Treating patients in a trauma room equipped with computed tomography and patients’ mortality: a non-controlled comparison study
Abstract
Background
To improve acute trauma care workflow, the number of trauma centers equipped with a computed tomography (CT) machine in the trauma resuscitation room has increased. The effect of the presence of a CT machine in the trauma room on a patient’s outcome is still unclear. This study evaluated the association between a CT machine in the trauma room and a patient’s outcome.
Methods
Our study included all trauma patients admitted to a trauma center in Yokohama, Japan, between April 2014 and March 2016. We compared 140 patients treated using a conventional resuscitation room with 106 patients treated in new trauma rooms equipped with a CT machine.
Results
For the group treated in a trauma room with a CT machine, the Injury Severity Score (13.0 vs. 9.0; p = 0.002), CT scans of the head (78.3 vs. 66.4%; p = 0.046), CT scans of the body trunk (75.5 vs. 58.6%; p = 0.007), intubation in the emergency department (48.1 vs. 30.7%; p = 0.008), and multiple trauma patients (47.2 vs. 30.0%; p = 0.008) were significantly higher and Trauma and Injury Severity Score probability of survival (96.75 vs. 97.80; p = 0.009) was significantly lower than the group treated in a conventional resuscitation room. In multivariate analysis and propensity score matched analysis, being treated in a trauma room with a CT machine was an independent predictor for fewer hospital deaths (odds ratio 0.002; 95% CI 0.00–0.75; p = 0.04, and 0.07; 0.00–0.98, respectively).
Conclusions
Equipping a trauma room with a CT machine reduced the time in decision-making for treating a trauma patient and subsequently lowered the mortality of trauma patients.
Keywords
Acute care Trauma resuscitation room CTAbbreviations
- AIS
Abbreviated Injury Score
- APTT
Activated partial thromboplastin time
- CT
Computed tomography
- ED
Emergency department
- FAST
Focused assessment with sonography for trauma
- Fbg
Fibrinogen
- FDP
Fibrin degradation products
- GCS
Glasgow Coma Scale
- HR
Heart rate
- ICUs
Intensive care units
- ISS
Injury Severity Score
- LOS
Length of hospital stay
- MC council
Medical control council
- MTOS
Major Trauma Outcome Study
- Ps
Probability of survival
- PT-INR
International normalized ratio of prothrombin time
- RTS
Revised Trauma Score
- SaO2
Percutaneous oxygen saturation
- SBP
Systolic blood pressure
- TAE
Transcatheter arterial embolization
- TBCT
Total-body CT scanning
- TRISS
Trauma and Injury Severity Score
- YCUMC
The Yokohama City University Medical Center
Background
Trauma is the leading cause of death among young people around the world [1] and in those aged < 45 years in Japan [2]. In addition, approximately 23,000 trauma deaths occur each year in Japan [2]. Trauma has a negative impact on the lives of people and is a risk for social welfare [1]. Improving therapeutic procedures and diagnostic evaluations for trauma patients is necessary to increase their survival and improve public health.
In recent years, computed tomography (CT) has provided faster operations and more detailed images and can be made easily available in acute trauma care. CT scanning in the early diagnostic phase of trauma care is critical and has become an essential part of a trauma diagnostic work-up. In previous studies, CT scanning contributed to a change of treatment without obvious external signs of injuries [3, 4, 5], gained time benefits compared with a conventional resuscitation [6, 7, 8, 9], and had potential survival benefits for trauma patients, especially when total-body CT scanning (TBCT) was performed [10, 11, 12, 13, 14, 15]. To improve acute trauma care workflow, the number of trauma centers equipped with a CT machine in the trauma resuscitation room has increased [6, 7, 16, 17, 18, 19, 20]. Equipping a CT machine in a trauma room is expensive, and the effect of a CT machine in the trauma room compared with a conventional resuscitation room on a patient’s outcome is still unclear because of the inconsistency in previous findings [6, 18, 19, 20, 21, 22]. Thus, we conducted a before and after comparison study to evaluate the association between the presence of a CT machine in the trauma resuscitation room and a patient’s outcome.
Methods
The new trauma resuscitation room at the Yokohama City University Medical Center
Before the protocol was introduced, a patient received a conventional resuscitation room and trauma care based on the guidelines of the Japan Advanced Trauma Evaluation and Care program by the Advanced Trauma Life Support [2, 26]. Briefly, in the primary survey, the trauma care team begins with priority-oriented resuscitation. The team performs a focused assessment with sonography for trauma (FAST) with chest and pelvic X-ray examinations for diagnosis during the primary survey. In addition, if available in the facility, a selective CT scan is performed before emergency bleeding control is initiated. Each team leader decides whether or not to perform the CT scan if life-threating problems are clearly detected in the FAST and X-ray images or if patient transfer is difficult because of hemodynamic instability. The CT machine is located on the same floor as the resuscitation room, approximately 50 m away. The time required to perform the CT scan, including patient transfer time, is approximately 20 min.
This observational study utilized data from all trauma patients admitted to YCUMC. Our study included all trauma patients admitted to YCUMC between April 2014 and March 2016. Inclusion criteria consisted of all adult trauma patients (aged ≥ 18 years). Exclusion criteria included the following: patients with traumatic cardiopulmonary arrest on arrival, burn patients, patients who were < 18 years, and those who were transferred from other hospitals. We categorized the patients into two groups: patients treated using the conventional resuscitation room and patients treated in the CT-equipped trauma room.
The following data were retrospectively obtained from the patients’ medical records: sex; age; Abbreviated Injury Score (AIS); Injury Severity Score (ISS); Revised Trauma Score (RTS); probability of survival (Ps); initial vital signs upon arrival to the hospital, including HR, SBP, the Glasgow Coma Scale (GCS), respiratory rates, and body temperature; CT scans of the head and body trunk; initial laboratory data, including lactate, base excess, hemoglobin, fibrinogen, activated partial thromboplastin time, international normalized ratio of prothrombin time (PT-INR), fibrin degradation products, and D-dimer levels; injury mechanisms; intubation in ED; chest tube placement in ED; use of the resuscitative endovascular balloon for occlusion of the aorta in ED; transcatheter arterial embolization (TAE); need for large transfusions defined as transfused red blood cells of 10 units or more within 24 h after arrival to ED; ED stay, which was the time from arrival to transfer to the operation room, the angiography room, or the intensive care units (ICUs); time to CT scan, which was the time from arrival to the start of the CT scan; time to emergency operations to control bleeding, which was the time from arrival to the initiation of the operation; time to TAE, which was the time from arrival to the start of TAE; length of hospital stay (LOS; in days); and the length of ICU stay (in days). The types of trauma were categorized as blunt or penetrating. RTS was calculated using a formula described by Champion et al. [26, 27]. Ps was calculated using the Trauma and Injury Severity Score (TRISS) methods [28]. Hypotension was defined as SBP below 90 mmHg at arrival. Isolated traumatic brain injury was defined as having a GCS score of below 9 and an AIS head score of 3 or above without non-head region AIS score of greater than 1. Patients with multiple traumas were defined as those with an ISS of 16 or above.
The primary outcome measure was hospital mortality. Secondary outcome measures included LOS, length of ICU stay, need for large transfusions, time from the CT scan to the initiation of surgeries for controlling bleeding, time from the CT scan to the start of TAE, and the length of ED stay.
Data were analyzed for all eligible patients. Data were presented as median and interquartile ranges for not normally distributed values or number with percentages as appropriate. Continuous variables were compared between the two patient groups using the Mann–Whitney U test. Categorical variables were analyzed using Fisher’s exact test. Predictive survival rates (TRISS Ps), actual survival rates, and their ratios were calculated for the two groups: a patient group treated in the trauma room with CT and treated in the conventional resuscitation room. In order to compare predicted survival rate and actual survival rate by each group, Z statistic was calculated. M statistic was calculated to compare the difference from the standard severity distribution by Major Trauma Outcome Study (MTOS) [28]. As subgroup analysis, we calculated predictive survival rate, actual survival rate, Z statistic, and M statistic for multiple trauma patients, defined as ISS ≥ 16. In addition, we compared the two groups in terms of clinical and basic characteristics, such as mortality, age, and sex, to acknowledge the difference between the included and excluded samples.
Multivariate logistic regression analysis was used to control for potentially confounding variables, identified as prior to locating the CT in the trauma resuscitation room. Based on clinical reasoning and avoiding multicollinearity within variables, the following variables were entered in the model: CT machine in the trauma room, age, gender, ISS, RTS, lactate, PT-INR, and time to CT scan.
Furthermore, to minimize the effect of confounding variables due to a non-randomized study in evaluating the effect of locating a CT machine in the trauma resuscitation room on mortality, propensity scores were calculated with locating the CT machine or not as a dependent variable and ISS, RTS, sex, PT-INR, fibrinogen, and performing CT as independent variables. We used optimal methods to create 1:1-matched study groups with a 0.05 caliper width. After adjusting for these confounding variables, we performed both univariate and multivariate logistic regression analyses with a forward selection, in which p < 0.10 was set as a criterion to include in the model for evaluating the effect of locating the CT machine in the trauma resuscitation room on mortality.
A p value of < 0.05 was considered to indicate statistical significance. All statistical analyses were performed using EZR, which is a graphical user interface for R (version 3.1.2, The R Foundation for Statistical Computing, Vienna, Austria) [29] and IBM SPSS Statistics, Version 22.0 (IBM Corp, Armonk, NY, USA).
Results
Study participant selection
Characteristics and outcome differences between patients treated in a trauma room with CT and a conventional resuscitation room (n = 246)
Total (n = 246) | Conventional resuscitation room (n = 140) | Trauma room with CT (n = 106) | p value | ||
---|---|---|---|---|---|
n (%)/median (IQR) | n (%)/median (IQR) | n (%)/median (IQR) | |||
Gender | Male | 181 (73.6) | 93 (66.4) | 88 (83.0) | 0.004 |
Female | 65 (26.4) | 47 (33.6) | 18 (17.0) | ||
Age | 51 (36, 69) | 50 (35, 70) | 54 (38, 69) | 0.769 | |
Initial vital signs | GCS | 14 (13, 15) | 15 (14, 15) | 14 (10, 15) | 0.017 |
Heart rate | 88 (72, 103) | 87 (72, 99) | 89 (73, 105) | 0.249 | |
Systolic pressure | 141 (118, 162) | 143 (121, 164) | 139 (113, 159) | 0.541 | |
Respiratory rate | 20 (17, 24) | 20 (17, 24) | 20 (18, 24) | 0.243 | |
Temperature | 36.4 (36.1, 36.9) | 36.4 (36.0, 36.9) | 36.4 (36.1, 36.9) | 0.618 | |
CT performed | 206 (83.7) | 113 (80.7) | 93 (87.7) | 0.164 | |
For head | 176 (71.5) | 93 (66.4) | 83 (78.3) | 0.046 | |
For body trunk | 162 (65.9) | 82 (58.6) | 80 (75.5) | 0.007 | |
Intubation in ER | 94 (38.2) | 43 (30.7) | 51 (48.1) | 0.008 | |
Use REBOA | 7 (2.8) | 1 (0.7) | 6 (5.7) | 0.045 | |
Arterial embolization | 25 (10.2) | 10 (7.1) | 15 (14.2) | 0.089 | |
Place chest tube in ER | 18 (7.5) | 6 (4.5) | 12 (11.3) | 0.052 | |
Type of Trauma | Blunt | 209 (85.0) | 118 (84.2) | 91 (85.8) | 0.857 |
Penetrate | 37 (15.0) | 22 (15.7) | 15 (14.1) | ||
Isolated TBI | 21 (8.5) | 12 (8.6) | 9 (8.5) | 1.000 | |
Polytrauma | 92 (37.4) | 42 (30.0) | 50 (47.2) | 0.008 | |
Hypotension | 29 (11.8) | 14 (10.0) | 15 (14.2) | 0.324 | |
TAC INR > 1.3 | 16 (3.9) | 5 (3.6) | 11 (10.4) | 0.038 | |
ISS category | 1–8 | 89 (36.2) | 58 (41.4) | 31 (29.2) | 0.011 |
9–15 | 65 (26.4) | 40 (28.6) | 25 (23.6) | ||
16–24 | 54 (22.0) | 29 (20.7) | 25 (23.6) | ||
≥ 25 | 38 (15.4) | 13 (9.3) | 25 (23.6) | ||
ISS | 10 (4, 18) | 9 (4, 16) | 13 (5, 22) | 0.002 | |
RTS | 7.84 (6.90, 7.84) | 7.84 (7.48, 7.84) | 7.84 (6.38, 7.84) | 0.015 | |
Ps | 97.6 (92.2, 99.3) | 97.8 (94.2, 99.4) | 96.8 (81.3, 99.2) | 0.009 | |
Lactate | 2.0 (1.3, 2.9) | 2.0 (1.3, 2.9) | 1.9 (1.3, 3.0) | 0.876 | |
BE | −0.20 (−2.62, 1.33) | −0.30 (−2.6, 1.2) | −0.10 (−2.8, 1.5) | 0.807 | |
Hg | 13.2 (11.4, 14.4) | 13.2 (11.6, 14.5) | 13.2 (11.2, 14.0) | 0.439 | |
Fbg | 286 (230, 336) | 298 (257, 353) | 260 (208, 314) | < 0.001 | |
APTT | 26.4 (24.1, 28.8) | 26.4 (24.1, 28.5) | 26.9 (24.3, 29.4) | 0.283 | |
PT-INR | 1.04 (0.97, 1.12) | 1.02 (0.95, 1.10) | 1.06 (0.99, 1.15) | 0.001 | |
FDP | 13.7 (3.6, 53.2) | 10.8 (3.2, 30.9) | 18.4 (4.7, 87.0) | 0.025 | |
D-dimer | 7.6 (1.4, 29.4) | 6.6 (1.2, 21.4) | 9.7 (1.7, 46.1) | 0.043 | |
Transfusion | RBC | 0 (0, 6) | 0 (0, 4) | 0 (0, 8) | 0.009 |
FFP | 0 (0, 4) | 0 (0, 0) | 0 (0, 10) | 0.002 | |
Mortality | In-hospital | 15 (6.1) | 6 (4.3) | 9 (8.5) | 0.189 |
24 h | 6 (2.4) | 2 (1.4) | 4 (3.8) | 0.407 | |
RBC ≥ 10 U/24 h | 39 (15.9) | 17 (12.1) | 22 (20.8) | 0.079 | |
Time to CT (min) | 30 (23, 42) | 37 (30, 48) | 23 (18, 28) | < 0.001 | |
Time to TAE (min) | 81 (67, 93) | 81 (56, 97) | 80 (73, 87) | 0.856 | |
Time to operation (min) | 94 (61, 122) | 97 (7, 123) | 83 (68, 121) | 0.687 | |
ED staying (min) | 81 (58, 117) | 91 (61, 122) | 72 (53, 113) | 0.044 | |
ICU stay (day) | 3 (2, 7) | 3 (2, 7) | 3 (2, 6) | 0.811 | |
Hospital stay (day) | 16 (5, 35) | 15 (5, 34) | 17 (5, 37) | 0.975 |
Multivariate logistic regression analysis on mortality with associated factors (n = 246)
Factors | Odds ratio | (95% CI) | p value | |
---|---|---|---|---|
Age | 1.16 | (1.02–1.33) | 0.028 | |
Gender | (reference: female) | 1.65 | (0.10–26.60) | 0.720 |
ISS | 1.20 | (1.02–1.42) | 0.029 | |
RTS | 0.11 | (0.03–0.42) | 0.002 | |
Lactate | 1.80 | (1.04–3.11) | 0.034 | |
PT-INR | 463 | (0.51–42 × 104) | 0.077 | |
Time to CT | 0.84 | (0.71–0.99) | 0.037 | |
Treated in trauma room with CT | (reference: treated in conventional resuscitation room) | 0.002 | (0.00–0.75) | 0.040 |
Results of multivariate logistic regression analysis and propensity score matched analysis on primary and secondary outcomes, comparing patients treated in the trauma room with CT and treated in the conventional resuscitation room. Adjusted models include age, gender, ISS, RTS, lactate, PT-INR, and time to CT as covariates
Characteristics and outcome differences between patients treated in trauma room with CT and conventional resuscitation room after propensity score matching (n = 176)
Total (n = 176) | Conventional resuscitation room (n = 88) | Trauma room with CT (n = 88) | p value | ||
---|---|---|---|---|---|
n (%)/median (IQR) | n (%)/median (IQR) | n (%)/median (IQR) | |||
Gender | Male | 145 (82.4) | 72 (81.8) | 73 (83.0) | 1.000 |
Female | 31 (17.6) | 16 (18.2) | 15 (17.0) | ||
Age | 50 (35.8,67.2) | 49 (33, 68.3) | 52.5 (36, 67) | 0.726 | |
Initial vital signs | GCS | 14 (13, 15) | 14 (13, 15) | 14 (13.8, 15) | 0.931 |
Heart rate | 88 (72, 103) | 88 (72, 102.3) | 89 (72.5, 103.1) | 0.877 | |
Systolic pressure | 142 (120, 162) | 143 (117.8, 164.8) | 140 (120, 159) | 0.747 | |
Respiratory rate | 20 (17, 24) | 20 (17, 24) | 20 (17, 24) | 0.366 | |
Temperature | 36.4 (36, 36.9) | 36.4 (35.9, 36.8) | 36.4 (36.1, 36.9) | 0.537 | |
CT performed | 152 (86.4) | 77 (87.5) | 93 (85.2) | 0.826 | |
For head | 127 (72.2) | 61 (69.3) | 83 (75.0) | 0.501 | |
For body trunk | 122 (69.3) | 58 (65.9) | 80 (72.7) | 0.414 | |
Intubation in ER | 72 (40.9) | 34 (38.6) | 38 (43.2) | 0.646 | |
Use REBOA | 5 (2.8) | 1 (1.1) | 4 (4.5) | 0.364 | |
Arterial embolization | 20 (11.4) | 9 (10.2) | 11 (12.5) | 0.812 | |
Place chest tube in ER | 15 (8.5) | 6 (6.8) | 9 (10.2) | 0.589 | |
Type of trauma | Blunt | 147 (83.5) | 73 (83.0) | 74 (84.1) | 1.000 |
Penetrate | 29 (16.5) | 15 (17.0) | 14 (15.9) | ||
Isolated TBI | 12 (6.8) | 8 (9.1) | 4 (4.5) | 0.370 | |
Polytrauma | 69 (39.2) | 35 (39.8) | 34 (38.6) | 1.000 | |
Hypotension | 20 (11.4) | 10 (11.4) | 10 (11.4) | 1.000 | |
TAC INR > 1.3 | 9 (5.1) | 5 (5.7) | 4 (4.5) | 1.000 | |
ISS category | 1–8 | 62 (35.2) | 32 (36.4) | 30 (34.1) | 0.696 |
9–15 | 45 (25.6) | 21 (23.9) | 24 (27.3) | ||
16–24 | 45 (22.2) | 22 (25.0) | 17 (19.3) | ||
≥ 25 | 30 (17.0) | 13 (14.8) | 17 (19.3) | ||
ISS | 10 (4.8, 20) | 10 (4.8, 17.3) | 10 (4.8, 20) | 0.709 | |
RTS | 7.84 (6.90, 7.84) | 7.84 (6.90, 7.84) | 7.84 (7.06, 7.84) | 0.873 | |
Ps | 97.7 (92.1, 99.3) | 97.7 (92.1, 99.2) | 97.6 (91.5, 99.3) | 0.781 | |
Lactate | 2 (1.3, 2.9) | 2 (1.4, 3.2) | 1.9 (1.3, 2.7) | 0.245 | |
BE | −0.3 (−2.6, 1.5) | −0.5 (−2.9, 1.1) | 0.15 (−2, 1.9) | 0.082 | |
Hg | 13.3 (11.4, 14.6) | 13.3 (11.2, 14.7) | 13.3 (11.4, 14.3) | 0.537 | |
Fbg | 280 (229, 327) | 289 (246, 332) | 268 (222, 317) | 0.278 | |
APTT | 26.4 (24.1, 28.7) | 26.2 (24.1, 28.6) | 26.7 (24.1, 28.9) | 0.771 | |
PT-INR | 1.04 (0.97, 1.12) | 1.02 (0.95, 1.12) | 1.06 (0.98, 1.12) | 0.096 | |
FDP | 14 (3.9, 47.3) | 15.3 (4.3, 37.8) | 12.7 (3.9, 67.9) | 0.858 | |
D-dimer | 7.6 (1.5, 25.8) | 8.5 (1.5, 23.3) | 7.1 (1.6, 35.6) | 0.955 | |
Transfusion | RBC | 0 (0, 6) | 0 (0, 6) | 0 (0, 6) | 0.909 |
FFP | 0 (0, 6) | 0 (0, 4) | 0 (0, 6) | 0.727 | |
Mortality | In-hospital | 9 (5.1) | 5 (5.7) | 4 (4.5) | 1.000 |
24 h | 3 (1.7) | 2 (2.3) | 1 (1.1) | 1.000 | |
RBC ≥ 10 U/24 h | 30 (17.0) | 15 (17.0) | 15 (17.0) | 1.000 | |
Time to CT (min) | 30 (22, 43) | 40 (30, 52) | 22 (17, 28) | < 0.001 | |
Time to TAE (min) | 81 (81, 100) | 77 (56, 98) | 81 (78, 91) | 0.438 | |
Time to operation (min) | 75 (60, 122) | 99 (60, 127) | 83 (70, 118) | 0.842 | |
ED staying (min) | 74 (56, 103) | 91 (65, 115) | 68 (52, 83) | < 0.001 | |
ICU stay (day) | 3 (2, 7) | 3 (2, 9) | 3 (2, 6) | 0.401 | |
Hospital stay (day) | 17 (5, 39) | 17 (5.5, 40) | 17 (5, 37) | 0.534 |
Multivariate logistic regression analysis after propensity score matching on mortality with associated factors (n = 176)
Factors | Odds ratio | (95% CI) | p value | |
---|---|---|---|---|
Age | 1.14 | (1.04–1.25) | < 0.001 | |
ISS | 1.16 | (1.02–1.31) | 0.024 | |
RTS | 0.09 | (0.02–0.37) | < 0.001 | |
Lactate | 1.28 | (0.979–1.67) | 0.07 | |
Treated in trauma room with CT | (reference: treated in conventional resuscitation room) | 0.065 | (0.00–0.985) | 0.0487 |
Discussion
Our study showed for the first time that a CT machine in the trauma room had a significantly positive effect on mortality. Patient mortality in the room with a CT machine was higher than that treated with the standard work-up; however, there were no statistically significant differences in hospital mortality after univariate analysis. This was after YCUMC was designated as a trauma center with more severe patients, higher ISS, and lower Ps. However, multivariate logistic regression analysis of the entire sample and the samples after propensity score matching showed positive effect on mortality. This significant association might attribute to a reduced time in decision-making. Equipping a trauma room with a CT machine allows clinicians quicker access to the machine to provide clinical decisions to treat faster with greater accuracy than a standard work-up. This speed with accuracy in the decision-making likely contributes to a lower mortality.
In addition, we had prepared and conducted series of simulation training in advance using the new trauma room with staffs involved in acute trauma care such as doctors, nurses, and laboratory technicians. Improvement of workflow through these simulation trainings might contribute to lower mortality for the trauma room with the CT group.
We did not find other significant associations in the secondary outcomes, such as the length of ICU stay and hospital stay. Our results suggest that the quality of care for patients will improve in a trauma room with a CT machine, independent of the severity of the trauma.
Previous studies with a pre–post study design showed inconsistent findings on the association between a CT machine in the trauma resuscitation room and an improvement in clinical outcomes [6, 17, 18, 19]. A randomized control trial, the RACT1 trial, compared a CT machine in the trauma room to the conventional resuscitation room in two Dutch trauma centers (n = 1124) and found no significant effects of the CT machine in the trauma room on patient mortality [21]. Recently, a multicenter randomized control trial to examine the effect of immediate TBCT scanning, the REACT 2 trial, conducted in several trauma centers found no significance in the reduction of mortality [30]; however, not all the trauma centers conducting the immediate TBCT had a CT machine in the trauma room. Stefan Huber-Wagner et al. compared the distance of the CT machine from the trauma resuscitation room with survival from several trauma centers [14]. Our study was the first to identify the significant and positive effect of a trauma room equipped with a CT machine on patient mortality.
Our study also showed that a CT machine in the trauma room reduced the time to the start of CT scan by 20 min (from 37 to 23 min) and the length of the ED stay by 19 min (from 91 to 72 min). In selected samples after propensity score matching, time to start CT scan was reduced by 18 min (from 40 to 22 min) and the length of the ED stay reduced by 25.5 min (from 94.5 to 69 min). This reduction was comparable or larger than that described in previous studies [7, 18, 20, 21, 22, 30]. This time saved could improve the workflow in a trauma care center and has a beneficial effect for the department staff. Previous studies have shown that the diagnostic work-up time was significantly longer in patients undergoing a conventional resuscitation [7, 18, 20, 21, 22, 30]. A rapid overview of all threatened body regions can be obtained, which increased decision-making and treatment times, leading to a lower mortality.
The presence of a CT machine in a trauma resuscitation room also has the following potential benefits. Installing a CT machine in a trauma room reduces the number of transfers to a CT room. Patient transfers can be time-consuming and laborious as the patient has to be moved to a transport stretcher and then back to a CT table. In a previous study, it was dangerous to transfer patients with hemodynamic instability to a CT room, which was called the tunnel of death [31]. These hemodynamically unstable patients could undergo a CT scan using the CT machine located in the trauma room. In our study, there were no patients who were unable to receive a CT scan because of hemodynamic instability in the group of patients treated in the trauma room with a CT machine. Installing a CT machine in a trauma room may resolve decision-making dilemmas in acute trauma care in patients without an obvious primary source or potentially multiple sources of hemorrhage. Such patients would benefit the most from CT scan information, as well as the reduced time to treatment.
We acknowledge several limitations of our study. First, this was a retrospective study; therefore, it was impossible to perform a sample size calculation. The current sample size would justify the utilization of a regression model with given proportions of outcomes [32]. Second, significant differences in baseline, including ISS and RTS, were observed between the two groups, which suggest heterogeneity in patients and raise concerns regarding the inability to control the effects of confounding factors. Thus, we employed a valid multivariate model to control these differences in our analysis. In addition, to overcome the bias, we further performed propensity score matching analysis because randomly allocating a patient into use or non-use of a trauma room with a CT machine could be difficult in certain clinical situations. Third, we also conducted a single-center study. There could be selection bias and a limitation in generalizability. Patients admitted to our hospital might be treated with a shorter time to transfer compared to those admitted in hospitals in a rural region. To evaluate the effects of a CT machine in the trauma room, our study design would be still appropriate. Fourth, we excluded pediatric patients and patients with CPA. This exclusion might affect the generalization of our study findings. Lastly, there was selection bias due to potential differences in decisions on performing the CT scan made by each trauma leader. The leaders were trained in YCUMC, and daily conferences by the trauma team could guarantee equality in decision-making.
Conclusions
In conclusion, our study showed the effects on mortality using a CT-equipped trauma room. Our study also showed the time benefits of placing a CT machine in the trauma room. This time benefit could be critical in severe trauma patients, allowing life-threatening problems to be detected and allowing earlier critical decision-making. Installing a CT machine in the trauma room could reduce time for decision-making in treating a trauma patient and subsequently lower the mortality of trauma patients.
Notes
Acknowledgements
The authors would like to thank all staffs at YCUMC.
Funding
The study did not receive any funding.
Availability of data and materials
The datasets used during the current study are available from the corresponding author on reasonable request.
Authors’ contributions
SF and TA wrote the study protocol. SF collected data from the hospital. SF and TA analyzed the data and drafted the manuscript, with critical review from all authors. All authors contributed with critical revision of the protocol. All authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the ethics committee of YCUMC. The ethics committee at our institution does not require informed consent for observational studies using anonymous data previously collected for routine operations. The reference number is B170400019.
Consent for publication
This study was an observational study. Thus, obtaining a consent from a patient was waved by the institutional review board.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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