European trauma guideline compliance assessment: the ETRAUSS study

In Europe, blunt trauma dominates epidemiology in small centres as well as in larger centres with more than 500 trauma admissions per year. This differs from North American trauma centre data [10]. In Europe, the trauma admission volume per centre and per year seem to be inferior to those reported in North America. In an important study of patients with an Injury Severity Score higher than 15, Nathens et al. showed the positive impact on length of stay and mortality in centres admitting more than 300 trauma patients per year [11]. This number exceeds the volume reported for most trauma centres in our survey (Table 2). Nevertheless, the comparison of European and North American trauma care systems is made difficult by significant organisational divergences in emergency medical systems and even the primary specialties of trauma leaders (Fig. 2). Furthermore, the European trauma centre organisation, staffing and resources in our survey sample were all quite heterogeneous. That said, the core elements of any trauma system—a dedicated trauma team and a designated and identifiable leader—were reported for the majority of centres.

Our survey suggests a large variability in compliance with the 2013 guidelines. This is highlighted by the levels of compliance regarding blood pressure targets, vasopressor use, blood product ratios and use of adjunct haemostatic products. Maintaining a target systolic arterial blood pressure of 80–90 mmHg in patients with ongoing haemorrhage is a relatively high-level recommendation (1C). However, only 38 % of responders stated that they target this level of systolic blood pressure in patients without TBI. Some 35 % of responders still use mean arterial pressure as a target. In contrast, the ongoing controversy about vasopressor use results in its being just a grade 2C recommendation. Nevertheless, vasopressor administration prevails according to 75 % of responders. Only 22 % of them reported considering the potential deleterious effects related to vasopressor use.

Similar conclusions can be drawn for the use of fresh frozen plasma (grade 1C) and the ratio of fresh frozen plasma to red blood cells (grade 2C). Until recently [12], no high-level evidence was available to support this strategy. However, a ratio of fresh frozen plasma to red blood cells between 1:2 and 1:1 seemed highly consensual, even though doubts emerged from a recent study about the benefits and effects of using this measure [13].

Adjunctive agent use was highly variable. The administration of tranexamic acid is supported by a large, multicentre, randomised clinical trial (grade 1A). Despite this study, responders seemed not entirely convinced by this recommendation. In contrast, the use of fibrinogen appeared frequent, even though its level of recommendation is low. Our data also suggest increasing use of viscoelastic diagnostic methods to monitor trauma-associated coagulation disorders.

The relatively low rate of guideline compliance we found is not surprising compared with the results of other practice survey studies. For example, overall compliance with the Surviving Sepsis Campaign guidelines was around 31 %, even after a large international educational campaign [14]. One study done in a large, multicentre network in France demonstrated a 24 % rate of compliance with high-level practice recommendations [15]. Of note is the large variability of adherence to a specific guideline in this study, ranging from 20 % to 96 %. This observation was corroborated in a recent survey on shock management [16].

Hence, the level of evidence does not seem to be the major criterion associated with guideline adherence. Both national context and specialty training affect compliance rates. For example, crystalloids are a consensual choice for fluid resuscitation. However, therapeutic choices for fluid in intravenous fluid resuscitation differ between anaesthetists, intensivists, surgeons and emergency physicians. Another example is vasopressor use, in which surgeons are less likely to indulge than intensivists or anaesthetists. Some other important determinants are probably associated with knowledge levels [17, 18], attitudes and personal values. Finally, organisational and administrative models of trauma centres may influence compliance with guidelines [19].

In stressful environments such as trauma centres, health care professionals often adopt heuristic decision-making strategies to reduce cognitive load [20, 21]. Trauma care is stressful and characterised by uncertainty, and, as such, gaps between knowledge and routine practice may evolve [22, 23]. In addition, the low level of evidence for most recommendations probably encourages these processes. Nevertheless, in the face of uncertainty, guidelines should be used to facilitate decision-making processes, thereby reducing the burden of uncertainty and anxiety and reassuring practitioners, patients and patients’ relatives.

The univariate analysis showed that the structures specifically organised for trauma care (trauma centres, trauma ICUs) were significantly linked to better guideline compliance. Strikingly, this was independent of their academic label. Along the same lines, a previous study underscored the variations in care between different institutions, impacting patient outcomes [24]. Elsewhere, guideline compliance was associated with improved outcomes [25]. The interest in these results is to show that, among European countries, compliance with guidelines seems to be improved among professionals working in dedicated trauma centres. We also found an association between specialty and guideline compliance. The European guidelines are published by the ESICM that is composed of more anaesthesiologists and intensivists than other specialists. This probably impacted the accuracy of responses. We did not compare the differences between countries, for several reasons. The representation was imbalanced among European countries, and combining different countries (e.g., based on their geographic region) might have been similarly prone to bias, as most countries differ in their trauma care organisation and face different local and/or regional constraints.

Our survey has inherent limitations. First, a selection bias cannot be excluded. Given the process of dissemination, it is difficult to provide an estimation of the nonresponder-to-responder ratio. We targeted practitioners working primarily in trauma care, but of course results from this sample cannot be extrapolated to the practice of all physicians in Europe participating in major trauma care. The overrepresentation of academic hospitals and the low recruitment rate in some quite large European countries may also have introduced further bias. As the survey was produced by the ESICM, physicians from Western European countries were represented more than those from other specialities. Furthermore, any self-reported survey is highly prone to bias; thus we could not assess the gap between routine practice and self-perception. As such, guideline compliance in the present study reflects no more than self-perceived and self-reported compliance.