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Reducing the mortality rate related to RTA in respect to the
West Midland approaches in establishing of MTC around a city.
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The research title:
Reducing the mortality rate related to RTA in respect to the West Midland approaches in
establishing of MTC around a city.
The abstract:
Road traffic accidents (RTAs) consider the leading cause of death in the worldwide for
people who are under 45 years old. This high mortality rate lead some of the devoloped
countries to establish new trauma system to reduce the mortality rate of trauma especially
from RTAs. These systems brought an idea of Major Trauma Centres (MTCs) which is a
specialist hospital contain all the trauma patients needs without a necessity for a further
transfer for more advanced hospital. These MTCs have shown a significant reduction in the
mortality rate of trauma. Furthermore, almost there is no previous study which examine the
effect of those MTCs isolated from other trauma injuries.
This study will focus on the MTCs in the West Midland which include three MTCs by a
comparison between the data before the establishment of those MTCs, the data after
establishment in one year and the last year data. However, there will not be a direct contact
with the patients and their data will be coded. However, this research aims to study the
effect of MTCs on the reducing mortality rate of RTAs.
The research topic:
The developing countries suffer from deaths resulting from trauma especially road traffic
accidents (RTA) which is consider the leading death in worldwide for the population under
45 years old (Oestern, Garg and Kotwal, 2013). These deaths can be avoided when the
government improve the road safety standards and health service systems. On the other
hand, some of the developed countries have established new trauma networks to deal with
trauma injuries which shows a significant reduction in the mortality rate.
Furthermore, in the UK, the new trauma network produce specialist hospitals called major
trauma centres (MTCs) contains all the services that trauma patients could need without a
necessity to a second transfer to a more advanced hospital. These MTCs have shown a
remarkable reduction in the mortality rate of trauma injuries (Davenport et al., 2010). In
addition, based on the previous studies in this research in chapter 3, almost there is no
research studied the effect of those major trauma centres on RTAs isolated from other
trauma injuries. In this research, the effect of MTCs on RTAs patients will be studied using
the endpoint of mortality rate. This will illustrate the impact of MTCs for those countries
who suffer from a high mortality rate resulting from RTAs.
Literature review:
Major trauma considers as the leading cause of death in the UK for people aged under 45
years old (Morrissey et al., 2015)(Morrissey et al., 2015) In addition, major trauma is a
remarkable cause of disability, causing about 250 million disabilities worldwide each year
which resulting in a sever changing in life’s patients(Kieffer et al., 2016) (McCullough et al.,
2014) . These changes include especially head and spinal cord injuries which cause the most
dangerous disabilities on a community. Both deaths and disabilities resulting from trauma
affecting countries by reducing a manpower that the community could use it to improve
and develop within that community. For instance, Today, One quarter of the death result
from road traffic accidents(Lendrum and Lockey, 2013). These deaths could be preventable
if governments ameliorate their health services. From a wider prospective, World Health
organization (WHO) estimates that the death because major trauma in 2020 would be the
leading cause of death worldwide (Manson et al., 2013).
However, major trauma is defined widely as each trauma with Injury Severity Score (ISS) >
15 (Kehoe et al., 2015). ISS is a one of scoring system that describe the severity of the
trauma numerically which is used nowadays internationally. This scoring system divide the
body into six regions which are: head and neck, face, chest, abdomen, extremities and
external, and calculated by the sum of squares of abbreviate injury scale (AIS) for the most
severely injured regions of the body (Kehoe et al., 2015) . ISS system helps fieldworkers like
paramedics and emergency medical technicians (EMT) to inspect the severity of the injury
quickly to decide whether they have to transport a trauma patient to a local hospital or to a
major trauma centre.
The first major trauma centre was established in the UK in April 2010 located in London as a
result of a new trauma network system (McCullough et al., 2014), while major trauma
centres were gone live before that in the USA (Davenport et al., 2010),(Morrissey et al.,
2015). The idea behind establishing a major trauma centre was to locate a speciality hospital
to receive any case of trauma which match the standers that used and centralise the care
that a trauma patient could need without needing for a secondary transfer. Nowadays,
there are 26 major trauma networks in England and each one has a major trauma centre
(McCullough et al., 2014) and department of health has standardized the criteria that each
major trauma network has to follow to implement a major trauma centre (Jansen et al.,
2015).
The effect of those major trauma centres was studied widely on reducing the mortality rate
and number of disabilities. Davenport et al (Davenport et al., 2010) state that major trauma
centres have reduced the mortality rate within a few years after establishment. In
particular, (Shuman and Meyers, 2015) clarified that better outcomes could take from five
to eight years to become apparent. In addition, (Stammers et al., 2013) suggest that major
trauma centres offer better outcomes for trauma patients than other emergency services
while (MacKenzie et al., 2006) state that death after injuries was reduced for patients who
were treated in trauma centre more than others who are treated in non-trauma centre.
Another study from USA shows that centralization the care provided to major trauma can
reduce in-hospital mortality (Lendrum and Lockey, 2013).
In particular, road traffic accidents consider the leading cause of death for those who are
under 45 years in the world (Oestern, Garg and Kotwal, 2013). In addition, WHO estimate
that the road traffic accidents will be the leading cause of death in 2020. In the UK, the road
traffic accidents cause about 5400 death each year based on the national audit office.
However, despite that (MacKenzie et al., 2006) state that treatment in major centres is
more effective when the patients are 55 years, the impact of major trauma centres on
trauma was studied widely but almost none study from the previous studies examine the
effect of the major trauma centres on the Road traffic accidents particularly. There were
some studies which provide some bases of the effect of major trauma centre on road traffic
accidents. For instance, (Kehoe et al., 2015) found that the mortality rate was reduced by a
half between 1990 to 2013, as a result of establishment major trauma centres with other
effective regulations. In 1990, the most common cause of death in the UK was road traffic
accident which was represent 60% of mechanisms while in 2013, which is after
implementation the major trauma centres in the UK, there was a reduction to reach 30%.
In general, the major trauma centres in the UK have another impact not only on the
mortality rate. In additions, (Stammers et al., 2013) shows that the major trauma centres
provide more than a reduction in the mortality rate. For example, the major trauma centres
reduce the time that trauma patients could take to arrive to a specialist care from 205.7
hours to be 37.4 hours. It is believed that transporting the patient to a definitive care is a
core role for the emergency medical services to save patient’s lives. Another impact of the
major trauma centre is a reduction on the in-hospital stay. Stammers found that, there was
an obvious reduction on the length of stay in hospital after the implementation of major
trauma centres. In contrast, (Hannon et al., 2013) state that the number of calls and patient
admitted to a hospital after establishment of major trauma centre was significantly
increased. The number of calls was increased by 200% from 30 calls before major trauma
centres to be 90 calls in after while the number of patients admitted to a hospital was
increased from 22 to 64 after the major trauma centres.
From all the previous studies, this research found that there is a significant gap to study the
impact of major trauma centres on the road traffic accidents’ patients. In particular, this
research assumes that there are insufficient researches that illustrate the demographical
characteristics of those patients. In addition, the effect of these major trauma centres was
not studied enough to help those countries that suffer from a high mortality rate as result
from road traffic accidents to decide whether the establishing a major trauma centre can
help them to reduce the mortality rate or not.
The research question:
Does the establishing of Major Trauma Centres (MTCs) in the West Midland reduce the
mortality rate related to Road traffic accidents (RTA)?
The design:
This research is a retrospective or a secondary research which means that the data are
already exist in the data base and ready to be analysed for further research that required
access to those data. This research will be divided to two phases in term of dealing with
data. The first phase is the collecting data phase. in this phase, the focus will be on sources
of the data, types of the data that will be focusing on and the way of choosing and selecting
the data, and. The second phase is the analysing phase where the focusing here will be on
the benefit of data analysing methods and the software that could be used to analyse data.
The collecting data phase divides to three steps. The first step is the defining of the data
sources. The sources that will be used in this research will be Research Audit Trauma
Network (TRAN) for the statistics of those patients who admitted alive to major trauma
centres. In addition, the data of patients who did not reach to major trauma centres alive
will be collected from the calls log that ambulance services or National Health Services
(NHS) provide. Furthermore, the data of patients who discharged alive from major trauma
centres or died in the hospital will be collected from TRAN and hospital log.
The second step is the type of the data that will be collected. These data will be related to
the patients, accidents and major trauma centres. For instance, the data-related patients
include age, gender and severity of the injury. Furthermore, the data that related to
accidents comprise location and time of accidents, transferring time to major trauma
centres, type of ambulance services that response to the call, type of the interventions that
were provided, the status of the patients when they arrive to the major trauma centres.
Afterward, the data-related major trauma centres involve the time of admission and
discharge, the type of interventions that were provided in the major trauma centres, 30-day
mortality rate endpoint and the status of the patients in hospital.
The next step is the way of choosing the data. the data that will be chosen will divide to
three periods which are before the establishment of major trauma centres (pre-MTCs), one
year after establishing the major trauma centres and data of last year from recent. Each
period will include a year and each year will be divided to three durations. From each
duration one month will be picked randomly to compare it with the same months on the
other years in the study. However, the data of pre-MTCs will be collected from data of the
county, the department of health or the data of those hospitals themselves before being a
MTCs.
The second phase of this study is the analysing data. Firstly, the data will be analysed based
on the periods of the study. In particular, the data before establishing major trauma centres
will compare with the data after in one year to get the fast impact of establishing major
trauma centre while comparing the data before the establishment of major trauma centres
with the data last year will explore the long effect of major trauma centres on the public
health. In addition, to illustrate the on-going progress of major trauma centres over a period
after the establishment until last year, the date after the implementation will be compared
with those in the last year. However, there are recommended software that could use to
analyses the data. For instance, MATLAP or SPSS which are provided as free for university of
Birmingham students. Both software are dealing with quantitative data while NVivo
software could help with the qualitative data if there.
The population and sample:
This research will be focused on the West Midland as a population. The West Midland was
chosen as the second highest county population in the UK after London. This ignorance of
London refers to the special features of the city that could be difficult to apply it on another
city. In addition, London city was ignored because the West Midland have the highest
population who over 16 years old (West Midlands Databook 2017, 2017). However, the
West Midland have three major trauma centres which includes the Queen Elizabeth
Hospital Birmingham, University Hospital Coventry and Warwickshire and Royal Stoke
University Hospital. All of those centres will be included in the sample size. Furthermore,
this research will concentrate on the patients who had road traffic accidents whether they
arrive to major trauma centres or not. In particular, the data of those patients who did not
reach to major trauma centres will be collected from calls log while those who do arrive
their data will be found in Trauma Audit and Research Network (TARN). For this purpose, a
cluster sampling will be used after dividing the sample size into three periods (before MTCs
– one year after MTCs – last year of MTCs). Each period will include a whole year while the
sample will be the same month in each period. This month will be chosen randomly.
The procedure and instrument:
First of all, this retrospective research requires a contact with NHS in the West Midland to
decide whether the research will need an ethical approval on not. In case yes, the ethical
approval will be sought from the online integrated Research Application system (IRAS).
Furthermore, NHS will be contacted to have access to the calls log in the specific times of
this study. In addition, this research requires an access to the data base of Trauma Audit and
Research Network (TARN).
After completing all the paper work that will be necessary to implement this research, data
collection process will be started. In particular, the data will be collected in specific forms
which illustrate patients characterises, major trauma centres statistics and calls log. These
forms will be divided into three main parts that each one represents one major trauma
centre. In addition, each form will include three sub-group which represent the periods of
the study (pre-MTCs, one year post-MTCs and last year MTCs). After that, the data will be
exported to a software program preparing it to the analysis process.
The instrument that will be used to answer the question research is the comparison
between the three periods in the all major trauma centres. Furthermore, the comparison
between the pre-MTCs and one year post-MTCs will shows the fast impact of establishing a
major trauma centre on the mortality rate of road traffic accidents patients. In addition, the
comparison between Pre-MTCs and last year of MTCs will illustrate the long progress of
major trauma centres and the impact of this progress on the mortality rate of RTA patients.
After that, the comparison between the one year post-MTCs and last year of MTCs will
explore the improvement on these MTCs and the effect of these improvement on the
patients’ lives. However, the result will be shown in graphs and tables after finishing the
data analysis.
The ethics:
This research will collect the data from the data base like Trauma Audit and Research
Network (TRAN) and calls log and analyse them without any contacting with patients. This
kind of data include the demographical characteristics of the road traffic accidents patients
whom admitted to major trauma centres in the West Midland, UK. These data supposed to
be pure and mostly coded. This coding system will protect the privacy of the patients that
their data will be collected. However, in case the data were not coded, the approval from
the NHS or department of health will be needed.
Furthermore, this research required to an access of the data of those patients who dead
recently as result of road traffic accidents for the research purpose. These data are
necessary for the research to illustrate the mortality rate of the patients of road traffic
accidents who arrive to the major trauma centres alive. In this case, it is recommended to
contact with Research Ethical Committees (REC) for get an advice wither this research would
need to have approval from National Health Services (NHS REC) or not.
Based on the ethical principles, and despite the issues that mentioned earlier, this research
will not be harmful on the patients where the contact will be with data. In addition, the
informed consent will not be required from the patients as there in no directly contact with
them. Furthermore, as a result of this study is a retrospective research, there is no
deception while the research dealing with the data base. In addition, there is no benefit for
the participations as a result of there is no interviews or surveys to participate in.
The impact:
This research aims to study the effect of major trauma centres (MTCs) on the mortality rate
of road traffic accidents (RTAs). This will help countries that suffer from the high mortality
rate of RTAs to decide whether these MTCs will be effective in their countries or not.
Furthermore, this research will study the progress of these MTCs in terms of dealing with
RTAs over the years since it was established. This will show their effect and the
ameliorations that will be needed to improve their effectiveness.
•
References:
Davenport, R.A., Tai, N., West, A., Bouamra, O., Aylwin, C., Woodford, M., McGinley, A.,
Lecky, F., Walsh, M.S. and Brohi, K. (2010) ‘A major trauma centre is a specialty hospital not
a hospital of specialties’, The British journal of surgery, 97(1), pp. 109-117. doi:
10.1002/bjs.6806.
Hannon, E., Potter, S., Jaiganesh, T., Muhktar, Z. and Okoye, B. (2013) ‘The impact of adult
major trauma centre status on paediatric trauma activity’, Emergency medicine journal :
EMJ, 30(10), pp. 828-830. doi: 10.1136/emermed-2012-201125.
Jansen, J.O., Morrison, J.J., Tai, N. and Midwinter, M.J. (2015) ‘A survey of major trauma
centre staffing in England’, Journal of the Royal Army Medical Corps, , pp. 000350.
Kehoe, A., Smith, J.E., Edwards, A., Yates, D. and Lecky, F. (2015) ‘The changing face of major
trauma in the UK’, Emerg Med J, 32(12), pp. 911-915.
Kieffer, W.K.M., Michalik, D.V., Gallagher, K., McFadyen, I., Bernard, J. and Rogers, B.A.
(2016) ‘Temporal variation in major trauma admissions’, Annals of the Royal College of
Surgeons of England, 98(2), pp. 128-137. doi: 10.1308/rcsann.2016.0040.
Lendrum, R.A. and Lockey, D.J. (2013) ‘Trauma system development’, Anaesthesia, 68, pp.
30-39. doi: 10.1111/anae.12049.
MacKenzie, E.J., Rivara, F.P., Jurkovich, G.J., Nathens, A.B., Frey, K.P., Egleston, B.L.,
Salkever, D.S. and Scharfstein, D.O. (2006) ‘A national evaluation of the effect of traumacenter care on mortality’, New England Journal of Medicine, 354(4), pp. 366-378.
Manson, J., Cooper, S., West, A., Foster, E., Cole, E. and Tai, N.R. (2013) ‘Major trauma and
urban cyclists: physiological status and injury profile’, Emerg Med J, 30(1), pp. 32-37.
McCullough, A.L., Haycock, …
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