Objective: to analyse compliance with the registry of the initial care given to the patient with severe trauma at the Trauma and Emergency Intensive Care Unit of the Hospital 12 de Octubre in Madrid.
Material and method: descriptive study of the registry of the initial care given­ to the patient with severe trauma (RAIT), based on the Advanced Trauma Life Support. 10 primary variables (PV) were designed (VP) to assess compliance: demographic, symptoms, initial care vital signs, vital signs during intrahospital transfer, diagnostic test outside the unit vital signs, water
balance, prehospital care, care at the unit, diagnostic tests-laboratory work, care team. The level of total compliance was related to the Injury Severity Score (ISS), shift and shift-change. A descriptive analysis of the variables was
carried and the Kruskall-Wallis test was used for bivariate analysis.
Results: the registries of 331 patients were reviewed. Mean total compliance rate was 49,5%. No significant differences were found between total compliance, ISS, shift and shift-change. The registry of PV: demographic 82,18%, symptoms 3,63%, vital signs on initial care 44,4%, vital signs and diagnostic tests outside the unit 16,9%, water balance 0,9%, no recording of vital signs during intrahospital transfer, prehospital care 68,9%, care given at the unit 91,8%, diagnostic tests-laboratory work 95%, care team 90,3%.
Conclusion: it is necessary to improve compliance with the RAIT protocol. Areas in need of improvement are detected such as increased recordings in the registry of vital signs at initial care (temperature), increased recordings of vital signs during diagnostic tests/laboratory work and increased recor­ding of water balance (blood loss) and blood type, given the importance that these data have in the management of patients with severe trauma.