The Trauma Audit Filters Trial: Does Institutional Implementation of Audit Filters Reduce Mortality in Adult Trauma Patients?

Survey of the field

Trauma, defined as the clinical entity composed of physical injury and the body's associated response, kills almost five million people each year. This is more than the total number of annual deaths from malaria, tuberculosis, HIV/AIDS, and maternal conditions combined. More than 90% of trauma deaths occur in low and middle income countries (LMIC), and about 30-50% of these deaths have been reported to occur in hospital. Research show that almost 11% of the global burden of disease estimated using disability adjusted life years are due to trauma, and that disability adjusted life years from road traffic trauma has increased by 35% in the last 25 years.

The United Nation now vows to reduce the number of road traffic deaths by 50% by 2020. Although primary prevention will play a major role in achieving this, several international actors, including the World Health Organization (WHO), emphasise the importance of strengthened trauma care. A considerable body of research on the strengthening of trauma care attributes improvements in trauma patient outcomes to the implementation of quality improvement programmes, defined as programmes to improve "health care through monitoring the process of care and measuring outcomes".

For example, a recent single centre study from Australia showed a reduction in in-hospital mortality from 16 to 10% after the implementation of a quality improvement programme. This programme included interventions such as a protocol for trauma team activation, massive transfusion protocols, case reviews and the recording and follow up audit filters. Similarly, research from Thailand and Pakistan show reduced mortality after the implementation of such programmes. Unfortunately the heterogeneity of interventions included in most quality improvement programmes makes it hard to draw conclusions about the impact of individual components.

Despite this heterogeneity, audit filters constitute a common denominator across different quality improvement programmes. Such filters can be defined as "pre-identified variables that are routinely tracked to identify whether accepted standards of care are being met". Hence, audit filters are also referred to as quality indicators or key performance indicators. The concept of audit filters in trauma care originates from the American College of Surgeons guidelines on trauma care . They defined 22 filters and the basic idea was that each filter should represent a "sentinel event" associated with poor patient outcome.