 3 | 16 |
| 2016 December | 21 | 6 | 27 |
| 2016 November | 20 | 4 | 24 |
| 2016 October | 47 | 5 | 52 |
| 2016 September | 27 | 7 | 34 |
| 2016 August | 27 | 3 | 30 |
| 2016 July | 18 | 3 | 21 |
| 2016 June | 22 | 16 | 38 |
| 2016 May | 32 | 13 | 45 |
| 2016 April | 33 | 4 | 37 |
| 2016 March | 24 | 19 | 43 |
| 2016 February | 25 | 5 | 30 |
| 2016 January | 14 | 9 | 23 |
| 2015 December | 25 | 5 | 30 |
| 2015 November | 14 | 6 | 20 |
| 2015 October | 33 | 8 | 41 |
| 2015 September | 26 | 7 | 33 |
| 2015 August | 11 | 6 | 17 |
| 2015 July | 13 | 2 | 15 |
| 2015 June | 12 | 1 | 13 |
| 2015 May | 25 | 2 | 27 |
| 2015 April | 20 | 7 | 27 |
| 2015 March | 21 | 6 | 27 |
| 2015 February | 29 | 7 | 36 |
| 2015 January | 24 | 4 | 28 |
| 2014 December | 43 | 8 | 51 |
| 2014 November | 18 | 7 | 25 |
| 2014 October | 35 | 4 | 39 |
| 2014 September | 31 | 4 | 35 |
| 2014 August | 21 | 2 | 23 |
| 2014 July | 20 | 4 | 24 |
| 2014 June | 19 | 4 | 23 |
| 2014 May | 11 | 5 | 16 |
| 2014 April | 15 | 8 | 23 |
| 2014 March | 24 | 5 | 29 |
| 2014 February | 15 | 2 | 17 |
| 2014 January | 11 | 7 | 18 |
| 2013 December | 19 | 7 | 26 |
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