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Venturini S, Fountain DM, Glancz LJ, Livermore LJ, Coulter IC, Bond S, Matta B, Santarius T, Hutchinson PJ, Brennan PM, Kolias AG. Time to surgery following chronic subdural hematoma: post hoc analysis of a prospective cohort study. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2019; 1:e000012. [PMID: 35047776 PMCID: PMC8749282 DOI: 10.1136/bmjsit-2019-000012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/26/2019] [Accepted: 10/04/2019] [Indexed: 12/03/2022] Open
Abstract
Background Chronic subdural hematoma (CSDH) is a common neurological condition; surgical evacuation is the mainstay of treatment for symptomatic patients. No clear evidence exists regarding the impact of timing of surgery on outcomes. We investigated factors influencing time to surgery and its impact on outcomes of interest. Methods Patients with CSDH who underwent burr-hole craniostomy were included. This is a subset of data from a prospective observational study conducted in the UK. Logistic mixed modelling was performed to examine the factors influencing time to surgery. The impact of time to surgery on discharge modified Rankin Scale (mRS), complications, recurrence, length of stay and survival was investigated with multivariable logistic regression analysis. Results 656 patients were included. Time to surgery ranged from 0 to 44 days (median 1, IQR 1–3). Older age, more favorable mRS on admission, high preoperative Glasgow Coma Scale score, use of antiplatelet medications, comorbidities and bilateral hematomas were associated with increased time to surgery. Time to surgery showed a significant positive association with length of stay; it was not associated with outcome, complication rate, reoperation rate, or survival on multivariable analysis. There was a trend for patients with time to surgery of ≥7 days to have lower odds of favorable outcome at discharge (p=0.061). Conclusions This study provides evidence that time to surgery does not substantially impact on outcomes following CSDH. However, increasing time to surgery is associated with increasing length of stay. These results should not encourage delaying operations for patients when they are clinically indicated.
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Affiliation(s)
- Sara Venturini
- Department of Neurosurgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Daniel M Fountain
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Ian C Coulter
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Department of Anaesthesia, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Thomas Santarius
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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The Golden Hour After Injury Among Civilians Caught in Conflict Zones. Disaster Med Public Health Prep 2019; 13:1074-1082. [DOI: 10.1017/dmp.2019.42] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTIntroduction:The term “golden hour” describes the first 60 minutes after patients sustain injury. In resource-available settings, rapid transport to trauma centers within this time period is standard-of-care. We compared transport times of injured civilians in modern conflict zones to assess the degree to which injured civilians are transported within the golden hour in these environments.Methods:We evaluated PubMed, Ovid, and Web of Science databases for manuscripts describing transport time after trauma among civilian victims of trauma from January 1990 to November 2017.Results:The initial database search identified 2704 abstracts. Twenty-nine studies met inclusion and exclusion criteria. Conflicts in Yugoslavia/Bosnia/Herzegovina, Syria, Afghanistan, Iraq, Israel, Cambodia, Somalia, Georgia, Lebanon, Nigeria, Democratic Republic of Congo, and Turkey were represented, describing 47 273 patients. Only 7 (24%) manuscripts described transport times under 1 hour. Transport typically required several hours to days.Conclusion:Anticipated transport times have important implications for field triage of injured persons in civilian conflict settings because existing overburdened civilian health care systems may become further overwhelmed if in-hospital health capacity is unable to keep pace with inflow of the severely wounded.
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Colgrave N, Ibbett I, Thani N. Transfer times and patient outcomes - A review of head injuries requiring surgery in Tasmania 2006-2017. J Clin Neurosci 2019; 64:122-126. [PMID: 30935750 DOI: 10.1016/j.jocn.2019.03.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/30/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
The Royal Hobart Hospital (RHH) provides the only neurosurgical service in the state of Tasmania, Australia, with many patients requiring surgical treatment of intracranial injuries needing to be transferred from peripheral hospitals around the state to Hobart. This retrospective review analysed the medical records of all patients who underwent a neurosurgical intervention at RHH for an intracranial injury over a 10½ year period to ascertain if prolonged transfer times correlated with poorer patient outcomes. A total of 360 patients were included in the study, with 159 patients presenting initially to a peripheral hospital and subsequently transferred to RHH for surgery. A correlation analysis found no statistically significant relationship between transfer times from peripheral hospitals and patient Glasgow Outcome Scale (GOS) scores at 6 months post-surgery (r = 0.065, P = 0.434). There was also no correlation between transfer times and discharge destination (r = 0.088, P = 0.275). We concluded that patient transfers for head injury management in Tasmania are timely and meeting patient needs.
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Affiliation(s)
- Nevin Colgrave
- Department of Neurosurgery, Royal Hobart Hospital, 48 Liverpool Street, Hobart, TAS 7000, Australia.
| | - Imogen Ibbett
- Department of Neurosurgery, Royal Hobart Hospital, 48 Liverpool Street, Hobart, TAS 7000, Australia
| | - Nova Thani
- Department of Neurosurgery, Royal Hobart Hospital, 48 Liverpool Street, Hobart, TAS 7000, Australia
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Jin XQ, Du XF, Yang MF, Zhang Q. Development and Validation of Prognostic Model for Patients with Acute Subdural Hematoma-Reliable Nomogram. World Neurosurg 2018; 124:S1878-8750(18)32904-8. [PMID: 30593962 DOI: 10.1016/j.wneu.2018.12.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE By extracting clinical and computed tomography imaging data of patients with acute subdural hematoma (ASDH), factors that were significantly associated with poor prognosis were screened and a nomogram model was established and validated. METHODS All patients with ASDH who underwent subdural hematoma removal and decompressive craniectomy from January 2014 to March 2018 in Qinghai Provincial People's Hospital were continuously collected. Finally, 124 patients were included in the study. According to the Glasgow Outcome Scale at 3 months after operation, patients were divided into a good prognosis group and a poor prognosis group. RESULTS Univariate and binary logistic regression analysis were performed to screen out independent predictors that were significantly associated with poor prognosis of ASDH. On the basis of these factors, a nomogram model was established. CONCLUSIONS The nomogram model had high accuracy for predicting poor prognosis in patients with ASDH, and it was easy to promote. In the future, large sample and multicenter prospective studies are necessary to complement and identify the results.
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Affiliation(s)
- Xiao-Qing Jin
- Department of Graduate School, Qinghai University, Xining, Qinghai, China
| | - Xiao-Feng Du
- Department of Nursing, Qinghai Institute of Health Sciences, Xining, Qinghai, China
| | - Ming-Fei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China.
| | - Qiang Zhang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China
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Schroeder PH, Napoli NJ, Barnhardt WF, Barnes LE, Young JS. Relative Mortality Analysis Of The “Golden Hour”: A Comprehensive Acuity Stratification Approach To Address Disagreement In Current Literature. PREHOSP EMERG CARE 2018; 23:254-262. [DOI: 10.1080/10903127.2018.1489021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Kinoshita T, Hayashi M, Yamakawa K, Watanabe A, Yoshimura J, Hamasaki T, Fujimi S. Effect of the Hybrid Emergency Room System on Functional Outcome in Patients with Severe Traumatic Brain Injury. World Neurosurg 2018; 118:e792-e799. [PMID: 30026142 DOI: 10.1016/j.wneu.2018.07.053] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The timely treatment of severe traumatic brain injury (TBI) is essential for limiting the effects of damage; however, there is no consensus regarding an effective method for early intervention. In August 2011, our hospital launched a novel trauma workflow using the hybrid emergency room (ER), consisting of an interventional radiology-computed tomography (CT) unit installed in the trauma resuscitation room to facilitate early interventions. The aim of this study was to evaluate effects of the hybrid ER system on functional outcomes in patients with severe TBI. METHODS We conducted a retrospective historical control study of patients with severe TBI (Glasgow Coma Scale score ≤8) who received conventional treatment (August 2007-July 2011) or treatment in the hybrid ER (August 2011-July 2015). The primary end point was unfavorable outcome at 6 months after injury (death, vegetative state, or lower severe disability) as evaluated by the Glasgow Outcome Scale-Extended. Secondary end points included time from arrival to the start of CT examination and emergency intracranial operation. Potential confounders were adjusted with multivariable logistic regressions. RESULTS Among 158 included patients, 88 were in the conventional group and 70 were in the hybrid ER group. After model adjustment, the hybrid ER group was significantly associated with a reduction in unfavorable outcomes. Times to CT examination and intracranial operation were significantly shorter in the hybrid ER group than that in the conventional group. CONCLUSIONS The hybrid ER system is useful for realizing immediate CT examination and emergency surgery and improving functional outcomes in patients with severe TBI.
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Affiliation(s)
- Takahiro Kinoshita
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Motohisa Hayashi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan.
| | - Atsushi Watanabe
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
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Park YS, Kogeichi Y, Shida Y, Nakase H. Efficacy of the All-in-One Therapeutic Strategy for Severe Traumatic Brain Injury: Preliminary Outcome and Limitation. Korean J Neurotrauma 2018; 14:6-13. [PMID: 29774192 PMCID: PMC5949525 DOI: 10.13004/kjnt.2018.14.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 12/04/2022] Open
Abstract
Objective Despite recent advances in medicine, no significant improvement has been achieved in therapeutic outcomes for severe traumatic brain injury (TBI). In the treatment of severe multiple traumas, accurate judgment and prompt action corresponding to rapid pathophysiological changes are required. Therefore, we developed the “All-in-One” therapeutic strategy for severe TBI. In this report, we present the therapeutic concept and discuss its efficacy and limitations. Methods From April 2007 to December 2015, 439 patients diagnosed as having traumatic intracranial injuries were treated at our institution. Among them, 158 patients were treated surgically. The “All-in-One” therapeutic strategy was adopted to enforce all selectable treatments for these patients at the initial stages. The outline of this strategy is as follows: first, prompt trepanation surgery in the emergency room (ER); second, extensive decompression craniotomy (DC) in the operating room (OR); and finally, combined mild hypothermia and moderate barbiturate (H-B) therapy for 3 to 5 days. We performed these approaches on a regular basis rather than stepwise rule. If necessary, internal ecompression surgery and external ventricular drainage were performed in cases in which intracranial pressure could not be controlled. Results Trepanation surgery in the ER was performed in 97 cases; among these cases, 46 had hematoma removal surgery and also underwent DC in the OR. Craniotomy was not enforced unless the consciousness level and pupil findings did not improve after previous treatments. H-B therapy was administered in 56 cases. Internal decompression surgery, including evacuation of traumatic intracerebral hematoma, was additionally performed in 12 cases. Three months after injury, the Glasgow Outcome Scale (GOS) score yielded the following results: good recovery in 25 cases (16%), mild disability in 28 (18%), severe disability in 33 (21%), persistent vegetative state in 9 (6%), and death in 63 (40%). Furthermore, 27 (36%) of the 76 most severe patients who had an abnormal response of bilateral eye pupils were life-saving. Because many cases of a GOS score of ≤5 are included in this study, this result must be satisfactory. Conclusion This therapeutic strategy without any lose in the appropriate treatment timing can improve the outcomes of the most severe TBI cases. We think that the breakthrough in the treatment of severe TBI will depend on the shift in the treatment policy.
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Affiliation(s)
- Young-Soo Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Yohei Kogeichi
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Yoichi Shida
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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Jagannath S, Sarcevic A, Marsic I. An Analysis of Speech as a Modality for Activity Recognition during Complex Medical Teamwork. INTERNATIONAL CONFERENCE ON PERVASIVE COMPUTING TECHNOLOGIES FOR HEALTHCARE : [PROCEEDINGS]. INTERNATIONAL CONFERENCE ON PERVASIVE COMPUTING TECHNOLOGIES FOR HEALTHCARE 2018; 2018:88-97. [PMID: 30323960 PMCID: PMC6183054 DOI: 10.1145/3240925.3240941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We analyzed the nature of verbal communication among team members in a dynamic medical setting of trauma resuscitation to inform the design of a speech-based automatic activity recognition system. Using speech transcripts from 20 resuscitations, we identified common keywords and speech patterns for different resuscitation activities. Based on these patterns, we developed narrative schemas (speech "workflow" models) for five most frequently performed activities and applied linguistic models to represent relationships between sentences. We evaluated the narrative schemas with 17 new cases, finding that all five schemas adequately represented speech during activities and could serve as a basis for speech-based activity recognition. We also identified similarities between narrative schemas of different activities. We conclude with design implications and challenges associated with speech-based activity recognition in complex medical processes.
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Affiliation(s)
- Swathi Jagannath
- Drexel University Philadelphia, PA, United States {sj532,aleksarc}@drexel.edu
| | - Aleksandra Sarcevic
- Drexel University Philadelphia, PA, United States {sj532,aleksarc}@drexel.edu
| | - Ivan Marsic
- Rutgers University Piscataway, NJ, United States
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Roh YI, Kim HI, Cha YS, Cha KC, Kim H, Lee KH, Hwang SO, Kim OH. Mortality Reduction in Major Trauma Patients after Establishment of a Level I Trauma Center in Korea: A Single-Center Experience. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.4.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Young Il Roh
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyung Il Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kang Hyun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Oh Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Shaw BI, Wangara AA, Wambua GM, Kiruja J, Dicker RA, Mweu JM, Juillard C. Geospatial relationship of road traffic crashes and healthcare facilities with trauma surgical capabilities in Nairobi, Kenya: defining gaps in coverage. Trauma Surg Acute Care Open 2017; 2:e000130. [PMID: 29766119 PMCID: PMC5887833 DOI: 10.1136/tsaco-2017-000130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/04/2017] [Accepted: 11/07/2017] [Indexed: 12/13/2022] Open
Abstract
Background Road traffic injuries (RTIs) are a cause of significant morbidity and mortality in low- and middle-income countries. Access to timely emergency services is needed to decrease the morbidity and mortality of RTIs and other traumatic injuries. Our objective was to describe the distribution of roadtrafficcrashes (RTCs) in Nairobi with the relative distance and travel times for victims of RTCs to health facilities with trauma surgical capabilities. Methods RTCs in Nairobi County were recorded by the Ma3route app from May 2015 to October 2015 with latitude and longitude coordinates for each RTC extracted using geocoding. Health facility administrators were interviewed to determine surgical capacity of their facilities. RTCs and health facilities were plotted on maps using ArcGIS. Distances and travel times between RTCs and health facilities were determined using the Google Maps Distance Matrix API. Results 89 percent (25/28) of health facilities meeting inclusion criteria were evaluated. Overall, health facilities were well equipped for trauma surgery with 96% meeting WHO Minimal Safety Criteria. 76 percent of facilities performed greater than 12 of three pre-selected ‘Bellweather Procedures’ shown to correlate with surgical capability. The average travel time and distance from RTCs to the nearest health facilities surveyed were 7 min and 3.4 km, respectively. This increased to 18 min and 9.6 km if all RTC victims were transported to Kenyatta National Hospital (KNH). Conclusion Almost all hospitals surveyed in the present study have the ability to care for trauma patients. Treating patients directly at these facilities would decrease travel time compared with transfer to KNH. Nairobi County could benefit from formally coordinating the triage of trauma patients to more facilities to decrease travel time and potentially improve patient outcomes. Level of evidence III
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Affiliation(s)
- Brian I Shaw
- School of Medicine, University of California, San Francisco, California, USA
| | - Ali Akida Wangara
- Accident and Emergency Department, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Jason Kiruja
- Department of Pediatrics, Kenyatta National Hospital, Nairobi, Kenya
| | - Rochelle A Dicker
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California, USA
| | | | - Catherine Juillard
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California, USA
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Patel A, Vissoci JRN, Hocker M, Molina E, Gil NM, Staton C. Qualitative evaluation of trauma delays in road traffic injury patients in Maringá, Brazil. BMC Health Serv Res 2017; 17:804. [PMID: 29197385 PMCID: PMC5712173 DOI: 10.1186/s12913-017-2762-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/23/2017] [Indexed: 11/18/2022] Open
Abstract
Background Road traffic injuries (RTIs) are the eighth leading cause of death worldwide, with an estimated 90% of RTIs occurring in low- and middle-income countries (LMICs) like Brazil. There has been minimal research in evaluation of delays in transport of RTI patients to trauma centers in LMICs. The objective of this study is to determine specific causes of delays in prehospital transport of road traffic injury patients to designated trauma centers in Maringá, Brazil. Methods A qualitative method was used based on the Consolidated Criteria for Reporting Qualitative Research (COREQ) approach. Eleven health care providers employed at prehospital or hospital settings were interviewed with questions specific to delays in care for RTI patients. A thematic analysis was conducted. Results Responses to primary causes of delay in treatment to RTI patients fell into the following categories: 1) lack of public education, 2) traffic, 3) insufficient personnel/ambulances, 4) bureaucracy, and 5) poor location of stations. Suggestions for improvement in delays fell into the categories of 1) need for centralized station/avoid traffic, 2) improving public education, 3) Increase personnel, 4) increase ambulances, 5) proper extrication/rapid treatment. Conclusion Our study found varied responses between hospital and SAMU providers regarding specific causes of delay for RTI patients; SAMU providers cited primarily traffic, bureaucracy, and poor location as primary factors while hospital employees focused more on public health aspects. These results mirror prehospital system challenges in other developing countries, but also provide solutions for improvement with better infrastructure and public health campaigns.
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Affiliation(s)
- Anjni Patel
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC, USA.,Department of Emergency Medicine, Section of Prehospital and Disaster Medicine, Emory University, Atlanta, Georgia, USA
| | - João Ricardo Nickenig Vissoci
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC, USA.,Department of Medicine, Faculdade Inga, Maringá, Parana, Brazil
| | - Michael Hocker
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC, USA.,Department of Emergency Medicine, Augusta University, Augusta, GA, USA
| | - Enio Molina
- Department of Medicine, Faculdade Inga, Maringá, Parana, Brazil
| | | | - Catherine Staton
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC, USA.
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Alliez JR, Kaya JM, Leone M. Ematomi intracranici post-traumatici in fase acuta. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Candefjord S, Winges J, Malik AA, Yu Y, Rylander T, McKelvey T, Fhager A, Elam M, Persson M. Microwave technology for detecting traumatic intracranial bleedings: tests on phantom of subdural hematoma and numerical simulations. Med Biol Eng Comput 2017; 55:1177-1188. [PMID: 27738858 PMCID: PMC5544814 DOI: 10.1007/s11517-016-1578-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 09/21/2016] [Indexed: 11/28/2022]
Abstract
Traumatic brain injury is the leading cause of death and severe disability for young people and a major public health problem for elderly. Many patients with intracranial bleeding are treated too late, because they initially show no symptoms of severe injury and are not transported to a trauma center. There is a need for a method to detect intracranial bleedings in the prehospital setting. In this study, we investigate whether broadband microwave technology (MWT) in conjunction with a diagnostic algorithm can detect subdural hematoma (SDH). A human cranium phantom and numerical simulations of SDH are used. Four phantoms with SDH 0, 40, 70 and 110 mL are measured with a MWT instrument. The simulated dataset consists of 1500 observations. Classification accuracy is assessed using fivefold cross-validation, and a validation dataset never used for training. The total accuracy is 100 and 82-96 % for phantom measurements and simulated data, respectively. Sensitivity and specificity for bleeding detection were 100 and 96 %, respectively, for the simulated data. SDH of different sizes is differentiated. The classifier requires training dataset size in order of 150 observations per class to achieve high accuracy. We conclude that the results indicate that MWT can detect and estimate the size of SDH. This is promising for developing MWT to be used for prehospital diagnosis of intracranial bleedings.
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Affiliation(s)
- Stefan Candefjord
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden.
- MedTech West, Sahlgrenska University Hospital, Röda Stråket 10 B, 413 45, Gothenburg, Sweden.
- SAFER Vehicle and Traffic Safety Centre at Chalmers, Gothenburg, Sweden.
| | - Johan Winges
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden
| | - Ahzaz Ahmad Malik
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden
| | - Yinan Yu
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden
- MedTech West, Sahlgrenska University Hospital, Röda Stråket 10 B, 413 45, Gothenburg, Sweden
| | - Thomas Rylander
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden
| | - Tomas McKelvey
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden
- MedTech West, Sahlgrenska University Hospital, Röda Stråket 10 B, 413 45, Gothenburg, Sweden
| | - Andreas Fhager
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden
- MedTech West, Sahlgrenska University Hospital, Röda Stråket 10 B, 413 45, Gothenburg, Sweden
| | - Mikael Elam
- MedTech West, Sahlgrenska University Hospital, Röda Stråket 10 B, 413 45, Gothenburg, Sweden
- Clinical Neurophysiology, Sahlgrenska University Hospital, Blå Stråket 5, 413 45, Gothenburg, Sweden
| | - Mikael Persson
- Department of Signals and Systems, Chalmers University of Technology, 412 96, Gothenburg, Sweden
- MedTech West, Sahlgrenska University Hospital, Röda Stråket 10 B, 413 45, Gothenburg, Sweden
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Moussa WMM, Khedr WM, Elwany AH. Prognostic significance of hematoma thickness to midline shift ratio in patients with acute intracranial subdural hematoma: a retrospective study. Neurosurg Rev 2017; 41:483-488. [DOI: 10.1007/s10143-017-0873-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
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Shibahashi K, Sugiyama K, Kashiura M, Okura Y, Hoda H, Hamabe Y. Emergency Trepanation as an Initial Treatment for Acute Subdural Hemorrhage: A Multicenter Retrospective Cohort Study. World Neurosurg 2017; 106:185-192. [PMID: 28669875 DOI: 10.1016/j.wneu.2017.06.134] [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: 04/20/2017] [Revised: 06/21/2017] [Accepted: 06/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Rapid decompression with trepanation and drainage in an emergency room has been proposed as a potentially effective initial intervention for early-stage acute subdural hemorrhage; however, the actual safety and efficacy of the procedure remain unclear. The aim of this study was to evaluate the feasibility of emergency trepanation as an initial treatment for acute subdural hemorrhage. METHODS We investigated patients with thick subdural hemorrhages who had undergone craniotomy between 2004 and 2015 in Japan using a nationwide trauma registry (the Japan Trauma Data Bank). The endpoint was survival at discharge. We compared patients who underwent trepanation in an emergency room with those who did not undergo trepanation, and adjusted for potential confounders using a multivariate logistic regression model. RESULTS During the study period, 236,698 patients were registered in the Japan Trauma Data Bank. Of the 1391 patients who were eligible for analysis, 305 had undergone trepanation in an emergency room. The survival rate was 37.7% in patients who had undergone emergency trepanation and 59.3% in those who had not. Performing emergency trepanation was significantly associated with decreased survival even after adjusting for possible confounders (adjusted odds ratio, 0.55; 95% confidence interval, 0.40-0.76; P < 0.001). CONCLUSIONS Our results indicate that performing trepanation in an emergency room is associated with a decreased survival rate.
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Affiliation(s)
- Keita Shibahashi
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan.
| | - Kazuhiro Sugiyama
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Masahiro Kashiura
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Yoshihiro Okura
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Hidenori Hoda
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Yuichi Hamabe
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
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A novel methodology to characterize interfacility transfer strategies in a trauma transfer network. J Trauma Acute Care Surg 2017; 81:658-65. [PMID: 27488492 DOI: 10.1097/ta.0000000000001187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND More than half of severely injured patients are initially transported from the scene of injury to nontrauma centers (NTCs), with many requiring subsequent transfer to trauma center (TC) care. Definitive care in the setting of severe injury is time sensitive. However, transferring severely injured patients from an NTC is a complex process often fraught with delays. Selection of the receiving TC and the mode of interfacility transport both strongly influence total transfer time and are highly amenable to quality improvement initiatives. METHODS We analyzed transfer strategies, defined as the pairing of a destination and mode of transport (land vs. rotary wing vs. fixed wing), for severely injured adult patients. Existing transfer strategies at each NTC were derived from trauma registry data. Geographic Information Systems network analysis was used to identify the strategy that minimized transfer times the most as well as alternate strategies (+15 or +30 minutes) for each NTC. Transfer network efficiency was characterized based on optimality and stability. RESULTS We identified 7,702 severely injured adult patients transferred from 146 NTCs to 9 TCs. Nontrauma centers transferred severely injured patients to a median of 3 (interquartile range, 1-4) different TCs and utilized a median of 4 (interquartile range, 2-6) different transfer strategies. After allowing for the use of alternate transfer strategies, 73.1% of severely injured patients were transported using optimal/alternate strategies, and only 40.4% of NTCs transferred more than 90% of patients using an optimal/alternate transfer strategy. Three quarters (75.5%) of transfers occurred between NTCs and their most common receiving TC. CONCLUSION More than a quarter of patients with severe traumatic injuries undergoing interfacility transport to a TC in Ontario are consistently transported using a nonoptimal combination of destination and mode of transport. Our novel analytic approach can be easily adapted to different system configurations and provides actionable data that can be provided to NTCs and other stakeholders. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Schweigkofler U, Flohé S, Hoffmann R, Matthes G, Paffrath T, Wölfl C, Fischer M, Kehrberger E, Marung H, Moecke H, Prückner S, Urban B, Trentzsch H. [Tracer diagnosis severe injury/polytrauma in key issue paper 2016]. Unfallchirurg 2017; 119:961-963. [PMID: 27757483 DOI: 10.1007/s00113-016-0256-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- U Schweigkofler
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt am Main, Deutschland
| | - S Flohé
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Städtisches Klinikum Solingen gemeinnützige GmbH, Solingen, Deutschland
| | - R Hoffmann
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt am Main, Deutschland
| | - G Matthes
- Klinik für Unfallchirurgie und Orthopädie, Unfallkrankenhaus Berlin, Berlin, Deutschland
| | - T Paffrath
- Klinik für Unfallchirurgie, Orthopädie & Sporttraumatologie, Lehrstuhl für Unfallchirurgie & Orthopädie, Klinikum der Privaten Universität Witten/Herdecke, Köln, Deutschland
| | - C Wölfl
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Krankenhaus Hetzelstift, Neustadt/Weinstraße, Deutschland
| | - M Fischer
- Arbeitsgemeinschaft Südwestdeutscher Notärzte e. V. (AGSWN), Filderstadt, Deutschland
- Klinik für Anästhesiologie, Operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinik am Eichert, Göppingen, Deutschland
| | - E Kehrberger
- Arbeitsgemeinschaft Südwestdeutscher Notärzte e. V. (AGSWN), Filderstadt, Deutschland
- Klinik für Anästhesiologie und operative Intensivmedizin, Kreiskliniken Esslingen, Paracelsus-Krankenhaus Ruit, Ostfildern, Deutschland
| | - H Marung
- Institut für Rettungs- und Notfallmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
- Institut für Notfallmedizin (IfN), Asklepios Klinikum Harburg, Hamburg, Deutschland
| | - H Moecke
- Institut für Notfallmedizin (IfN), Asklepios Klinikum Harburg, Hamburg, Deutschland
| | - S Prückner
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, Ludwig-Maximilians-Universität München, Schillerstraße 53, 80336, München, Deutschland
| | - B Urban
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, Ludwig-Maximilians-Universität München, Schillerstraße 53, 80336, München, Deutschland
| | - H Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, Ludwig-Maximilians-Universität München, Schillerstraße 53, 80336, München, Deutschland.
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Botchey IM, Hung YW, Bachani AM, Paruk F, Mehmood A, Saidi H, Hyder AA. Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study. Surgery 2017; 162:S45-S53. [PMID: 28385178 DOI: 10.1016/j.surg.2017.01.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/26/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Injury is a leading cause of disability and death worldwide, accounting for over 5 million deaths each year. The injury burden is higher in low- and middle-income countries where more than 90% of injury-related deaths occur. Despite this burden, the use of prospective trauma registries to describe injury epidemiology and outcomes is limited in low- and middle-income countries. Kenya lacks robust data to describe injury epidemiology and care. The objective of this study was to investigate the epidemiology and outcomes of injuries at 4 referral hospitals in Kenya using hospital-based trauma registries. METHODS From January 2014 to May 2015, all injured patients presenting to the casualty departments of Kenyatta National, Thika Level 5, Machakos Level 5, and Meru Level 5 Hospitals were enrolled prospectively. Data collected included demographic characteristics, type of prehospital care received, prehospital time, injury pattern, and outcomes. RESULTS A total of 14,237 patients were enrolled in our study. Patients were predominantly male (76.1%) and young (mean age 28 years). The most common mechanisms of injury were road traffic injuries (36.8%), falls (26.4%), and being struck/hit by a person or object (20.1%). Burn was the most common mechanism of injury in the age category under 5 years. Body regions commonly injured were lower extremity (35.1%), upper extremity (33.4%), and head (26.0%). The overall mortality rate was 2.4%. Significant predictors of mortality from multivariate analysis were Glasgow Coma Scale ≤12, estimated injury severity score ≥9, burns, and gunshot injuries. CONCLUSION Hospital-based trauma registries can be important sources of data to study the epidemiology of injuries in low- and middle-income countries. Data from such trauma registries can highlight key needs and be used to design public health interventions and quality-of-care improvement programs.
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Affiliation(s)
- Isaac M Botchey
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yuen W Hung
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Abdulgafoor M Bachani
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Fatima Paruk
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Amber Mehmood
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Hassan Saidi
- Department of Human Anatomy, University of Nairobi, Nairobi, Kenya
| | - Adnan A Hyder
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
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Siletz A, Jin K, Cohen M, Lewis C, Tillou A, Cryer HM, Cheaito A. Emergency department length of stay in critical nonoperative trauma. J Surg Res 2017. [PMID: 28624030 DOI: 10.1016/j.jss.2017.02.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Prolonged emergency department (ED) stays correlate with negative outcomes in critically ill nontrauma patients. This study sought to determine the effect of ED length of stay (LOS) on trauma patients. MATERIALS AND METHODS Two hundred forty-one trauma patients requiring direct intensive care unit (ICU) admission were identified. Patients requiring immediate operative intervention were excluded. Odds ratios (ORs) of outcomes for patients transferred to ICU in ≤90 min were compared with patients transferred in >90 min, adjusting for Injury Severity Score (ISS). RESULTS One hundred two of 241 patients (42%) were transferred to the ICU in ≤90 min. Increased ED LOS was associated with decreased complications (OR 0.545, 95% confidence interval 0.312-0.952). Although the result was not statistically significant, patients with an ISS >15 were less likely to have long ED stays (OR 0.725, 95% CI 0.407-1.290). No significant difference was seen in mortality. No difference in duration of intubation was observed for patients intubated in the ED versus the ICU. For the subgroup with ISS ≤15, there was a significant decrease in ICU LOS for patients who remained in the ED >90 min (5.5 d versus 2.7 d, P = 0.02). No other differences in LOS were identified. CONCLUSIONS In a mature trauma center with standardized activation protocols and focused resource allocation in the ED trauma bay, trauma activation and subsequent management appear to mitigate the negative effects of prolonged ED LOS seen in other critically ill populations.
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Affiliation(s)
- Anaar Siletz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Kexin Jin
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Marilyn Cohen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Catherine Lewis
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Areti Tillou
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Henry Magill Cryer
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ali Cheaito
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.
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Fountain DM, Kolias AG, Lecky FE, Bouamra O, Lawrence T, Adams H, Bond SJ, Hutchinson PJ. Survival Trends After Surgery for Acute Subdural Hematoma in Adults Over a 20-year Period. Ann Surg 2017; 265:590-596. [PMID: 27172128 PMCID: PMC5300032 DOI: 10.1097/sla.0000000000001682] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period. SUMMARY OF BACKGROUND DATA ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time. METHODS Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data. RESULTS The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors. CONCLUSIONS A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.
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Affiliation(s)
- Daniel M. Fountain
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Fiona E. Lecky
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
- Emergency Medicine Research in Sheffield (EMRiS), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Omar Bouamra
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Thomas Lawrence
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Simon J. Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- MRC Biostatistics Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
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Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, McCormick T, Vinson DR, Hoffman JR. Computed Tomography Use for Adults With Head Injury: Describing Likely Avoidable Emergency Department Imaging Based on the Canadian CT Head Rule. Acad Emerg Med 2017; 24:22-30. [PMID: 27473552 DOI: 10.1111/acem.13061] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/12/2016] [Accepted: 07/25/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Millions of head computed tomography (CT) scans are ordered annually, but the extent of avoidable imaging is poorly defined. OBJECTIVES The objective was to determine the prevalence of likely avoidable CT imaging among adults evaluated for head injury in 14 community emergency departments (EDs) in Southern California. METHODS We conducted an electronic health record (EHR) database and chart review of adult ED trauma encounters receiving a head CT from 2008 to 2013. The primary outcome was discordance with the Canadian CT Head Rule (CCHR) high-risk criteria; the secondary outcome was use of a neurosurgical intervention in the discordant cohort. We queried systemwide EHRs to identify CCHR discordance using criteria identifiable in discrete data fields. Explicit chart review of a subset of discordant CTs provided estimates of misclassification bias and assessed the low-risk cases who actually received an intervention. RESULTS Among 27,240 adult trauma head CTs, EHR data classified 11,432 (42.0%) discordant with CCHR recommendation. Subsequent chart review showed that the designation of discordance based on the EHR was inaccurate in 12.2% (95% confidence interval [CI] = 5.6% to 18.8%). Inter-rater reliability for attributing CCHR concordance was 95% (κ = 0.86). Thus, we estimate that 36.8% of trauma head CTs were truly likely avoidable (95% CI = 34.1% to 39.6%). Among the likely avoidable CT group identified by EHR, only 0.1% (n = 13) received a neurosurgical intervention. Chart review showed none of these were actually "missed" by the CCHR, as all 13 were misclassified. CONCLUSION About one-third of head CTs currently performed on adults with head injury may be avoidable by applying the CCHR. Avoidance of CT in such patients is unlikely to miss any important injuries.
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Affiliation(s)
- Adam L. Sharp
- Department of Research and Evaluation Kaiser Permanente Southern California Pasadena CA
- Department of Emergency Medicine Los Angeles Medical Center Kaiser Permanente Southern California Los Angeles CA
| | - Ganesh Nagaraj
- Department of Emergency Medicine San Diego Medical Center Kaiser Permanente Southern California San Diego CA
| | - Ellen J. Rippberger
- Department of Research and Evaluation Kaiser Permanente Southern California Pasadena CA
| | - Ernest Shen
- Department of Research and Evaluation Kaiser Permanente Southern California Pasadena CA
| | - Clifford J. Swap
- Department of Emergency Medicine San Diego Medical Center Kaiser Permanente Southern California San Diego CA
| | - Matthew A. Silver
- Department of Emergency Medicine San Diego Medical Center Kaiser Permanente Southern California San Diego CA
| | - Taylor McCormick
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | - David R. Vinson
- Department of Emergency Medicine Kaiser Permanente Sacramento Medical Center Sacramento CA
- The Permanente Medical Group and Kaiser Permanente Division of Research Oakland CA
| | - Jerome R. Hoffman
- Department of Emergency Medicine University of California Los Angeles CA
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Zangbar B, Serack B, Rhee P, Joseph B, Pandit V, Friese RS, Haider AA, Tang AL. Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study. Am Surg 2016. [DOI: 10.1177/000313481608201228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010–2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13–15), and median head Abbreviated Injury Scale score was 3 (2–4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay ( P = 0.02) and longer intensive care unit length of stay ( P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.
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Affiliation(s)
- Bardiya Zangbar
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bradley Serack
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Viraj Pandit
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Randall S. Friese
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Ansab A. Haider
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew L. Tang
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
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Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda. Afr J Emerg Med 2016; 6:191-197. [PMID: 30456094 PMCID: PMC6234177 DOI: 10.1016/j.afjem.2016.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/27/2016] [Accepted: 10/04/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction Injury accounts for 9.6% of the global mortality burden, disproportionately affecting those living in low- and middle-income countries. In an effort to improve trauma care in Rwanda, the Ministry of Health developed a prehospital service, Service d’Aide Médicale Urgente (SAMU), and established an emergency medicine training program. However, little is known about patients receiving prehospital and emergency trauma care or their outcomes. The objective was to develop a linked prehospital–hospital database to evaluate patient characteristics, mechanisms of injury, prehospital and hospital resource use, and outcomes among injured patients receiving acute care in Kigali, Rwanda. Methods A retrospective cohort study was conducted at University Teaching Hospital – Kigali, the primary trauma centre in Rwanda. Data was included on all injured patients transported by SAMU from December 2012 to February 2015. SAMU’s prehospital database was linked to hospital records and data were collected using standardised protocols by trained abstractors. Demographic information, injury characteristics, acute care, hospital course and outcomes were included. Results 1668 patients were transported for traumatic injury during the study period. The majority (77.7%) of patients were male. The median age was 30 years. Motor vehicle collisions accounted for 75.0% of encounters of which 61.4% involved motorcycles. 48.8% of patients sustained injuries in two or more anatomical regions. 40.1% of patients were admitted to the hospital and 78.1% required surgery. The overall mortality rate was 5.5% with nearly half of hospital deaths occurring in the emergency centre. Conclusion A linked prehospital and hospital database provided critical epidemiological information describing trauma patients in a low-resource setting. Blunt trauma from motor vehicle collisions involving young males constituted the majority of traumatic injury. Among this cohort, hospital resource utilisation was high as was mortality. This data can help guide the implementation of interventions to improve trauma care in the Rwandan setting.
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Jarman MP, Castillo RC, Carlini AR, Kodadek LM, Haider AH. Rural risk: Geographic disparities in trauma mortality. Surgery 2016; 160:1551-1559. [PMID: 27506860 PMCID: PMC5118091 DOI: 10.1016/j.surg.2016.06.020] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and nonrural residents with traumatic injuries. METHODS Using data from the 2009-2010 Nationwide Emergency Department Sample, multiple logistic regression analyses were conducted to estimate odds of death after traumatic injury for rural residents compared with nonrural residents, while controlling for age, sex, injury type and severity, comorbidities, trauma designation, and Census region. RESULTS Rural residents were 14% more likely to die after traumatic injury compared with nonrural residents (P < .001). Increased odds of death for rural residents were observed at level I (odds ratio = 1.20, P < .001), level II (odds ratio = 1.34, P < .001), and level IV/nontrauma centers (odds ratio = 1.23, P < .001). The disparity was greatest for injuries occurring in the South and Midwest (odds ratio = 1.54, P < .001 and odds ratio = 2.06, P < .001, respectively) and for cases with an injury severity score <9 or unknown severity (odds ratio = 2.09, P < .001 and odds ratio = 1.31, P < .001, respectively). CONCLUSION Rural residents are significantly more likely than nonrural residents to die after traumatic injury. This disparity varies by trauma center designation, injury severity, and US Census region. Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization.
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Affiliation(s)
- Molly P Jarman
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lisa M Kodadek
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adil H Haider
- Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard T.H. Chan School of Public Health, Center for Surgery and Public Health, Boston, MA
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Tansini G, Ducci RDP, Nóvak EM, Germiniani FMB, Zétola VF, Lange MC. Exclusive bed for thrombolysis. A simple measure that allows 85% of ischemic stroke patients to be treated in the first hour. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:373-5. [PMID: 27191232 DOI: 10.1590/0004-282x20160048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 12/09/2015] [Indexed: 11/21/2022]
Abstract
The door-to-needle time is an important goal to reduce the time to treatment in intravenous thrombolysis. Objective Analyze if the inclusion of an exclusive thrombolytic bed reduces the door-to-needle time. Method One hundred and fifty patients admitted for neurological evaluation with ischemic stroke were separated in two groups: in the first, patients were admitted in the Emergency Room for intravenous thrombolysis (ER Group); in the second, patients were admitted in an exclusive thrombolytic bed in the general neurology ward (TB Group). Results Sixty-eight (86.0%) patients from TB Group were treated in the first 60 minutes of arrival as compared to 48 (67.6%) in the ER Group (p = 0.011). Conclusion The introduction of a thrombolytic bed in a general hospital setting can markedly reduce the door-to-needle time, allowing more than 85% of patients to be treated within the first hour of admission.
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Affiliation(s)
- Gabriella Tansini
- Departamento de Medicina Interna, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Renata Dal-Prá Ducci
- Departamento de Medicina Interna, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Edison Matos Nóvak
- Departamento de Medicina Interna, Universidade Federal do Paraná, Curitiba, PR, Brazil
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Hendrickson SA, Khan MA, Verjee LS, Rahman KMA, Simmons J, Hettiaratchy SP. Plastic surgical operative workload in major trauma patients following establishment of the major trauma network in England: A retrospective cohort study. J Plast Reconstr Aesthet Surg 2016; 69:881-7. [PMID: 27025358 DOI: 10.1016/j.bjps.2016.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 01/15/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The introduction of major trauma centres (MTCs) in England has led to 63% reduction in trauma mortality.(1) The role of plastic surgeons supporting these centres has not been quantified previously. This study aimed to quantify plastic surgical workload at an urban MTC to determine the contribution of plastic surgeons to major trauma care. METHODS All Trauma Audit and Research Network (TARN)-recorded major trauma patients who presented to an urban MTC in 2013 and underwent an operation were identified retrospectively. Patients who underwent plastic surgery were identified and the type and date of procedure(s) were recorded. The trauma operative workload data of another tertiary surgical specialty and local historical plastics workload data from pre-MTC go-live were collected for comparison. RESULTS Of the 416 major trauma patients who required surgical intervention, 29% (n = 122) underwent plastic surgery. Of these patients, 43% had open lower limb fractures, necessitating plastic surgical involvement according to British Orthopaedic Association Standards for Trauma (BOAST) 4 guidance. The overall plastic surgery operative workload increased sevenfold post-MTC go-live. A similar proportion of the same cohort required neurosurgery (n = 115; p = 0.589). DISCUSSION This study quantifies plastic surgery involvement in major trauma and demonstrates that plastic surgical operative workload is at least on par with other tertiary surgical specialties. It also reports one centre's experience of a significant change in plastic surgery activity following designation of MTC status. The quantity of plastic surgical operative workload in major trauma must be considered when planning major trauma service design and workforce provision, and for plastic surgical postgraduate training.
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Affiliation(s)
- S A Hendrickson
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK.
| | - M A Khan
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - L S Verjee
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - K M A Rahman
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - J Simmons
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - S P Hettiaratchy
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
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Luck T, Treacy PJ, Mathieson M, Sandilands J, Weidlich S, Read D. Emergency neurosurgery in Darwin: still the generalist surgeons' responsibility. ANZ J Surg 2015; 85:610-4. [PMID: 25916661 DOI: 10.1111/ans.13138] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Royal Darwin Hospital (RDH) is the only major hospital for the 'Top End' of Northern Territory and Western Australia. As retrieval distances exceed 2600 km, resident generalist surgeons undertake all emergency neurosurgery. METHODS Retrospective clinical study from RDH records and review of prospectively collected datasets from RDH Intensive Care Unit and National Critical Care Trauma Response Centre for all emergency neurosurgery patients between 2008 and 2013. RESULTS Data were obtained from 161 patients with 167 admissions (73% male, 39% indigenous) who underwent 195 procedures (33 per year), including burr hole, craniotomy, cerebral and posterior fossa craniectomy, elevation fracture and ventricular drain. Trauma accounted for 68%, with alcohol as a known factor in 57%. Subdural haematoma (SDH) accounted for 53%. Severity of head injury at presentation correlated with outcome (R(2) = 0.12, P < 0.001). Factors associated with death included injury at remote location (P = 0.022), time injury to operation >24 h (P = 0.023) and specific diagnoses of acute SDH (P = 0.006), acute-on-chronic SDH (P = 0.053) and infection (P = 0.052). Indigenous patients were younger (40 versus 55 years, P < 0.001) and more likely to have alcohol as a factor in trauma cases (71% versus 49%, P = 0.027). Time from injury to hospital was high for accidents at a remote location (12.9 versus 1.3 h, P < 0.001); however, Glasgow Outcome Scales (P = 0.13) were no different to accident at metropolitan Darwin. CONCLUSION General surgeons at RDH perform a wide range of emergency neurosurgical procedures primarily for trauma. Factors contributing to poor outcomes included remote location of trauma and delay in reaching the hospital. Outcomes at 3 months appear acceptable.
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Affiliation(s)
- Tara Luck
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Peter John Treacy
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Matthew Mathieson
- Department of Anaesthetics, Modbury Hospital, Adelaide, South Australia, Australia
| | - Jessica Sandilands
- Department of Surgery, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Stephanie Weidlich
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - David Read
- Department of Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Harmsen AMK, Giannakopoulos GF, Moerbeek PR, Jansma EP, Bonjer HJ, Bloemers FW. The influence of prehospital time on trauma patients outcome: a systematic review. Injury 2015; 46:602-9. [PMID: 25627482 DOI: 10.1016/j.injury.2015.01.008] [Citation(s) in RCA: 233] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/05/2015] [Accepted: 01/07/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the 'golden hour', the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients. METHODS A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality. RESULTS Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury. CONCLUSION Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.
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Affiliation(s)
- A M K Harmsen
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands.
| | | | - P R Moerbeek
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands
| | - E P Jansma
- Medical Library, VU university Medical Center, Amsterdam, The Netherlands
| | - H J Bonjer
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands
| | - F W Bloemers
- Department of Surgery, VU university Medical Center, Amsterdam, The Netherlands
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Rogers FB, Rittenhouse KJ, Gross BW. The golden hour in trauma: dogma or medical folklore? Injury 2015; 46:525-7. [PMID: 25262329 DOI: 10.1016/j.injury.2014.08.043] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 08/30/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick B Rogers
- Trauma Services, Lancaster General Hospital, Lancaster, PA, United States.
| | | | - Brian W Gross
- Trauma Services, Lancaster General Hospital, Lancaster, PA, United States.
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Goldberg SA, Rojanasarntikul D, Jagoda A. The prehospital management of traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:367-78. [PMID: 25702228 DOI: 10.1016/b978-0-444-52892-6.00023-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.
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Affiliation(s)
- Scott A Goldberg
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Dhanadol Rojanasarntikul
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA; Chulalongkorn University, Bangkok, Thailand
| | - Andrew Jagoda
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA; Brain Trauma Foundation, New York, NY, USA.
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Gaieski DF, Edwards JM, Kallan MJ, Mikkelsen ME, Goyal M, Carr BG. The relationship between hospital volume and mortality in severe sepsis. Am J Respir Crit Care Med 2014; 190:665-74. [PMID: 25117723 DOI: 10.1164/rccm.201402-0289oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Severe sepsis is increasing in incidence and has a high rate of inpatient mortality. Hospitals that treat a larger number of patients with severe sepsis may offer a survival advantage. OBJECTIVES We sought to assess the effect of severe sepsis case volume on mortality, hypothesizing that higher volume centers would have lower rates of inpatient death. METHODS We performed a retrospective cohort study over a 7-year period (2004-2010), using a nationally representative sample of hospital admissions, examining the relation between volume, urban location, organ dysfunction, and survival. MEASUREMENTS AND MAIN RESULTS To identify potential differences in outcomes, hospitals were divided into five categories (<50, 50-99, 100-249, 250-499, and 500+ annual cases) and adjusted mortality was compared by volume. A total of 914,200 patients with severe sepsis were identified over a 7-year period (2004-2010). Overall in-hospital mortality was 28.1%. In a fully adjusted model, there was an inverse relationship between severe sepsis case volume and inpatient mortality. Hospitals in the highest volume category had substantially improved survival compared with hospitals with the lowest case volume (adjusted odds ratio, 0.64; 95% confidence interval, 0.60-0.69). In cases of severe sepsis with one reported organ dysfunction, a mortality of 18.9% was found in hospitals with fewer than 50 annual cases compared with 10.4% in hospitals treating 500+ cases (adjusted odds ratio, 0.54; 95% confidence interval, 0.49-0.59). Similar differences were found in patients with up to three total organ dysfunctions. CONCLUSIONS Patients with severe sepsis treated in hospitals with higher case volumes had improved adjusted outcomes.
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Affiliation(s)
- David F Gaieski
- 1 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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83
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Seidenberg P, Cerwensky K, Brown RO, Hammond E, Mofu Y, Lungu J, Mulla Y, Biemba G, Mowafi H. Epidemiology of injuries, outcomes, and hospital resource utilisation at a tertiary teaching hospital in Lusaka, Zambia. Afr J Emerg Med 2014. [DOI: 10.1016/j.afjem.2014.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Sharp AL, Cobb EM, Dresden SM, Richardson DK, Sabbatini AK, Sauser K, Kocher KE. Understanding the value of emergency care: a framework incorporating stakeholder perspectives. J Emerg Med 2014; 47:333-42. [PMID: 24881891 DOI: 10.1016/j.jemermed.2014.04.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 12/16/2013] [Accepted: 04/22/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined. OBJECTIVES To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services. METHODS A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions. RESULTS We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition. CONCLUSION The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care.
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Affiliation(s)
- Adam L Sharp
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan; Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California
| | - Enesha M Cobb
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Scott M Dresden
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois; Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Derek K Richardson
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Amber K Sabbatini
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kori Sauser
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy (CHOP), University of Michigan, Ann Arbor, Michigan
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KARIBE H, HAYASHI T, HIRANO T, KAMEYAMA M, NAKAGAWA A, TOMINAGA T. Surgical Management of Traumatic Acute Subdural Hematoma in Adults: A Review. Neurol Med Chir (Tokyo) 2014; 54:887-94. [DOI: 10.2176/nmc.cr.2014-0204] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Atsuhiro NAKAGAWA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Teiji TOMINAGA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
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Pucher PH, Aggarwal R, Batrick N, Jenkins M, Darzi A. Nontechnical skills performance and care processes in the management of the acute trauma patient. Surgery 2013; 155:902-9. [PMID: 24468038 DOI: 10.1016/j.surg.2013.12.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 12/27/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute trauma management is a complex process, with the effective cooperation among multiple clinicians critical to success. Despite this, the effect of nontechnical skills on performance on outcomes has not been investigated previously in trauma. METHODS Trauma calls in an urban, level 1 trauma center were observed directly. Nontechnical performance was measured using T-NOTECHS. Times to disposition and completion of assessment care processes were recorded, as well as any delays or errors. Statistical analysis assessed the effect of T-NOTECHS on performance and outcomes, accounting for Injury Severity Scores (ISS) and time of day as potential confounding factors. Meta-analysis was performed for incidence of delays. RESULTS Fifty trauma calls were observed, with an ISS of 13 (interquartile range [IQR], 5-25); duration of stay 1 (IQR, 1-8) days; T-NOTECHS, 20.5 (IQR, 18-23); time to disposition, 24 minutes (IQR, 18-42). Trauma calls with low T-NOTECHS scores had a greater time to disposition: 35 minutes (IQR, 23-53) versus 20 (IQR, 16-25; P = .046). ISS showed a significant correlation to duration of stay (r = 0.736; P < .001), but not to T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = 0.113; P = .494). There was no difference between "in-hours" and "out-of-hours" trauma calls for T-NOTECHS scores (21 [IQR, 18-22] vs 20 [IQR, 20-23]; P = .361), or time to disposition (34 minutes [IQR, 24-52] vs 17 [IQR, 15-27]; P = .419). Regression analysis revealed T-NOTECHS as the only factor associated with delays (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.06-0.95). CONCLUSION Better teamwork and nontechnical performance are associated with significant decreases in disposition time, an important marker of quality in acute trauma care. Addressing team and nontechnical skills has the potential to improve patient assessment, treatment, and outcomes.
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Affiliation(s)
- Philip H Pucher
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Rajesh Aggarwal
- Department of Surgery and Cancer, Imperial College London, London, UK; Department of Gastrointestinal Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nicola Batrick
- St Mary's Hospital Major Trauma Centre, Imperial College London, London, UK
| | - Michael Jenkins
- St Mary's Hospital Major Trauma Centre, Imperial College London, London, UK; Regional Vascular Unit, St Mary's Hospital, Imperial College London, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
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Matityahu A, Elliott I, Marmor M, Caldwell A, Coughlin R, Gosselin RA. Time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems. Bull World Health Organ 2013; 92:40-50. [PMID: 24391299 DOI: 10.2471/blt.13.120436] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 08/08/2013] [Accepted: 08/23/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate the use of time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems. METHODS Time intervals from injury to admission, admission to surgery and surgery to discharge for patients with isolated femur fractures in four low- and middle-income countries were compared with the corresponding values from one German hospital, an Israeli hospital and the National Trauma Data Bank of the United States of America by means of Student's t-tests. The correlations between the time intervals recorded in a country and that country's expenditure on health and gross domestic product (GDP) were also evaluated using Pearson's product moment correlation coefficient. FINDINGS Relative to patients from high-income countries, those from low- and middle-income countries were significantly more likely to be male and to have been treated by open femoral nailing, and their intervals from injury to admission, admission to surgery and surgery to discharge were significantly longer. Strong negative correlations were detected between the interval from injury to admission and government expenditure on health, and between the interval from admission to surgery and the per capita values for total expenditure on health, government expenditure on health and GDP. Strong positive correlations were detected between the interval from surgery to discharge and general government expenditure on health. CONCLUSION The time intervals for the treatment of femur fractures are relatively long in low- and middle-income countries, can easily be measured, and are highly correlated with accessible and quantifiable country data on health and economics.
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Affiliation(s)
- Amir Matityahu
- San Francisco General Hospital, University of California in San Francisco, 2550 Twenty-third Street, Building 9, 2nd Floor, San Francisco, CA 94110, United States of America (USA)
| | | | - Meir Marmor
- Orthopaedic Trauma Institute, University of California, San Francisco, USA
| | - Amber Caldwell
- Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, USA
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Increasing time to operation is associated with decreased survival in patients with a positive FAST examination requiring emergent laparotomy. J Trauma Acute Care Surg 2013; 75:S48-52. [PMID: 23778511 DOI: 10.1097/ta.0b013e31828fa54e] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Focused assessment with sonography for trauma (FAST) is commonly used to facilitate the timely diagnosis of life-threatening hemorrhage in injured patients. Most patients with positive findings on FAST require laparotomy. Although it is assumed that an increasing time to operation (T-OR) leads to higher mortality, this relationship has not been quantified. This study sought to determine the impact of T-OR on survival in patients with a positive FAST who required emergent laparotomy. METHODS We retrospectively analyzed patients from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study who underwent laparotomy within 90 minutes of presentation and had a FAST performed. Cox proportional hazards models including Injury Severity Score (ISS), age, base deficit, and hospital site were created to examine the impact of increasing T-OR on in-hospital survival at 24 hours and 30 days. The impact of time from the performance of the FAST examination to operation (TFAST-OR) on in-hospital mortality was also examined using the same model. RESULTS One hundred fifteen patients met study criteria and had complete data. Increasing T-OR was associated with increased in-hospital mortality at 24 hours (hazard ratio [HR], 1.50 for each 10-minute increase in T-OR; confidence interval [CI], 1.14-1.97; p = 0.003) and 30 days (HR, 1.41; CI, 1.18-2.10; p = 0.002). Increasing TFAST-OR was also associated with higher in-hospital mortality at 24 hours (HR, 1.34; CI, 1.03-1.72; p = 0.03) and 30 days (HR, 1.40; CI, 1.06-1.84; p = 0.02). CONCLUSION In patients with a positive FAST who required emergent laparotomy, delay in operation was associated with increased early and late in-hospital mortality. Delays in T-OR in trauma patients with a positive FAST should be minimized.
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89
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Dinh MM, Bein K, Roncal S, Byrne CM, Petchell J, Brennan J. Redefining the golden hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient outcomes. Injury 2013; 44:606-10. [PMID: 22336130 DOI: 10.1016/j.injury.2012.01.011] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 11/01/2011] [Accepted: 01/13/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND In patients with severe head injuries, transportation to a trauma centre within the "golden hour" are important markers of trauma system effectiveness but evidence regarding impacts on patient outcomes is limited. OBJECTIVE To determine the effect of patient arrival within the golden hour on patient outcomes. METHODS A retrospective cohort of adult patients with severe head injuries (head AIS ≥ 3) arriving within 24h of injury was identified using the trauma registry from 2000 to 2011. Survival analysis was used to determine the effect of patient arrival time on overall mortality. Study outcomes were in hospital mortality and survival to hospital discharge without requiring transfer for ongoing rehabilitation or nursing home care. RESULTS There was a significant association with mortality with each incremental minute of patient arrival (HR 1.002, 95%CI 1.001-1.004, p=0.001). There was however no survival benefit observed for patients arriving within 60 min of injury time (HR 0.77, 95%CI 0.50-1.18, p=0.22) but an apparent benefit for those presenting within 2h of injury time (HR 0.31, 95%CI 0.15-0.66, p=0.002). Patient arrival within 60 min of injury time was associated with increased odds of survival to hospital discharge without requiring ongoing rehabilitation (OR 1.78, 95%CI 1.14-2.79, p=0.01). CONCLUSION A survival benefit exists in patients arriving earlier to hospital after severe head injury but the benefit may extend beyond the golden hour. There was evidence of improved functional outcomes in patients arriving within 60 min of injury time.
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Affiliation(s)
- Michael M Dinh
- Royal Prince Alfred Hospital, Trauma Office level 10, Missenden Road, Camperdown, NSW 2050, Australia.
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90
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91
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Reply to Letter: "Time-to-treatment and mortality in patients with acute subdural Hematoma". Ann Surg 2013; 257:e9. [PMID: 23470512 DOI: 10.1097/sla.0b013e318289f691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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92
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Taussky P, Hidalgo ET, Landolt H, Fandino J. Age and Salvageability: Analysis of Outcome of Patients Older than 65 Years Undergoing Craniotomy for Acute Traumatic Subdural Hematoma. World Neurosurg 2012; 78:306-11. [DOI: 10.1016/j.wneu.2011.10.030] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 10/20/2011] [Accepted: 10/20/2011] [Indexed: 10/15/2022]
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