Thesis: Assessing patient safety challenges in the initial care of older trauma patients in Norway
Mathias Cuevas-Østrem’s thesis builds on one simple premise: older patients have the right to high-quality emergency care when critically ill or injured. Optimal chances of survival and good quality of life after severe injuries are primarily achievable through trauma systems, also for older people. These systems aim to establish a seamless transition of information and care from the incident site to rehabilitation. Studies from trauma systems internationally have found concerning disparities in care for older trauma patients in general and patients with head injuries in particular, yet this was not investigated in the Norwegian context. The aim of this thesis was, therefore, to assess whether patient safety challenges exist in the initial care of older trauma patients in Norway.
Through analyses of data from the national Norwegian Trauma Registry and focus group interviews with involved clinicians, this thesis identified patient safety challenges in the current system, but also strengths. Two studies focused on the epidemiology and management of the general trauma population and compared older and younger adults. The subsequent two studies focused on patients with isolated traumatic brain injuries (TBI) admitted to non-neurosurgical acute care trauma hospitals. We investigated care pathways and which factors influenced interhospital transfer, including the role of age and comorbidities.
Our studies predominantly revealed prehospital challenges, with older trauma patients receiving less advanced prehospital care despite comparable injury severity. Notably, they received prehospital doctor/paramedic team attendance, advanced interventions, and air ambulance transportation less frequently. Upon hospital admission, they were less often met by a trauma team and showed lower trauma center admission rates. Older patients showed an almost 5-fold 30-day mortality rate.
We found that more than every third of older trauma patients had a severe head injury. Older patients underwent prehospital intubation less frequently despite Glasgow Coma Scale scores <9. Furthermore, we observed that older patients with isolated moderate-to-severe TBI were more frequently directed to non-neurosurgical hospitals for primary admission than their younger counterparts. Factors such as advanced age, comorbidities, and preinjury functional impairments contributed to a reduced probability of interhospital transfer to a neurotrauma center. The intricate transfer decision process exhibited susceptibility to communication errors.
However, our studies also identified important strengths of the current system. When a trauma team was activated upon hospital admission, there were few clinically significant management differences between young and older adults. And clinicians tried to make patient-centered decisions about whom to transfer for specialized neurotrauma care based on individual patients’ health statuses and chances of favorable outcomes.
This undertaking is the first large study to assess patient safety challenges for older trauma patients in Norway. It has confirmed that patient safety challenges comparable to those found in studies from other countries also exist here, in a Scandinavian setting characterized by a publicly funded healthcare system. Moreover, it has unveiled novel insights about the use of doctor/paramedic teams in the care of older trauma patients. And it has contributed information about traumatic brain injury management of older patients within mature trauma systems, contributing to an emerging research field internationally.
Identifying problems within a system serves as a steppingstone for their resolution. In this light, this thesis not only underscores existing challenges but also charts the course for future improvement efforts: dispatch of prehospital resources, decision support for prehospital personnel, and improved interhospital communication regarding TBI transfer. As populations are aging and healthcare resources face increasing constraints, the imperative to optimize resource allocation and improve patient outcomes becomes even more pronounced. Through continued refinement of the trauma system, these goals remain attainable.
Mathias Cuevas-Østrem is a medical doctor, currently working as a resident in anesthesia and critical care at Akershus University Hospital. He defended his thesis on January 18th, 2024. His PhD was focused on epidemiology and patient safety of older trauma patients in Norway and was undertaken at the PhD program in Health and Medicine at the faculty of Health Sciences at the University of Stavanger in collaboration with the Norwegian Air Ambulance Foundation and the Norwegian Trauma Registry.
Supervisors
Main supervisor:
Assistant professor Elisabeth Jeppesen, University of Stavanger, Stavanger, Norway / VID Specialized University, Oslo, Norway
Co-supervisor:
Professor Torben Wisborg, University of Tromsø – the Arctic University of Norway, Hammerfest, Norway / Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
Professor Olav Røise, University of Stavanger, Stavanger, Norway / University of Oslo, Oslo, Norway / Norwegian Trauma Registry, Oslo University Hospital, Oslo, Norway
