Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma

Does Direct Helicopter Retrieval Improve Survival of Severely Injured Trauma Patients From Rural Western Australia?

OBJECTIVE

In remote Western Australia, mortality from major trauma is more than 4 times higher than mortality rates from major trauma in the capital city of Perth. The objective of this study was to determine whether direct helicopter emergency medical service (HEMS) retrieval from an incident scene within the zone 50 to 250 km of Perth to a tertiary hospital improves survival in severely injured trauma patients. Direct HEMS retrieval was compared with indirect retrieval whereby patients were transferred by ambulance to a nearby rural hospital before retrieval to a tertiary hospital in Perth.

METHODS

A retrospective analysis (2006-2015) was undertaken of all Western Australia trauma registries, and coronial data were collected for all major trauma patients who died before retrieval to a tertiary hospital in Perth.

RESULTS

A total of 1,374 major trauma patients (indirect retrieval = 1,031 and direct HEMS = 343) met the study inclusion criteria. There was a 51% increased risk of death in the indirect patients compared with the direct HEMS patients (15.3% vs. 10.2%, P ≤ .001).

CONCLUSION

Direct HEMS retrieval from the incident scene to a tertiary hospital substantially improves the chances of survival for severely injured trauma patients in rural locations in the zone 50 to 250 km of Perth.

The Effect of Trauma Care on the Temporal Distribution of Homicide Mortality in Jefferson County, Alabama

The distribution of time from acute traumatic injury to death has three peaks: immediate (less than or equal to one hour), early (6 to 24 hours), and late (days to weeks). It has been suggested that coordinated trauma care dampens the late peak; however, this research may be more reflective of unintentional than intentional deaths. This study examines whether a coordinated trauma system (TS) alters the temporal distribution for assault-related deaths. Data were obtained from homicides examined by the Jefferson County Coroner's/Medical Examiner's Office from 1987 to 2008. Homicides were categorized—based on year of death—as occurring in the presence of no TS, during TS implementation, in the early years of the TS, or in a mature TS. The temporal distribution of homicide mortality was compared among TS categories using a χ2 test. A Cox Markov multistate model was used to estimate proportional changes in the temporal distribution of death adjusted for assault mechanism. With a TS, after adjusting for assault mechanism, a lower proportion of homicide victims survived through the first hour (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.54 to 1.03) and from one to six hours (HR, 0.68; 95% CI, 0.49 to 0.96). Additionally, the presence of a TS was associated with a proportional decrease in deaths after 24 hours ( P = 0.0005). These results suggest that a trauma system is effective in preventing late homicide deaths; however, other means of preventing death (such as violence prevention programs) are needed to decrease the burden of immediate homicide-related deaths.

Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017

OBJECTIVES

Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality.

METHODS

We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017.

RESULTS

Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%).

CONCLUSIONS

The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.

Short-term versus long-term trauma mortality: A systematic review

BACKGROUND

Trauma is the leading cause of death in the United States for persons under 44 years and the fourth leading cause of death in the elderly. Advancements in clinical care and standardization of treatment protocols have reduced 30-day trauma mortality to less than 4%. However, these improvements do not seem to correlate with long-term outcomes. Some reports have shown a greater than 20% mortality rate when looking at long-term outcomes. The aim of this study was to systematically review the incongruence between short- and long-term mortality for trauma patients.

METHODS

For this systematic review, we searched the Cochrane Library, EMBASE, Ovid Medline, Google Scholar, and Web of Science database to obtain relevant English, German, French, and Portuguese articles from 1965 to 2018.

RESULTS

Trauma patients have decreased long-term survival when compared to the general population and when compared with age-matched cohorts. Postdischarge trauma mortality is significantly higher (mean, 4.6% at 3-6 months, 15.8% at 2-3 years, 26.3% at 5-25 years) compared with controls (mean, 1.3%, 2.2%, and 15.6%, respectively). Patient comorbidities likely contribute to long-term trauma deaths. Trauma patients discharged to a skilled nursing facility have worse mortality compared with those discharged either to home or a rehabilitation center. In contrast to data available which illustrate that short-term mortality has improved, quality of evidence was not sufficient to determine if any improvements in long-term trauma mortality outcomes have also occurred.

CONCLUSIONS

The decreased short-term mortality observed in trauma patients does not appear correlated with decreased long-term mortality. The extent to which increased long-term trauma mortality is related to the initial traumatic insult-versus rising population age and comorbidity burden as well as suboptimal discharge location-requires further study.

LEVEL OF EVIDENCE

Systematic Review, level IV.

The importance of wearing a seatbelt correctly - A case report of blunt trauma causing complete shearing transection of the gastroduodenal junction

•

Seat belt related injuries can cause significant morbidity and mortality in road traffic accidents.

•

We present a case where an improperly worn seatbelt caused traumatic shearing transection of the gastroduodenal junction.

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A systematic multidisciplinary assessment approach enabled all injuries to be identified early.

•

The patient underwent damage control exploratory laparotomy then delayed reconstruction of the alimentary tract.

Introduction

Global mortality as a result of road traffic accidents (RTA) has reduced significantly since mandatory implementation of seatbelts. Whilst seatbelt related injury, or “seatbelt syndrome,” is a recognised phenomenon, unrestrained passengers have considerably worse survival outcomes. Improper positioning of seatbelts, as is discussed in the following case, can cause extensive injury.

Presentation of case

Our patient is a 35-year-old female who was a restrained front seat passenger in a car vs. tree collision at 80 km/h. Her seat belt was worn with the shoulder strap under her left axilla. She sustained multiple injuries including complete transection of the gastroduodenal junction. In addition to this she had splenic, liver, transverse colonic, left lower rib and humeral injury. She underwent damage control laparotomy with splenectomy; re-look with gastrojejunostomy and transverse colonic resection with defunctioning ileostomy. She made a good recovery and was discharged after a 4 week admission.

Discussion

Improperly worn seatbelts redistribute decelerative forces to sensitive regions. A multidisciplinary approach is required to effectively manage complex multi-system trauma. In trauma the simplest reconstructive measures can be the most effective and minimise risk of further complications for the patient.

Conclusion

Improperly worn seatbelts pose a significant risk to patients. A traumatic complete gastroduodenal transection can be effectively reconstructed with gastrojejunostomy anastomosis.

Direct transport vs secondary transfer to level I trauma centers in a French exclusive trauma system: Impact on mortality and determinants of triage on road-traffic victims

Background

Transporting a severely injured patient directly to a trauma center (TC) is consensually considered optimal. Nevertheless, disagreement persists regarding the association between secondary transfer status and outcome. The aim of the study was to compare adjusted mortality between road traffic trauma patients directly or secondarily transported to a level 1 trauma center (TC) in an exclusive French trauma system with a physician staffed prehospital emergency medical system (EMS).

Methods

A retrospective cohort study was performed using 2015–2017 data from a regional trauma registry (Traumabase®), an administrative database on road-traffic accidents and prehospital-EMS records.

Multivariate logistic regression models were computed to determine the role of the modality of admission on mortality and to identify factors associated with secondary transfer. The primary outcome was day-30 mortality.

Results: During the study period, 121.955 victims of road-traffic accident were recorded among which 4412 trauma patients were admitted in the level 1 regional TCs, 4031 directly and 381 secondarily transferred from lower levels facilities. No significant association between all-cause 30-day mortality and the type of transport was observed (Odds ratio 0.80, 95% confidence interval (CI) [0.3–1.9]) when adjusted for potential confounders. Patients secondarily transferred were older, with low-energy mechanism and presented higher head and abdominal injury scores. Among all 947 death, 43 (4.5%) occurred in lower-level facilities. The population-based undertriage leading to death was 0.15%, 95%CI [0.12–0.19].

Conclusion

In an exclusive trauma system with physician staffed prehospital care, road-traffic victims secondarily transferred to a TC do not have an increased mortality when compared to directly transported patients.

Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients

Importance

A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system.

Objective

To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients.

Design, Setting, and Participants

Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury.

Main Outcomes and Measures

The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol.

Results

A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication.

Conclusions and Relevance

More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol.

The Dubrava Model-A Novel Approach in Treating Acutely Neurotraumatized Patients in Rural Areas: A Proposal for Management

Introduction Neurotrauma is one of the leading causes of death and disabilities nowadays and represents one of the largest socioeconomic problems in rich countries, as well as developing ones. A satisfying, medically viable, and cost-effective model of managing acutely neurotraumatized patients, especially ones who come from distant and/or rural areas, has yet to be found. Patient outcome after acute neurotrauma depends on many factors of which the possibility of urgent treatment by an experienced specialist team has a crucial role. Here, we present our own way of managing acutely neurotraumatized patients from distant places which is unique in Croatia, the Dubrava model. Methods We present our 5-year experience cooperating with general hospitals in four neighboring cities (Ĉakovec, Bjelovar, Sisak, and Koprivnica) in managing, operating, and taking care of acutely neurotraumatized patients. Results More than 300 surgeries have been performed in these hospitals through the Dubrava model. Our experience so far provides encouraging results that this system could also be successfully implemented in other institutions. Furthermore, we recorded an increased number of surgeries each year, as well as a good mutual cooperation with the local general hospitals. Discussion This trauma managing model is one of a kind in Croatia. We argue that it is not only better for the patients, providing them with better chances of survival, and disability-free recovery, but is also far superior in many ways to the dominant and currently prevalent way of treating these patients in other parts of Croatia. Conclusion The Dubrava model of treating patients in rural and distant areas is a reliable and proven model with many benefits and as such its implementation should be considered in other institutions as well.

Factors Associated With the Interhospital Transfer of Emergency General Surgery Patients

BACKGROUND

Transferred emergency general surgery (EGS) patients constitute a highly vulnerable, acutely ill population. Guidelines to facilitate timely, appropriate EGS transfers are lacking. We determined patient- and hospital-level factors associated with interhospital EGS transfers, a critical first step to identifying which patients may require transfer.

METHODS

Adult EGS patients (defined by American Association for the Surgery of Trauma International Classification of Diseases, Ninth Revision diagnosis codes) were identified within the 2008-2013 Nationwide Inpatient Sample (n = 17,175,450). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multivariate proportional cause-specific hazards model with a competing risk analysis to assess the effect of risk factors for transfer.

RESULTS

1.8% of encounters resulted in a transfer (n = 318,286). Transferred patients were on average 62 y old and most commonly had Medicare (52.9% [n = 168,363]), private (26.7% [n = 84,991]), or Medicaid insurance (10.8% [n = 34,279]). 67.7% were white. The most common EGS diagnoses among transferred patients were related to hepatic-pancreatic-biliary (n = 90,989 [28.6%]) and upper gastrointestinal tract (n = 60,088 [18.9%]) conditions. Most transferred patients (n = 269,976 [84.8%]) did not have a procedure before transfer. Transfer was more likely if patients were in small (hazard ratio 2.52, 95% confidence interval 2.28-2.79) or medium (1.32, 1.21-1.44) versus large facilities, government (1.19, 1.11-1.28) versus private facilities, and rural (4.58, 3.98-5.27) or urban nonteaching (1.89, 1.70-2.10) versus urban teaching facilities. Patient-level factors were not strong predictors of transfer.

CONCLUSIONS

We identified that hospital-level characteristics more strongly predicted the need for transfer than patient-related factors. Consideration of these factors by providers as care is delivered in the context of the resources and capabilities of local institutions may facilitate transfer decision-making.

Early experience of a regional trauma center in Gangwon province: First step toward organizing a regional trauma system

Background:

The Korean Ministry of Health and Welfare decided to establish a trauma medical service system to reduce preventable deaths. OO hospital in Gangwon Province was selected as a regional trauma center and was inaugurated in 2015.

Objectives:

This study examines the impact of this center, comparing mortality and other variables before and after inaugurating the center.

Methods:

Severely injured patients (injury severity score > 15) presenting to OO hospital between January 2014 and December 2016 were enrolled and categorized into two groups: before trauma center (n = 365) and after trauma center (n = 904). Patient characteristics, variables, and patient outcomes (including mortality rate) before and after the establishment of trauma centers were compared accordingly for both groups. Risk factors for in-hospital mortality were also identified.

Results:

Probability of survival using trauma and injury severity score (%) method was significantly lower in the after trauma center group (81.3 ± 26.1) than in the before trauma center group (84.7 ± 21.0) (p = 0.014). In-hospital mortality rates were similar in both groups (before vs after trauma center group: 13.2% vs 14.2%; p = 0.638). The Z and W statistics revealed higher scores in the after trauma center group than in the before trauma center group (Z statistic, 4.69 vs 1.37; W statistic, 4.52 vs 2.10); 2.42 more patients (per 100 patients) survived after trauma center establishment.

Conclusion:

Although the mortality rates of trauma patients remained unchanged after the trauma center establishment, the Z and W statistics revealed improvements in the quality of care.

Patient-tailored triage decisions by anaesthesiologist-staffed prehospital critical care teams: a retrospective descriptive study

OBJECTIVES

The primary objective was to estimate the incidence of patients in the Central Denmark Region triaged to bypass the local emergency department without being part of a predefined fast-track protocol. The secondary objective was to describe these triage decisions in more detail with regard to the most common diagnoses, incidence of direct referral sorted by the prehospital critical care team (PHCCT) and the destination hospital.

DESIGN

Retrospective descriptive study.

SETTING AND PARTICIPANTS

The emergency medical service in the Central Denmark Region primarily consists of emergency medical technician (EMT)-staffed ambulances and anaesthesiologist-EMT-staffed PHCCTs. Patients treated by the nine ground-based PHCCTs in the region constituted the study population. The inclusion criteria were all patients treated by the PHCCTs during 2013 and 2014. The exclusion criteria were interhospital transfers, and patients with ST-segment elevation myocardial infarction, stroke or were in active labour.

ENDPOINTS

Incidence of prehospital critical care anaesthesiologist-initiated direct referral, prehospital tentative diagnoses and transport destination.

RESULTS

During the study period, the PHCCTs treated 39 396 patients and diverted 989 (2.5%) patients not covered by a predefined fast-track protocol to a specialised hospital department. 'Resuscitated from cardiac arrest' (n=143), 'treatment and observations following road traffic accident' (n=105) and 'observation and treatment for an unspecified disease/condition' (n=78) were the most common prehospital tentative diagnoses, accounting for 33.0% of all diverted patients. In total, 943 (95.3%) of the PHCCT-diverted patients were diverted to a department at Aarhus University Hospital.

CONCLUSION

Our results demonstrate that in 1 out of 40 patient contacts, the anaesthesiologist-staffed PHCCTs in the Central Denmark Region divert critically ill and injured patients directly to a specialised hospital department, bypassing local emergency departments and potentially reducing time to definitive care for these patients. There may be a potential for increased referral of patients with no predefined fast-track directly to specialised departments in the Central Denmark Region.

Trauma system in Greece: Quo Vadis?

INTRODUCTION

Implementation of trauma systems has markedly assisted in improving outcomes of the injured patient. However, differences exist internationally as diverse social factors, economic conditions and national particularities are placing obstacles. The purpose of this paper is to critically evaluate the current Greek trauma system, provide a comprehensive review and suggest key actions.

METHODS

An exhaustive search of the - scarce on this subject - English and Greek literature was carried out to analyze all the main components of the Greek trauma system, according to American College of Surgeons' criteria, as well as the WHO Trauma Systems Maturity Index.

RESULTS

Regarding prevention, efforts are in the right direction lowering the road traffic incidents-related death rate, however rural and insular regions remain behind. Hellenic Emergency Medical Service (EKAB) has well-defined communications and emergency phone line but faces problems with educating people on how to use it properly. In addition, equal and systematic training of ambulance personnel is a challenge, with the lack of pre-hospital registry and EMS quality assessment posing a question on where the related services are currently standing. Redistribution of facilities' roles with the establishment of the first formal trauma centre in the existing infrastructure would facilitate the development of a national registry and introduction of the trauma surgeon subspecialty with proper training potential. Definite rehabilitation institutional protocols that include both inpatient and outpatient care are needed. Disaster preparedness entails an extensive national plan and regular drills, mainly at the pre-hospital level. The lack, however, of any accompanying quality assurance programs hampers the effort to yield the desirable results.

CONCLUSION

Despite recent economic crisis in Greece, actions solving logistics and organising issues may offer a well-defined, integrated trauma system without uncontrollably raising the costs. Political will is needed for reforms that use pre-existing infrastructure and working power in a more efficient way, with a first line priority being the establishment of the first major trauma centre that could function as the cornerstone for the building of the Greek trauma system.

Analysis of Helicopter-Transported Trauma Patients at a Regional Trauma Center

Our medical center's regional helicopter emergency medical service (HEMS) serves southeastern North Carolina. Judicious HEMS use is vital to ensure that the resource is available for critically injured patients and to reduce morbidity and mortality by providing timely access to definitive care. We reviewed HEMS use, clinical outcomes, and overtriage rates. The data included airlifted trauma patients from January 2004 to December 2012. Of 1210 total patients, 733 were flown directly from the scene (FS) and 477 from referring hospitals (FH). The HEMS catchment area was a 100-mile radius of our trauma center. FS patients were younger and sustained more motor vehicle collisions. FH patients were older and sustained more falls. FS patients required more hospital resources including longer ventilator requirements, intensive care unit (ICU) stay, and hospital stay. For all HEMS patients, there was 92.2 per cent blunt injury, 47.5 per cent required Trauma I or II activation, 31 per cent required mechanical ventilation, and 50 per cent required ICU care. 59.5 per cent of HEMS trauma patients were critically injured (defined as requiring either immediate surgical intervention, immediate ICU admission, or immediate death). The overtriage rate was 1.8 per cent. The emergency department mortality rate was 2.3 per cent and the ultimate mortality rate was 7.5 per cent. Most of the airlifted trauma patients were critically injured, and therefore, HEMS transport was appropriate. However, overtriage was low, suggesting high incidence of undertriage. There should be a lower threshold for HEMS use for trauma patients in our region. More research is needed to determine ideal overtriage and undertriage rates.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time

BACKGROUND

The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children.

OBJECTIVES

To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes.

METHODS

We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics.

RESULTS

From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%).

CONCLUSIONS

Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.

Characterization of the occult nature of frequently occurring pediatric motor vehicle crash injuries

BACKGROUND

Occult injuries are those likely to be missed on initial assessment by first responders and, though initially asymptomatic, they may present suddenly and lead to rapid patient decompensation. No scoring systems to quantify the occultness of pediatric injuries have been established. Such a scoring system will be useful in the creation of an Advanced Automotive Crash Notification (AACN) system that assists first responders in making triage decisions following a motor vehicle crash (MVC).

STUDY DESIGN

The most frequent MVC injuries were determined for 0-4, 5-9, 10-14 and 15-18 year olds. For each age-specific injury, experts with pediatric trauma expertise were asked to rate the likelihood that the injury may be missed by first responders. An occult score (ranging from 0-1) was calculated by averaging and normalizing the responses of the experts polled.

RESULTS

Evaluation of all injuries across all age groups demonstrated greater occult scores for the younger age groups compared to older age groups (mean occult score 0-4yo: 0.61 ± 0.23, 5-9yo: 0.53 ± 0.25, 10-14yo: 0.48 ± 0.23, and 15-18yo: 0.42 ± 0.22, p < 0.01). Body-region specific occult scores revealed that experts judged abdominal, spine and thoracic injuries to be more occult than injuries to other body regions.

CONCLUSIONS

The occult scores suggested that injuries are more difficult to detect in younger age groups, likely given their inability to express symptoms. An AACN algorithm that can predict the presence of clinically undetectable injuries at the scene can improve triage of children with these injuries to higher levels of care.

A Qualitative Study of Multidisciplinary Providers' Experiences With the Transfer Process for Injured Children and Ideas for Improvement

OBJECTIVE

Most injured children initially present to a community hospital, and many will require transfer to a regional pediatric trauma center. The purpose of this study was 1) to explore multidisciplinary providers' experiences with the process of transferring injured children and 2) to describe proposed ideas for process improvement.

METHODS

This qualitative study involved 26 semistructured interviews. Subjects were recruited from 6 community hospital emergency departments and the trauma and transport teams of a level I pediatric trauma center in New Haven, Conn. Participants (n = 34) included interprofessional providers from sending facilities, transport teams, and receiving facilities. Using the constant comparative method, a multidisciplinary team coded transcripts and collectively refined codes to generate recurrent themes across interviews until theoretical saturation was achieved.

RESULTS

Participants reported that the transfer process for injured children is complex, stressful, and necessitates collaboration. The transfer process was perceived to involve numerous interrelated components, including professions, disciplines, and institutions. The 5 themes identified as areas to improve this transfer process included 1) Creation of a unified standard operating procedure that crosses institutions/teams, 2) Enhancing 'shared sense making' of all providers, 3) Improving provider confidence, expertise, and skills in caring for pediatric trauma transfer cases, 4) Addressing organization and environmental factors that may impede/delay transfer, and 5) Fostering institutional and personal relationships.

CONCLUSIONS

Efforts to improve the transfer process for injured children should be guided by the experiences of and input from multidisciplinary frontline emergency providers.

Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes

INTRODUCTION

Open tibial fractures are orthopedic emergencies that may present with severe soft tissue damage. Free tissue transfer is often required when local tissues are insufficient and patients may require hospital transfer to tertiary care centers for this purpose. Although the negative impact of inter-facility transfer has been well demonstrated in trauma patients, less is known regarding transfers for lower extremity injury patients. This study investigates differences in outcomes based on transfer status after open tibial fracture.

METHODS

Thirty-four consecutive open tibial fractures requiring free tissue transfer over a 13-year period (2001-2014) were retrospectively reviewed. Patients transferred from outside facilities were compared to non-transferred patients in regards to demographics, injury, surgical characteristics, and outcomes (mean follow-up of 2.5 years). Student t tests and chi square analysis were used to compare means and proportions, respectively.

RESULTS

One-half of patients were transferred from an outside hospital. Transferred and nontransferred patients were not significantly different in regard to age, sex, comorbidities, mechanism of injury, and Gustilo grade. There was no significant difference in the method of bony fixation or free flap used for soft tissue coverage. The time to wound vacuum-assisted closure placement was longer in transferred patients, though this difference was not found to be significant (2.4 vs 3.3 days, P = 0.55). Time to definitive bony fixation was delayed in the transfer group by 9 days (5.2 vs 14.1 days, P = 0.05) and to tissue coverage by 7 days (14.2 vs 20.9 days, P = 0.13). Rates of flap loss and amputation did not differ between the groups. However, transferred patients were more likely to develop osteomyelitis (risk ratio [RR], 3.0; P = 0.03), nonunion (RR, 5.0; P = 0.09), and require hardware removal (RR, 3.3; P = 0.01).

CONCLUSIONS

Transferred and nontransferred patients were not significantly different in their demographics or presentation. However, an analysis of clinical outcomes showed that transfer was associated with increased rates of osteomyelitis, nonunion, and hardware removal. Although likely multifactorial, this study suggests that a delay to definitive fixation and soft tissue coverage contributes to the increased rate of complications and poorer prognosis.

Prevalence and Predictors of Under-Diversion in the Primary Trauma Diversion System in Hong Kong

Introduction

Primary trauma diversion (PTD) enables direct transfer of major trauma patients to trauma centres for definitive care. This study aimed to evaluate the performance of PTD in the New Territories West Cluster (NTWC) of Hospital Authority and to identify the predictors for under-diversion.

Methods

A cross-sectional study based on local trauma registry. All major trauma patients (defined as ISS>15 or requiring trauma team activation) in the catchment area of the local hospital from September 2007 to December 2011 were included. The appropriateness of diversion decision was independently evaluated by an expert team (a trauma nurse coordinator and an emergency medicine practitioner). The sensitivity, specificity, predictive values, agreement, over-diversion and under-diversion rates were calculated. Potential predictors for under-diversion including age, Glasgow Coma Scale, mechanism of injury, injured body part, and the distance from scene to the trauma centre/local hospital were employed for logistic regression analysis.

Results

There were 141 eligible cases identified. The sensitivity and specificity for PTD were 59.5% and 96.5% respectively. The over-diversion rate was 3.5% and the under-diversion rate was 40.5%. The overall accuracy was around 74.5%. Non-motor vehicle accident (OR 13, 95% confidence interval [CI]=3.5-48.0, p<0.01) and isolated head injury (OR 5.35, 95% CI=1.5-19.5, p=0.01) were 2 independent predictors for under-diversion in PTD.

Conclusions

The overall field triage compliance by the paramedics is satisfactory. Under-diversion rate in NTWC is high. Non-motor vehicle accident mechanism and isolated head injury are 2 significant predictors for under-diversion. Reinforcement in training to avoid potential pitfalls would improve the paramedics' trauma triage performance.

A Regional Study on Primary Trauma Diversion in Hong Kong

Background

Primary trauma diversion (PTD) allows ambulance crews to transport severely injured patients directly to trauma centres. It has been launched in Kowloon Central Cluster (KCC) of Hospital Authority, Hong Kong since 2006.

Objective

The study investigated the performance of PTD with a view to provide relevant information for further development. The compliance with PTD, under-triage and over-triage were the major outcomes measurement. Patients' characteristics and their clinical information were also described.

Method

This was a retrospective descriptive study. We reviewed and analyzed the data in our hospital trauma registry during the study period between 1st July 2006 and 30th June 2009.

Result

One hundred and sixty-three trauma patients were diverted to our trauma centre during the study period. The mean Injury Severity Score was 11.72 with 90 of them being classified as severely injured. We found that 47 and 73 patients were under and over triage respectively. About 74% eligible trauma patients were diverted to the trauma centre according to PTD criteria.

Conclusion

Although the initial experience of PTD in KCC is satisfactory, more severely injured patients will benefit from our trauma centre service by improving the under-triage rate. We also foresee a better compliance with trauma diversion in the future.

The Outcome of Severe Traumatic Brain Injury in Latin America

BACKGROUND

Traumatic brain injury (TBI) disproportionately affects lower- and middle-income countries (LMIC). The factors influencing outcomes in LMIC have not been examined as rigorously as in higher-income countries.

METHODS

This study was conducted to examine clinical and demographic factors influencing TBI outcomes in Latin American LMIC. Data were prospectively collected during a randomized trial of intracranial pressure monitoring in severe TBI and a companion observational study. Participants were aged ≥13 years and admitted to study hospitals with Glasgow Coma Scale score ≤8. The primary outcome was Glasgow Outcome Scale, Extended (GOS-E) score at 6 months. Predictors were analyzed using a multivariable proportional odds model created by forward stepwise selection.

RESULTS

A total of 550 patients were identified. Six-month outcomes were available for 88%, of whom 37% had died and 44% had achieved a GOS-E score of 5-8. In multivariable proportional odds modeling, higher Glasgow Coma Scale motor score (odds ratio [OR], 1.41 per point; 95% confidence interval [CI], 1.23-1.61) and epidural hematoma (OR, 1.83; 95% CI, 1.17-2.86) were significant predictors of higher GOS-E score, whereas advanced age (OR, 0.65 per 10 years; 95% CI, 0.57-0.73) and cisternal effacement (P < 0.001) were associated with lower GOS-E score. Study site (P < 0.001) and race (P = 0.004) significantly predicted outcome, outweighing clinical variables such as hypotension and pupillary examination.

CONCLUSIONS

Mortality from severe TBI is high in Latin American LMIC, although the rate of favorable recovery is similar to that of high-income countries. Demographic factors such as race and study site played an outsized role in predicting outcome; further research is required to understand these associations.

Predicting Pediatric Patients Who Require Care at a Trauma Center: Analysis of Injuries and Other Factors

BACKGROUND

Triage decision correctness for children in motor vehicle crashes can be affected by occult injuries. There is a need to develop a transfer score (TS) metric for children that can help quantify the likelihood that an injury is present that would require transfer to a trauma center (TC) from a non-TC, and improve triage decision making. Ultimately, the TS metric might be useful in an advanced automatic crash notification algorithm, which uses vehicle telemetry data to predict the risk of serious injury after a motor vehicle crash using an approach that includes metrics to describe injury severity, time sensitivity, and predictability.

STUDY DESIGN

Transfer score metrics were calculated in 4 pediatric age groups (0 to 4, 5 to 9, 10 to 14, 15 to 18 years) for the most frequent motor vehicle crash injuries using the proportions of children transferred to a TC or managed at a non-TC using the National Inpatient Sample years 1998 to 2007. To account for the maximum Abbreviated Injury Scale (MAIS) injury, a co-injury adjusted transfer score (TS_MAIS) was calculated. The TS and TS_MAIS range from 0 to 1, with 1 indicating highly transferred injuries.

RESULTS

Injuries in younger patients were more likely to be transferred (median TS 0.48, 0.35, 0.25, and 0.23 for 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years, respectively). Injuries more likely to be transferred in younger children occurred in the thorax and abdomen. Regardless of age, spine (median TS_MAIS 0.59), head (median TS_MAIS 0.48), and thorax (median TS_MAIS 0.46) injuries had the highest frequency for transfer.

CONCLUSIONS

The TS metrics quantitatively describe age-specific transfer practices for children with particular injuries. This information can be useful in advanced automatic crash notification systems to alert first responders to the possibility of occult injuries and reduce undertriage of commonly missed injuries.

"One-way-street" streamlined admission of critically ill trauma patients reduces emergency department length of stay

Emergency department (ED) overcrowding remains a significant problem in many hospitals, and results in multiple negative effects on patient care outcomes and operational metrics. We sought to test whether implementing a quality improvement project could decrease ED LOS for trauma patients requiring an ICU admission from the ED, specifically by directly admitting critically ill trauma patients from the ED CT scanner to an ICU bed. This was a retrospective study comparing patients during the intervention period (2013-2014) to historical controls (2011-2013). Critically ill trauma patients requiring a CT scan, but not the operating room (OR) or Interventional Radiology (IR), were directly admitted from the CT scanner to the ICU, termed the "One-way street (OWS)". Controls from the 2011-2013 Trauma Registry were matched 1:1 based on the following criteria: Injury Severity Score; mechanism of injury; and age. Only patients who required emergent trauma consult were included. Our primary outcome was ED LOS, defined in minutes. Our secondary outcomes were ICU LOS, hospital LOS and mortality. Paired t test or Wilcoxon signed rank test were used for continuous univariate analysis and Chi square for categorical variables. Logistic regression and linear regressions were used for categorical and continuous multivariable analysis, respectively. 110 patients were enrolled in this study, with 55 in the OWS group and 55 matched controls. Matched controls had lower APACHE II score (12 vs. 15, p = 0.03) and a higher GCS (14 vs. 6, p = 0.04). ED LOS was 229 min shorter in the OWS group (82 vs. 311 min, p < 0.0001). The time between CT performed and ICU disposition decreased by 230 min in the OWS arm (30 vs. 300 min, p < 0.001). There was no difference in ED arrival to CT time between groups. Following multivariable analysis, mortality was primarily predicted by the APACHE II score (OR 1.29, p < 0.001), and not ISS, mechanism of injury, or age. After controlling for APACHE II score, there was no difference in mortality between the two cohorts (OR = 0.49, p = 0.28). Expedited admission of critically ill trauma patients immediately following CT imaging significantly reduced ED LOS by 3.82 h (229 min), without a change in ICU LOS, hospital LOS, or mortality. Further studies are needed to assess the impact of expedited admission on morbidity and mortality.

Does prehospital time affect survival of major trauma patients where there is no prehospital care?

BACKGROUND

Survival after major trauma is considered to be time dependent. Efficient prehospital care with rapid transport is the norm in developed countries, which is not available in many lower middle and low-income countries. The aim of this study was to assess the effect of prehospital time and primary treatment given on survival of major trauma patients in a setting without prehospital care.

MATERIALS AND METHODS

This prospective observational study was carried out in a university hospital in Mumbai, from January to December 2014. The hospital has a trauma service but no organized prehospital care or defined interhospital transfer protocols. All patients with life- and/or limb-threatening injuries were included in the study. Injury time and arrival time were noted and the interval was defined as "prehospital time" for the directly arriving patients and as "time to tertiary care" for those transferred. Primary outcome measure was in-hospital death (or discharge).

RESULTS

Of 1181 patients, 352 were admitted directly from the trauma scene and 829 were transferred from other hospitals. In-hospital mortality was associated with age, mechanism and mode of injury, shock, Glasgow Coma Score <9, Injury Severity Score ≥16, need for intubation, and ventilatory support on arrival; but neither with prehospital time nor with time to tertiary care. Transferred patients had a significantly higher mortality (odds ratio = 1.869, 95% confidence interval = 1.233-2.561, P = 0.005) despite fewer patients with severe injury. Two hundred and ninety-four (35%) of these needed airway intervention while 108 (13%) needed chest tube insertion on arrival to the trauma unit suggesting inadequate care at primary facility.

CONCLUSION

Mortality is not associated with prehospital time but with transfers from primary care; probably due to deficient care. To improve survival after major trauma, enhancement of resources for resuscitation and capacity building of on-duty doctors in primary centers should be a priority in countries with limited resources.

Outcomes after Motor Vehicle Trauma: Transfers to Level I Trauma Centers Compared with Direct Admissions

BACKGROUND

The multilevel designation system given to U.S. trauma centers has proven useful in providing injury-level-appropriate care and guiding field triage. Despite the system, patients are often transferred to Level I trauma centers for higher-level care/specialized services.

OBJECTIVES

The objective of this study is to assess whether there is a difference in outcomes of patients transferred to Level I centers compared with direct admissions.

METHODS

The Nationwide Inpatient Sample was queried to identify patients involved in motor vehicle accidents, using International Classification of Diseases, Ninth Revision, Clinical Modification E-codes. Patients that were admitted to Level I trauma centers were identified using American College of Surgeons or American Trauma Society designations.

RESULTS

There were 343,868 patients that met inclusion criteria. Of these patients, 29.2% (100,297) were admitted to Level I trauma centers, 5.7% (5691) of which were identified as trauma transfers. The lead admitting diagnosis for transfers was pelvic fracture (11.5%). Caucasians were 2.62 times as likely to be transferred as African-Americans (confidence interval 2.32-2.97), and 3.71 times as likely as Hispanics (confidence interval 3.25-4.23). Despite transfer patients having higher adjusted severity scores and higher adjusted risk of mortality, there were no differences in mortality (p = 0.95).

CONCLUSIONS

Nationally, trauma transfers do not have an increase in mortality when compared with directly admitted patients, despite a higher adjusted severity of illness and higher adjusted risk of mortality.

The Effect of Sporting Events on Medical Transport Time at a Level 1 Trauma Center: a Retrospective Cohort Study

OBJECTIVE

We investigate how West Virginia University football games affect transport to Ruby Memorial Hospital, which shares a parking lot with Milan Puskar Football Stadium.

METHODS

A retrospective chart review of a trauma registry from a level 1-trauma center was conducted from 2007 to 2011 for all home and away football games. Home games served as time period of interest and away games served as a control time period. Patient charts were collected for a 36-hour time window surrounding the game. 250 patient charts were complete for home games and 185 patient charts for away games. Data analyzed were time from scene to arrival at hospital, use of air transport, transport time in relation to kick-off, and comparison between demographic and emergency department disposition of patients arriving during home games vs. patients arriving during away games.

RESULTS

No statistically significant differences were found for demographic data or emergency department disposition between groups. For ground transport directly from scene, the average time to arrival at the hospital was 44.9 minutes for home games and 45.1 minutes for away games. For air transport directly from the scene, the average time to arrival at the hospital was 44.9 minutes for home games and 44.0 minutes for away games. For ground transfer from another facility, the average time to arrival at the hospital was 76.4 minutes for home games and 52.9 minutes for away games. For air transport from another facility, the average time to arrival at the hospital was 37.4 minutes for home games and 24.0 minutes for away games. Air transportation utilization was increased in inter-facility transfers during home games (5/16, 31.3% vs. 4/20, 22.2%), and helicopters traveled a further distance (avg. 66.6 vs. 50.25 air miles). For patients coming from the scene during a home game, if the start of the game occurred after the trauma but before arrival to the trauma center, the average time of ground transport increased from 44.9 minutes to 120 minutes (p<0.0001).

CONCLUSION

A mass gathering in close proximity to a rural trauma center does affect transport patterns and transport times for trauma patients. Further investigation is warranted in order to improve patient care during mass gathering events.

Regionalisation of trauma care in England

AIMS

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

PATIENTS AND METHODS

An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital.

RESULTS AND CONCLUSION

A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

The Effect of Interhospital Transfers on the Outcome of Rural Trauma

Urban areas house the majority of the population in the United States but trauma deaths occur more commonly in rural areas. In this study, we aimed to investigate if direct patient admission to a Level I trauma center improves outcomes in rural trauma. We retrospectively reviewed data in our trauma database from January 2008 to the end of December 2012 to compare the overall outcomes between direct admissions (DAs) and interhospital transfers (IHTs). Of the 6118 patients who met the inclusion criteria, 59.5 per cent were in the DA group and 40.5 per cent in the IHT group. Injury severity score was similar between the two groups but severe traumatic brain injury was more common (P = 0.001) in the DA group. Hospital length of stay, complication rate, and in-hospital mortality were not different between the two groups (all P > 0.2). In multivariate analysis, there was no difference in survival between the two modes of admission (odds ratio, 95% confidence interval: 0.91, 0.69–1.20, P = 0.51). We concluded that rural trauma IHTs had no detrimental impact on the outcome. Prospective studies would better elucidate factors associated with patient outcomes in rural trauma.

Anomaly Detection Outperforms Logistic Regression in Predicting Outcomes in Trauma Patients

OBJECTIVE

Recent advancements in trauma resuscitation have shown a great benefit of early identification and control of hemorrhage, which is the most common cause of death in injured patients. We introduce a new analytical approach, anomaly detection (AD), as an alternative method to the traditional logistic regression (LR) method in predicting which injured patients receive transfusions, intensive care, and other interventions.

METHODS

We abstracted routinely collected prehospital vital sign data from patient records (adult patients who survived more than 15 minutes after being directly admitted to a level 1 trauma center). The vital signs of the study cohort were analyzed using both LR and AD methods. Predictions on blood transfusions generated by these approaches were compared with hospital records using the respective areas under the receiver operating characteristic curves (AUROC).

RESULTS

Of the patients seen at our trauma center between January 1, 2009, and December 31, 2010, 5,464 were included. AD significantly outperformed LR, identifying which patients would receive transfusions of uncrossmatched blood, transfusion of blood between the time of admission and 6 hours later, the need for intensive care, and in-hospital mortality (mean AUROC = 0.764 and 0.720, respectively). AD and LR provided similar predictions for the patients who would receive massive transfusion. Under the stratified 10 fold times 10 cross-validation test, AD also had significantly lower AUROC variance across subgroups than LR, suggesting AD is a more stable predictions model.

CONCLUSIONS

AD provides enhanced predictions for clinically relevant outcomes in the trauma patient cohort studied and may assist providers in caring for acutely injured patients in the prehospital arena.

Traumatic brain injury patient volume and mortality in neurosurgical intensive care units: a Finnish nationwide study

Background

Differences in outcomes after traumatic brain injury (TBI) between neurosurgical centers exist, although the reasons for this are not clear. Thus, our aim was to assess the association between the annual volume of TBI patients and mortality in neurosurgical intensive care units (NICUs).

Methods

We collected data on all patients treated in the five Finnish university hospitals to examine all patients with TBI treated in NICUs in Finland from 2009 to 2012. We used a random effect logistic regression model to adjust for important prognostic factors to assess the independent effect of ICU volume on 6-month mortality. Subgroup analyses were performed for patients with severe TBI, moderate-to-severe TBI, and those who were undergoing mechanical ventilation or intracranial pressure monitoring.

Results

Altogether 2,328 TBI patients were treated during the study period in five NICUs. The annual TBI patient volume ranged from 61 to 206 patients between the NICUs. Univariate analysis, showed no association between the NICUs’ annual TBI patient volume and 6-month mortality (p = 0.063). The random effect model showed no independent association between the NICUs’ annual TBI patient volume and 6-month mortality (OR = 1.000, 95% CI = 0.996–1.004, p = 0.876). None of the pre-defined subgroup analyses indicated any association between NICU volume and patient mortality (p > 0.05 for all).

Discussion and Conclusion

We did not find any association between annual TBI patient volume and 6-month mortality in NICUs. These findings should be interpreted taking into account that we only included NICUs, which by international standards all treated high volumes of TBI patients, and that we were not able to study the effect of NICU volume on neurological outcome.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0320-6) contains supplementary material, which is available to authorized users.

Ambulance smartphone tool for field triage of ruptured aortic aneurysms (FILTR): study protocol for a prospective observational validation of diagnostic accuracy

INTRODUCTION

Rupture of an abdominal aortic aneurysm (rAAA) carries a considerable mortality rate and is often fatal. rAAA can be treated through open or endovascular surgical intervention and it is possible that more rapid access to definitive intervention might be a key aspect of improving mortality for rAAA. Diagnosis is not always straightforward with up to 42% of rAAA initially misdiagnosed, introducing potentially harmful delay. There is a need for an effective clinical decision support tool for accurate prehospital diagnosis and triage to enable transfer to an appropriate centre.

METHODS AND ANALYSIS

Prospective multicentre observational study assessing the diagnostic accuracy of a prehospital smartphone triage tool for detection of rAAA. The study will be conducted across London in conjunction with London Ambulance Service (LAS). A logistic score predicting the risk of rAAA by assessing ten key parameters was developed and retrospectively validated through logistic regression analysis of ambulance records and Hospital Episode Statistics data for 2200 patients from 2005 to 2010. The triage tool is integrated into a secure mobile app for major smartphone platforms. Key parameters collected from the app will be retrospectively matched with final hospital discharge diagnosis for each patient encounter. The primary outcome is to assess the sensitivity, specificity and positive predictive value of the rAAA triage tool logistic score in prospective use as a mob app for prehospital ambulance clinicians. Data collection started in November 2014 and the study will recruit a minimum of 1150 non-consecutive patients over a time period of 2 years.

ETHICS AND DISSEMINATION

Full ethical approval has been gained for this study. The results of this study will be disseminated in peer-reviewed publications, and international/national presentations.

TRIAL REGISTRATION NUMBER

CPMS 16459; pre-results.

Opening a New Level II Trauma Center Near an Established Level I Trauma Center: Is This Good for Trauma Care?

OBJECTIVES

To describe how the initiation and later removal of a provisional level II trauma center (PL2TC) status at a community hospital affected the volume and severity of injured patients seen at an established academic level 1 trauma center (AL1TC).

METHODS

Census data including counts of injury ICD-9 codes and patients seen in the emergency department (ED) and trauma center at an AL1TC were collected monthly from January 2010 to October 2014. An interrupted time series analysis was used to model the monthly census data with 2 time interruptions to describe the change in patient volume at the interruptions. The interruptions were (1) the initiation of the PL2TC status at a nearby community hospital and (2) the subsequent removal of the PL2TC status.

RESULTS

The number of diagnoses, encounters, and patients seen at the AL1TC ED decreased while the PL2TC was operating. After the removal of the PL2TC status, there was a 19.4% increase in the ED patient volume per month at the AL1TC. The number of orthopaedic trauma patients seen through the ED at the AL1TC dropped 11.1% per month when the PL2TC began functioning as a trauma center. However, the volume of orthopaedic patients at the AL1TC did not recuperate after the PL2TC lost level 2 status.

CONCLUSIONS

A significant decrease in patient volume was seen at the AL1TC with the initiation of the PL2TC in close proximity. Orthopaedic patient volume did not recuperate after the removal of the PL2TC status.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue

OBJECTIVES

We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay.

DESIGN

Prospective consecutive series.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0.

INTERVENTION

Femur, pelvis, or spine fractures treated surgically.

MAIN OUTCOME MEASUREMENTS

Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded.

RESULTS

Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days).

CONCLUSIONS

Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults

OBJECTIVE

Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups.

METHODS

Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes.

RESULTS

Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means.

CONCLUSION

Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI.

Are appendectomy outcomes in level I trauma centers as good as we think?

BACKGROUND

Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy.

METHODS

An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007-2011). All patients with an ICD-90-CM diagnosis of "acute appendicitis" (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors.

RESULTS

There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14-0.36]), stayed in hospital longer (0.83 d [0.36-1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13-2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes.

CONCLUSIONS

Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings.

Assessing access to paediatric trauma centres in Canada, and the impact of the golden hour on length of stay at the hospital: an observational study

OBJECTIVES

In Canada injuries are a leading cause of death and morbidity among the paediatric population. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. However, not all populations have equal access to trauma care services. This is an observational study with the aim of assessing the impact of geographical access to paediatric trauma centres (PTCs) on patient outcomes, and to determine spatial access to PTCs across Canada.

SETTING

To examine the relationship between access to PTC and injury outcome, length of stay at the PTC was determined for all injured patients who live within and outside of 60 min driving time of the PTC. To determine spatial access to PTCs across Canada, a list of level 1 and 2 PTCs was identified across Canada. A 1 h driving time catchment was created around each PTC in order to estimate spatial accessibility.

PARTICIPANTS

Hospital administration data sets from British Columbia (BC) and the Nova Scotia (NS) trauma registry were used to assess the impact of spatial access on paediatric injury (ages 0-15 years) outcomes. The data sets provided case-level data including the Injury Severity Score, postal code of place of residence, age and length of hospital stay.

RESULTS

In NS and BC, average length of stay at the hospital is significantly lower inside 60 min driving time compared to outside of 60 min driving time from a PTC (p<0.05, using a non-parametric t test). In Canada, approximately 65% of the paediatric population resides within 1 h of a PTC.

CONCLUSIONS

This paper highlights differences in injury outcomes as a result of access. However, further investigation is needed as other considerations such as type of injury, age and/or gender may also affect injury outcomes.

Temporal delays in trauma craniotomies

OBJECTIVE The Brain Trauma Foundation recommendation regarding the timing of surgical evacuation of epidural hematomas and subdural hematomas is to perform the procedure as soon as possible. Indeed, faster evacuation is associated with better outcome. However, to the authors' knowledge, no study has looked at where delays in intrahospital care occurred for patients suffering from traumatic intracranial mass lesions. The goals of this study were as follows: 1) to characterize the performance of a Level 1 trauma center in terms of delays for emergency trauma craniotomies, 2) to review step by step where delays occurred in patient care, and 3) to propose ways to improve performance. METHODS A retrospective review was conducted covering a 5-year period of all emergency trauma craniotomies. Demographic data, injury severity, neurological status, and functional outcome data were collected. The time elapsed between emergency department (ED) arrival and CT imaging, between CT imaging and arrival at the operating room (OR), between ED arrival and OR arrival, between OR arrival and skin incision, and between ED arrival and skin incision were calculated. Patients were also subcategorized as either having immediate life-threatening emergencies (E0) or life-threatening emergencies (E1). The operative technique was also reviewed (standard craniotomy opening vs immediate bur hole decompression followed by craniotomy). RESULTS The study included 166 patients. Of these, 58 (35%) were classified into the E0 group and 108 (64.2%) into the E1 group. The median ED-to-CT delay was 54 minutes with no significant difference between the E0 and the E1 groups. The median CT-to-OR time delay was 57 minutes. The median delay for the E0 group was 39 minutes and that for the E1 group was 70 minutes (p = 0.002). The median delay from ED to OR arrival for patients with a CT scanning done at an outside hospital was 75 minutes. The median delay from ED to OR arrival was 85 minutes for the E0 group and 127 minutes for the E1 group (p < 0.0001). The median delay from OR arrival to skin incision was 35 minutes (E0: median 27 minutes; E1: median 39 minutes; p < 0.0001). The median total time elapsed between ED arrival and skin incision was 150 minutes (E0: median 131 minutes; E1: median 180 minutes). Overall, only 17% of patients underwent immediate bur hole decompression, but the proportion climbed to 41% in the E0 group. A lower Glasgow Coma Scale score was associated with a shorter delay (p = 0.0004). CONCLUSIONS A long delay until surgery still exists for patients requiring urgent mass lesion evacuation. Many factors contribute to this delay, including performing imaging and transfer to and preparation in the OR. Strategies can be implemented to reduce delays and improve the delivery of care.

Is 15 minutes an appropriate resuscitation duration before termination of a traumatic cardiac arrest? A case-control study

BACKGROUND

Previous guidelines suggest up to 15 minutes of cardiopulmonary resuscitation (CPR) accompanied by other resuscitative interventions before terminating resuscitation of a traumatic cardiac arrest. The current study evaluated the duration of CPR according to outcome using the model of a county-based emergency medical services (EMS) system in Taiwan.

METHODS

This study was performed as a prospectively defined retrospective review from EMS records and cardiac arrest registration between June 2011 and November 2012 in Taoyuan, Taiwan.

RESULTS

A total of 396 patients were enrolled. Among the blunt injuries, most incidents were traffic accidents (66.5%) followed by falls (31.5%). Bystander CPR was performed in 34 patients (8.6%). Of the patients, 18.4% were sent to intermediate to advanced level traumatic care hospitals. Although 4.8% of patients survived for 24 hours, only 2.3% survived to discharge, and 0.8% achieved cerebral performance category 1 or 2. Among all patients who developed return of spontaneous circulation (ROSC), 14.3% of ROSC was achieved within 15 minutes since CPR. Except for 1, most patients who developed ROSC over 24 hours but did not survive to discharge received CPR more than 15 minutes. Four of 6 patients who survived to discharge achieved ROSC after CPR for more than 15 minutes (16, 18, 22, and 24 minutes). Three patients discharged with cerebral performance category 1 or 2 received CPR for 6, 16, and 18 minutes, respectively.

CONCLUSIONS

Fifteen minutes of CPR before terminating resuscitation is inappropriate for patients undergoing traumatic cardiac arrsests, as longer duration resuscitation increases ROSC and survival.

Vittel criteria for severe trauma triage: Characteristics of over-triage

AIM

Over-triage rates related to the use of Vittel criteria are unknown. We compared severe stable trauma patients with and without significant visceral injuries.

STUDY DESIGN

A single-centre retrospective analysis of a single-centre prospective cohort.

PATIENTS AND METHODS

Trauma patients with at least one positive Vittel criterion from June 2010 to January 2012 in a level-1 trauma centre. Initial management included a systematic whole-body scanner. All significant lesions in stable trauma patients were recorded.

RESULTS

A total of 252 trauma patients were admitted. One hundred and twenty were stable. In this group without vital distress, 72 (60%) had at least one occult lesion, 21 (17.5%) had an isolated orthopaedic injury and 27 (22.5%) had no injury. Thoracic injuries accounted for 44% of visceral injuries, abdominal for 17%, spinal for 16% and cerebral for 15%. Overall, the over-triage rate was 19%. Surgery for significant visceral injury was performed in 13 patients (18%) and arteriography in 4 patients (5.5%). Admission in an intensive care unit was required for 13 patients with occult injuries and for one patient without such a lesion (18% versus 2%, P=0.008). Hospital stays were longer in the group with visceral injuries (4±7 versus 9±8days; P=0.006).

CONCLUSION

Vittel criteria use in trauma patients induces an acceptable over-triage rate. A large proportion of stable trauma patients have occult lesions. These visceral injuries frequently require special care. These data highlight the imperative need to transport major trauma patients immediately to a dedicated trauma centre and supports whole-body scanner use.

Factors Associated with Time to Arrival at a Regional Pediatric Trauma Center

OBJECTIVE

The goal of this study was to test the hypothesis that the prehospital time between injury and arrival at a trauma center for critically injured children is associated with patient injury severity and mode of transport.

METHODS

Secondary analysis of prospectively collected data on children 0-17 years of age admitted with traumatic injuries to a designated Level I pediatric trauma center from January 1, 2006 through September 30, 2007 was conducted. Multivariate regression methods were used to assess for factors independently associated with prehospital time.

RESULTS

Of 1,175 admissions during the study period, only 355 (30%) had a prehospital time within 60 minutes of injury. Prehospital time within 60 minutes of injury was associated with higher frequency of coma, higher mean injury severity scores (ISS), and greater frequency of admission to the intensive care unit when compared with prehospital time beyond 60 minutes of injury. Children who arrived at the trauma center within 60 minutes versus beyond 60 minutes were 13-fold (odds ratio [OR]: 12.9; 95% Confidence Interval [CI], 7.6-22.0) more likely to be transported via air ambulance than a private vehicle, and had 4.8-fold greater odds (95% CI, 2.2-10.3) of transport via ground ambulance than private vehicle. For each kilometer of distance between the injury zip code and the trauma center, the odds of arrival within 60 minutes versus beyond 60 minutes decreased by 15% (OR: 0.85; 95% CI, 0.79-0.91).

CONCLUSION

Field triage and decision making appeared to correlate with severity of patient injury with expeditious transport of the most severely injured children to definitive trauma care. This finding serves as important groundwork that might enable further study into factors that influence triage and overall prehospital care for critically injured children.