***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: STUDY OBJECTIVE The trauma services provided by  6 hospitals operating at 2 levels of care ( 4 secondary or district general hospitals and 2 tertiary care hospitals ) in Malaysia are compared in terms of mortality and disability for direct admissions to emergency departments to test the hypothesis that care at a tertiary care hospital is better than at a district general hospital . METHODS All cases were recruited prospect ively for 1 year . The hospitals were purpose fully selected as typical for Malaysia . There are 3 primary outcome measures : death , musculoskeletal impairment , and disability at discharge . Adjustment was made for potential covariates and within-hospital clustering by using multivariable r and om-effects logistic regression analysis . RESULTS For direct admissions , logistic-regression-identified odds of dying were associated with older age ( > 55 years ) , odds ratio ( OR ) 1.9 ( 95 % confidence interval [ CI ] 1.3 to 2.8 ) ; head injury , OR 2.7 ( 95 % CI 1.9 to 3.9 ) ; arrival by means other than ambulance , OR 0.6 ( 95 % CI 0.4 to 0.8 ) ; severe injuries ( Injury Severity Score > 15 ) at a district general hospital , OR 45.2 ( 95 % CI 27.0 to 75.7 ) ; severe injuries at a tertiary care hospital , OR 11.2 ( 95 % CI 7.3 to 17.3 ) ; and admission to a tertiary care hospital compared to a district general hospital if severely injured ( Injury Severity Score > 15 ) , OR 0.2 ( 95 % CI 0.1 to 0.4 ) . Admission to a tertiary care hospital was associated with increased odds of disability ( OR 1.9 ; 95 % CI 1.5 to 2.3 ) and musculoskeletal impairment ( OR 3.5 ; 95 % CI 2.7 to 4.4 ) at discharge . CONCLUSION Care at a tertiary care hospital was associated with reduced mortality ( by 83 % in severe injuries ) , but with a higher likelihood of disability and impairment , which has implication s for improving access to trauma services for the severely injured in Malaysia and other low- and middle-income setting IN THE EARLY 1890S , DR WILLIAM HALSTED DEVELOPED radical mastectomy for breast cancer . Surgeons performed the Halsted procedure for more than 80 years even though there was little systematic evidence for its success . Then a new breed of scholars subjected the procedure to formal methods of evaluation unknown to Halsted . The methods —r and omized controlled trials ( RCTs ) principal among them — led to a surprise : radical mastectomy had no advantage over simpler forms of treatment . This is but 1 example of the hard-won victory of evidence over belief in medicine . The pioneers of the formal evaluation of medical practice s raised questions that traditional practitioners did not welcome . But in time , formal evaluation prevailed . The pioneers developed a hierarchy of evidentiary rigor relating the design of a study to the confidence that could be placed in the findings , from the lowly , nearly valueless anecdote to the royalty of evidence , the RCT . Concurrently , a similar story of hard-won learning unfolded in the so-called quality movement . Scholars illuminated the scale and types of defects in the processes of care and the outcomes , including high rates of unscientific care , inappropriate care , geographic variations in practice , latent disagreements among specialists , and oftenunrecognized medical injury to patients . Like the pioneers of evidence -based medicine , students of medical quality were at first largely ignored , but no longer . In 1999 and 2001 , the Institute of Medicine published 2 l and mark reports on the evidence for quality failures and called urgently for re design of care systems to achieve improvements . The story could end here happily with 2 great streams of endeavor merging into a framework for conjoint action : improving clinical evidence and improving the process of care . Instead , the 2 endeavors are often in unhappy tension . Neither disputes that progress toward health care ’s main goal , the relief of illness and pain , requires research of many kinds : basic , clinical , systems , epidemiologic . The disagreement centers on epistemology — ways to get at “ truth ” and how those ways should vary depending on the knowledge sought . Individuals most involved in day-to-day improvement work fear that if “ evidence ” is too narrowly defined and the approach to gathering evidence too severely constrained , progress may be the victim . For example , the RCT is a powerful , perhaps unequaled , research design to explore the efficacy of conceptually neat components of clinical practice —tests , drugs , and procedures . For other crucially important learning purpose s , however , it serves less well . Recent controversies about the evaluation of rapid response  teams  provide a case in point . These controversies show the importance of adjusting research methods to fit research questions . Although only 10 % to 15 % of in patients resuscitated outside intensive care units survive to hospital discharge , early warning signs are present in a large percentage of patients who ultimately experience cardiac arrest .  Rapid response team systems bring expert clinicians to the bedsides of deteriorating patients before arrest occurs . In the mid 1990s , based largely on reports from Australian investigators , the Institute for Healthcare Improvement and others began introducing the concept to willing hospitals . Local experience strongly suggested that these systems often , although not always , were associated with improved outcomes , including reduced anxiety among nursing staff ; increased interdisciplinary teamwork ; decreased cardiac arrests outside of intensive care units ; and , in some cases , declines in mortality . The evidence base took a turn in June 2005 with the publication of the Medical Early Response Intervention and Therapy ( MERIT ) Study , a cluster r and omized prospect i ve trial that cl aim ed to find no beneficial effect of these teams on several primary outcomes . Controversy has continued since then regarding the scientific evidence for rapid response systems . In fact , the MERIT trial was not negative ; it was inconclusive . The study team encountered an array of serious problems in execution , common in social science . For example , although the study ’s power calculation assumed a baseline rate of 30 events per 1000 admissions , the actual rate proved to be fewer than 7 events per 1000 admissions ; thus , the study was ef fect ively underpowered by 500 % . Crosscontamination abounded ; some control hospitals implemented rapid response protocol s , and several study OBJECTIVE To evaluate the ability of five quality assurance/ quality improvement audit filters to identify opportunities for improvement in patient care in a mature trauma system . DESIGN Retrospective analysis of prospect ively collected data . MATERIAL S AND METHODS Total patient population at risk and audit filter fallouts were evaluated for the following audit filters : patients with ( 1 ) Glasgow Coma Scale ( GCS ) score < 14 who did not receive a CT scan within 2 hours of admission ; ( 2 ) subdural/ epidural hematomas who did not undergo craniotomy within 4 hours ; ( 3 ) open tibial fractures who did not undergo debridement within 8 hours ; ( 4 ) abdominal gunshot wounds who did not undergo laparotomy within 4 hours ; and ( 5 ) all deaths where a quality assurance action was taken . The filters were used for 1 year . Mortality was compared between fallouts and nonfallouts in each category and the frequency of corrective actions for each category were determined . RESULTS Corrective actions were taken in 97 of the 418 fallouts from 3,787 patients at risk . The majority ( 77 % ) of these actions were for patients in the death audit filter group . There were 343 nondeath fallouts , representing 13 % of the 2,719 nondeath patients at risk . Of these , 22 corrective actions were taken , representing 6.4 % of the fallouts and less than 1 % of the patients at risk . CONCLUSION The non-death process based audit filters that we evaluated in our trauma system documented adherence to care process st and ards but found few opportunities for quality improvement , suggesting that audit filters should be periodically evaluated and changed when their goals have been accomplished OBJECTIVE To decrease paramedic on-scene times ( OSTs ) for major trauma patients through a focused quality improvement ( QI ) program . METHODS A prospect i ve study was conducted from 1993 through 1997 to determine the impact of a QI program on paramedic OSTs . All penetrating trauma patients transported by paramedics to Los Angeles County/USC Medical Center , a Level-1 trauma center , were included , and all cases with OSTs > 20 minutes were review ed in detail for extenuating circumstances . Cases including multiple victims or unsecured scenes were considered " acceptable deviations . " All others were considered " fallouts , " which prompted extensive review with the paramedics and their field supervisors . RESULTS Prior to the inception of the QI project there was a 4.1 % fallout rate of penetrating trauma patients with OSTs > 20 minutes . This fallout rate fell to 1.5 % in 1997 ( p < 0.01 ) . Mortality rates among these fallouts decreased from 5.1 % to 0.8 % during the study period ( p < 0.01 ) . CONCLUSIONS An intensive QI program can have a significant , positive impact on paramedic OSTs among patients with penetrating trauma Background : To date , the benefit of prehospital advanced life-support programs on  trauma-related mortality and morbidity has not been established Methods : The Ontario Prehospital Advanced Life Support ( OPALS ) Major Trauma Study was a before – after systemwide controlled clinical trial conducted in 17 cities . We enrolled adult patients who had experienced major trauma in a basic life-support phase and a subsequent advanced life-support phase ( during which paramedics were able to perform endotracheal intubation and administer fluids and drugs intravenously ) . The primary outcome was survival to hospital discharge . Results : Among the 2867 patients enrolled in the basic life-support ( n = 1373 ) and advanced life-support ( n = 1494 ) phases , characteristics were similar , including mean age ( 44.8 v. 47.5 years ) , frequency of blunt injury ( 92.0 % v. 91.4 % ) , median injury severity score ( 24 v. 22 ) and percentage of patients with Glasgow Coma Scale score less than 9 ( 27.2 % v. 22.1 % ) . Survival did not differ overall ( 81.1 % among patients in the advanced life-support phase v. 81.8 % among those in the basic life-support phase ; p = 0.65 ) . Among patients with Glasgow Coma Scale score less than 9 , survival was lower among those in the advanced life-support phase ( 50.9 % v. 60.0 % ; p = 0.02 ) . The adjusted odds of death for the advanced life-support v. basic life-support phases were nonsignificant ( 1.2 , 95 % confidence interval 0.9–1.7 ; p = 0.16 ) . Interpretation : The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients . We also found that during the advanced life-support phase , mortality was greater among patients with Glasgow Coma Scale scores less than 9 . We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma OBJECTIVE The use of " care bundles " in the prevention of ventilator-associated pneumonia ( VAP ) and other intensive care unit ( ICU ) complications have been increasingly used in critical care practice . However , the effective implementation of these strategies represents a challenge in a busy Level I trauma ICU . We devised a daily " Quality Rounds Checklist " ( QRC ) tool for use in the ICU to increase compliance with these prophylactic measures and identify areas for improvement in quality of care . METHODS A prospect i ve before-after design was used to examine the effectiveness of the QRC tool in promoting compliance with 16 prophylactic measures for VAP , deep venous thrombosis or pulmonary embolism , central line infection and other ICU complications . Compliance was assessed for 1 month before institution of the QRC . On daily analysis , the QRC was then applied by the ICU fellow to assess compliance . Any deficiencies were actively corrected in real time . Compliance was assessed by a multidisciplinary team for the next 3 months and compared with the pre-QRC compliance rates . RESULTS Implementation of the QRC tool facilitated improvement of all measures not already at > 95 % compliance . Compliance with VAP prevention measures of head of bed elevation > 30 degrees ( 35.2 % vs. 84.5 % ) , sedation holiday ( 78.0 % vs. 86.0 % ) , and prophylaxis for both peptic ulcer disease ( 76.2 % vs. 92.3 % ) and deep venous thrombosis ( 91.4 % vs. 92.8 % ) were all increased . A decrease in central line duration > 72 hours ( 62.4 % vs. 52.8 % ) and ventilator duration > 72 hours ( 74.0 % vs. 61.7 % ) was also noted . Additionally , a decrease in mean monthly rates per 1,000 device days of VAP ( 16.3 vs. 8.9 ) , central line infection ( 11.3 vs. 5.8 ) and self-extubation ( 7.8 vs. 2.2 ) was demonstrated . CONCLUSION Introducing a daily QRC tool facilitated improved compliance rates for 16 clinical ly significant prophylactic measures in a busy Level I trauma ICU . The daily use of this tool , requiring just a few minutes per patient to complete , results in a sustainable improvement in patient outcomes 
    Output:
    
We were unable to identify any studies of sufficient method ological quality to draw conclusions regarding the effectiveness of audit filters  as a performance improvement intervention in trauma systems .