Effective trauma management requires a coordinated and integrated approach. The trauma system organization reflects the trimodal distribution of mortality in traumatized patients and organized trauma management systems help prevent trauma-related deaths and can have a favorable impact on patient outcomes.

The introduction of a Trauma Team (TT) to a level III hospital provides a multidisciplinary, “horizontal,” approach to trauma patients delivered by a group of specialists with specific knowledge and skills. It contributes to improved patient management, and the resulting surgical outcomes compared with the standard, “vertical” support delivered by a single physician applying the advanced trauma life support (ATLS) protocol.

At Careggi University Hospital, the introduction of a TT and the implementation of the related services has produced significant beneficial effects (new emergency and trauma surgery operating rooms (OR), implementation of interventional radiology with hybrid OR for angio-embolization procedures, implementation of dedicated post-trauma management pathways for intensive and sub-intensive care, presence of highly specialized professionals such as vascular surgeon, thoracic surgeon, cardiac surgeon and neurosurgeon).

Besides the development of specific ATLS training courses, simulation pathways, and the introduction of a pool of experts specialized in the pathology and treatment of traumatic injuries, a TT has contributed to the general improvement in the management of trauma patients. The importance of training through ATLS courses, and the need for comparisons between all specialists involved in trauma care are widely recognized aspects in preventing management errors, and strengthening teamwork and team-building. With the introduction of a TT and multidisciplinary reception, a further novelty for the hospital was the arrival of prehospital dispatch in the Shock Room (SR). The whole team decides collectively the diagnostic-therapeutic process under coordination of the trauma leader who, in our case, is the emergency doctor. Before the TT, the surgical, anesthesiological and orthopedic activity was consulting, now it is multidisciplinary with a team leader. Multidisciplinary management is crucial in an efficient TT since the trauma patient can require distinct resuscitation of several vital functions, in a “horizontal approach,” and prompt surgical decision-making. Briefing and debriefing are essential in trauma care. Performing a briefing before patient arrival will provide a shared mental model of the patient’s status, his/her potential needs and is crucial for proper team role allocation. Debriefing after successful and, particularly, after unsuccessful resuscitations, can have multiple benefits. These include improved team morale and cohesion, and learning from the mistakes, in a non-judgmental environment, to improve future patients’ outcomes.

In 2016, our level III university hospital was designated a trauma center as part of the National Trauma Network. The TT was officially established on the 1^st August 2018. A shared path and multidisciplinary teamwork was applied which allowed faster and better treatment of trauma patients.

The objective of this study was to compare polytrauma patients treated at our institution in the 20 months prior to the establishment of the TT with patients managed in the following 20 months. The primary aim was to assess whether the introduction of the TT has resulted in better management and outcomes for trauma patients. The secondary aim was to evaluate if and how the decision-making process for performing surgical and/or interventional procedures had changed since the implementation of the TT.

This is a non-randomized single-center retrospective study reporting on a consecutive series of patients with polytrauma who accessed the SR in the period between 01/12/2016 and 31/03/2020. Patients were divided into 2 subgroups: 20 months prior to the establishment of the TT (preTT; from 01/12/2016 to 31/07/2018) and 20 months post the establishment of the TT (postTT; from 01/08/2018 to 31/03/2020).

All patients with clinical, anatomical, and dynamic criteria for major trauma (according to ATLS) and who met the TT activation criteria were included. Exclusion criteria were: age < 18 years; trauma patients who died in SR.

The introduction of a TT provides a multidisciplinary, “horizontal,” approach to trauma patient care delivered by a group of specialists with specific knowledge and skills that contribute to improved patient management and surgical outcome compared with the standard, “vertical” support by a single physician applying the ATLS protocol.

At our institution, the introduction of a TT and the implementation of the services related to it was evaluated (new emergency and trauma surgery operating rooms, implementation of interventional radiology with hybrid operating rooms for angio-embolization procedures, implementation of dedicated post trauma management pathways for intensive and sub-intensive care, and presence of highly specialized professionals such as a vascular surgeon, thoracic surgeon, cardiac surgeon, and neurosurgeon).

Besides, the development of specific training courses, simulation pathways, and the introduction of a pool of experts specialized in traumatic injuries, the TT has contributed to a general improvement in the management of trauma patients. The importance of training and the need for regular comparisons between all specialists involved in trauma care are widely recognized aspects in preventing care management errors in trauma patients [1,2].

Since our trauma center was recently implemented, an opportunity to compare standard preTT management with the multidisciplinary postTT management presented. Previous studies have shown that severely injured patients resuscitated by a TT have a higher chance of survival [3–5]. To the best of our knowledge, this is the first study that retrospectively evaluated the quality of care for major traumas with reference to patients undergoing surgical and/or interventional radiology treatment and compared TT management of polytrauma patients with standard management.

Considering the study population, the number of traumas observed in the period after the establishment of the TT was higher than in the preTT period. The 2 groups present homogeneous descriptive epidemiological characteristics and trauma severity, which was expected, given that our university hospital is the referral hospital for the whole region for traumas. It can also be explained by the introduction of specific protocols relating to secondary centralization from other spoke facilities to our hub center. As a result, the establishment of a TT did not have any influence on the type and severity of injuries of the polytraumatized patients referred to our trauma center.

In order to compare trauma severity between the 2 groups, ISS, Revised Trauma Score and Trauma Injury Severity scores were used. The usefulness of these tools is debated in the literature [6–10]. It is evident that all 3 scores do not take in consideration the comorbidity of the traumatized patient, but do play a decisive role in determining prognosis. It is undeniable that the use of these scores guarantees a unified language, allowing common comprehension, for the various professionals called to assess injury severity. An attempt has been made to overcome this drawback by using the American Society of Anesthesiologists (ASA) score, that provides an estimate for grading comorbidity in trauma patients. The resulting median ASA score in both groups was 2, in line with the fact that patients who are victims of trauma are, on average, younger, and hence with less comorbidities.

In this study, the median ISS (calculated for all 947 patients) was 17, higher than in other Italian case studies [11,12]. This is most likely due to the centralization of patient access for many severe cases, and our hospital is favored due to the presence of a heliport allowing the rapid transport and treatment of the critical care patient.

No difference was observed in the ISS, Revised Trauma Score and Trauma Injury Severity Score between the pre and post TT groups, because even before the formal establishment of the TT, many severe traumas were already centralized, since many of the services that characterize a trauma center were already present within our institution.

A reduction in the arrival time of TT members to the SR and in the execution of some diagnostic and therapeutic procedures in the SR which were not statistically significant when considered individually, may be important if taken as a whole, for the reduction of the overall time spent in the Emergency Room. This might indicate a better coordination amongst staff members that facilitated rapid clinical and diagnostic assessments of patients who could be more promptly transferred for definitive care. Besides, this parameter affects the trauma patient’s “golden hour” and hence mortality, in particular the deaths grouped under the 2^nd peak of the classic trimodal mortality distribution. This may suggest that early patient assessments and care may have improved both in the SR and in the region because the Emergency Room medical and paramedic staff had received specific training. In addition, after the establishment of a major trauma coordination committee, several meetings have taken place with the coordinators of regional emergency service, with the aim to improve triage criteria, centralize access of patients severely injured and better coordinate the initial emergency response.

The overall mortality was 9.3% in this study which was similar to mortality rates in other Italian trauma centers [11,12]. In this study, the most frequent cause of death was severe brain injury, as also observed in a recent systematic review, that showed a relative increase in brain injury-related death (which are frequently nonavoidable deaths) because of the reduction of the other causes of death (multiple organ failure, adult respiratory distress syndrome, and sepsis) [13].

A decrease in mortality was observed from 11% of the preTT group to 7.9% of the postTT group which, although not statistically significant, presents an important trend that is repeated when comparing mortality only amongst patients with an ISS ≥ 16. It should also be considered that the study pertains to cases from a hospital that has staff with lots of experience in the management of complex cases where mortality was already low even before the official establishment of the trauma center.

The SOFA score was used to assess the status of the injured person at the entrance to the ICU, thus, the efficacy of the care first delivered to the patient could be evaluated [14–16]. A statistically significant reduction of the SOFA score was observed in the postTT group. This indicated that the level of care first received in the region and in the SR had improved. The TT evaluation and the patient’s hemodynamic stabilization in the SR had an impact through the application of the principles of DCS and Damage Control Resuscitation (DCR).

Other parameters studied in hospitalized patients in the ICU have been the number of days that they required amine support, which increased but not significantly, the number of days with required assisted ventilation, which significantly increased, and the number of bags of transfused blood products, which increased, however not significantly. These results, as previously reported, demonstrated an increase in the use of the numbers of procedures linked to the principles of DCR, and were performed by maintaining a permissive hypotension status with the use of massive transfusion protocols as described previously [16]. These factors, with an increase in damage control surgery procedures in which the patient remained intubated longer, required a greater number of assisted ventilation days.

With regards to surgical patients, the study population was comparable to the description previously reported, with male prevalence (72%), higher involvement of the active segment of the population (mean age 51.5 years), and a higher rate of road traffic injuries (55%) [12].

An interesting difference compared with another study was the severity of treated traumas. The patients in this current study who required surgery had a median ISS of 33, which was higher than reported in another Italian case study [12]. The first sign of improvement in the trauma patient management considered the frequency of hemodynamic instability in patients who underwent surgery, which passed from 33.3% of the preTT group to 46.5% in the postTT group. This was not statistically significant, but showed a trend in the improvement in the diagnostic-therapeutic pathway, since after the TT introduction, the indication for surgery mainly concerned hemodynamically unstable patients not subject to conservative treatment.

Analyzing the types of surgery performed, some statistically significant differences were observed between the preTT and postTT groups with regards to the number of DCS procedures (30.2% vs 10.3%, p = 0.008), packing (25.6% vs 5.9%, p = 0.003), VAC positioning (23.2% vs 7.3%, p = 0.008), and hemorrhage control (46.5% vs 23.5%, p = 0.012). This result shows an important change in the mindset of the surgeon. In fact, it is fundamental to treat life-threatening lesions quickly. This often implies the limitation of the number of interventions of demolitive surgery, and indicates that a laparostomy should be performed. The patient should be promptly sent to the ICU to continue the procedures of DCR which were begun in the SR. Eventual reconstruction steps (“second looks”) are generally postponed to 24/48 hours following the 1^st operation, when the patient is stabilized [17–19].

The average length of stay was 25.8 days, 9.41 of which was in the ICU and 4.4 was in the SICU. In the comparison between the preTT and post TT groups, a reduction trend was observed in the total average length of stay that went from 28.6 days to the current 21.9 days (with a decrease of 6.7 days), although this result was not significant, but showed a trend in improved management.

Overall, there were 63 complications, with a frequency of Clavien Dindo ≥ 3 of 38.7% (43 cases); in the preTT group 37 cases were observed with postoperative complications (54.4%), 28 of which with Clavien Dindo ≥ 3 (41.1%); in the postTT group 26 cases with postoperative complications (60.5%), 15 of which with Clavien Dindo ≥ 3 (34.9%). This decreasing trend in the number of complications, in particular the most severe ones that require a surgical reintervention or a procedure of interventional radiology with consequent hospitalization in the ICU, further substantiates the improved management of trauma patients.

NOM was undertaken in 24.6% of the total patients for injuries involving spleen, liver, retroperitoneum, soft tissues and other regions (including the kidneys and adrenal gland). In 21.5% of cases, NOM was accompanied by embolization, with an overall failure rate recorded in 5.1% of cases. Comparing the preTT with the postTT group, the number of NOM cases showed a significant increase, whereas embolization data were similar. Evaluating the number of failures in the 2 groups, a decrease was observed in the postTT group that, although not statistically significant, is a positive trend, considering that this study was using retrospective data from a hospital that has been a regional referral center for polytrauma patients for quite some time.

Splenic trauma NOM has been performed in 58.6% of cases, and when comparing the preTT with the postTT group, a significant increase in the number of NOM cases was recorded. Embolization did not increase significantly, and the decreased rate of NOM failure was similarly not significant. The data in this current study are in line with reported literature [20]. When studying the splenic traumas, after having subdivided according to AAST grade, it was possible to observe a significant increase in the number of NOM cases, and the contemporary decrease in surgical interventions which mainly occurred in AAST Grade 3 and 4 in the postTT group. Furthermore, a significant increase in embolization was also recorded for AAST Grade 3. These results reflect a variation in the 2018 WSES guidelines for splenic trauma [21]. Whereas, previously the indication to embolization was given only for AAST Grades 4 or 5 or in the event of contrast medium blush, now the indication is given for lower grades, in the presence of other vascular lesions in addition to blush (such as MAV and pseudoaneurysm), despite the fact that these vascular lesions are risk factors for NOM failure. This current study also reflects the increased provision of services correlated with the establishment of the TT, and the strengthening of interventional radiology with 24-hour assessments of eligible patients.

Further subdivision according to World Society of Emergency Surgery Guidelines (WSES) classification and preTT and postTT period, showed a significant decrease of splenectomies in the postTT subgroup, where only 15 patients underwent surgery. Analysis showed that in most cases, the indication for splenectomy was given by the copresence of other abdominal lesions for which laparotomy was mandatory (n = 5) or by the presence of active bleeding that could not be embolized (n = 7). These results are in line with the indications provided in the WSES Guidelines and hence demonstrate the appropriateness of splenic injury management by the TT. This change in splenic trauma management is particularly evident in AAST Grade 3 and 4 cases that traditionally have been the most controversial [20,22,23], and whereby the change of approach from surgical to conservative, caused a significant decrease in the total number of hospitalization days for NOM cases. Considering the immunological function of the spleen and the high risk of post splenectomy infections, the conservative approach should be promoted, limiting surgery to selected cases.

For these reasons, the number of splenectomy cases and/or the ratio between splenectomies and NOM cases might be valid indicators of good practice in the splenic injury management in a trauma center.

There were 105 (11.1%) cases of traumas with hepatic involvement. A significant increase in the number of NOM cases were observed. In these cases, the number of embolizations and NOM failures, between the preTT and postTT period, did not show any difference. The results reflect the indication of the latest WSES guidelines for liver trauma [24].

Given the small size of this cohort, it was not possible to perform an inferential analysis comparing the 2 periods of study based on the AAST grade of the liver injury. In evaluating the hepatic trauma-related outcomes, mortality did not change between the 2 periods, as well as the number of total hospitalization days, and the number of days of hospitalization in the ICU. On the other hand, a statistically significant difference in the number of days of hospitalization in the SICU was observed, which raised from an average of 2.3 days in the preTT period to 4.1 days in the postTT. This difference is probably linked to an increase in the number of NOM cases that, in case of hepatic trauma, require a longer period of observation, and the increase in number of days, albeit not significant, in more severe trauma-related complications (Clavien-Dindo > 3), also correlated with the augmented number of NOM cases performed.

The hospital where the study was conducted is a center where staff have had a lot of experience in the treatment of polytrauma patients, even before the formal institution of the trauma center. This aspect might have led to underestimated improvements related to the transition from the standard management to the TT management.

Even the relatively small case series under study, due to the low trauma incidence rate in Italy, may itself have constituted a limit in reaching the statistical significance of numerous improvement trends observed in the management of these patients (reduced latency between SR and OR, improvements in hospitalization stay, severity of post-treatment complications and mortality rates). This aspect is particularly relevant for liver traumas where the small number of patients could have been a limit in data analysis. For these reasons, it would be extremely useful to extend the examined period to collect a larger sample size to power the study. Furthermore, as trauma centers are established and TT’s are activated, the number of patients being transferred externally increases, and an environment of overtriage is created, which can cause patients’ injury severity score (ISS) to drop for a few years. Therefore, when comparing patient groups, it is thought that it would be most accurate to compare patients with the same specific index (e.g., groups with similar ISS) rather than comparing all patients before and after implementation of a TT. However, the goal of this study was to analyze how the introduction of a TT affected all the analyzed parameters, regardless of the severity of the injury. Considering the study population, the number of traumas observed in the period after the TT establishment was higher than in the preTT period. However, the 2 groups present homogeneous descriptive epidemiological characteristics and trauma severity, which was expected, given that our university hospital was the referral hospital for the whole region for traumas before the TT implementation. It can also be explained by the introduction of specific protocols relating to secondary centralization from other spoke facilities to our hub center. As a result, the establishment of a TT did not influence the type and severity of injuries of the polytraumatized patients referred to our trauma center, hence it should be acceptable to compare the whole groups of patients instead of using ISS grades. Moreover, the data in this study was compliant with European case studies reported in the literature.

This study demonstrated that the introduction of a TT at a level III university hospital improved the management of traumatic pathology, significantly reducing the length of the diagnostic-therapeutic pathway of the polytrauma patient in the Emergency Department. Although, these results have not yet led to a significant improvement in performance outcomes, a decreasing trend has been observed in mortality, severity of postoperative complications, number of surgical interventions performed, and a simultaneous increase in the number of NOM cases.

As to the secondary endpoint of the study, a significant change has been observed in the type of surgical procedures performed. Following the implementation of the TT, more damage control procedures like packing or VAC positioning and bleeding control operations were performed as suggested by the most recent international guidelines [23]. The increase in the number of DCS procedures contributed to the reduction of surgical operation time with a better control of the “lethal triad,” and a significant decrease in blood loss during surgery was observed.

Besides the change of the surgical procedures performed, a significant increase in the number of NOM cases was observed in the period following the implementation of the trauma center. This is particularly evident in splenic trauma management, where a complete alignment with the WSES guidelines recommendations was observed.

In conclusion, we believe that the management of traumatic pathology with a TT represents the best approach for the polytrauma patient. In the future, it could be useful, in all centers dedicated to the management of trauma patients, to enhance services offered by a trauma center, continuous training programs for all TT members, and establish a team of surgeons specifically dedicated to trauma management.