Impact of Trauma Center Designation and Interfacility Transfer on Renal Trauma Outcomes: Evidence for Universal Management

A retrospective study of pediatric renal trauma: A single-center experience in Japan

OBJECTIVES

To report pediatric renal trauma experiences at the National Center for Child Health and Development in Japan according to the Japanese Association for the Surgery of Trauma (JAST) classification 2008.

METHODS

Medical records were retrospectively reviewed for 45 children younger than 18 years old diagnosed with renal trauma from February 2004 to December 2021, regarding details of external causes, treatments, complications, and injury scales according to the JAST classification 2008. The cases who cannot be classified into the JAST classification 2008 will be categorized into our original type 0.

RESULTS

There were 24 males and 21 females with a mean age of 8.5 years. Left kidneys were the predominantly affected side. Blunt injury was involved in every case (mainly falls and traffic accidents). Concomitant organ injuries were found in 13 cases. The injury scales were type Ia (13.3%), II (11.1%), IIIa (13.3%), IIIb (24.4%). Type 0 accounted for 37.8%, which were type 0c (congenital anomalies of the kidney and urinary tract without hematoma and/or laceration of kidney parenchyma) at 11.1% and type 0h (only hematuria and normal radiologic finding) at 26.7%. Treatments were blood transfusion, ureteral stenting, nephrostomy, and no nephrectomy. Complications were pseudoaneurysm, hypertension, and infection.

CONCLUSIONS

Nearly 38% of cases cannot be classified into the JAST classification 2008, comprising at least two irrelevant types (type 0c and type 0h ). Accordingly, a pediatric renal injury scale should be established to achieve the precise diagnosis and treatments. However, further studies are still needed.

Resource utilization and secondary overtriage for patients with traumatic renal injuries in a regional trauma system

BACKGROUND

While renal trauma management has shifted to conservative nonoperative management, insufficient data exist to guide interhospital renal trauma transfer protocols. Secondary overtriage is defined as the potentially avoidable transfer of patients from a lower to a higher-level trauma center despite the lack of need for higher-level care. The goal of this study was to determine the prevalence and predictors of secondary overtriage in renal trauma patients to a level 1 trauma center.

METHODS

A retrospective cohort study was performed of all renal trauma patients transferred to a level 1 institution between 2005 and 2017. Secondary overtriage was defined as a potentially avoidable transfer that consisted of hospital stay <72 hours with survival, no surgical or interventional radiology procedure, and all nonabdominal Abbreviated Injury Scale scores of <3 after transfer. Multivariate logistic regression was performed to estimate odds of secondary overtriage based on predefined clinical criteria.

RESULTS

Of the 612 renal trauma patients transferred between 2005 and 2017, 71 (11.6%) met the criteria for secondary overtriage. Female patients and patients coming from level IV/V trauma centers were more likely to have potentially avoidable transfers (p = 0.01 and p < 0.001, respectively). Mean (SD) Injury Severity Score was 10 (4.2) and 30.7 (14.3) in overtriaged and appropriately triaged patients, respectively (p < 0.001). Of the 71 overtriaged patients, 70.4% had isolated renal injuries. Patients with isolated renal injuries (odds ratio, 39.0; 95% confidence interval, 16.44-105.39) and those transferred from a level IV/V trauma center (odds ratio, 3.85; 95% confidence interval, 1.64-9.61) had a higher likelihood of secondary overtriage.

CONCLUSION

Within our regional trauma system, the majority of secondary overtriage was due to potentially avoidable transfers from level IV/V centers and of patients with isolated renal injuries. By implementing strategies to reduce the secondary overtriage burden on major trauma centers, regional trauma systems can avoid unnecessary costs while maintaining patient safety and ensuring appropriate care.

LEVEL OF EVIDENCE

Therapeutic/care management, Level III.

Impact of Hospital Volume on the Outcomes of Renal Trauma Management

Background

Some health care systems have set up referral trauma centers to centralize expertise to improve trauma management. There is scant and controversial evidence regarding the impact of provider’s volume on the outcomes of trauma management.

Objective

To evaluate the impact of hospital volume on the outcomes of renal trauma management in a European health care system.

Design, setting, and participants

A retrospective multicenter study, including all patients admitted for renal trauma in 17 French hospitals between 2005 and 2015, was conducted.

Intervention

Nephrectomy, angioembolization, or nonoperative management.

Outcome measurements and statistical analysis

Four quartiles according to the caseload per year: low volume (eight or fewer per year), moderate volume (nine to 13 per year), high volume (14–25/yr), and very high volume (≥26/yr). The primary endpoint was failure of nonoperative management defined as any interventional radiology or surgical procedure needed within the first 30 d after admission.

Results and limitations

Of 1771 patients with renal trauma, 1704 were included. Nonoperative management was more prevalent in the very-high- and low-volume centers (p = 0.02). In a univariate analysis, very high hospital volume was associated with a lower risk of nonoperative management failure than low (odds ratio [OR] = 0.54; p = 0.05) and moderate (OR = 0.48; p = 0.02) hospital volume. There were fewer nephrectomies in the high- and very-high-volume groups (p = 0.003). In a multivariate analysis, very high volume remained associated with a lower risk of nonoperative management failure than low (OR = 0.48; p = 0.04) and moderate (OR = 0.42; p = 0.01) volume. Study limitations include all the shortcomings inherent to its retrospective multicenter design.

Conclusions

In this multicenter study, management of renal trauma varied according to hospital volume. There were lower rates of nephrectomy and failure of nonoperative management in very-high-volume centers. These results raise the question of centralizing the management of renal trauma, which is currently not the case in our health care system.

Patient summary

In this study, management of renal trauma varied according to hospital volume. Very-high-volume centers had lower rates of nephrectomy and failure of nonoperative management.

[Renal Parenchyma Trauma and General Trauma Recommandations]

INTRODUCTION

Among trauma emergencies, kidney damage is uncommon. The urologist is frequently on the second line in the management of patients with multiple traumatic lesions. Knowledge of treatment is necessary to be able to integrate the different teams involved in an approach that is both vital in the context of damage control and functional with a concern for parenchymal preservation.

METHODS

A systematic review of the literature was carried out using the Medline database in order to identify the most relevant articles in English and French.

RESULTS

Kidney trauma occurs either by direct shock or by a deceleration mechanism. They are classified by severity according to the AAST classification. Management is mostly conservative by avoiding surgery and controlling bleeding by arterial embolization. Surveillance checks for complications occurrence in high-grade trauma. Traumatic dissection of the renal artery, with a poor functional prognosis requires a short delay before treatment.

CONCLUSION

The prognosis for trauma to the kidney, regardless of the grade, is currently good, with improvements of effective resuscitation and embolization in the event of bleeding.

Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States

Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police.Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police.Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13-15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321-2.333); p = 0.776).Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.

Characteristics and outcomes of pediatric blunt renal trauma: a nationwide cohort study in Japan

PURPOSE

The aim of this study was to describe epidemiologic features of pediatric blunt renal trauma.

METHODS

We performed a retrospective analysis using the Japan Trauma Data Bank over 15 years. We included patients younger than 18 years with blunt renal trauma. We analyzed temporal trends and variations across age groups in patient characteristics, intervention, and in-hospital mortality. We also assessed factors associated with in-hospital mortality.

RESULTS

We identified 435 pediatric patients with blunt renal trauma. Their median age was 14 years and median Injury Severity Score (ISS) was 17. The most common mechanism of injury was traffic accident in all age groups. Nephrectomy was performed in 3.2%, and the overall in-hospital mortality was 4.6%, both of which showed decreasing trends. The most common mechanism of injury by age group was a pedestrian accident in infants/toddlers/preschoolers (43.5%), pedestrian accident in middle childhood (18.5%), bicycle accident in young teens (24.7%), and motorcycle accident in teenagers (41.2%). Sports-related injury was common in young teens (23.3%) and teenagers (15.2%). Factors such as ISS, shock, concomitant injury, and nephrectomy were associated with high in-hospital mortality.

CONCLUSIONS

We described decreasing trends in nephrectomy and in-hospital mortality in pediatric blunt renal trauma and found traffic accident and sports-related injury were common in the pediatric population in Japan.

Resource Utilization and Outcomes in Isolated Low-Grade Renal Trauma at a Level 1 Trauma Center

OBJECTIVE

To examine admission and transfer patterns of isolated low-grade renal trauma given lack of evidenced based guidelines.

METHODS

We employed a retrospective cohort design to analyze patients with low grade renal trauma from 2005 to 2018. We used an Abbreviated Injury Score (AIS) <3 for non-abdominal categories to ensure that intensive care unit admission/hospital transfer was due to renal trauma (n = 87). Treatment and discharge survival were compared.

RESULTS

Mean age for floor (n = 31) and intensive care unit (ICU) (n = 46) patients were 33 (IQR = 20) and 42 (IQR = 46) years old, respectively. Mean injury severity score (ISS) was 7.7 (IQR 4) for floor and 8 (IQR=3.75) for ICU admissions (P = .61) Mean ISS was 7.53 (IQR = 4) for transfers and 8.27 (IQR = 3.25) for non-transfers (P = .26). Blood products were administered only to 3 (6.5%) ICU patients all over 60 years old. Fourteen (45.1%) and 26 (56.5%) of floor and ICU admissions were transferred from a lower-level trauma center. ICU mean length of stay (LOS) was 37 hours (IQR = 23 h.). Mean hospital LOS was 43.4 hours and 71.9 hours for the floor and ICU patients (P = .08), and 69.02 hours and 52.58 hours for transfer vs non-transferred (P = .31). All patients were discharged alive and the majority (94%) was discharged home.

CONCLUSION

Given expedient ICU discharge, low transfusion rate, and low complication rate, inter-hospital transfer and ICU admission are unnecessary for patients under 65 years. Transfer and admission protocols for isolated renal trauma are needed to avoid resource overutilization.

Robotic Partial Nephrectomy: Update on Techniques

Surgical techniques for robot-assisted partial nephrectomy are driven by the aims of simplifying the most challenging surgical steps, maximizing functional and oncologic outcomes, and consistently pushing the envelope on possibilities. Over the past several years, we have seen an emergence in not only innovation in surgical technique, and robotic platforms, but integration of a variety of imaging techniques. We believe with developing robotic expertise, practicing urologists will continue to push the envelope in nephron preservation and complication-free recovery.

Impact of trauma center designation in pediatric renal trauma: National Trauma Data Bank analysis

INTRODUCTION

The pediatric kidney is the most common urinary tract organ injured in blunt abdominal trauma. Trauma care in the United States has been established into a hierarchical system verified by the American College of Surgeons (ACS). Literature evaluating management of pediatric renal trauma across trauma tier designations is scarce.

OBJECTIVE

To examine the differences in the management and outcomes of renal trauma in the pediatric population based on trauma level designation across the United States.

STUDY DESIGN

We performed a review of the ACS - National Trauma Data Bank database. Pediatric patients (age 0-18 years) who were treated for renal injury between years 2011-2016 were identified. Our primary outcome was the difference in any complication rate amongst Level I versus Non-Level I trauma centers. Management strategies were evaluated as secondary outcomes. Propensity score matching (PSM) was utilized to adjust for baseline differences between cohorts. Multivariable regression analysis was performed to determine the independent effects of individual factors on complications, operative intervention, minimally invasive procedure, and blood transfusions.

RESULTS

Overall, 12,097 pediatric patients were diagnosed with renal trauma between 2011 and 2016 using target ICD-9 and AAST codes. After PSM, there was a total of 1623 subjects withing each group. No difference was identified between groups for occurrence on any complication [105 (6.5%) vs 114 (7.0%), p = 0.576. There were no differences in the rate of minimally invasive interventions [67 (4.1%) vs 48 (3.0%), p = 0.087], operative intervention [58 (3.6%) vs 68 (4.2%), p = 0.413], or nephrectomy [42 (2.6%) vs 47 (2.9%), p = 0.667] between Level I and Non-Level I trauma designations, respectively. Length of stay was longer in the Level I cohort compared to Non-Level I (days (SD)) [6.9 (8.8) vs 6.2 (7.9), p = 0.024. When specifically looking at risk factors associated with operative intervention, higher renal injury grade and injury severity score were highly correlated, whereas, trauma level designation was not found to be predictive for more aggressive management.

DISCUSSION & CONCLUSION

Our results corroborate with previous literature that renal injury grade and injury severity score are strong predictors of morbidity, invasive management, and complications. Pediatric renal trauma was managed similarly across trauma center designations, with the rate of complication and intervention more prevalent in patients with high grade renal injuries and concomitant injuries. Further studies are necessary to identify patients who will benefit most from transfer to a level I center.

Trends and outcomes of blunt renal trauma management: a nationwide cohort study in Japan

Background

There is a paucity of information for predicting patient outcomes other than the American Association for the Surgery of Trauma (AAST) renal injury scale. The aim of this study was to evaluate the association between the patient characteristics and outcomes of patients with blunt renal trauma using a nationwide database in Japan.

Methods

We performed a retrospective analysis of the Japan Trauma Data Bank (JTDB) from 2004 to 2018. We identified patients with blunt renal trauma by AIS codes converted to AAST grades. We evaluated trends in patient characteristics and management and assessed factors associated with mortality and nephrectomy using a multivariable logistic regression analysis.

Results

We identified 3550 patients with blunt renal trauma. Their median age was 43 years and 74.2% were male. Nephrectomy was performed in 3.8%, and the overall mortality rate was 9.5%. We found increasing trends in age and emergency abdominal angiography and decreasing trends in nephrectomy and mortality over the 15-year period. The following factors were associated with mortality: age ≥ 65 years (adjusted OR 3.36); pedestrian accident (adjusted OR 1.94); fall from height (adjusted OR 1.91); shock on arrival (adjusted OR 4.02); concomitant injuries to the head/neck (adjusted OR 3.14), pelvis/lower-extremity (adjusted OR 1.59), liver (adjusted OR 1.68), spleen (adjusted OR 1.45), and gastrointestinal tract (adjusted OR 1.90); AAST grades III–V (adjusted ORs 1.42, 2.16, and 5.55); and emergency abdominal angiography (adjusted OR 0.70). The following factors were associated with nephrectomy: shock on arrival (adjusted OR 1.98), concomitant injuries to the thorax (adjusted OR 0.46) and spleen (adjusted OR 2.07), AAST grades III, IV, and V (adjusted ORs 18.40, 113.89, and 468.17), and emergency abdominal angiography (adjusted OR 0.28).

Conclusions

We demonstrated that the AAST grade and emergency angiography were associated with mortality and nephrectomy in blunt renal trauma in the Japanese population.