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Maughan BC, Lin A, Caughey AB, Bulger EM, McConnell KJ, Malveau S, Griffiths D, Newgard CD. Field Trauma Triage among Older Adults: A Cost-Effectiveness Analysis. J Am Coll Surg 2022; 234:139-154. [PMID: 35213435 DOI: 10.1097/xcs.0000000000000025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND National guidelines for prehospital trauma triage aim to identify seriously injured patients who may benefit from transport to trauma centers. These guidelines have poor sensitivity for serious injury among older adults. We evaluated the cost-effectiveness of a high-sensitivity triage strategy for older adults. STUDY DESIGN We developed a Markov chain Monte Carlo microsimulation model to estimate the cost-effectiveness of high-sensitivity field triage criteria among older adults compared with current practice. The model used a retrospective cohort of 3621 community-dwelling Medicare beneficiaries who were transported by emergency medical services after an acute injury in 7 counties in the northwestern US during January to December 2011. These data informed model estimates of emergency medical services triage assessment, hospital transport patterns, and outcomes from index hospitalization up to 1 year after discharge. Outcomes beyond 1 year were modeled using published literature. Differences in cost and quality-adjusted life years (QALYs) were calculated for both strategies using a lifetime analytical horizon. We calculated the incremental cost-effectiveness ratio (cost per QALY gained) to assess cost-effectiveness, which we defined using a threshold of less than $100,000 per QALY. RESULTS High-sensitivity trauma field triage for older adults would produce a small incremental benefit in average trauma system effectiveness (0.0003 QALY) per patient at a cost of $1,236,295 per QALY. Sensitivity analysis indicates that the cost of initial hospitalization and emergency medical services adherence to triage status (ie transporting triage-positive patients to a trauma center) had the largest influence on overall cost-effectiveness. CONCLUSIONS High-sensitivity trauma field triage is not cost-effective among older adults.
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Lupton JR, Neth MR, Sahni R, Wittwer L, Le N, Jui J, Newgard CD, Daya MR. The Association Between the Number of Prehospital Providers On-Scene and Out-of-Hospital Cardiac Arrest Outcomes. PREHOSP EMERG CARE 2021; 26:782-791. [PMID: 34669565 DOI: 10.1080/10903127.2021.1995799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: The ideal number of emergency medical services (EMS) providers needed on-scene during an out-of-hospital cardiac arrest (OHCA) resuscitation is unknown. Our objective was to evaluate the association between the number of providers on-scene and OHCA outcomes. Methods: This was a secondary analysis of adults (≥18 years old) with non-traumatic OHCA from a 10-site North American prospective cardiac arrest registry (Resuscitation Outcomes Consortium) including a 2005-2011 cohort and a 2011-2015 cohort. The primary outcome was survival to hospital discharge. We calculated the median number of EMS providers on-scene during the first 10 minutes of the resuscitation and used multivariable logistic regression adjusting for age, sex, witness status, bystander CPR, arrest location, initial rhythm, and dispatch to EMS arrival time. Results: There were 30,613 and 41,946 patients with necessary variables in the 2005-2011 and 2011-2015 cohorts, respectively. Survival to hospital discharge (95% CI) was higher with 9 or more providers on-scene (17.2% [15.8-18.5] and 14.0% [12.6-15.4]) compared to 7-8 (14.1% [13.4-14.8] and 10.5% [9.9-11.1]), 5-6 (10.0% [9.5-10.5] and 8.5% [8.1-8.9]), 3-4 (10.5% [9.3-11.6] and 9.3% [8.5-10.1]), and 1-2 (8.6% [7.2-10.0] and 8.0% [7.1-9.0]) providers for the 2005-2011 and 2011-2015 cohorts, respectively. In multivariable logistic regressions, compared to 5-6 providers, there were no significant differences in survival to hospital discharge for 1-2 or 3-4 providers, while having 7-8 (adjusted odds ratios (aORs) 1.53 [1.39-1.67] and 1.31 [1.20-1.44]) and 9 or more (aORs 1.76 [1.56-1.98] and 1.63 [1.41-1.89]) providers were associated with improved survival in both the 2005-2011 and 2011-2015 cohorts, respectively. Conclusions: The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers.
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Jenkins PC, Dixon BE, Savage SA, Carroll AE, Newgard CD, Tignanelli CJ, Hemmila MR, Timsina L. Comparison of a trauma comorbidity index with other measures of comorbidities to estimate risk of trauma mortality. Acad Emerg Med 2021; 28:1150-1159. [PMID: 33914402 DOI: 10.1111/acem.14270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Comorbidities influence the outcomes of injured patients, yet a lack of consensus exists regarding how to quantify that association. This study details the development and internal validation of a trauma comorbidity index (TCI) designed for use with trauma registry data and compares its performance to other existing measures to estimate the association between comorbidities and mortality. METHODS Indiana state trauma registry data (2013-2015) were used to compare the TCI with the Charlson and Elixhauser comorbidity indices, a count of comorbidities, and comorbidities as separate variables. The TCI approach utilized a randomly selected training cohort and was internally validated in a distinct testing cohort. The C-statistic of the adjusted models was tested using each comorbidity measure in the testing cohort to assess model discrimination. C-statistics were compared using a Wald test, and stratified analyses were performed based on predicted risk of mortality. Multiple imputation was used to address missing data. RESULTS The study included 84,903 patients (50% each in training and testing cohorts). The Indiana TCI model demonstrated no significant difference between testing and training cohorts (p = 0.33). It produced a C-statistic of 0.924 in the testing cohort, which was significantly greater than that of models using the other indices (p < 0.05). The C-statistics of models using the Indiana TCI and the inclusion of comorbidities as separate variables-the method used by the American College of Surgeons Trauma Quality Improvement Program-were comparable (p = 0.11) but use of the TCI approach reduced the number of comorbidity-related variables in the mortality model from 19 to one. CONCLUSIONS When examining trauma mortality, the TCI approach using Indiana state trauma registry data demonstrated superior model discrimination and/or parsimony compared to other measures of comorbidities.
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Sheridan DC, Baker S, Dehart R, Lin A, Hansen M, Tereshchenko LG, Le N, Newgard CD, Nagel B. Heart Rate Variability and Its Ability to Detect Worsening Suicidality in Adolescents: A Pilot Trial of Wearable Technology. Psychiatry Investig 2021; 18:928-935. [PMID: 34555890 PMCID: PMC8542751 DOI: 10.30773/pi.2021.0057] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/27/2021] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Suicide is the 2nd leading cause of death in adolescence, and acute pediatric mental health emergency department (ED) visits have doubled in the past decade. The objective of this study was to evaluate physiologic parameters relationship to suicide severity. METHODS This was a prospective, observational study from April 2018 thru November 2019 in a tertiary care pediatric emergency department (ED) and inpatient pediatric psychiatric unit enrolling acutely suicidal adolescent patients. Patients wore a wrist device that used photoplethysmography for 7 days during their acute hospitalization to measure heart rate variability (HRV). During that time, Columbia Suicide Severity Scores (CSSRS) were assessed at 3 time points. RESULTS There was complete device data and follow-up for 51 patients. There was an increase in the high frequency (HF) component of HRV in patients that had a 25% or greater decrease in their CSSRS (mean difference 11.89 ms/ Hz ; p-value 0.005). Patients with a CSSRS≥15 on day of enrollment had a lower, although not statistically significant, HF component (mean difference -8.34 ms/ Hz; p-value 0.071). CONCLUSION We found an inverse correlation between parasympathetic activity measured through the HF component and suicidality in an acutely suicidal population of adolescents. Wearable technology may have the ability to improve outpatient monitoring for earlier detection and intervention.
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Newgard CD, Lin A, Olson LM, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Malveau S, Smith M, Dai M, Nathens AB, Glass NE, Jenkins PC, McConnell KJ, Remick KE, Hewes H, Mann NC. Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers. JAMA Pediatr 2021; 175:947-956. [PMID: 34096991 PMCID: PMC8185631 DOI: 10.1001/jamapediatrics.2021.1319] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/25/2021] [Indexed: 01/20/2023]
Abstract
Importance The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers. Objective To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers. Design, Setting, and Participants A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources. Exposures Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment. Main Outcomes and Measures In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100. Results There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers. Conclusions and Relevance In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.
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Nishijima DK, Yang Z, Newgard CD. Cost-effectiveness of field trauma triage among injured children transported by emergency medical services. Am J Emerg Med 2021; 50:492-500. [PMID: 34536721 DOI: 10.1016/j.ajem.2021.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A pediatric field triage strategy that meets the national policy benchmark of ≥95% sensitivity would likely improve health outcomes but increase heath care costs. Our objective was to compare the cost-effectiveness of current pediatric field triage practices to an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity. STUDY DESIGN We developed a decision-analysis Markov model to compare the outcomes and costs of the two strategies. We used a prospectively collected cohort of 3507 (probability weighted, unweighted n = 2832) injured children transported by 44 emergency medical services (EMS) agencies to 28 trauma and non-trauma centers in the Northwestern United States from 1/1/2011 to 12/31/2011 to derive the alternative field triage strategy and to populate model probability and cost inputs for both strategies. We compared the two strategies by calculating quality adjusted life years (QALYs) and health care costs over a time horizon from the time of injury until death. We set an incremental cost-effectiveness ratio threshold of less than $100,000 per QALY for the alternative field triage to be a cost-effective strategy. RESULTS Current pediatric field triage practices had a sensitivity of 87.4% (95% confidence interval [CI] 71.9 to 95.0%) and a specificity of 82.3% (95% CI 81.0 to 83.5%) and the alternative field triage strategy had a sensitivity of 97.3% (95% CI 82.6 to 99.6%) and a specificity of 46.1% (95% CI 43.8 to 48.4%). The alternative field triage strategy would cost $476,396 per QALY gained compared to current pediatric field triage practices and thus would not be a cost-effective strategy. Sensitivity analyses demonstrated similar findings. CONCLUSION Current field triage practices do not meet national policy benchmarks for sensitivity. However, an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity is not a cost-effective strategy.
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Piantino JA, Lin A, Luther M, Centeno LD, Williams CN, Newgard CD. Simultaneous Heart Rate Variability and Electroencephalographic Monitoring in Children in the Emergency Department. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2021; 14:165-175. [PMID: 33986903 PMCID: PMC8099962 DOI: 10.1007/s40653-020-00313-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Changes in heart rate variability (HRV) and electroencephalographic (EEG) background are promising tools for risk stratification and outcome prediction in children seen in the Emergency Department (ED). Novel monitoring technologies offer an opportunity for determining the clinical value of these physiologic variables, however, studies evaluating these measurements obtained in the Pediatric ED are sparse. The current study used a single center, prospective, observational cohort study of HRV and EEG as early predictors of outcome in children with acute trauma. ECG and HRV data were successfully collected in 167 subjects and simultaneous collection of ECG and EEG data using a wireless monitoring device was piloted in 17 patients with 15 patients having EEG data rated as appropriate for clinical interpretation. The mean time from ED arrival to ECG and EEG recording start was 7.5 (SD 11.6) and 34.5 (SD 15.5) minutes, respectively. The mean time required for EEG electrode placement was 9.3 min (SD 5.8 min). Results showed recording early HRV and EEG is feasible in children with acute injury seen in the ED. This study suggests that high consent rates are possible with the adequate research infrastructure and physiologic variables may offer an early, non-invasive marker for injury stratification and prognosis in children.
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Jenkins PC, Newgard CD. The Effect of Trauma Center Verification on Outcomes of Traumatic Brain Injury Patients Undergoing Interfacility Transfer. Acad Emerg Med 2021; 28:375-376. [PMID: 33258185 DOI: 10.1111/acem.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
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Newgard CD, Cheney TP, Chou R, Fu R, Daya MR, O'Neil ME, Wasson N, Hart EL, Totten AM. Out-of-hospital Circulatory Measures to Identify Patients With Serious Injury: A Systematic Review. Acad Emerg Med 2020; 27:1323-1339. [PMID: 32558073 DOI: 10.1111/acem.14056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 06/12/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The objective was to systematically identify and summarize out-of-hospital measures of circulatory compromise as diagnostic predictors of serious injury, focusing on measures usable by emergency medical services to inform field triage decisions. METHODS We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from 1996 through August 2017 for published literature on individual circulatory measures in trauma. We reviewed reference lists of included articles for additional relevant citations. Measures of diagnostic accuracy included sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Indicators of serious injury included resource need, serious anatomic injury, and mortality. We pooled estimates when data permitted. RESULTS We identified 114 articles, reporting results of 111 studies. Measures included systolic blood pressure (sBP), heart rate (HR), shock index (SI), lactate, base deficit, and HR variability. Pooled out-of-hospital sensitivity estimates were sBP < 90 mm Hg = 19% (95% confidence interval [CI] = 12% to 29%), HR ≥ 110 beats/min = 28% (95% CI = 20% to 37%), SI > 0.9 = 37% (95% CI = 22% to 56%), and lactate > 2.0 mmol/L = 74% (95% CI = 48% to 90%). Pooled specificity estimates were sBP < 90 mm Hg = 95% (95% CI = 91% to 97%), HR ≥ 110 beats/min = 85% (95% CI = 74% to 91%), SI > 0.9 = 85% (95% CI = 72% to 92%), and lactate > 2.0 mmol/L = 62% (95% CI = 51% to 72%). Pooled AUROCs included sBP = 0.67 (95% CI = 0.58 to 0.75), HR = 0.67 (95% CI = 0.56 to 0.79), SI = 0.72 (95% CI = 0.66 to 0.77), and lactate = 0.77 (95% CI = 0.67 to 0.82). Strength of evidence was low to moderate. CONCLUSIONS Out-of-hospital circulatory measures are associated with poor to fair discrimination for identifying trauma patients with serious injuries. Many seriously injured patients have normal circulatory measures (low sensitivity), but when present, the measures are highly specific for identifying patients with serious injuries.
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Daya MR, Cheney TP, Chou R, Fu R, Newgard CD, O'Neil ME, Wasson N, Hart EL, Totten AM. Out-of-hospital Respiratory Measures to Identify Patients With Serious Injury: A Systematic Review. Acad Emerg Med 2020; 27:1312-1322. [PMID: 32569406 DOI: 10.1111/acem.14055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/27/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The objective was to systematically review the published literature on the diagnostic accuracy of out-of-hospital respiratory measures for identifying patients with serious injury, focusing on measures feasible for field triage by emergency medical services personnel. METHODS We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from January 1, 1996, through August 31, 2017. We included studies on the diagnostic accuracy (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) for all respiratory measures used to identify patients with serious injury (resource use, serious anatomic injury, and mortality). We assessed studies for risk of bias and strength of evidence (SOE). We performed meta-analysis for measures with sufficient data. RESULTS We identified 46 articles reporting results of 44 studies. Out-of-hospital respiratory measures included respiratory rate, pulse oximetry, and airway support. Meta-analysis was only possible for respiratory rate, which demonstrated a pooled sensitivity for serious injury of 13% (95% confidence interval [CI] = 5 to 29, I2 = 97.8%), specificity of 96% (95% CI = 83 to 99, I2 = 99.6%), and AUROC of 0.70 (95% CI = 0.66 to 0.79, I2 = 16.6%). For oxygen saturation, sensitivity ranged from 13% to 63%; specificity, 85% to 99%; and AUROC, 0.53 to 0.76. Need for airway support had a sensitivity of 8% to 53% and specificity of 61% to 100%; studies did not report AUROC. Across respiratory measures, the SOE was low. Other respiratory measures (pH, end-tidal carbon dioxide [CO2 ], and sublingual partial pressure of CO2 ) were reported only in emergency department studies. CONCLUSIONS Data on the accuracy of out-of-hospital respiratory measures for field triage are limited and of low quality. Based on available research, respiratory rate, oxygen saturation, and need for airway intervention all have low sensitivity, high specificity, and poor to fair discrimination for identifying seriously injured patients.
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Newgard CD, Lin A, Caughey AB, Eckstrom E, Bulger EM, Staudenmayer K, Maughan B, Malveau S, Griffiths D, McConnell KJ. The Cost of a Fall Among Older Adults Requiring Emergency Services. J Am Geriatr Soc 2020; 69:389-398. [PMID: 33047305 DOI: 10.1111/jgs.16863] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/10/2020] [Accepted: 09/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community-dwelling older adults who fell and required ambulance transport, including acute versus post-acute periods, the primary drivers of cost, and comparison to baseline expenditures. DESIGN Retrospective cohort analysis. SETTING Forty-four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. PARTICIPANTS We included 2,494 community-dwelling adults, 65 years and older, transported by ambulance after a fall with continuous fee-for-service Medicare coverage. MEASUREMENTS The primary outcome was total Medicare expenditures to 1 year (2019 U.S. dollars), with separation by acute versus post-acute periods and by cost category. We included 48 variables in a standardized risk-adjustment model to generate adjusted cost estimates. RESULTS The median age was 83 years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634-$68,086), including acute care median $1,957 (IQR = $1,298-$12,924) and post-acute median $20,560 (IQR = $5,673-$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479-$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = -$185 to $51,189). CONCLUSION Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post-acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs.
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Sheridan DC, Pettersson D, Newgard CD, Selden NR, Jafri MA, Lin A, Rowell S, Hansen ML. Can QuickBrain MRI replace CT as first-line imaging for select pediatric head trauma? J Am Coll Emerg Physicians Open 2020; 1:965-973. [PMID: 33145547 PMCID: PMC7593443 DOI: 10.1002/emp2.12113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/15/2020] [Accepted: 05/01/2020] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE The current standard of care for initial neuroimaging in injured pediatric patients suspected of having traumatic brain injury is computed tomography (CT) that carries risks associated with radiation exposure. The primary objective of this trial was to evaluate the ability of a QuickBrain MRI (qbMRI) protocol to detect clinically important traumatic brain injuries in the emergency department (ED). The secondary objective of this trial was to compare qbMRI to CT in identifying radiographic traumatic brain injury. METHODS This was a prospective study of trauma patients less than 15 years of age with suspected traumatic brain injury at a level 1 pediatric trauma center in Portland, Oregon between August 2017 and March 2019. All patients in whom a head CT was deemed clinically necessary were approached for enrollment to also obtain a qbMRI in the acute setting. Clinically important traumatic brain injury was defined as the need for neurological surgery procedure, intubation, pediatric intensive care unit stay greater than 24 hours, a total hospital length of stay greater than 48 hours, or death. RESULTS A total of 73 patients underwent both CT and qbMRI. The median age was 4 years (interquartile range [IQR] = 1-10 years). Twenty-two patients (30%) of patients had a clinically important traumatic brain injury, and of those, there were 2 deaths (9.1%). QbMRI acquisition time had a median of 4 minutes and 52 seconds (IQR = 3 minutes 49 seconds-5 minutes 47 seconds). QbMRI had sensitivity for detecting clinically important traumatic brain injury of 95% (95% confidence interval [CI] = 77%-99%). For any radiographic injury, qbMRI had a sensitivity of 89% (95% CI = 78%-94%). CONCLUSION Our results suggest that qbMRI has good sensitivity to detect clinically important traumatic brain injuries. Further multi-institutional, prospective trials are warranted to either support or refute these findings.
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Bland ML, McNally C, Cicchino JB, Zuby DS, Mueller BC, McCarthy ML, Newgard CD, Kulie PE, Arnold BN, Rowson S. Laboratory Reconstructions of Bicycle Helmet Damage: Investigation of Cyclist Head Impacts Using Oblique Impacts and Computed Tomography. Ann Biomed Eng 2020; 48:2783-2795. [PMID: 32974755 DOI: 10.1007/s10439-020-02620-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/11/2020] [Indexed: 12/01/2022]
Abstract
Although head injuries are common in cycling, exact conditions associated with cyclist head impacts are difficult to determine. Previous studies have attempted to reverse engineer cyclist head impacts by reconstructing bicycle helmet residual damage, but they have been limited by simplified damage assessment and testing. The present study seeks to enhance knowledge of cyclist head impact conditions by reconstructing helmet damage using advanced impact testing and damage quantification techniques. Damage to 18 helmets from cyclists treated in emergency departments was quantified using computed tomography and reconstructed using oblique impacts. Damage metrics were related to normal and tangential velocities from impact tests as well as peak linear accelerations (PLA) and peak rotational velocities (PRV) using case-specific regression models. Models then allowed original impact conditions and kinematics to be estimated for each case. Helmets were most frequently damaged at the front and sides, often near the rim. Concussion was the most common, non-superficial head injury. Normal velocity and PLA distributions were similar to previous studies, with median values of 3.4 m/s and 102.5 g. Associated tangential velocity and PRV medians were 3.8 m/s and 22.3 rad/s. Results can inform future oblique impact testing conditions, enabling improved helmet evaluation and design.
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Lerner EB, Newgard CD, Mann NC. Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on the U.S. Emergency Medical Services System: A Preliminary Report. Acad Emerg Med 2020; 27:693-699. [PMID: 32557999 PMCID: PMC7323429 DOI: 10.1111/acem.14051] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 01/17/2023]
Abstract
Background Our objective was to quantify trends in emergency medical services (EMS) incidents as the effects of the COVID‐19 pandemic spread across the United States and to determine if there was an increase in EMS‐attended deaths. Methods We conducted a 3‐year comparative retrospective cohort analysis of data from the National EMS Information System. Data were included if care was provided between the 40th and 21st weeks of the next year and compared over 3 years. We included incidents identified through 9‐1‐1 where patient contact was made. The total number of EMS incidents per week was used as the denominator to calculate the rate of patient deaths and possible injury. We assessed for temporal and seasonal trends. Results Starting in the 10th week of 2020 there was a decrease in the number of EMS activations in the United States compared to the prior weeks and the same time period in previous years. The number of activations between week 10 and week 16 decreased by 140,292 or 26.1%. The portion of EMS activations reporting a patient disposition of death nearly doubled between the 11th and 15th weeks of 2020 (1.49%–2.77% of all activations). The number of EMS activations documenting a possible injury decreased from 18.43% to 15.27% between weeks 10 and 13. Conclusion We found that early in the COVID‐19 outbreak there was a significant decrease in the number of EMS responses across the United States. Simultaneously the rate of EMS‐attended death doubled, while the rate of injuries decreased.
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Kline JA, Burton JH, Carpenter CR, Meisel ZF, Miner JR, Newgard CD, Quest T, Martin IB, Holmes JF, Kaji AH, Bird SB, Coates WC, Lall MD, Mills AM, Ranney ML, Wolfe RE, Dorner SC. Unconditional Care in Academic Emergency Departments. Acad Emerg Med 2020; 27:527-528. [PMID: 32407561 PMCID: PMC7272880 DOI: 10.1111/acem.14010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 11/30/2022]
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Cicchino JB, McCarthy ML, Newgard CD, Wall SP, DiMaggio CJ, Kulie PE, Arnold BN, Zuby DS. Not all protected bike lanes are the same: Infrastructure and risk of cyclist collisions and falls leading to emergency department visits in three U.S. cities. ACCIDENT; ANALYSIS AND PREVENTION 2020; 141:105490. [PMID: 32388015 DOI: 10.1016/j.aap.2020.105490] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Protected bike lanes separated from the roadway by physical barriers are relatively new in the United States. This study examined the risk of collisions or falls leading to emergency department visits associated with bicycle facilities (e.g., protected bike lanes, conventional bike lanes demarcated by painted lines, sharrows) and other roadway characteristics in three U.S. cities. METHODS We prospectively recruited 604 patients from emergency departments in Washington, DC; New York City; and Portland, Oregon during 2015-2017 who fell or crashed while cycling. We used a case-crossover design and conditional logistic regression to compare each fall or crash site with a randomly selected control location along the route leading to the incident. We validated the presence of site characteristics described by participants using Google Street View and city GIS inventories of bicycle facilities and other roadway features. RESULTS Compared with cycling on lanes of major roads without bicycle facilities, the risk of crashing or falling was lower on conventional bike lanes (adjusted OR = 0.53; 95 % CI = 0.33, 0.86) and local roads with (adjusted OR = 0.31; 95 % CI = 0.13, 0.75) or without bicycle facilities or traffic calming (adjusted OR = 0.39; 95 % CI = 0.23, 0.65). Protected bike lanes with heavy separation (tall, continuous barriers or grade and horizontal separation) were associated with lower risk (adjusted OR = 0.10; 95 % CI = 0.01, 0.95), but those with lighter separation (e.g., parked cars, posts, low curb) had similar risk to major roads when one way (adjusted OR = 1.19; 95 % CI = 0.46, 3.10) and higher risk when they were two way (adjusted OR = 11.38; 95 % CI = 1.40, 92.57); this risk increase was primarily driven by one lane in Washington. Risk increased in the presence of streetcar or train tracks relative to their absence (adjusted OR = 26.65; 95 % CI = 3.23, 220.17), on downhill relative to flat grades (adjusted OR = 1.92; 95 % CI = 1.38, 2.66), and when temporary features like construction or parked cars blocked the cyclist's path relative to when they did not (adjusted OR = 2.23; 95 % CI = 1.46, 3.39). CONCLUSIONS Certain bicycle facilities are safer for cyclists than riding on major roads. Protected bike lanes vary in how well they shield riders from crashes and falls. Heavier separation, less frequent intersections with roads and driveways, and less complexity appear to contribute to reduced risk in protected bike lanes. Future research should systematically examine the characteristics that reduce risk in protected lanes to guide design. Planners should minimize conflict points when choosing where to place protected bike lanes and should implement countermeasures to increase visibility at these locations when they are unavoidable.
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Newgard CD, Bulger EM. Inclusion of All Patients Admitted for Trauma in Trauma Registries-Reply. JAMA Surg 2020; 155:265-266. [PMID: 31800006 DOI: 10.1001/jamasurg.2019.4941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Daya MR, Leroux BG, Dorian P, Rea TD, Newgard CD, Morrison LJ, Lupton JR, Menegazzi JJ, Ornato JP, Sopko G, Christenson J, Idris A, Mody P, Vilke GM, Herdeman C, Barbic D, Kudenchuk PJ. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020; 141:188-198. [PMID: 31941354 PMCID: PMC7009320 DOI: 10.1161/circulationaha.119.042240] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known. METHODS In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration. RESULTS Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06-1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5-9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02-1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7-8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66-1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74-1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant. CONCLUSIONS We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.
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Uribe-Leitz T, Jarman MP, Sturgeon DJ, Harlow AF, Lipsitz SR, Cooper Z, Salim A, Newgard CD, Haider AH. National Study of Triage and Access to Trauma Centers for Older Adults. Ann Emerg Med 2019; 75:125-135. [PMID: 31732372 DOI: 10.1016/j.annemergmed.2019.06.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level. METHODS Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation. RESULTS Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles. CONCLUSION Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed.
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Newgard CD, Caughey A, McConnell KJ, Lin A, Eckstrom E, Griffiths D, Malveau S, Bulger E. Comparison of Injured Older Adults Included in vs Excluded From Trauma Registries With 1-Year Follow-up. JAMA Surg 2019; 154:e192279. [PMID: 31290955 DOI: 10.1001/jamasurg.2019.2279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Trauma registries are the primary data mechanism in trauma systems to evaluate and improve the care of injured patients. Research has suggested that trauma registries may miss high-risk older adults, who commonly experience morbidity and mortality after injury. Objective To compare injured older adults who were included in with those excluded from trauma registries, with a focus on patients with serious injuries, requiring major surgery, or dying after injury. Design, Setting, and Participants This cohort study included all injured adults 65 years and older transported by 44 emergency medical services agencies to 51 trauma and nontrauma centers in 7 counties in Oregon and Washington from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. Record linkage was used to match emergency medical services records with state trauma registries, state discharge databases, state death registries, and Medicare claims. Data were analyzed from August to November 2018. Exposures Inclusion in vs exclusion from a trauma registry. Main Outcomes and Measures Mortality up to 12 months, including time to death and causes of death. Results Of 8161 included patients, 5579 (68.4%) were women, and the mean (SE) age was 82.2 (0.10) years. A total of 1720 older adults (21.1%) were matched to a trauma registry record. Seriously injured patients not captured by trauma registries ranged from 18% (7 of 38 patients with abdominal-pelvic Abbreviated Injury Scale score of 3 or greater) to 80.0% (1792 of 2241 patients with extremity Abbreviated Injury Scale score of 3 or greater), while 68 of 186 patients requiring major nonorthopedic surgery (36.6%) and 1809 of 2325 patients requiring orthopedic surgery (77.8%) were not included in trauma registries. Of patients with serious injuries or undergoing major surgery missed by trauma registries (range by injury and procedure type, 36.0% to 57.1%), 36.4% (39.3% when excluding serious extremity injuries and orthopedic procedures) were treated at trauma centers, particularly level III through V hospitals. When registry and nonregistry groups were tracked over 12 months, 93 of 188 in-hospital deaths (49.5%) and 1531 of 1887 total deaths (81.1%) occurred in the nonregistry cohort. Conclusions and Relevance In their current form, trauma registries are ineffective in capturing, tracking, and evaluating injured older adults, although mortality following injury is frequently due to noninjury causes. High-risk injured older adults are not included in registries because of care in nontrauma hospitals, restrictive registry inclusion criteria, and being missed by registries in trauma centers.
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Newgard CD, Uribe-Leitz T, Haider AH. Undertriage Remains a Vexing Problem for Even the Most Highly Developed Trauma Systems: The Need for Innovations in Field Triage. JAMA Surg 2019; 153:328. [PMID: 29094149 DOI: 10.1001/jamasurg.2017.4499] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Piantino J, Lim MM, Newgard CD, Iliff J. Linking Traumatic Brain Injury, Sleep Disruption and Post-Traumatic Headache: a Potential Role for Glymphatic Pathway Dysfunction. Curr Pain Headache Rep 2019; 23:62. [DOI: 10.1007/s11916-019-0799-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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McCarthy ML, Haynes S, Li X, Mann NC, Newgard CD, Lewis JF, Simon AE, Wood SF, Zeger SL. "Make the Call, Don't Miss a Beat" Campaign: Effect on Emergency Medical Services Use in Women with Heart Attack Signs. Womens Health Issues 2019; 29:392-399. [PMID: 31350017 DOI: 10.1016/j.whi.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 06/10/2019] [Accepted: 06/12/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Our objective was to evaluate the relationship between the "Make The Call, Don't Miss a Beat" national mass media campaign and emergency medical services (EMS) use among women with possible heart attack symptoms. METHODS We linked campaign TV public service advertisement data with national EMS activation data for 2010 to 2014. We identified EMS activations (i.e., responses) for possible heart attack symptoms and for unintentional injuries for both women and men. We estimated the impact of the campaign on the fraction of the 1.7 to 15.9 million activations of women with possible heart attack symptoms compared with 1.9 million female activations for unintentional injuries within each EMS agency and month using quasi-binomial logistic regression controlling for time and state. RESULTS Of the 3,175 U S. counties, 90% were exposed to the campaign. However, less than 2% of U.S. counties reached moderate TV exposure (≥300 gross rating points) during the entire campaign period. We did not observe an increase in the fraction of female activations for possible heart attack during periods or in counties with higher campaign exposure. CONCLUSIONS This mass media campaign that relied heavily on TV public service advertisements was not associated with increased EMS use by women with possible heart attack symptoms, even among counties that were more highly exposed to the campaign advertisements.
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Garwe T, Stewart KE, Newgard CD, Stoner JA, Sacra JC, Cody P, Oluborode B, Albrecht RM. Survival Benefit of Treatment at or Transfer to a Tertiary Trauma Center among Injured Older Adults. PREHOSP EMERG CARE 2019; 24:245-256. [PMID: 31211622 DOI: 10.1080/10903127.2019.1632997] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: It is well established that seriously injured older adults are under-triaged to tertiary trauma centers. However, the survival benefit of tertiary trauma centers (TC) compared to a non-tertiary trauma centers (Non-TCs) remains unclear for this patient population. Using improved methodology and a larger sample, we hypothesized that there was a difference in hospital mortality between injured older adults treated at TCs and those treated at Non-TCs. Methods: This was a retrospective cohort study of injured older adults (> =55 years) reported to the Oklahoma statewide trauma registry between 2005 and 2014. The outcome of interest was 30-day in-hospital mortality and the exposure variable of interest was level of definitive trauma care (TC vs Non-TC). Overall survival benefit of treatment at a TC as well as the survival benefit of transferring injured older adults to a TC were evaluated using multivariable survival analyses as well as propensity score-adjusted analyses. Results: Of the 25,288 patients eligible for analysis, 43% (10,927) were treated at TCs. Multivariable Cox regression analyses revealed effect modification by age group and time. After adjusting for potential confounders within the age strata, overall, patients treated at TCs were significantly less likely to die within 7 days of admission and this effect was stronger for patients aged 55-64 years (HR 0.41, 95% CI 0.31-0.52) compared to those > =65 years (HR 0.62, 95% CI 0.55-0.70). Overall survival benefit of TCs beyond 7 days was also observed (HR 0.68, 95% CI 0.56-0.83). Similarly, for the survival benefit of transferring injured older adults, after adjusting for the propensity to be transferred and other confounders, transfer to a TC was associated with lower 30-day mortality both for patients less than 65 years old (HR 0.36, 95% CI: 0.27-0.49) and those 65 years and older (HR 0.55, 95% CI: 0.48-0.64). Conclusions: Our results suggest a survival benefit for injured older adults treated at TCs. This benefit was also observed for patients transferred from non-tertiary trauma centers. Further research should focus on identifying specific subgroups of patients who would especially benefit from this level of care to minimize trauma triage inefficiencies.
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Newgard CD, Lin A, Yanez ND, Bulger E, Malveau S, Caughey A, McConnell KJ, Zive D, Griffiths D, Mirlohi R, Eckstrom E. Long-term outcomes among injured older adults transported by emergency medical services. Injury 2019; 50:1175-1185. [PMID: 31101411 DOI: 10.1016/j.injury.2019.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION/OBJECTIVE Little is known about the long-term outcomes of injured older adults cared for in trauma systems. We sought to describe mortality and causes of death over time, and the independent association of injury severity, comorbidities, and other factors on 12-month mortality among injured older adults transported by emergency medical services (EMS). MATERIALS AND METHODS This was a population-based cohort study of injured adults ≥ 65 years in the United States transported by 44 EMS agencies to 51 hospitals from January 1, 2011 to December 31, 2011, with 12-month follow-up through December 31, 2012. The primary outcomes were time to death and causes of death. We used descriptive statistics and Cox proportional hazards models to generate adjusted hazard ratios (HR). RESULTS 15,649 injured older adults were transported by EMS, frequently after a fall (84.5%). Serious injuries (Injury Severity Score [ISS] ≥ 16) occurred in 3.5%, with serious extremity injury (Abbreviated Injury Scale score ≥ 3) being most common (17.8%). Mortality rates were: 1.6% in-hospital, 5.1% at 30 days, 9.4% at 90 days and 20.3% at 1 year. The adjusted HR for patients in the highest comorbidity quartile was 2.20 (versus lowest quartile, 95% CI 1.97-2.46, p < .001), while the HR for ISS ≥ 25 was 2.69 (versus ISS 0-8, 95% CI 1.60-4.51, p = .001). Cardiovascular etiologies (53.3%) and dementia (32.7%) were the most common causes of death, with injury listed in 12.8% of death certificates. CONCLUSIONS Injury requiring EMS transport is a sentinel event among older adults, with death typically occurring months later, often due to cardiovascular causes and dementia. A heavy comorbidity burden had an adjusted mortality risk comparable to severe injury.
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