The management of trauma victims in England and Wales: a study by the National Confidential Enquiry into Patient Outcome and Death.

Objective: Trauma is the leading cause of death in the first four decades of life in western countries. A national prospective study was conducted in the UK to examine the process and quality of care of severely injured patients. We present a previously unpublished analysis of the severity of injury, place of treatment, quality of care and survival amongst patients with thoracic injuries.

Methods: All UK hospitals with an emergency department were asked to provide prespecified clinical and process data on all patients presenting with significant injuries between 1st February and 30th April 2006. All data were stripped of patient, clinician and institutional identifiers before review by expert advisors.

Results: Data adequate for analysis were obtained on 1735 of 2203 injured patients reported. An injury severity score (ISS) > or = 16, the threshold for severe injury, was derived from case records of 795 patients, who comprise the study denominator. Of these, 387 (49%) had a thoracic injury, usually as part of polytrauma. The mortality rate was 8% (of 13) 9% (of 23) 10% (of 175) 14% (of 136) 22% (of 37) and 100% (of 3) for the six ascending grades of severity for the thoracic component of the ISS score. One hundred and seventy-six of the 795 patients (22%) had a thoracic injury sufficient for them to be classified as severely injured regardless of any other injuries. The quality of care as assessed by expert advisors showed an apparent association with overall trauma volume of the 142 treating hospitals. For patients with thoracic injuries where the specialty of the team in charge could be identified (n = 284/387) trauma and orthopaedics (T and O) cared for 36%, critical medicine 22%, general surgery 19%, neurosurgery 8% and only 5% were in the care of thoracic surgeons. One or more chest drains were inserted in 203/795 (26%) of patients, few of them by thoracic surgeons.

Conclusions: Given that polytrauma patients rarely come under the care of thoracic surgeons and yet frequently have severe thoracic injuries there is a clear need for T and O surgeons and generalists to have a good grounding in thoracic procedures.