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

Survival benefit of transfer to tertiary trauma centers for major trauma patients initially presenting to nontertiary trauma centers

OBJECTIVES

Recent evidence suggests a measurable reduction in mortality for patients transferred from a nontertiary trauma center (Level III or IV) to a Level I trauma center, but not for those transferred to a Level II trauma center. Whether this can be generalized to a predominantly rural region with fewer tertiary trauma care resources is uncertain. This study sought to evaluate mortality differences for patients initially presenting to nontertiary trauma centers in a predominantly rural region depending on transfer status.

METHODS

This was a retrospective cohort study of patients initially presenting to 104 nontertiary trauma centers in Oklahoma and meeting the state's criteria for major trauma. Patients dying within 1 hour of emergency department (ED) arrival at the nontertiary trauma center were excluded. The exposure variable of interest was admission status, which was categorized as either transfer to a tertiary (Level I or II) trauma center within 24 hours or admission to a nontertiary trauma center. Propensity scores were used to minimize the selection bias inherent in the decision to admit or transfer a patient for higher-level care. Multiple logistic regression was used to generate three propensity score models: probability of transfer to either a Level I or II, Level I only, and Level II only. Propensity scores were then included as a covariate in multivariable Cox regression models assessing outcome differences between admitted and transferred patients. The outcome of interest was 30-day mortality, defined as death at either the nontertiary trauma center or the tertiary trauma center within 30 days of arrival at the initial Level III/IV center's ED.

RESULTS

A total of 6,229 patients met study criteria, of whom 2,669 (43%) were transferred to tertiary trauma centers. Of those transferred, 1,422 patients (53%) were transferred to a Level I trauma center. Crude mortality was lower for patients transferred to tertiary trauma centers compared to those remaining at nontertiary trauma facilities (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.48 to 0.72). After adjusting for the propensity to be transferred, Injury Severity Score (ISS), presence of severe head injury, and age, transfer to a tertiary trauma center was associated with a significantly lower 30-day mortality (HR = 0.38; 95% CI = 0.30 to 0.50) compared to admission and treatment at a nontertiary trauma center. The observed survival benefit was similar for patients transferred to a Level I trauma center (HR = 0.36; 95% CI = 0.20 to 0.4) and those transferred to a Level II center (HR = 0.45; 95% CI = 0.33 to 0.61).

CONCLUSIONS

This study suggests a survival benefit among patients initially presenting to nontertiary trauma centers who are subsequently transferred to tertiary trauma centers compared to those remaining in nontertiary trauma centers, even after adjusting for variables affecting the likelihood of transfer. Although this survival benefit was larger for patients treated at a Level I trauma center, Level II trauma centers in a region with few tertiary trauma resources demonstrated a measurable benefit as well.

Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children

OBJECTIVES

Timely transfer of injured children to pediatric trauma centers (PTCs) that can address their unique needs is important. This study was designed to understand the characteristics of transferred injured children.

METHODS

Data from our level I PTC over 5 years (2002-2006) were reviewed. Transferred patients were divided based on time from injury to arrival at our PTC: early (<2 hours) and late (>2 hours). Data collected included demographics, Injury Severity Scale score, Glasgow Coma Scale score, mode of transportation, referring hospital information including pretransfer imaging, and disposition from our emergency room.

RESULTS

Seven hundred forty-eight patients were included. Eighty-two percent (n = 612) were in the late group and arrived, on average, 6 hours after those transferred early (420 vs 69.9 minutes, P < 0.05). Seventy-nine percent (n = 147) of transfers with severe injuries (Injury Severity Scale score >15) and 47% (n = 15) of those with severe head injuries (Glasgow Coma Scale score <8) arrived late. The disproportionate number of late transfers was consistent among all transferring hospitals regardless of distance and only slightly improved in the group transferred by air ambulance. In addition, those transferred late had significantly more pretransfer imaging (49% vs 23%, P = 0.0025).

CONCLUSIONS

Despite the advantages of care in trauma centers, a significant number of severely injured children are transferred well beyond 2 hours after injury. This study has demonstrated that this pattern of delayed transfer is a systemic problem occurring among all transferring hospitals regardless of distance or mode of patient transfer and is associated with increased use of imaging before transfer.

Regional Systems of Care for Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post–cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

Triage and mortality in 2875 consecutive trauma patients

BACKGROUND

Most studies on trauma and trauma systems have been conducted in the United States. We aimed to describe the factors predicting mortality in European trauma patients, with focus on triage.

METHODS

We prospectively registered all trauma patients in Eastern Denmark over 12 consecutive months. We analysed the flow of trauma patients through the system, the time spent at different locations, and we assessed the risk factors of mortality.

RESULTS

We included 2875 trauma patients, of whom 158 (5.5%) died before arrival at the hospital. Most patients (75.3%) were brought to local hospitals and patients primarily (n=82) or secondarily triaged (n=203) to the level I trauma centre were the most severely injured. Secondarily transferred patients spent a median of 150 min in the local hospital before transfer to the level I trauma centre and 48 min on transportation. Severe injury with an injury severity score >15 was seen in 345 patients, of whom 118 stayed at the local hospital. They had a significantly higher mortality than 116 of those secondarily transferred [45/118, 38.1% vs. 11/116, 9.7% (P<0.0001)]. Mortality within 30 days was 4.3% in admitted patients, and significant risk factors of death were violence [odds ratio (OR)=5.72], unconsciousness (OR=4.87), hypotension (OR=4.96), injury severity score >15 (OR=27.42), and age.

CONCLUSIONS

Around 50% of all trauma deaths occurred at the scene. Increased survival of severely injured patients may be achieved by early transfer to highly specialised care.

Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006

BACKGROUND

Although efforts have been made to address disparities in access to trauma care in the past decade, there is little evidence to show if utilization has changed. We use patient-level data to describe the changes in utilization of trauma centers (TCs) in an 8-year period in California.

METHODS

We analyzed all statewide trauma admissions (n = 752,706) using the California Office of Statewide Health Planning and Discharge Patient Discharge Database from the period of 1999 to 2006, and determined the trends in admissions and place of care.

RESULTS

The proportion of severe injuries admitted increased by 3.6% (p < 0.05), with a concomitant rise in the proportion of patients with trauma to TCs, from 39.3% (95% CI: 39.0%-39.7%) to 49.7% (49.4%-50.0%). Within the severely injured with injury severity scores (ISS) >15, 82.4% were treated in a TC if they resided in a county with a TC, compared with 30.8% of patients who did not live in a county with a TC. After adjustment, patients living greater than 50 miles away from a TC still had a likelihood ratio of 0.11 (p < 0.0001) of receiving care in a TC compared with those less than 10 miles away. Similarly, even severely injured patients not living in a county with a TC had a likelihood ratio of 0.35 (p < 0.0001) of being admitted to a TC compared with those residing in counties with TCs.

CONCLUSION

Admissions to TCs for all categories of injury severity are increasing. There remains, however, a large disparity in TC care depending on geographical distance and availability of a TC within county.

A major trauma centre is a specialty hospital not a hospital of specialties

BACKGROUND

High estimates of preventable death rates have renewed the impetus for national regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance improvement programme was hypothesized to have resulted in improved outcomes for severely injured patients.

METHODS

This was a comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma Audit and Research Network (England and Wales), 2000-2005. Preventable mortality was evaluated by prospective analysis of the RLH performance improvement programme.

RESULTS

Mortality from critical injury at the RLH was 48 per cent lower in 2005 than 2000 (17.9 versus 34.2 per cent; P = 0.001). Overall mortality rates were unchanged for acute hospitals (4.3 versus 4.4 per cent) and other multispecialty hospitals (8.7 versus 7.3 per cent). Secondary transfer mortality in critically injured patients was 53 per cent lower in the regional network than the national average (5.2 versus 11.0 per cent; P = 0.001). Preventable death rates fell from 9 to 2 per cent (P = 0.040) and significant gains were made in critical care and ward bed utilization.

CONCLUSION

Institution of a specialist trauma service and performance improvement programme was associated with significant improvements in outcomes that exceeded national variations.

Severity of head computed tomography scan findings fail to explain racial differences in mortality following child abuse

INTRODUCTION

Differences in head injury severity may not be fully appreciated in child abuse victims. The purpose of this study was to determine if differential findings on initial head computed tomography (CT) scan could explain observed differential outcome by race.

METHODS

We identified 164 abuse patients from our trauma registry with an Injury Severity Score (ISS) > or = 15. Their initial head CT scan was graded from 1 to 4 (normal to severe). Statistical analysis was performed to asses the correlation between race, head CT grade, Glasgow Coma Scale (GCS) score, and mortality.

RESULTS

Overall mortality was 17%: 11% for white children, 32% for African-American children (P < .05). In review of the head CT scans there was no difference by race in types of injuries or head CT grade. Using a multivariate regression model, African-American race remained an independent risk factor for mortality with an odd ratio of 4.3 (95% confidence interval [CI] 1.6-11.5).

CONCLUSION

African-American children had a significantly higher mortality rate despite similar findings on initial head CT scans. Factors other than injury severity may explain these disparate outcomes.

Emergency Medical Treatment andActive Labor Act andTrauma Triage

The Emergency Medical Treatment and Active Labor Act (EMTALA) was conceived as a means to ensure that patients with emergent conditions would receive stabilizing care and to avert the potentially dangerous, economically driven, interhospital transfer of patients. This legislation and its subsequent application arrived near the time that regional and statewide trauma systems were established. Trauma systems were developed to guide optimal resource use for the injured patient regardless of the patient's ability to pay. Unfortunately, when coupled with current economic and litigation threats to community emergency and surgical practitioners, EMTALA represents a threat to the continuation of the trauma system concept. Trauma systems are dependent on a tiered hospital network where severely injured patients are taken to a hospital with resources aligned to manage the worst of injuries. When primary triage from the field cannot accomplish this task, secondary triage from a nondesignated or lower-level hospital to the higher-level trauma center is needed. EMTALA has served as a driver to change the priority for secondary triage from addressing the needs of the severely injured patient to filling community hospital surgical specialist emergency department on-call coverage gaps for less severely injured patients. Further, legal action associated with claims of EMTALA violations has needlessly extended medical examination and "stabilization" efforts at community emergency departments prior to needed secondary triage. Higher-level trauma centers will benefit from codifying system-wide emergency medical services practices related to primary and secondary triage, establishing trauma center capacity and divert practices, and initiating "transfer center" operations that control transfer of patients to these centers.

Financial triage in transfer of trauma patients: a myth or a reality?

BACKGROUND

It has been alleged that smaller hospitals transfer out uninsured trauma patients (wallet biopsy), putting the financial burden on major trauma centers.

METHODS

We undertook a retrospective analysis of the National Trauma Data Bank to compare patients who received care at major trauma centers after being transferred from another hospital (transfer group, n = 72,900) with patients who received definitive care at a smaller hospital (nontransfer group, n = 6,826).

RESULTS

Transfer patients were more likely to be uninsured (18% vs 14%; P < .001), but were more severely injured (Injury Severity Score, 11 +/- 10 vs 7 +/- 7; P < .001), or had multiple injuries. After adjustment for these differences, uninsured patients were no more likely to be transferred than insured ones (odds ratio, .95; 95% confidence interval, .88-1.04; P = .3).

CONCLUSIONS

There was no relationship between lack of insurance and likelihood of transfer to a major trauma center.

Prehospital management of traumatic brain injury

The aim of this study was to review the current protocols of prehospital practice and their impact on outcome in the management of traumatic brain injury. A literature review of the National Library of Medicine encompassing the years 1980 to May 2008 was performed. The primary impact of a head injury sets in motion a cascade of secondary events that can worsen neurological injury and outcome. The goals of care during prehospital triage, stabilization, and transport are to recognize life-threatening raised intracranial pressure and to circumvent cerebral herniation. In that process, prevention of secondary injury and secondary insults is a major determinant of both short- and longterm outcome. Management of brain oxygenation, blood pressure, cerebral perfusion pressure, and raised intracranial pressure in the prehospital setting are discussed. Patient outcomes are dependent upon an organized trauma response system. Dispatch and transport timing, field stabilization, modes of transport, and destination levels of care are addressed. In addition, special considerations for mass casualty and disaster planning are outlined and recommendations are made regarding early response efforts and the ethical impact of aggressive prehospital resuscitation. The most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of prehospital care is a major determinant of long-term outcome for patients with traumatic brain injury.

Interhospital transfer of critically ill and injured children: an evaluation of transfer patterns, resource utilization, and clinical outcomes

OBJECTIVE

To describe patterns of transfer, resource utilization, and clinical outcomes associated with interhospital transfer of critically ill and injured children.

DESIGN

Secondary analysis of administrative claims data.

PARTICIPANTS

Children 0 to 18 years in the Michigan Medicaid program who underwent interhospital transfer for intensive care from January 1, 2002 to December 31, 2004. The 3 sources of transfer from referring hospitals were: emergency department (ED), ward, or intensive care unit (ICU).

MEASUREMENTS

Mortality and duration of hospital stay at the receiving hospitals.

RESULTS

Of 1643 interhospital transfer admissions to intensive care at receiving hospitals, 62%, 31%, and 7% were from the ED, ward, and ICU of referring hospitals, respectively. Nineteen percent had comorbid illness, while 11% had organ dysfunction at the referring hospital. After controlling for comorbid illness, patient age, and pretransfer organ dysfunction; compared with ED transfers, mortality in the receiving hospital was higher for ward transfers (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.02-3.03) but not for ICU transfers. Also, compared with ED transfers, hospital stay was longer by 1.5 days for ward transfers and by 13.5 days for ICU transfers.

CONCLUSION

In this multiyear, statewide sample, mortality and resource utilization were higher among children who underwent interhospital transfer to intensive care after initial hospitalization, compared with those transferred directly from emergency to intensive care. Decision-making underlying initial triage and subsequent interhospital transfer of critically ill children warrants further study.

Emergency room management of trauma patients in Greece: preliminary report of a national study

AIM OF THE STUDY

The aim of this study was to record and to evaluate the epidemiology of trauma in Greece and to assess the quality of management provided for trauma patients in the emergency department in Greek hospitals.

METHODS

The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. The representatives that responded positively, met with the Board of the society in succeeding meetings to establish the reporting form and the inclusion criteria. Inclusion criteria were defined as trauma patients requiring admission, transfer to a higher level center or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic data base and analyzed. The design of the study was prospective and observational.

RESULTS

In total 8862 patients were included in the study in 12 months time. Of them 68.7% (n=6084) were male, aged 41.8+/-20.6 (mean+/-S.D.) and 31.3% were female (n=2778), aged 52.7+/-24.1 (mean+/-S.D.). The mean duration of treatment in the emergency room department was 1h and 28min. Of the total number of patients, 2312 (26.1%) were initially assessed and managed by a specialist and 6249 (70.5%) were initially assessed and managed by a resident.

CONCLUSIONS

Data from this study show that there is substantial room for improvement in the patient care in the emergency department following trauma. Further evaluation will be required to identify particular management patterns that can be readily altered.

Validation of a prehospital trauma triage tool: a 10-year perspective

BACKGROUND

Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication. The rural county adjacent to our developed trauma system uses standardized triage criteria to identify patients for direct transport to our TCs. We hypothesized these criteria accurately identify major trauma victims (MTV) and further that communication could be simplified to expedite transport.

METHODS

Prehospital personnel use a MAP (mechanism, anatomy, and physiology) scoring system to triage trauma patients. Patients with > or = 2 "hits" are defined as MTV. In 2004, the triage policy was changed so that MTV would be transported directly to a TC without base hospital consultation (previously required). The Emergency Medical Services (EMS) Medical Director reviewed cases transported to the TC to determine the appropriateness of triage decisions (over- and under-triage using the American College of Surgeons Committee on Trauma definitions). Data were compared before and after this policy change.

RESULTS

For 2004 to 2006, we evaluated 676 air transports to TC and compared them to 468 in the prior 56 months. The overall transport rate increased slightly 7% to 10%. During the study period the over-triage rate was 31% compared with 21%, before the policy change. The MAP triage tool yielded a 93.8% sensitivity and a 99.5% specificity. Therefore, it determined the need for air-medical transport out of a rural environment into an established trauma system with > 90% accuracy.

CONCLUSIONS

Prehospital personnel can accurately use a trauma triage tool to identify MTV. Eliminating base station contact, a potential for introducing communication error, did increase over-triage but still well within accepted limits. The system change also resulted in the transport of a greater proportion of minor trauma patients who later proved to have major injuries.

Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated increased radiation exposure

INTRODUCTION

Community hospitals commonly obtain computed tomographic (CT) imaging of pediatric trauma patients before triaging to a level I pediatric trauma center (PTC). This practice potentially increases radiation exposure when imaging must be duplicated after transfer.

METHODS

A retrospective review of our level 1 PTC registry from January 1, 2004, to December 31, 2006, was conducted. Level I and II trauma patients were grouped based on whether they had undergone outside CT examination (head and/or abdomen) at a referring hospital (group 1) or received initial CT examination at our institution (group 2). Subgroups were analyzed based on whether duplicate CT examination was required at our PTC (Fischer's Exact test).

RESULTS

A duplicate CT scan (within 4 hours of transfer) was required in 91% (30/33) of group 1 transfer patients, whereas no group 2 patient required a duplicate scan (0/55; P < .0001). There was no significant difference within the groups for weight, age, or intensive care unit length of stay.

CONCLUSION

A significant number of pediatric trauma patients who receive CT scans at referring hospitals before transfer to our level I PTC require duplicate scans of the same anatomical field(s) after transfer, exposing them to increase potential clinical risk and cost.

Rural trauma: is trauma designation associated with better hospital outcomes?

CONTEXT

While trauma designation has been associated with lower risk of death in large urban settings, relatively little attention has been given to this issue in small rural hospitals.

PURPOSE

To examine factors related to in-hospital mortality and delayed transfer in small rural hospitals with and without trauma designation.

METHODS

Analysis of data from the Nationwide Inpatient Sample for discharges between 1998 and 2003 of patients hospitalized with moderate to major traumatic injury in nonfederal, short-stay rural hospitals with annual discharges of 1,500 or fewer patients (N = 9,590). Logistic regression was used to control for patient and hospital characteristics, stratifying by hospital volume. Main outcome measures were in-hospital death and transfer to another acute care facility after initial admission.

FINDINGS

A total of 333 patients (3.5%) died in-hospital. After adjusting for patient, injury and hospital characteristics, in-hospital death was more likely among patients treated at the non-designated hospitals with fewer than 500 discharges per year (OR 2.35; 95% CI 1.25-4.41) than among patients treated at similar trauma-designated hospitals. Patients admitted to non-designated hospitals were more likely to be transferred after admission, although this finding was significant only in the larger-volume hospitals with discharges of 500-1,500 per year (OR 1.41, 95% CI 1.08-1.83).

CONCLUSIONS

Associations between trauma designation and outcomes in rural hospitals warrant further study to determine whether expanding designation to more rural hospitals might lead to further improvement in trauma outcomes.

Trauma

In terms of cost and years of potential lives lost, injury arguably remains the most important public health problem facing the United States. Care of traumatically injured patients depends on early surgical intervention and avoiding delays in the diagnosis of injuries that threaten life and limb. In the critical care phase, successful outcomes after injury depend almost solely on diligence, attention to detail, and surveillance for iatrogenic infections and complications.

Impact of Acute Care General Surgery Coverage by Trauma Surgeons on the Trauma Patient

Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days ( P < 0.0001), intensive care unit length of stay ( P < 0.0001), and hospital length of stay ( P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.

The Value of the Trauma Mechanism in the Triage of Severely Injured Elderly

BACKGROUND

The triage of trauma patients is currently based on the trauma mechanism. However, it is known that elderly patients can sustain severe injuries due to insignificant trauma mechanisms. As such, triage methods might be questionable.

OBJECTIVE

To evaluate whether current trauma triage criteria are appropriate in severely injured elderly patients.

METHODS

To analyze the effect of the trauma mechanism on triage and treatment, consecutive patients ≥ 55 years of age, with an injury severity score > 15, treated from 2002 to 2005 were divided into those who sustained a high-energy trauma (HET) versus a low energy trauma (LET). Pre-hospital and in-hospital data, injury characteristics, and data on mortality and disablement one year postinjury (sickness impact profile) were analyzed for HET and LET groups.

RESULTS

Age, sex and co-morbidity rate were similar in 84 HET patients and 107 LET patients. HET patients (mean ISS 28) received more sophisticated trauma care than LET patients (mean ISS 22), although mortality was similar (38 vs. 34%). Long-term disablement was also similar (median SIP scores 4 vs. 6). Severe head injuries and the Revised Trauma Score were related to mortality. Physical disablement was related to preexisting co-morbidities. No variables were related to psychosocial disablement.

CONCLUSIONS

In elderly people a low energy trauma may lead to severe consequences. Not only the trauma mechanism, but also age, co-morbidity, and the likelihood of a brain injury should be leading in the triage and subsequent management of severely injured elderly.

Changes in the incidence and outcome for early acute kidney injury in a cohort of Australian intensive care units

INTRODUCTION

There is limited information on whether the incidence of acute kidney injury (AKI) in critically ill patients has changed over time and there is controversy on whether its outcome has improved.

METHODS

We interrogated the Australian New Zealand Intensive Care Society Adult Patient Database to obtain data on all adult admissions to 20 Australian intensive care units (ICUs) for >or= 24 hours from 1 January 1996 to 31 December 2005. Trends in incidence and mortality for ICU admissions associated with early AKI were assessed.

RESULTS

There were 91,254 patient admissions to the 20 study ICUs, with 4,754 cases of AKI, for an estimated crude cumulative incidence of 5.2% (95% confidence interval, 5.1 to 5.4). The incidence of AKI increased during the study period, with an estimated annual increment of 2.8% (95% confidence interval, 1.0 to 5.6, P = 0.04). The crude hospital mortality was significantly higher for patients with AKI than those without (42.7% versus 13.4%; odds ratio, 4.8; 95% confidence interval, 4.5 to 5.1; P < 0.0001). There was also a decrease in AKI crude mortality (annual percentage change, -3.4%; 95% confidence interval, -4.7 to -2.12; P < 0.001), however, which was not seen in patients without AKI. After covariate adjustment, AKI remained associated with a higher mortality (odds ratio, 1.23; 95% confidence interval, 1.14 to 1.32; P < 0.001) and there was a declining trend in the odds ratio for hospital mortality.

CONCLUSION

Over the past decade, in a large cohort of critically ill patients admitted to 20 Australian ICUs, there has been a significant rise in the incidence of early AKI while the mortality associated with AKI has declined.

A prospective study of the impact of multiple patient transports on care provided during aeromedical transport

OBJECTIVES

The purpose of the current study was to determine reasons for multiple-patient transports using a helicopter emergency medical services (HEMS) and to observe for any negative impact on patient care caused by the presence of the second patient.

METHODS

The study was a prospective observational study of all two-patient trauma transports (doubles) over a 12-month period, from January 2004 through December 2004. The authors selected a sample of 20% of single-patient transports (singles) from the same time period for comparison. Flight crews completed a study form after the flight. Information requested included Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS), and negative impact on care of the primary patient caused by transporting the secondary patient. Data were analyzed using Mann-Whitney rank test and descriptive statistics.

RESULTS

There were a total of 59 double-trauma transports. A total of 269 single-trauma transports were identified for comparison. Although there was no statistically significant difference in GCS score or RTS (single vs. primary double), doubles never included the most severely injured trauma patients. The secondary patients from the doubles were the least severely injured. There were nine patients in whom the crew felt there was a negative impact from the second patient. Need for trauma center evaluation of the second patient and distance of transport were common reasons for double transports.

CONCLUSIONS

Patients transported as doubles do not include the most severely injured trauma patients. In only a small percentage of doubles did the second patient have a perceived impact on care of the primary patient.

The influence of insurance status on the transfer of femoral fracture patients to a level-I trauma center

BACKGROUND

The aim of the present study was to evaluate transfer patterns and insurance status for patients with a femoral fracture who were definitively managed within a six-hospital health-care system. We hypothesized that insurance status significantly influenced transfer of these patients to the level-I trauma center and that the level-I center provided definitive care for a disproportionate percentage of uninsured femoral fracture patients.

METHODS

The present retrospective cohort study was performed within a six-hospital health-care system. The system comprises a single American College of Surgeons-designated level-I trauma center and five nondesignated community hospitals. We identified 243 patients with 251 femoral shaft fractures that had been definitively treated with intramedullary nail fixation within the system. From the health-care system billing database and trauma registries, we obtained diagnosis and procedure codes, insurance status, and trauma center transfer data. Differences in the proportions of uninsured and insured patients were calculated.

RESULTS

One hundred and seventy-two (71%) of the 243 patients who were definitively managed within our health-care system initially had been taken to the regional level-I center, and thirty-eight patients (16%) had been transferred to the trauma center. Of the thirty-eight patients who had been transferred, eighteen (47%) had met appropriate transfer criteria. Of the twenty patients with an isolated femoral fracture who had been transferred from hospitals with regular orthopaedic coverage, four (20%) had met appropriate transfer criteria. Twenty-two (58%) of the thirty-eight patients who had been transferred were uninsured, and all thirty-three patients who had not been transferred were insured (p = 0.0008); this observation remained when controlling for injury severity and available orthopaedic coverage (p < 0.0001). The proportion of insured patients definitively managed at the trauma center (52%) differed significantly from the proportion of insured patients definitively managed at the community hospitals (100%) (p < 0.0001).

CONCLUSIONS

The majority (71%) of the patients with a femoral fracture who had been managed definitively within our health-care system, regardless of injury severity, had been taken directly to the trauma center. This finding suggests over-triage, which errs on the side of patient well-being. Because there was a significant difference in insurance status between patients who had been transferred to the level-I center and those who had not been transferred as well as between patients who had been definitively managed at the level-I center and those who had been managed in community hospitals, it can be assumed that insurance status as well as injury severity and orthopaedic surgeon availability influence the decision to transfer femoral fracture patients to a level-I trauma center.

Quand faut-il décider d'un transfert en milieu neurochirurgical spécialisé?

The annual incidence of severe head injury lies between 9 and 25/100000 inhabitants, depending on the criteria used for its definition. In most countries, the shortage in neurosurgical ICU beds makes it impossible to take in charge all patients with a severe brain injury. But the beneficial effect of a specialized neurosurgical ICU on outcome after brain injury has been demonstrated in several retrospective studies. Ideally, the best strategy is to admit the patients with a severe head injury directly in a neurosurgical centre. When this is not possible, the appropriate decision of a secondary transfer relies on the quality of the relationships between physicians in the community and the neurosurgical hospitals. Teleradiology is the best method to avoid unnecessary transportation or deleterious delays before transfer. In an era of decreasing medical budgets, technical improvements to enhance medical cooperation should be encouraged.

Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room

INTRODUCTION

Successful management of emergency patients with multiple trauma in the hospital resuscitation room depends on the immediate diagnosis and rapid treatment of the most life-threatening injuries. In order to reduce the time spent in the resuscitation room, an in-hospital algorithm was developed in an interdisciplinary team approach with respect to local structures. The aim of the study was to analyse whether this algorithm affects the interval between hospital admission and the completion of diagnostic procedures and the start of life-saving interventions. Moreover, in-hospital mortality was investigated before and after the algorithm was introduced.

MATERIAL AND METHODS

In this prospective study, all consecutive trauma patients in the resuscitation room were investigated before (group I, 01/04-10/04) and after (group II, 01/05-11/05) introduction of the algorithm. The times between hospital admission and the end of the diagnostic procedures (ultrasound [sono], chest X-ray [CF], and cranial computed tomography [CCT]), and between hospital admission and the start of life-saving interventions were registered and in-hospital mortality analysed.

RESULTS

In the study period, 170 patients in group I and 199 patients in group II were investigated. Injury severity score (ISS) were comparable between the two groups. The intervals between admission and completion of diagnostic procedures were significantly lower after the algorithm was introduced (mean+/-S.D.): sono (11 +/- 10 min versus 7 +/- 6 min, p < 0.05), CF (21 +/- 12 min versus 12 +/- 9 min, p < 0.01), and CCT (55 +/- 27 min versus 32 +/- 14 min, p < 0.01). Moreover, the interval to the start of life-saving interventions was significantly shorter (126 +/- 90 min versus 51 +/- 20 min, p < 0.01). After introducing the algorithm, in-hospital mortality was reduced significantly from 33.3% to 16.7% (p < 0.05) in the most severely injured patients (ISS>or=25).

CONCLUSION

The introduction of an algorithm for early management of emergency patients significantly reduced the time spent in the resuscitation room. The periods to completion of sono, CF, and CCT, respectively, and the start of life-saving interventions were significantly shorter after introduction of the algorithm. Moreover, introduction of the algorithm reduced mortality in the most severely injured patients. Although further investigations are needed to evaluate the effects of the Heidelberg treatment algorithm in terms of outcome and mortality, the time reduction in the resuscitation room seems to be beneficial.

Do trauma teams make a difference?

OBJECTIVE

To evaluate the association between trauma team activation according to well-established protocols and patient survival.

METHODS

Single centre, registry study of data collected prospectively from trauma patients (who were treated in a trauma resuscitation room, who died or who were admitted to ICU) of a tertiary referral trauma centre Emergency Department (ED) in Hong Kong. A 10-point protocol was used to activate rapid trauma team response to the ED. The main outcome measures were mortality, need for ICU care, or operation within 6h of injury.

RESULTS

Between 1 January 2001 and 31 December 2005, 2539 consecutive trauma patients were included in our trauma registry, of which 674 patients (mean age 43 years, S.D. 22; 71% male; 94% blunt trauma) met trauma call criteria. Four hundred and eighty two (72%) correctly triggered a trauma call, and 192 (28%) were not called ('undercall'). Patients were less likely to have a trauma call despite meeting criteria if they were aged over 64 years, had sustained a fall, had a respiratory rate <10 or >29 per minute, a systolic blood pressure between 60 and 89 mm Hg, or a GCS of 9-13. In a sub-group of moderately poor probability of survival (probability of survival, P(s), 0.5-0.75), the odds ratio for mortality in the undercall group compared with the trauma call group was 7.6 (95% CI, 1.1-33.0).

CONCLUSIONS

In our institution, undercalls account for 28% of patients who meet trauma call criteria and in patients with moderately poor probability of survival undercall is associated with decreased survival. Although trauma team activation does not guarantee better survival, better compliance with trauma team activation protocols optimises processes of care and may translate into improved survival.

Transfer of Pediatric Trauma Patients to a Tertiary Pediatric Trauma Centre: Appropriateness and Timeliness

OBJECTIVE

To study the appropriateness of, and time taken, to transfer pediatric trauma patients in New South Wales to The Children's Hospital at Westmead (CHW), a pediatric trauma center.

METHODS

All trauma patients transferred to CHW from June 2003 to July 2004 were included in the study. Indications and time periods relevant to the transfer of the patient from the referring institute were retrieved and analyzed. Pediatric and adult retrieval services were compared.

RESULTS

Three hundred ninety-eight patients were transferred to CHW, of whom 332 were from the metropolitan region. Falls and burns were the commonest mechanism of injury. Burn was the commonest indication for transfer (107 of 398). Mean Injury Severity Score was eight. Nearly half the patients had minor injuries (Injury Severity Score<9). Patients spent an average of 5 hours at the referring hospital. Pediatric retrieval ambulances had significantly longer mean transfer times than did nonpediatric ambulance services with a total time spent of about 2.64 hours versus 1.30 hours, respectively. For aeromedical transfers, on the other hand, the difference between pediatric retrieval services and nonpediatric air ambulances was not significant.

CONCLUSIONS

The majority of the patients transferred had minor injuries. Pediatric trauma patients spend considerable time in their referring hospitals. Pediatric retrieval services appear to take significantly longer to transfer patients than nonpediatric ambulance transfers even after allowing for patient age and injury severity. Although this did not result in mortality or morbidity, there appears to be considerable scope for a reduction in transfer times through better coordination of these services.

Statewide tracking of crash victims' medical system utilization and outcomes

BACKGROUND

For the study year, the state of Massachusetts had the lowest fatal motor vehicle crash rate in the nation. The state was interested in exploring new approaches to save additional lives. The study goal was to determine the potential for Massachusetts's medical system to reduce fatalities through alternative utilization of existing transport methods, treatment hospital types, and victim pathways.

METHODS

This was a 1-year retrospective statewide population-based study of all persons involved in a trafficway motor vehicle crash in which at least one person died within 30 days. Database linkage was used to track the pathway and outcome of every involved victim from the crash scene, including air medical and ground ambulance utilization, community or trauma center treatment, and interhospital transfers; air and trauma center (TC) scene triage levels were computed retrospectively. All crash and hospital locations were geomapped and confounding factors were included.

RESULTS

Air and ground scene transports to TCs were underutilized by 7:1 and 4.5:1, respectively. No request was the major reason for air underutilization. Underutilization was associated with reduced lived-to-died ratio (L/D) by pathway of up to 10:1. Statewide, air transport to Level I trauma centers had both the highest (1.0, scene) and lowest L/Ds (0.6, interfacility). A 4.5:1 difference in L/D was associated with fulfilled versus unfulfilled air requests. By emergency medical service region, L/D varied by nearly 3:1 and utilization of scene air and TC transports by 5:1 and 4:1. Victim helicopter emergency medical services transport to a TC with an Injury Severity Score > or =19 was identified as critical and was associated with L/D differences of 3.7:1. The paradox of lower L/D for scene air transports to TCs occurring simultaneously with higher overall system L/D was observed and explained. System-based L/D differences of 1.8:1 were observed associated with increases in appropriate triage. Results that explain the "golden hour" effect are shown and discussed.

CONCLUSION

Appropriate scene triage decision-making and the resulting victim pathways are associated with systemwide L/D increases of 1.8:1. On that basis, potentially 53 to 90 lives in this study (13% to 22% of the statewide total) could have been saved.

Field triage, and the fragile supply of "optimal resources" for the care of the injured patient

Conventional field triage schemes, including those discussed in this series of reports, assume a high degree of consistency in the availability of resources at designated receiving hospitals. In an organized trauma system, designated trauma receiving facilities of all levels are typically required to maintain a high level of consistency in terms of available facility and human resources for the care of the injured patient. These resources, both facility and provider, are becoming increasingly vulnerable to gaps in availability, however, for a variety of reasons. When gaps in resource availability do occur, their often unpredictable nature nullifies the effectiveness of any established triage protocol, may result in trauma center closures or downgrades, and undermines the entire system of care. It may be necessary in some regions to develop more flexible triage processes, creating a time-sensitive responsiveness to fluctuations in resource availability in a way that dynamically minimizes overtriage and undertriage.

Replantation surgery in Quebec: The bottlenecks to rapid care

INTRODUCTION

Time delays resulting in prolonged ischemia have a significant impact on the successful reattachment of amputated body parts. No studies have addressed the issues surrounding delays from the time of the accident to the start of replantation surgery. The present paper identifies the bottlenecks that prolong the time before patients are able to gain access to a replant team.

METHODS

A total of 50 patients underwent microsurgical replantation, because of traumatic amputation, at a university-based hospital from 1996 to 2003. The charts were analyzed to ascertain individual time intervals from the onset of injury until the beginning of replant surgery.

RESULTS

The average length of time for patients who came directly to the replant centre was 3 h 40 min before surgery began. In contrast, for those referred from outlying hospitals, the elapsed time was 6 h 21 min.

CONCLUSIONS

Two major bottlenecks were found. First, for patients who were referred from other health centres, delays were due to a lack of information as to where patients could receive appropriate replant surgery. Second, delays at the replant centre were primarily due to insufficient physical and human resources in the operating room.

An outcome analysis of patients transferred to a regional burn center: transfer status does not impact survival

BACKGROUND

Optimal burn care is provided at specialized burn centers. Given the geographic location of these centers, many burn patients receive initial treatment at local emergency departments prior to transfer. The purpose of this study was to determine whether patients transferred from other facilities have worse outcomes than those admitted directly from the field.

STUDY DESIGN

A retrospective cohort study was performed comparing the outcomes of patients admitted to our burn center directly from the field with patients requiring transfer from a preliminary care facility. The outcomes of interest were mortality, length of stay, length of stay/TBSA burned, number of operations and hospital charges. Poisson regression or Cox proportional hazards model was used to evaluate differences in outcomes after adjusting for potential confounders.

RESULTS

From 2000 to 2003 a total of 1877 patients were admitted to our burn center and 953 (51%) were transferred from a preliminary care facility. No difference (p<0.05) was found in length of stay, number of operations, hospital charges and mortality between the two cohorts.

CONCLUSIONS

This study demonstrates that patients transferred to a regional burn center from local hospitals have equivalent mortality, length of stay and hospital charges as those admitted directly from the field.

Trauma and falls in the elderly

The number of people living longer and staying active continues to rise, resulting in an increase in the incidence of trauma-related vis-its by older persons to emergency departments. The elderly sustain a disproportionate share of fractures and serious injury, and represent a unique subset of patients with special needs and considerations. This article reviews the current literature on the management of elderly patients with trauma, including the physiologic changes of aging relevant to the management of trauma, injury patterns unique to geriatric victims of trauma, and aspects particular to resuscitation and general management of geriatric trauma victims. We include a discussion of the evaluation and management of falls in the elderly, including assessment of fall risk.

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury

OBJECTIVE

To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care.

METHODS

We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS > or =3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule.

RESULTS

504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation.

CONCLUSIONS

This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.

Is paramedic judgement useful in prehospital trauma triage?

Precise prehospital trauma triage criteria are critical for ensuring patients with severe injuries are transported to trauma centres. Most prehospital trauma triage criteria adopt a combination of physiological, anatomic and mechanism of injury components, but this approach still fails to identify a number of patients with severe injuries and often burdens trauma centres with patients suffering minor injuries. Paramedic judgement has been identified as an alternative method for the triage of trauma patients. This study critically reviewed the literature regarding the ability of paramedics to predict injury severity, and found there is no clear evidence supporting paramedic judgement as an accurate triage method. However, the studies were limited due to significant data losses, variable definitions of major trauma, differences across EMS and trauma care systems, variable paramedic experience levels and incomparable methods of data collection. The role of paramedic judgement in identifying patients with severe blunt anatomic injuries requires further investigation.

A review of the current management of severe traumatic brain injury

Traumatic brain injury accounts for up to half of trauma related fatalities. This review describes current management practices including pre-hospital care, surgical interventions and various treatment modalities for intracranial hypertension. The lack of class I evidence for the majority of interventions is highlighted.

The relationship between the location of pediatric intensive care unit facilities and child death from trauma: a county-level ecologic study

OBJECTIVES

To describe the relationship between the location of Pediatric Intensive Care Unit (PICU) facilities and county-level child death from trauma in the contiguous USA.

STUDY DESIGN

We conducted a cross-sectional ecologic study using county-level data on death due to trauma in children 0 to 14 years of age from 1996 to 1998. These data were linked to 1997 county-level data on availability of PICU facilities.

RESULTS

In 1997, PICU facilities were present in 9% of USA counties. There were 18,337 childhood deaths from trauma in the study period. The presence of PICU facilities in a county was associated with lower mortality from trauma (incidence rate ratio [IRR] = 0.72; 95% CI 0.67-0.78) compared to counties without PICU facilities. After controlling for residence in rural and low-income counties, and the presence of adult medicosurgical intensive care units, the presence of PICU facilities in a county remained associated with lower rates of death from trauma (IRR = 0.82; 95% CI 0.75-0.89).

CONCLUSION

The presence of PICU facilities is related to lower mortality rates due to traumatic injuries at the county level. This finding may reflect the concentration of pediatric subspecialty care in counties with PICUs. This association merits further study with individual-level observations.

The association between trauma system and trauma center components and outcome in a mature regionalized trauma system

BACKGROUND

Regionalized trauma systems have been shown repeatedly to improve the outcome of seriously injured patients. However, we do not have data regarding which components of these systems have the most impact on outcome and to what degree. The objective of this study was to understand the association between various components that make up a trauma system and outcome.

METHODS

Surveys were administered to trauma directors at 59 hospitals in the province of Quebec, Canada. Data from the surveys were then linked with specific outcome variables obtained from a regionalized trauma database. Specific outcomes were assigned to trauma system- and in-hospital-based components after controlling for injury severity.

RESULTS

Over 4.8 years, 72,073 patients met inclusion criteria. Components found to affect survival after risk adjustment were prehospital notification (OR, 0.61; 95% CI, 0.39-0.94) and the presence of a performance improvement program in that hospital (OR, 0.44; 95% CI, 0.20-0.94). Increased patient volume was associated with a reduction in risk-adjusted mortality (OR, 0.98; 95% CI, 0.97-0.99). Tertiary trauma centers were also associated with a reduction in risk-adjusted mortality compared with both secondary and primary centers (OR, 0.68; 95% CI, 0.48-0.99).

CONCLUSIONS

Improvements in outcome in a regionalized trauma system are secondary to a combination of elements, as well as to the interplay of these elements on each other. Prehospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.

Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers?

BACKGROUND

Trauma triage criteria have been in place for many years and were updated in 1999 by the American College of Surgeons. We are unaware of any studies that have directly examined the ability of these criteria to reduce short-term mortality by transporting patients to trauma centers rather than to noncenters.

STUDY DESIGN

Retrospective observational cohort study of adult patients meeting physiologic triage criteria who were transported to 9 regional (Level I) trauma centers, 21 area (Level II) trauma centers, and 119 noncenters in New York in 1996 to 1998. For each triage criterion and for one or more of the criteria, odds ratios and their confidence intervals for mortality in regional and area trauma centers versus noncenters and odds ratios and their confidence intervals for mortality in regional centers versus area centers and noncenters were used to measure performance.

RESULTS

Patients in regional trauma centers had considerably lower mortality than patients in area trauma centers and noncenters for two individual triage criteria and for patients with one or more triage criteria (odds ratio, 0.75; 95% CI, 0.63-0.90 for one or more criteria). Also, patients with head injuries who were treated in regional centers had notably lower mortality than patients in other hospitals (odds ratio, 0.67; 95% CI, 0.53-0.85).

CONCLUSIONS

In New York, regional trauma centers exhibit considerably lower mortality than area trauma centers or noncenters for adult patients meeting specific physiologic triage criteria. It is important that population-based trauma systems with data from centers and noncenters be developed for the purpose of evaluating and redesigning trauma systems.

Trauma bypass in south-eastern Sydney: An 8-year review

OBJECTIVE

The New South Wales (NSW) Health Department and the Ambulance Service of NSW introduced a trauma bypass system in Sydney on 29 March 1992. This study aims to review the outcomes of trauma bypass patients brought to St George Hospital, a major trauma service in south-eastern Sydney, and to assess the performance of the current prehospital trauma triage protocol.

METHODS

The St George Hospital Department of Trauma Services prospectively collected data on all trauma bypass patients for the 8-year period from 29 March 1992 to 29 March 2000.

RESULTS

A total of 1990 patients were brought to hospital on trauma bypass. The average age was 32 years, 70% were men and 66% were from road traffic accidents. The positive predictive value of the prehospital triage tool for serious injury (Injury Severity Score [ISS] > 15) was 18.6% (95% CI 16.9-20.4). This is well below the benchmark previously established by the NSW Health Department Trauma System Advisory Committee. For all trauma bypass patients, 33.8% (95% CI 31.7-35.9) were discharged home from the ED. The overall death rate was 2.5% (95% CI 1.9-3.3).

CONCLUSIONS

According to the proposed benchmark, current prehospital trauma triage guidelines are underperforming. This suggests that a review of the benchmarks of current local trauma systems and of the trauma triage tool is required.