Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact?

Contemporary Management of Blunt Splenic Trauma in Adults: An Analysis of the Trauma Quality Improvement Program Registry

PURPOSE

The aim of this study was to evaluate the effectiveness of management strategies for blunt splenic injuries in adult patients.

METHODS

Patients 18 years and older with blunt splenic injuries registered via the Trauma Quality Improvement Program (2013-2019) were identified. Management strategies initiated within 24 hours of hospital presentation were classified as watchful waiting, embolization, surgery, or combination therapy. Patients were stratified by injury grade. Linear models estimated each strategy's effect on hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality.

RESULTS

Of 81,033 included patients, 86.3%, 10.9%, 2.5%, and 0.3% of patients received watchful waiting, surgery, embolization, and combination therapy, respectively. Among patients with low-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (9.4 days, Q < .001, Cohen's d = .30) and ICU LOS (5.0 days, Q < .001, Cohen's d = .44). Among patients with high-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (8.7 days, Q < .001, Cohen's d = .12) and ICU LOS (4.5 days, Q < .001, Cohen's d = .23). Among patients with low- and high-grade injuries, the odds ratios for in-hospital mortality associated with surgery compared with embolization were 4.02 (Q < .001) and 4.38 (Q < .001), respectively.

CONCLUSIONS

Among patients presenting with blunt splenic injuries and compared with surgery, embolization was associated with shorter hospital LOS, shorter ICU LOS, and lower risk for mortality.

Variability in Standardized Mortality Rates Among Pediatric Traumatic Brain Injury Patients: A Comparative Analysis of Trauma Centers

INTRODUCTION

Traumatic brain injury (TBI) causes significant morbidity and mortality in pediatric patients and care is highly variable. Standardized mortality ratio (SMR) summarizes the mortality rate of a specific center relative to the expected rates across all centers, adjusted for case-mix. This study aimed to evaluate variations in SMRs among pediatric trauma centers for TBI.

METHODS

Patients aged 1-18 diagnosed with TBI within the National Trauma Data Bank (NTDB) from 2017 to 2019 were included. Center-specific SMRs and 95% confidence intervals identified centers with mortality rates significantly better or worse than the median SMR for all centers.

RESULTS

316 centers with 10,598 patients were included. SMRs were risk-adjusted for patient risk factors. Unadjusted mortality ranged from 16.5 to 29.5%. Three centers (1.5%) had significantly better SMR (SMR <1) and three centers (1.5%) had significantly worse SMR (SMR >1). Significantly better centers had a lower proportion of neurosurgical intervention (2.4% vs. 11.8%, p < 0.001), a higher proportion of supplemental oxygen administration (93.7% vs. 83.5%, p = 0.004) and venous thromboembolism prophylaxis (53.2% vs. 40.6%, p < 0.001) compared to significantly worse centers.

CONCLUSIONS

This study identified centers that have significantly higher and lower mortality rates for pediatric TBI patients relative to the overall median rate. These data provide a benchmark for pediatric TBI outcomes and institutional quality improvement.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective Comparative Study.

Advanced and alternative research methods for the acute care surgeon scientist

Clinical research has evolved significantly over the last few decades to include many advanced and alternative study designs to answer unique questions. Recognizing a potential knowledge gap, the AAST Associate Member Council and Educational Development Committee created a research course at the 2022 Annual Meeting in Chicago to introduce junior researchers to these methodologies. This manuscript presents a summary of this AAST Annual Meeting session, and reviews topics including hierarchical modeling, geospatial analysis, patient-centered outcomes research, mixed methods designs, and negotiating complex issues in multicenter trials.

Doing more with less: low-titer group O whole blood resulted in less total transfusions and an independent association with survival in adults with severe traumatic hemorrhage

BACKGROUND

Low-titer group O whole blood (LTOWB) or component therapy (CT) may be used to resuscitate hemorrhaging trauma patients. LTOWB may have clinical and logistical benefits and may improve survival.

OBJECTIVES

We hypothesized LTOWB would improve 24-hour survival in hemorrhaging patients and would be safe and equally efficacious in non-group O compared with group O patients.

METHODS

Adult trauma patients with massive transfusion protocol activations were enrolled in this observational study. The primary outcome was 24-hour mortality. Secondary outcomes included 72-hour total blood product use. A Cox regression determined the independent associations with 24-hour mortality.

RESULTS

In total, 348 patients were included (CT, n = 180; LTOWB, n = 168). Demographics were similar between cohorts. Unadjusted 24-hour mortality was reduced in LTOWB vs CT: 8% vs 19% (P = .003), but 6-hour and 28-day mortality were similar. In an adjusted analysis with multivariable Cox regression, LTOWB was independently associated with reduced 24-hour mortality (hazard ratio, 0.21; 95% CI, 0.07-0.67; P = .004). LTOWB patients received significantly less 72-hour total blood products (80.9 [41.6-139.3] mL/kg vs 48.9 [25.9-106.9] mL/kg; P < .001). In stratified 24-hour survival analyses, LTOWB was associated with improved survival for patients in shock or with coagulopathy. LTOWB use in non-group O patients was not associated with increased mortality, organ injury, or adverse events.

CONCLUSION

In this hypothesis-generating study, LTOWB use was independently associated with improved 24-hour survival, predominantly in patients with shock or coagulopathy. LTOWB also resulted in a 40% reduction in blood product use which equates to a median 2.4 L reduction in transfused products.

The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated With Improved Survival in War-injured US Service Members

OBJECTIVE

To examine time from injury to initiation of surgical care and association with survival in US military casualties.

BACKGROUND

Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce.

METHODS

This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity.

RESULTS

Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed ( P = 0.67).

CONCLUSIONS

Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.

Contemporary Use of Prophylactic Inferior Vena Cava Filters in Patients With Severe Traumatic Injuries and High Thromboembolic Event Risk

PURPOSE

The aim of this study was to evaluate the relationship between prophylactic inferior vena cava filter (IVCF) implantation and in-hospital deep vein thrombosis (DVT), pulmonary embolism (PE), and mortality among adults with intracranial, pelvic or lower extremity, and spinal cord injuries.

METHODS

Patients 18 years and older with severe intracranial, pelvic or lower extremity, or spinal cord injuries captured by the Trauma Quality Improvement Program (2010-2019) were identified. IVCFs implanted ≤72 hours after hospital presentation and before performance of lower extremity ultrasonography were defined as prophylactic. Patients were stratified by pharmacologic venous thromboembolism (VTE) prophylaxis status. Logistic regression models estimated prophylactic inferior vena cava (IVC) filtration's effect on selected outcomes and identified attributes associated with prophylactic IVCF implantation.

RESULTS

Of 544,739 included patients, 1.3% (n = 7,247) underwent prophylactic IVCF implantation. Among patients who received pharmacologic VTE prophylaxis, prophylactic IVC filtration compared with expectant management was positively associated with DVT (odds ratio [OR], 4.30; P < .001) and PE (OR, 4.30; P < .001) but not associated with mortality (OR, 0.92; P = .43). Among patients who received no pharmacologic prophylaxis, prophylactic IVC filtration was positively associated with DVT (OR, 4.63; P < .001) and PE (OR, 5.02; P < .001) but negatively associated with mortality (OR, 0.43; P < .001).

CONCLUSIONS

Prophylactic IVC filtration was associated with increased likelihood of VTE among all adults with severe intracranial, pelvic or lower extremity, and spinal cord injuries. In patients who received no pharmacologic VTE prophylaxis, prophylactic IVC filtration was associated with decreased likelihood of in-hospital mortality.

Epidemiology and Management of Adult Laryngeal Trauma: An Analysis of the National Trauma Data Bank

INTRODUCTION

Laryngeal injuries are rare but life-threatening airway emergencies. Increased understanding of the epidemiology of these injuries can inform treatment and improve outcomes. We aimed to characterize the demographics and management of adult laryngeal trauma.

METHODS

The National Trauma Data Bank (NTDB) was queried from 2007 to 2015 for patients ≥18 years old with laryngeal trauma. Patient demographics, injury characteristics, and treatment course were collected. Outcomes were assessed via multivariate logistic regression.

RESULTS

From 7.3 million patients, 6,890 (0.1%) patients with laryngeal trauma were identified. Eighty-five percent of patients were male, and the median age was 40. Of these patients, 343 (5.0%) were dead on arrival and of the remaining patients, 510 (7.8%) of patients were deceased at discharge. Common concomitant injuries included facial fractures (27%), intracranial injuries (21%), and rib and sternum fractures (19%). The most common cause of injury was motor vehicle accident (26%), followed by assault with firearms/explosives (12%) and assault with cutting instruments (8%). Forty-three percent of patients received mechanical ventilation and 15% received surgical repair. After correcting for gender, age, and injury severity, firearm injuries (odds ratio [OR] 3.46, 95% CI: [2.88-4.15]) and cutting/piercing injuries (OR 2.23, 95% CI: [1.89-2.64]) were positively associated with the need for mechanical ventilation. Motor vehicle trauma (OR 0.63, 95% CI: [0.46-0.84]) was negatively associated with surgical repair while striking injuries (OR 1.61, 95% CI: [1.25-2.06]) were positively associated. Lastly, shorter time to tracheostomy was significantly associated with shorter ICU stays (p < 0.0001).

CONCLUSION

This study is the largest epidemiologic study of laryngeal trauma to date and identifies the risk of surgical intervention with firearm and cutting injuries as well as the importance of earlier time to tracheostomy for ICU management.

The Variation of Withdrawal of Life Sustaining Therapy in Older Adults With Traumatic Brain Injury

INTRODUCTION

The decision to withdraw life sustaining treatment (WDLST) in older adults with traumatic brain injury is subject to wide variability leading to nonbeneficial interventions and unnecessary use of hospital resources. We hypothesized that patient and hospital factors are associated with WDLST and WDLST timing.

METHODS

All traumatic brain injury patients ≥65 with Glasgow coma scores (GCS) of 4-11 from 2018 to 2019 at level I and II centers were selected from the National Trauma Data Bank. Patients with head abbreviated injury scores 5-6 or death within 24 h were excluded. Bayesian additive regression tree analysis was performed to identify the cumulative incidence function (CIF) and the relative risks (RR) over time for withdrawal of care, discharge to hospice (DH), and death. Death alone (no WDLST or DH) served as the comparator group for all analyses. A subanalysis of the composite outcome WDLST/DH (defined as end-of-life-care), with death (no WDLST or DH) as a comparator cohort was performed.

RESULTS

We included 2126 patients, of whom 1957 (57%) underwent WDLST, 402 (19%) died, and 469 (22%) were DH. 60% of patients were male, and the mean age was 80 y. The majority of patients were injured by fall (76%, n = 1644). Patients who were DH were more often female (51% DH versus 39% WDLST), had a past medical history of dementia (45% DH versus 18% WDLST), and had lower admission injury severity score (14 DH versus 18.6 WDLST) (P < 0.001). Compared to those who DH, those who underwent WDLST had a lower GCS (9.8 versus 8.4, P < 0.001). CIF of WDSLT and DH increased with age, stabilizing by day 3. At day 3, patients ≥90 y had an increased RR of DH compared to WDLST (RR 2.5 versus 1.4). As GCS increased, CIF and RR of WDLST decreased, while CIF and RR of DH increased (RR on day 3 for GCS 12: WDLST 0.42 versus DH 1.31).Patients at nonprofit institutions were more likely to undergo WDLST (RR 1.15) compared to DH (0.68). Compared to patients of White race, patients of Black race had a lower RR of WDLST at all timepoints.

CONCLUSIONS

Patient and hospital factors influence the practice of end-of-life-care (WDLST, DH, and death), highlighting the need to better understand variability to target palliative care interventions and standardize care across populations and trauma centers.

Trends in mandibular fractures in the USA: A 20-year retrospective analysis

BACKGROUND/AIM

The mandible is one of the most fractured bones in the maxillofacial region. This study analyzes trends in mandibular fracture patterns, demographics, and mechanisms since the early 2000s.

MATERIAL AND METHODS

Mandibular fractures were reviewed from the 2007, 2011, and 2017 National Trauma Data Bank including 13,142, 17,057, and 20,391 patients by year, respectively. This database contains hundreds of thousands of patients annually and represents the largest trauma registry in the United States. Variables included number of fractures, sex, age, injury mechanism, and fracture location. Mechanism of injury included assault, motor vehicle crash, fall, motorcycle, bicycle, pedestrian, and firearm. Anatomic locations based on ICD-9/10 codes included symphysis, ramus, condyle, condylar process, body, angle, and coronoid process. Frequencies were compared using Chi-square tests of homogeneity with effect sizes estimated using Cramer's V.

RESULTS

Mandibular fractures represent 2%-2.5% of all traumas reported in the database from 2001 to 2017. The proportion of patients sustaining a single reported mandibular fracture decreased from 82% in 2007 to 63% in 2017. Males consistently experienced 78%-80% of fractures. Eighteen to 54-year-olds experienced the largest percentages of fractures throughout the 21st century, while median age of fracture shifted from 28 to 32 between 2007 and 2017. The most common fracture mechanisms were assault (42% [2001-2005]-37% [2017]), motor vehicle crash (31%-22%) followed by falls (15%-20%). From 2001-2005 to 2017, a decrease was observed in assaults (-5%) and motor vehicle crash (-9%) and an increase in falls (+5%), particularly among elderly females. The mandibular body, condyle, angle, and symphysis represent approximately two-thirds of all fractures without a consistent temporal trend among them.

CONCLUSIONS

The temporal trends observed can be linked to shifting age demographics nationally that may aid clinicians in diagnosis and inform public safety policies aimed at reducing these injuries, particularly among the growing elderly population.

Factors Associated With Triage Decisions in Older Adult Trauma Patients: Impact on Mortality and Morbidity

INTRODUCTION

As medical advances have significantly increased the life expectancy among older adults, the number of older patients requiring trauma care has risen proportionately. Nevertheless, it is unclear among this growing population which sociodemographic and economic factors are associated with decisions to triage and transfer to level I/II centers. This study aims to assess for any association between patient sociodemographic characteristics, triage decisions, and outcomes during acute trauma care presentations.

METHODS

The National Trauma Data Bank was queried for patients aged 65 and older with an injury severity score > 15 between the years 2007 to 2017. Factors associated with subsequent levels of triage on presentation were assessed using multivariate logistic regression, and associations of levels of triage with outcomes of mortality, morbidity, and hospital length of stay are examined using logistic and linear regression models.

RESULTS

Triage of 210,310 older adult trauma patients showed significant findings. American Indian patients had higher odds of being transferred to level I/II centers, while Asian, Black, and Native Hawaiian patients had lower odds of being transferred to level I/II centers when compared to Caucasian patients (P < 0.001). Regarding insurance, self-pay (uninsured) patients were less likely to be transferred to a higher level of care; however, this was also demonstrated in private insurance holders (P < 0.001). Caucasian patients had significantly higher odds of mortality, with Black patients (odds ratio [OR] 0.80 [0.75, 0.85]) and American Indian patients (OR 0.87 [0.72, 1.04]) having significantly lower odds (P < 0.001). Compared to government insurance, private insurance holders (OR 0.82 [0.80, 0.85]) also had significantly lower odds of mortality, while higher odds among self-pay were observed (OR 1.75 [1.62, 1.90]), (P < 0.001).

CONCLUSIONS

Access to insurance is associated with triage decisions involving older adults sustaining trauma, with lower access increasing mortality risk. Factors such as race and gender were less likely to be associated with triage decisions. However, due to this study's retrospective design, further prospective analysis is necessary to fully assess the decisions that influence trauma triage decisions in this patient population.

Does treatment at a level I trauma center reduce disparities in patient outcomes for open tibia fractures? A retrospective analysis of the National trauma Databank

Background

Race and insurance status are independent predictors of healthcare outcomes following lower-extremity trauma. Level 1 trauma centers show better outcomes overall, but it is has not been extensively studied as to whether they specifically lower complication rates and shorten length of stay in those with Black race, with low socioeconomic status, and/or a lack of private health insurance. We performed a study with the objective of determining whether Level I trauma centers can improve the complication rate of those shown to be at high risk of experiencing adverse outcomes due to socioeconomic differences.

Hypothesis

Level 1 trauma centers will be successful in mitigating the disparity in complication rates and length of stay associated with racial and socioeconomic differences among trauma patients experiencing an open tibia fracture.

Patients and methods

The National Trauma Databank was reviewed from 2008 to 2015, identifying 81,855 encounters with an open tibia fracture, and 33,047 at a Level I trauma center. Regression models determined effects of race and insurance status on outcomes by trauma center while controlling for confounders.

Results

Black race [OR 1.36, 95% CI, 1.17-1.58; p < 0.05] and "other" race [OR 1.28, 95% CI, 1.07-1.52; p < 0.05] were associated with higher odds of injury-specific complications. Patients without private insurance and of non-White or Black race in comparison to White patients had a significantly longer length of stay [coefficient 1.66, 95% CI, 1.37-1.94; p < 0.001]. These differences persisted in patients treated at an American College of Surgeons (ACS) Level I trauma center.

Discussion

Treatment at an ACS Level I trauma center did not reduce the independent effects of race and insurance status on outcomes after open tibia fracture, emphasizing the need to recognize this disparity and improve care for at-risk populations.

Injury characteristics and predictors of mortality in patients undergoing pancreatic excision after abdominal trauma: A National Trauma Data Bank (NTDB) study

Pancreatic tumors and pancreatitis are the main indications for pancreatic excision (PE). However, little is known about this type of intervention in the context of traumatic injuries. Surgical care for traumatic pancreatic injuries is challenging because of the location of the organ and the lack of information on trauma mechanisms, vital signs, hospital deposition characteristics, and associated injuries. This study examined the demographics, vital signs, associated injuries, clinical outcomes, and predictors of in-hospital mortality in patients with abdominal trauma who had undergone PE. Following the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, we analyzed the National Trauma Data Bank and identified patients who underwent PE for penetrating or blunt trauma after an abdominal injury. Patients with significant injuries in other regions (abbreviated injury scale score ≥ 2) were excluded. Of the 403 patients who underwent PE, 232 had penetrating trauma (PT), and 171 had blunt trauma (BT). The concomitant splenic injury was more prevalent in the BT group; however, the frequency of splenectomy was comparable between groups. In particular, concomitant kidney, small intestine, stomach, colon, and liver injuries were more common in the PT group (all P < .05). Most injuries were observed in the pancreatic body and tail regions. The trauma mechanisms also differed between the groups, with motor vehicles accounting for most of the injuries in the BT group and gunshots accounting for most of the injuries in the PT group. In the PT group, major liver lacerations were approximately 3 times more common (P < .001). The in-hospital mortality rate was 12.4%, with no major differences between the PT and BT groups. Furthermore, there was no difference between BT and PT with respect to the location of the injuries in the pancreas, with the pancreatic tail and body accounting for almost 65% of injuries. Systolic blood pressure, Glasgow Coma Scale score, age, and major liver laceration were revealed by logistic regression as independent predictors of mortality, although trauma mechanisms and intent were not linked to mortality risk.

Racial, Gender, and Neighborhood-Level Disparities in Pediatric Trauma Care

BACKGROUND

Disparities in trauma outcomes and care are well established for adults, but the extent to which similar disparities are observed in pediatric trauma patients requires further investigation. The objective of this study was to evaluate the unique contributions of social determinants (race, gender, insurance status, community distress, rurality/urbanicity) on trauma outcomes after controlling for specific injury-related risk factors.

STUDY DESIGN

All pediatric (age < 18) trauma patients admitted to a single level 1 trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed (n = 14,398). Primary outcomes were receipt of opioids in the emergency department, post-discharge rehabilitation referrals, and mortality. Multivariate logistic regressions evaluated demographic, socioeconomic, and injury characteristics. Multilevel logistic regressions evaluated area-level indicators, which were derived from abstracted home addresses.

RESULTS

Analyses adjusting for demographic and injury characteristics revealed that Black children (n = 6255) had significantly lower odds (OR = 0.87) of being prescribed opioid medications in the emergency department compared to White children (n = 5883). Children living in more distressed and rural communities had greater odds of receiving opioid medications. Girls had significantly lower odds (OR = 0.61) of being referred for rehabilitation services than boys. Post hoc analyses revealed that Black girls had the lowest odds of receiving rehabilitation referrals compared to Black boys and White children.

CONCLUSION

Results highlight the need to examine both main and interactive effects of social determinants on trauma care and outcomes. Findings reinforce and expand into the pediatric population the growing notion that traumatic injury care is not immune to disparities.

A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database

BACKGROUND

Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach.

STUDY DESIGN

Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay.

RESULTS

Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001).

CONCLUSIONS

Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.

External validation of the Codman score in colorectal surgery: a pragmatic tool to drive quality improvement

AIM

The simple six-variable Codman score is a tool designed to reduce the complexity of contemporary risk-adjusted postoperative mortality rate predictions. We sought to externally validate the Codman score in colorectal surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file and colectomy targeted dataset of 2020 were merged. A Codman score (composed of six variables: age, American Society of Anesthesiologists score, emergency status, degree of sepsis, functional status and preoperative blood transfusion) was assigned to every patient. The primary outcome was in-hospital mortality and secondary outcome was morbidity at 30 days. Logistic regression analyses were performed using the Codman score and the ACS NSQIP mortality and morbidity algorithms as independent variables for the primary and secondary outcomes. The predictive performance of discrimination area under receiver operating curve (AUC) and calibration of the Codman score and these algorithms were compared.

RESULTS

A total of 40 589 patients were included and a Codman score was generated for 40 557 (99.02%) patients. The median Codman score was 3 (interquartile range 1-4). To predict mortality, the Codman score had an AUC of 0.92 (95% CI 0.91-0.93) compared to the NSQIP mortality score 0.93 (95% CI 0.92-0.94). To predict morbidity, the Codman score had an AUC of 0.68 (95% CI 0.66-0.68) compared to the NSQIP morbidity score 0.72 (95% CI 0.71-0.73). When body mass index and surgical approach was added to the Codman score, the performance was no different to the NSQIP morbidity score. The calibration of observed versus expected predictions was almost perfect for both the morbidity and mortality NSQIP predictions, and only well fitted for Codman scores of less than 4 and greater than 7.

CONCLUSION

We propose that the six-variable Codman score is an efficient and actionable method for generating validated risk-adjusted outcome predictions and comparative benchmarks to drive quality improvement in colorectal surgery.

Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers

Importance

Whole-blood (WB) resuscitation has gained renewed interest among civilian trauma centers. However, there remains insufficient evidence that WB as an adjunct to component therapy-based massive transfusion protocol (WB-MTP) is associated with a survival advantage over MTP alone in adult civilian trauma patients presenting with severe hemorrhage.

Objective

To assess whether WB-MTP compared with MTP alone is associated with improved survival at 24 hours and 30 days among adult trauma patients presenting with severe hemorrhage.

Design, Setting, and Participants

This retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2017, and December 31, 2018, included adult trauma patients with a systolic blood pressure less than 90 mm Hg and a shock index greater than 1 who received at least 4 units of red blood cells within the first hour of emergency department (ED) arrival at level I and level II US and Canadian adult civilian trauma centers. Patients with burns, death within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from February 2022 to September 2022.

Exposures

Resuscitation with WB-MTP compared with MTP alone within 24 hours of ED presentation.

Main Outcomes and Measures

Primary outcomes were survival at 24 hours and 30 days. Secondary outcomes selected a priori included major complications, hospital length of stay, and intensive care unit length of stay.

Results

A total of 2785 patients met inclusion criteria: 432 (15.5%) in the WB-MTP group (335 male [78%]; median age, 38 years [IQR, 27-57 years]) and 2353 (84.5%) in the MTP-only group (1822 male [77%]; median age, 38 years [IQR, 27-56 years]). Both groups included severely injured patients (median injury severity score, 28 [IQR, 17-34]; median difference, 1.29 [95% CI, -0.05 to 2.64]). A survival curve demonstrated separation within 5 hours of ED presentation. WB-MTP was associated with improved survival at 24 hours, demonstrating a 37% lower risk of mortality (hazard ratio, 0.63; 95% CI, 0.41-0.96; P = .03). Similarly, the survival benefit associated with WB-MTP remained consistent at 30 days (HR, 0.53; 95% CI, 0.31-0.93; P = .02).

Conclusions and Relevance

In this cohort study, receipt of WB-MTP was associated with improved survival in trauma patients presenting with severe hemorrhage, with a survival benefit found early after transfusion. The findings from this study are clinically important as this is an essential first step in prioritizing the selection of WB-MTP for trauma patients presenting with severe hemorrhage.

Injury characteristics and circumstances of firearm trauma: Assessing suicide survivors and decedents

INTRODUCTION

Despite representing fewer than 5% of suicide attempts, firearms account for over half of deaths. Yet there is little clinical information regarding firearm attempts, particularly survivors. We assessed clinical factors differentiating firearm suicide survivors from decedents, firearm attempters from other methods, and firearm attempters from similarly injured trauma patients.

METHODS

We used clinical data from the National Trauma Data Bank (2017) to assess firearm suicide attempts using cross-sectional and case-control designs. We used logistic and multinomial regression to compare groups and assess firearm type and discharge destination.

RESULTS

Older age, being uninsured, and injury location were associated with increased mortality among firearm attempters. Older age, White race, male sex, and being uninsured were associated with firearm attempts. Major psychiatric disorders were associated with firearm attempts and using a rifle or shotgun. Major psychiatric disorders, female sex, and smoking were associated with psychiatric discharge. Black and other race were associated with law enforcement discharge, and Black race was associated with lower odds of psychiatric discharge. Uninsured patients had lower odds of discharge to long-term care, psychiatric, or rehabilitation facilities.

CONCLUSIONS

This study identifies factors associated with firearm suicide and includes indicators of disparities in health services for patients at high risk of suicide death.

Lucky number 13: Association between center-specific chest wall stabilization volumes and patient outcomes

BACKGROUND

Chest wall stabilization (CWS) improves outcomes for patients with chest wall injury (CWI). We hypothesized that patients treated at centers with higher annual CWS volumes experience superior outcomes.

METHODS

A retrospective study of adults with acute CWI undergoing surgical stabilization of rib or sternal fractures within the 2019 Trauma Quality Improvement Program database, excluding those with 24-hour mortality or any Abbreviated Injury Scale body region of six, was conducted. Hospitals were grouped in quartiles by annual CWS volume. Our primary outcome was a composite of in-hospital mortality, ventilator-associated pneumonia, acute respiratory distress syndrome, sepsis, and unplanned intubation or intensive care unit readmission. Regression was controlled for age, sex, Injury Severity Scale, flail chest, medical comorbidities, and Abbreviated Injury Scale chest. We performed cut-point analysis and compared patient outcomes from high- and low-volume centers.

RESULTS

We included 3,207 patients undergoing CWS at 430 hospitals with annual volumes ranging from 1 to 66. There were no differences between groups in age, sex, or Injury Severity Scale. Patients in the highest volume quartile (Q4) experienced significantly lower rates of the primary outcome (Q4, 14%; Q3, 18.4%; Q2, 17.4%; Q1, 22.1%) and significantly shorter hospital and intensive care unit lengths of stay. Q4 versus Q1 had lower adjusted odds of the primary outcome (odds ratio, 0.58; 95% confidence interval, 0.43-0.80). An optimal cut point of 12.5 procedures annually was used to define high- and low-volume centers. Patients treated at high-volume centers experienced significantly lower rates of the primary composite outcome, in-hospital mortality, and deep venous thrombosis with shorter lengths of stay and higher rates of home discharge.

CONCLUSION

Center-specific CWS volume is associated with superior in-hospital patient outcomes. These findings support efforts to establish CWI centers of excellence. Further investigation should explore the impact of center-specific volume on patient-reported outcomes including pain and postdischarge quality of life.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

A serial cross-sectional study of trends and predictors of prescription controlled substance-related traumatic injury

Pre-injury drug use is a key contributor to traumatic injury. However, limited research has examined trends and predictors of controlled substance-related trauma. The present study aims to provide better clarity on the specific role of prescription-controlled substances (PCS) in traumatic injury events. The data source was the American College of Surgeons National Trauma Data Bank. Trends by injury mechanism and intent for patients with PCS and no-confirmed substances were compared from 2007 to 2014. Logistic regression models were also performed to examine the association between substance use and injury mechanism and intent for data across the study period. Of 405,334 trauma patients, 328,623 (81.1%) had no-confirmed substances and 76,711 (18.9%) had PCS detected. The majority of events in the PCS and no-confirmed substance groups were classified as unintentional. Motor vehicle traffic (MVT), falls, other transport, and cut/pierce injuries accounted for approximately 80% of all injuries. From 2007 to 2014, the proportion of injuries with PCS increased for all injury mechanisms and injury intents. The injury mechanisms of fire/burn, firearm, machinery, poisoning, and other transport were significantly more likely to have PCS relative to MVT injuries. For injury intent, self-harm was more likely to have a toxicology test positive for PCS, while assault was less likely to have a toxicology test positive for PCS compared to unintentional injuries. PCS-related traumatic injuries increased significantly over time and across injury mechanisms and intents. These findings can be used to inform prescribing and understand risk factors to reduce the likelihood of PCS-related traumatic injury.

Epidemiology and outcomes of severe injury patients: Nationwide community-based study in Korea

INTRODUCTION

The aim of this study was to estimate the annual incidence of various severe injuries, case fatality rates, and case disability rates for patients in Korea.

MATERIALS AND METHODS

This community-based observational study involved all residents in Korea between Jan. 1, 2018, and Dec. 31, 2018. Nationwide data were retrieved from the patient care report of the National Fire Agency and hospital medical records review of the Korea Disease Control and Prevention Agency. Severe injury was defined as any injury that resulted in emergency medical service (EMS) use and any field-based physiologic abnormality: systolic blood pressure ≤90 mm Hg, respiratory rate <10 or >29 per min, or AVPU scale nonalert. Crude and adjusted incidence rates were calculated without any exclusion. Outcomes including the Glasgow Outcome Scale (GOS) at hospital discharge were assessed according to a medical review. Case-fatality and case-disability rates were calculated after excluding patients with unknown vital status.

RESULTS

During the one-year period, 36,363 severe injuries occurred, yielding a crude annual incidence rate of 70.9 per 100,000 population; 57.8% were traumatic injuries, and 42.2% were nontraumatic injuries. The adjusted annual incidence rates were 61.7/100,000 for all severe injuries, 35.3/100,000 for traumatic injuries, and 26.4/100,000 for nontraumatic injuries. The case-fatality rate was 24.3% for all severe injuries, 27.0% for traumatic injuries, and 21.0% for nontraumatic injuries. The case-disability rate of GOS 3,4 was 6.0%, and the case-disability rate of GOS 2-4 was 16.4% for all severe injury patients.

CONCLUSIONS

This nationwide community-based study revealed incidence rates and outcomes of severe injury patients in Korea.

Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice

BACKGROUND

The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines.

METHODS

The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA.

RESULTS

To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses.

CONCLUSIONS

To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.

A Wider Perspective on Data Validation: A Multiregion Collaboration

BACKGROUND

Data validation is important in maintaining the high-quality data necessary for trauma programs and research. Most existing guidance focuses on trauma center-level data validation, but validation from a broader level (region, state) may also be a helpful tool.

OBJECTIVE

The purpose of this project is to improve data collection and submission at the local, regional, and state levels by performing logic-based data validation.

METHODS

Logic edits were identified and accuracy rates were tracked quarterly, as measures were taken to improve accuracy. Following completion of Phase 1 of validation, Phase 2 was initiated to include both new fields and fields from Phase 1 that did not meet the accuracy goal. Data from Phase 2 were then compared with data from the state trauma registry.

RESULTS

In both Phase 1 and Phase 2, five of the seven data fields validated reached 90% accuracy by the end of the respective project phase. The project facilitated registrar education and pursuit of data collection solutions in registry software. Systemic issues were identified at a higher level that had not been noticed at the trauma center level.

DISCUSSION

Robust data validation is critical for an accurate trauma registry. Engaging higher-level organizations, like trauma regions, provides new perspective in data validation.

CONCLUSION

This regional data validation approach provided additional value beyond usual center-level data validation.

Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality

BACKGROUND

Racial disparities in trauma care have been reported for a range of outcomes, but the extent to which these remain after accounting for socioeconomic and environmental factors remains unclear. The objective of this study was to evaluate the unique contributions of race, health insurance, community distress, and rurality/urbanicity on trauma outcomes after carefully controlling for specific injury-related risk factors.

METHODS

All adult (age, ≥18 years) trauma patients admitted to a single Level I trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed. Primary outcomes were mortality, rehabilitation referral, and receipt of opioids in the emergency department. Demographic, socioeconomic, and injury characteristics as well as indicators of community distress and rurality based on home address were abstracted from a trauma registry database.

RESULTS

Analyses revealed that Black patients (n = 13,073) were younger, more likely to be male, more likely to suffer penetrating injuries, and more likely to suffer assault-based injuries compared with White patients (n = 10,946; all p < 0.001). In adjusted analysis, insured patients had a 28% lower risk of mortality (odds ratio, 0.72; p = 0.005) and were 92% more likely to be referred for postdischarge rehabilitation than uninsured patients (odds ratio, 1.92; p = 0.005). Neither race- nor place-based factors were associated with mortality. However, post hoc analyses revealed a significant race by age interaction, with Black patients exhibiting more pronounced increases in mortality risk with increasing age.

CONCLUSION

The present findings help disentangle the social determinants of trauma disparities by adjusting for place and person characteristics. Uninsured patients were more likely to die and those who survived were less likely to receive referrals for rehabilitation services. The expected racial disparity in mortality risk favoring White patients emerged in middle age and was more pronounced for older patients.

LEVEL OF EVIDENCE

Prognostic and epidemiological, Level III.

Predictors of thoracic and lumbar spine injuries in patients with TBI: A nationwide analysis

OBJECTIVE

Cervical spine injury screening is common practice for traumatic brain injury (TBI) patients. However, risk factors for concomitant thoracolumbar trauma remain unknown. We characterized epidemiology and clinical risk for concomitant thoracolumbar trauma in TBI.

METHODS

We conducted a multi-center, retrospective cohort analysis of TBI patients in the National Trauma Data Bank from 2011-2014 using multivariable logistic regression.

RESULTS

Out of 768,718 TBIs, 46,654 (6.1%) and 42,810 (5.6%) patients were diagnosed with thoracic and lumbar spine fractures, respectively. Only 11% of thoracic and 7% of lumbar spine fracture patients had an accompanying spinal cord injury at any level. The most common mechanism of injury was motor vehicle accident (67% of thoracic and 71% and lumbar fractures). Predictors for both thoracic and lumbar fractures included moderate (thoracic: OR 1.26, 95%CI 1.21-1.31; lumbar: OR 1.13, 95%CI 1.08-1.18) and severe Glasgow Coma Scale (GCS) score (OR 1.71, 95%CI 1.67-1.75; OR 1.17, 95%CI 1.13-1.20) compared to mild; epidural hematoma (OR 1.36, 95%CI 1.28-1.44; OR 1.1, 95%CI 1.04-1.19); lower extremity injury (OR 1.38, 95%CI 1.35-1.41; OR 2.50, 95%CI 2.45-2.55); upper extremity injury (OR 2.19, 95%CI 2.14-2.23; OR 1.15, 95%CI 1.13-1.18); smoking (OR 1.09, 95%CI 1.06-1.12; OR 1.12, 95%CI 1.09-1.15); and obesity (OR 1.39, 95%CI 1.34-1.45; OR 1.29, 95%CI 1.24-1.35). Thoracic injuries (OR 4.45; 95% CI 4.35-4.55) predicted lumbar fractures, while abdominal injuries (OR 2.02; 95% CI 1.97-2.07) predicted thoracic fractures.

CONCLUSIONS

We identified GCS, smoking, upper and lower extremity injuries, and obesity as common risk factors for thoracic and lumbar spinal fractures in TBI.

A Hard Day at Work: An Analysis of Occupational Genitourinary Injuries in the United States Workforce

OBJECTIVE

To use national data to identify risk factors for occupational genitourinary (GU) injuries and to expose potential workplace safety issues requiring national regulation.

METHODS

The National Trauma Data Bank was queried to identify all adults who suffered a work-related GU injury from 2007-2016. Injury was stratified by individual organ and by organ type: intra-abdominopelvic (IAP) versus external genitalia (EG). Distinct multivariable logistic regression models were used to examine associations between prespecified risk factors and GU injury (organ and type) and to identify predictors of intensive care unit (ICU) and operating room (OR) transfer.

RESULTS

2139 patients (total of 2681 GU injuries), were included. A mean of 1.3 GU organ injuries and 7.6 total injuries were suffered per patient. 72% suffered an IAP GU injury, 23% an EG injury, and 5% suffered both. Patients working in agriculture/forestry/fishing, (OR 2.3, p=0.003), manufacturing (OR 1.9, p=0.05), and natural resources/mining (OR 2.3, p= 0.012) were at significantly increased risk of EG injury. The penis and urethra were particularly at-risk in agriculture/forestry/fishing (OR 4.0, p=0.005; OR 3.0, p=0.002) and the urethra in natural resources/mining (OR 3.4, p=0.004). IAP GU injury was a significant predictor of ICU transfer (OR 1.8, p < 0.001), whereas EG injury was a significant predictor of OR transfer (OR 2.5, p < 0.001).

CONCLUSIONS

Occupational GU injuries remain a major issue for blue-collar workers. External genitalia are particularly at-risk, and injuries often require emergent surgery. National occupational health agencies need to continue to enhance on-the-job safety for those at-risk.

Improving mortality in older adult trauma patients: Are we doing better?

BACKGROUND

Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care.

MATERIALS AND METHODS

This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality.

RESULTS

There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49).

CONCLUSION

Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care?

Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.

Suicide and self-injury outcomes for patients with comorbid psychiatric and physical health conditions

Suicide is a transdiagnostic public health issue that affects nearly all psychiatric disorders, individuals without a mental health diagnosis, and individuals with physical health issues. We assessed the relationship between these variables and suicide outcomes using a novel epidemiological research paradigm. Data were collected from the National Trauma Data Bank. Participants included patients admitted to trauma units for suicide and self-injury (n = 13,422). Patients were classified to one of four comorbid condition groups: no comorbidity, comorbid physical condition, comorbid major psychiatric condition, or multimorbidity (comorbid physical and psychiatric conditions). Multivariable logistic regression measured associations between comorbid condition and mortality and multivariable linear regression measured associations between comorbidity and injury severity. Mortality in patients with physical health comorbidity was not significant, but patients with psychiatric comorbidity or multimorbidity had significantly lower mortality than patients without either. No association between injury severity and comorbidity was detected. There were no differences in suicide mortality for individuals with a physical health comorbidity, but mortality was lower for individuals with a comorbid major psychiatric illness or multimorbidity. Since physical health conditions and psychiatric illness are associated with eventual suicide mortality, prevention strategies could target these populations at trauma units for suicide and self-injury admissions.

Association of venous thromboembolism following pediatric traumatic spinal injuries with injury severity and longer hospital stays

OBJECTIVE

Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs).

METHODS

The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014.

RESULTS

Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4-4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0-6.1), epidural hematoma (aOR 2.8, 95% CI 1.4-5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8-3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1-2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6-5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0-1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8-3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8-3.6).

CONCLUSIONS

VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.

Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly Trauma Patients

INTRODUCTION

The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity.

METHODS

The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality.

RESULTS

614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality (P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality (P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4).

CONCLUSIONS

Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

Outcomes following traumatic inhalational airway injury - Predictors of mortality and effect of procedural intervention

OBJECTIVE

Study outcomes, predictors of mortality, and effects of procedural interventions on patients following traumatic inhalational airway injury.

STUDY

Design: Retrospective study.

SETTING

National Trauma Data Bank METHODS: Patients over the age of eighteen admitted between 2008 and 2016 to NTDB-participating sites were included. In-hospital mortality and length of stay were the primary outcomes.

RESULTS

The final study cohort included 13,351 patients. History of active smoking was negatively associated with in-house mortality with an OR of 0.33 (0.25-0.44). History of alcohol use, and presence of significant medical co-morbidities were positively associated with in-house mortality with OR of 5.28 (4.32-6.46) 2.74 (19.4-3.86) respectively. There was little to no association between procedural interventions and in-house mortality. Intubation, laryngobronchoscopy, and tracheostomy had OR of 0.90 (0.67-1.20), 1.02 (0.79-1.30), and 0.94 (0.58-1.51), respectively. However, procedural intervention did affect both the median hospital and ICU lengths of stay of patients. Median hospital and ICU length of stay were shorter for patients receiving endotracheal intubation. Median hospital length of stay was longer for patients undergoing bronchoscopy and laryngoscopy, but median ICU length of stay was shorter for patients undergoing bronchoscopy and laryngoscopy. Patients receiving a tracheostomy have both significantly increased median hospital and ICU lengths of stay.

CONCLUSIONS

Active smoking was associated with decreased odds of in-hospital mortality, while presence of pre-existing medical comorbidities and history of alcohol use disorder was associated with increased odds of in-hospital mortality. Procedural intervention had little to no association with in-hospital mortality but did affect overall hospital and ICU LOS.

Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study

BACKGROUND

To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization.

MATERIALS AND METHODS

The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures.

RESULTS

Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM.

CONCLUSION

Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.

Early Trauma Predictors of Mobility in People with Spinal Cord Injury

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

This study aims to assess the potential value of very early trauma variables such as Abbreviated Injury Scale (AIS) and the Injury Severity Score for predicting independent ambulation following a traumatic spinal cord injury (TSCI).

SUMMARY OF BACKGROUND DATA

Several models for prediction of ambulation early after TSCI have been published and validated. The vast majority rely on the initial examination of American Spinal Injury Association (ASIA) impairment scale and level of injury; however, in many locations and clinical situations this examination is not feasible early after the injury.

METHODS

Patient characteristics, trauma data, and ASIA scores on admission to rehabilitation were collected for each of the 144 individuals in the study. Outcome measure was the indoor mobility item of the Spinal Cord Independence Measure taken upon discharge from rehabilitation. Univariate and multivariable models were created for each predictor, Odds ratios (ORs) were obtained by a multivariable logistic regression analysis, and area under the receiver operator curve was calculated for each model.

RESULTS

We observed a significant correlation between the trauma variables and independent ambulation upon discharge from rehabilitation. Of the early variables, the AIS for the spine region showed the strongest correlation.

CONCLUSION

These findings support using preliminary trauma variables for early prognostication of ambulation following a TSCI, allowing for tailored individual interventions.Level of Evidence: 3.

The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time

BACKGROUND

Evidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines.

MATERIALS AND METHODS

We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included.

RESULTS

The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001).

CONCLUSIONS

Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.

Improved Prediction of Older Adult Discharge After Trauma Using a Novel Machine Learning Paradigm

BACKGROUND

The ability to reliably predict outcomes after trauma in older adults (age ≥ 65 y) is critical for clinical decision making. Using novel machine-learning techniques, we sought to design a nonlinear, competing risks paradigm for prediction of older adult discharge disposition following injury.

MATERIALS AND METHODS

The National Trauma Databank (NTDB) was used to identify patients 65+ y between 2007 and 2014. Training was performed on an enriched cohort of diverse patients. Factors included age, comorbidities, length of stay, and physiologic parameters to predict in-hospital mortality and discharge disposition (home versus skilled nursing/long-term care facility). Length of stay and discharge status were analyzed via competing risks survival analysis with Bayesian additive regression trees and a multinomial mixed model.

RESULTS

The resulting sample size was 47,037 patients. Admission GCS and age were important in predicting mortality and discharge disposition. As GCS decreased, patients were more likely to die (risk ratio increased by average of 1.4 per 2-point drop in GCS, P < 0.001). As GCS decreased, patients were also more likely to be discharged to a skilled nursing or long-term care facility (risk ratio decreased by 0.08 per 2-point decrease in GCS, P< 0.001). The area under curve for prediction of discharge home was improved in the competing risks model 0.73 versus 0.43 in the traditional multinomial mixed model.

CONCLUSIONS

Predicting older adult discharge disposition after trauma is improved using machine learning over traditional regression analysis. We confirmed that a nonlinear, competing risks paradigm enhances prediction on any given hospital day post injury.

Substance use and suicide outcomes among self-injured trauma patients

BACKGROUND

Research indicates alcohol (AUD) or substance (SUD) use disorders and acute alcohol or drug use serve as risk factors for suicidal behaviors and death both distally and proximally to a suicidal event. However, limited research has investigated these relationships among medically serious suicide attempters at the time of injury without relying on cohorts of substance users only or by examining suicide decedent characteristics.

METHODS

Data were collected from the National Trauma Data Bank (NTDB) for 2017. The sample comprised patients who engaged in suicidal and self-injurious acts that were medically serious enough to require trauma admission and were tested for alcohol (N = 9,196) or drug (N = 8,121) exposure upon admission. Logistic regression determined relationships between acute alcohol/substance use, presence of AUDs and SUDs and suicide mortality risk, while linear regression evaluated substance conditions and injury severity and length of stay (LOS).

RESULTS

AUDs (OR = 0.59[0.42-0.83]) and SUDs (OR = 0.66[0.48-0.90]) had reduced odds of death but increased LOS (β = 1.7, p < .001; β = 0.82, p = .024). Blood alcohol concentration (BAC) was positively associated with reduced odds of death (OR = 0.20[0.06-0.61]), injury severity (β = -5.3, p < .001), and LOS (β = -7.5, p < .001). Presence of cocaine (β = -0.80, p = .044) and opioids (β = -1.4, p < .001) were associated lower injury severity, while MDMA (β = 3.6, p = .016) and methamphetamine (β = 1.5, p = .025) were associated with increased injury severity.

CONCLUSIONS

While higher BAC may be associated with lower odds of mortality during a single high-risk suicide event, substance users may be at increased risk for worse outcomes over time. Targeted interventions should be considered to interrupt and develop healthy alternatives for survivors with substance use conditions.

The Impact of Obesity on Renal Trauma Outcome: An Analysis of the National Trauma Data Bank from 2013 to 2016

BACKGROUND

The obesity paradox has been recently demonstrated in trauma patients, where improved survival was associated with overweight and obese patients compared to patients with normal weight, despite increased morbidity. Little is known whether this effect is mediated by lower injury severity. We aim to explore the association between body mass index (BMI) and renal trauma injury grade, morbidity, and in-hospital mortality.

METHODS

A retrospective cohort of adults with renal trauma was conducted using 2013-2016 National Trauma Data Bank. Multiple regression analyses were used to assess outcomes of interest across BMI categories with normal weight as reference, while adjusting for relevant covariates including kidney injury grade.

RESULTS

We analyzed 15181 renal injuries. Increasing BMI above normal progressively decreased the risk of high-grade renal trauma (HGRT). Subgroup analysis showed that this relationship was maintained in blunt injury, but there was no association in penetrating injury. Overweight (OR 1.02, CI 0.83-1.25, p = 0.841), class I (OR 0.92, CI 0.71-1.19, p = 0.524), and class II (OR 1.38, CI 0.99-1.91, p = 0.053) obesity were not protective against mortality, whereas class III obesity (OR 1.46, CI 1.03-2.06, p = 0.034) increased mortality odds. Increasing BMI by category was associated with a stepwise increase in odds of acute kidney injury, cardiovascular events, total hospital length of stay (LOS), intensive care unit LOS, and ventilator days.

CONCLUSIONS

Increasing BMI was associated with decreased risk of HGRT in blunt trauma. Overweight and obesity were associated with increased morbidity but not with a protective effect on mortality. The obesity paradox does not exist in kidney trauma when injury grade is accounted for.

Trends in utilization of whole-body computed tomography in blunt trauma after MVC: Analysis of the Trauma Quality Improvement Program database

BACKGROUND

The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma.

METHODS

We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS).

RESULTS

There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001).

CONCLUSION

Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction.

LEVEL OF EVIDENCE

Care management, Level IV.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank

INTRODUCTION

Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level.

METHODS

We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis.

RESULTS

We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers.

CONCLUSION

Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Delay in Hip Fracture Repair in the Elderly: A Missed Opportunity Towards Achieving Better Outcomes

BACKGROUND

Hip fractures are a major cause of morbidity and mortality in the elderly. The American Academy of Orthopedic Surgeons (AAOS) recommends surgical repair within 48 hours of admission, as this is associated with lower postoperative mortality and complications. This study demonstrates the association between patient demographics, level of care, and hospital region to delay in hip fracture repair in the elderly.

METHODS

The National Trauma Data Bank (NTDB) was queried for elderly patients (age >65 years) who underwent proximal femoral fracture repair. Identified patients were subcategorized into two groups: hip fracture repair in <48 hours, and hip fracture repair > 48 hours after admission. Patient and hospital characteristics were collected. Outcome variables were timed from the day of admission to surgery and inpatient mortality.

RESULTS

Out of 69,532 patients, 28,031 were included after inclusion criteria were applied. 23,470 (83.7%) patients underwent surgical repair within 48 hours. The overall median time to procedure was 21 (interquartile range [IQR] 7-38) hours. Females were less likely to undergo a delay in hip fracture repair (odds ratio [OR; 95% confidence interval {CI}]: 0.82 [0.76-0.88], P< 0.05), and patients with higher Injury Severity Score (ISS ≥25) had higher odds of delay in surgical repair (OR; 95% CI: 1.56 [1.07-2.29], P< 0.05). Patients treated at hospitals in the Western regions of the United States had lower odds of delay, and those treated in the Northeast and the South had higher odds of delay compared to the hospitals in the Midwest (taken as standard). There was no association between trauma level designation and odds of undergoing delay in hip fracture repair.

CONCLUSION

Variables related to patient demographic and hospital characteristics are associated with delay in hip fracture repair in the elderly. This study delineates key determinants of delay in hip fracture repair in the elderly patients.

A Leg to Stand on: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury

BACKGROUND

Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs).

STUDY DESIGN

We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication.

RESULTS

There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching.

CONCLUSIONS

In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity.

Making the Most of Big Data in Plastic Surgery: Improving Outcomes, Protecting Patients, Informing Service Providers

ABSTRACT

In medicine, "big data" refers to the interdisciplinary analysis of high-volume, diverse clinical and lifestyle information on large patient populations. Recent advancements in data storage and electronic record keeping have enabled the expansion of research in this field. In the United Kingdom, Big data has been highlighted as one of the government's "8 Great Technologies," and the Medical Research Council has invested more than £100 million since 2012 in developing the Health Data Research UK infrastructure. The recent Royal College of Surgeons Commission of the Future of Surgery concluded that analysis of big data is one of the 4 most likely avenues to bring some of the most innovative changes to surgical practice in the 21st century.In this article, we provide an overview of the nascent field of big data analytics in plastic and highlight how it has the potential to improve outcomes, increase safety, and aid service planning.We outline the current resources available, the emerging role of big data within the subspecialties of burns, microsurgery, skin and breast cancer, and how these data can be used. We critically review the limitations and considerations raised with big data, offer suggestions regarding database optimization, and suggest future directions for research in this exciting field.

Hospital volume-outcome relationship in severe traumatic brain injury: stratified analysis by level of trauma center

OBJECTIVE

The nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States.

METHODS

The authors queried the National Trauma Data Bank for the years 2007-2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1-Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size.

RESULTS

A total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I-IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40-4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3-7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6-4.8 days, p < 0.001).

CONCLUSIONS

Higher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.

Closing the gap in care of blunt solid organ injury in children

INTRODUCTION

Cross-sectional data of pediatric blunt solid organ injury demonstrates higher rates of nonoperative management and shorter lengths of stay (LOSs) in pediatric trauma centers (PTCs) versus adult trauma centers (ATCs) or dual trauma centers (DTCs). Recent iterations of guidelines (McVay 2008, J Pediatr Surg 2008;43(6):1072-1076 J Trauma Acute Care Surg 2015;79(4):683-693) have emphasized physiologic parameters rather than injury grade in clinical decision making, improving resource allocation and decreasing LOS. We sought to evaluate how these guidelines have influenced care.

METHODS

The National Trauma Data Bank (2007-2016) was queried for isolated spleen and liver injuries in patients younger than 19 years. Linear regression, odds ratio (OR), and χ test were used to determine significance between operative intervention or LOS among different trauma center types and grade of injury.

RESULT

A total of 55,036 blunt spleen or liver injuries were identified. Although operative rates decreased in ATCs over time (p = 0.037), patients treated at ATCs or DTCs continued to demonstrate higher ORs of operative intervention (OR, 4.43 and 2.88, respectively) compared with PTCs. Mean LOS decreased by 1.52 (p < 0.001), 0.49 (p = 0.26), and 1.31 (p = 0.05) days at ATC, DTC, and PTC to 6.43, 6.68, and 5.16 days. Improvement in LOS for ATCs was distributed across injury Grades I, II, and IV, while there was no correlation among PTCs for injury grade.

CONCLUSION

Despite more than a decade of guidelines in pediatric solid organ injury supporting nonoperative management and accelerated discharge pathways based on physiologic parameters, rates of operative intervention remain much higher in ATCs versus PTCs, and all centers appear to fall short of consensus guidelines for discharge.

LEVEL OF EVIDENCE

Care management study, level IV.

Pre- and in-hospital mortality for moderate-to-severe traumatic brain injuries: an analysis of the National Trauma Data Bank (2008-2014)

Objectives: This study aimed to: (1) evaluate pre- and in-hospital mortality for moderate-to-severe TBI in the U.S. by injury type (blunt vs. penetrating) and (2) estimate annual regression-adjusted mortality from 2008-2014.Methods: Data were analyzed from the National Trauma Data Bank (N=247,648). Multivariable logistic regression analyses were performed by injury type to assess changes in mortality between study periods (early period: 2008-2010; late period: 2011-2014) and to estimate annual regression-adjusted mortality. Mortality odds ratios and 95% confidence intervals were calculated.Results: Total observed mortality was 18.8%. After covariate adjustment, patients in the late period had an increased odds of prehospital mortality compared to patients in the early period for blunt (OR: 4.69; 95%CI: 4.41-4.98) and penetrating trauma (OR: 4.71; 95%CI: 4.39-5.06). In contrast, patients in the late period had a decreased odds of in-hospital mortality compared to patients in the early period for blunt (OR: 0.95; 95%CI: 0.91-0.98) and penetrating trauma (OR: 0.92; 95%CI: 0.85-0.98).Conclusions: The decreasing in-hospital mortality trend is consistent with previous literature. Additional research is warranted to validate the observed increase in prehospital mortality and to identify best practices that can improve prehospital outcomes for patients with moderate-to-severe TBI.

Association of Interfacility Transfer and Patient and Hospital Characteristics With Thumb Replantation After Traumatic Amputation

IMPORTANCE

Given that 40% of hand function is achieved with the thumb, replantation of traumatic thumb injuries is associated with substantial quality-of-life benefits. However, fewer replantations are being performed annually in the US, which has been associated with less surgical expertise and increased risk of future replantation failures. Thus, understanding how interfacility transfers and hospital characteristics are associated with outcomes warrants further investigation.

OBJECTIVE

To assess the association of interfacility transfer, patient characteristics, and hospital factors with thumb replantation attempts and success.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the US National Trauma Data Bank from 2009 to 2016 for adult patients with isolated traumatic thumb amputation injury who underwent revision amputation or replantation. Data analysis was performed from May 4, 2020, to July 20, 2020.

EXPOSURES

Interfacility transfer, defined as transfer of a patient from 1 hospital to another to obtain care for traumatic thumb amputation.

MAIN OUTCOMES AND MEASURES

Replantation attempt and replantation success, defined as having undergone a replantation without a subsequent revision amputation during the same hospitalization. Multilevel logistic regression models were used to assess the associations of interfacility transfer, patient characteristics, and hospital factors with replantation outcomes.

RESULTS

Of 3670 patients included in this analysis, 3307 (90.1%) were male and 2713 (73.9%) were White; the mean (SD) age was 45.8 (16.5) years. A total of 1881 patients (51.2%) were transferred to another hospital; most of these patients were male (1720 [91.4%]) and White (1420 [75.5%]). After controlling for patient and hospital characteristics, uninsured patients were less likely to have thumb replantation attempted (odds ratio [OR], 0.61; 95% CI, 0.47-0.78) or a successful replantation (OR, 0.64; 95% CI, 0.49-0.84). Interfacility transfer was associated with increased odds of replantation attempt (OR, 1.34; 95% CI, 1.13-1.59), with 13% of the variation at the hospital level. Interfacility transfer was also associated with increased replantation success (OR, 1.23; 95% CI, 1.03-1.47), with 14% of variation at the hospital level.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, interfacility transfer and particularly hospital-level variation were associated with increased thumb replantation attempts and successes. These findings suggest a need for creating policies that incentivize hospitals with replantation expertise to provide treatment for traumatic thumb amputations, including promotion of centralization of replantation care.

The Whole is Greater Than the Sum of its Parts: GCS Versus GCS-Motor for Triage in Geriatric Trauma

BACKGROUND

Trauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations.

MATERIALS AND METHODS

We conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007-2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared.

RESULTS

In total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non-motor-only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm.

CONCLUSIONS

Geriatric patients more frequently present with non-motor-only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.