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Lin PC, Wu MY, Wang CH, Tsai TY, Tu YC, Liu CY, Lee SJ, Tsai CH, Chung JY, Yiang GT. Prehospital Shock Index Multiplied by the Alert/Verbal/Painful/Unresponsive Score as a Predictor of Clinical Outcomes in Traumatic Injury. PREHOSP EMERG CARE 2024; 28:669-679. [PMID: 38820136 DOI: 10.1080/10903127.2024.2362921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/21/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Various prediction scores have been developed to predict mortality in trauma patients, such as the shock index (SI), modified SI (mSI), age-adjusted SI (aSI), and the shock index (SI) multiplied by the alert/verbal/painful/unresponsive (AVPU) score (SIAVPU). The SIAVPU is a novel scoring system but its prediction accuracy for trauma outcomes remains in need of further validation. Therefore, we investigated the accuracy of four scoring systems, including SI, mSI, aSI, and SIAVPU, in predicting mortality, admission to the intensive care unit (ICU), and prolonged hospital length of stay ≥ 30 days (LOS). METHODS This retrospective multicenter study used data from the Tzu Chi Hospital trauma database. The area under the receiver operating characteristic curve (AUROC) was determined for each outcome to assess their discrimination capabilities and comparing by Delong's test. Subgroup analyses were conducted to investigate the prediction accuracy of the SIAVPU in different patient populations. RESULTS In total, 5355 patients were included in the analysis. The median of SIAVPU were significantly higher among patients at those with major injury (1.47 vs 0.63), those admitted to the ICU (0.73 vs 0.62), those with prolonged hospital LOS≥ 30 days (0.83 vs 0.64), and those with mortality (1.08 vs 0.64). The AUROC of the SIAVPU was significantly higher than that of the SI, mSI, and aSI for 24-h mortality (AUROC: 0.845 vs 0.533, 0.540, and 0.678), 3-day mortality (AUROC: 0.803 vs 0.513, 0.524, and 0.688), 7-day mortality (AUROC: 0.755 vs 0.494, 0.505, and 0.648), in-hospital mortality (AUROC: 0.722 vs 0.510, 0.524, and 0.667), ICU admission (AUROC: 0.635 vs 0.547, 0.551, and 0.563). At the optimal cutoff value of 0.9, the SIAVPU had an accuracy of 82.2% for predicting 24-h mortality, 82.8% for predicting 3-day mortality, of 82.8% for predicting 7-day mortality, of 82.5% for predicting in-hospital mortality, of 73.9% for predicting Intensive Care Unit (ICU) admission, and of 81.7% for predicting prolonged hospital LOS ≥30 days. CONCLUSIONS Our results reveal that SIAVPU has better accuracy than the SI, mSI, and aSI for predicting 24-h, 3-day, 7-day, and in-hospital mortality; ICU admission; and prolonged hospital LOS ≥30 days among patients with traumatic injury.
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Affiliation(s)
- Po-Chen Lin
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
| | - Chien-Hsing Wang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Plastic Surgery, Department of Surgery and Trauma Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Tou-Yuan Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Emergency Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yueh-Cheng Tu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chi-Yuan Liu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shu-Jui Lee
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chia-Hung Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Surgery, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Jui-Yuan Chung
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
- School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
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Luotamo I, Snäll J, Toivari M. Complications and complaints in craniofacial fractures - Finnish national data for 20 years. Acta Odontol Scand 2024; 83:334-339. [PMID: 38804122 PMCID: PMC11302651 DOI: 10.2340/aos.v83.40570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/29/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Research on reasons for malpractice claims in oral and maxillofacial surgery is scarce. The aim of this study was to investigate the causes and prevalence of permanent harm among craniofacial fracture related malpractice claims. MATERIALS AND METHODS A retrospective register study was designed and implemented. All patients with a complaint and a diagnosis of facial or cranial fracture were included. The main outcome was the presence of permanent harm, and the predictor variable was the cause of complaint. Chi-square test was used for estimation of statistical significance. RESULTS Delay in correct diagnosis was the leading cause of malpractice claims (63.2%), and permanent harm was found in 23.1% of the population. 82.4% of injuries were facial fractures in total population. 65.3% (n = 98) of facial trauma were related with delayed diagnostics (p < 0.001). Permanent harm was more frequent in patients with delayed diagnosis (71.4%) than those without (60.7%, p = 0.299). CONCLUSIONS Claims of craniofacial trauma are related with under-diagnostics, and un-diagnosed facial fracture can lead to a high rate of permanent harm. Systematic clinical evaluation and facial trauma specialist consultation is recommended to set early correct diagnosis for and improve treatment of craniofacial trauma patients.
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Affiliation(s)
- Inka Luotamo
- Department of Oral and Maxillofacial Diseases, Kymenlaakso Central Hospital, Kotka, Finland; University of Helsinki, Helsinki, Finland.
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Helsinki, Finland
| | - Miika Toivari
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Helsinki, Finland
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Weykamp MB, Liu Z, Fernandez LR, Tuott E, Robinson BRH, Vavilala MS, Stansbury LG, Hess JR. Massive transfusion protocol reactivation as a novel marker of physician team under-triage after injury. Transfusion 2024; 64:248-254. [PMID: 38258481 DOI: 10.1111/trf.17719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/06/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Large trauma centers have protocols for the assessment of injury and triaging of care with attempts to over-triage to ensure adequate care for all patients. We noted that a significant number of patients undergo a second massive transfusion protocol (MTP) activation in the first 24 h of care and conducted a retrospective cohort study of patients involved over a 3-year period. METHODS Transfusion service records of MTP activations 2019-2021 were linked to Trauma Registry records and divided into cohorts receiving a single versus a reactivation of the MTP. Time of activation and amounts of blood products issued were linked to demographic, injury severity, and outcome data. Categorical and continuous data were compared between cohorts with chi-squared, Fisher's, and Wilcoxan tests as appropriate, and multivariable regression models were used to seek interactions (p < .05). RESULTS MTP activation was recorded for 1884 acute trauma patients over our 3-year study period, 142 of whom (7.5%) had reactivation. Factors associated with reactivation included older age (46 vs. 40 years), higher injury severity score (ISS, 27 vs. 22), leg injuries, and presentation during morning shift change (5-7 a.m., 3.3% vs. 7.7%). Patients undergoing MTP reactivation used more RBCs (5 U vs. 2 U) and had more ICU days (3 vs. 2). CONCLUSIONS Older patients and those presenting during shift change are at risk for failure to recognize their complex injury patterns and under-triage for trauma care. The fidelity and granularity of transfusion service records can provide unique opportunities for quality assessment and improvement in trauma care.
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Affiliation(s)
- Michael B Weykamp
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Zhinan Liu
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Lauren R Fernandez
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
| | - Erin Tuott
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Bryce R H Robinson
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - John R Hess
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Adeyemi OJ, Gibbons K, Schwartz LB, Meltzer-Bruhn AT, Esper GW, Grudzen C, DiMaggio C, Chodosh J, Egol KA, Konda SR. Diagnostic Accuracy of a Trauma Risk Assessment Tool Among Geriatric Patients With Crash Injuries. J Healthc Qual 2023; 45:340-351. [PMID: 37919956 PMCID: PMC11309630 DOI: 10.1097/jhq.0000000000000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
ABSTRACT The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a risk stratification tool. We evaluated the STTGMA's accuracy in predicting 30-day mortality and the odds of unfavorable clinical trajectories among crash-related trauma patients. This retrospective cohort study (n = 912) pooled adults aged 55 years and older from a single institutional trauma database. The data were split into training and test data sets (70:30 ratio) for the receiver operating curve analysis and internal validation, respectively. The outcome variables were 30-day mortality and measures of clinical trajectory. The predictor variable was the high-energy STTGMA score (STTGMAHE). We adjusted for the American Society of Anesthesiologists Physical Status. Using the training and test data sets, STTGMAHE exhibited 82% (95% CI: 65.5-98.3) and 96% (90.7-100.0) accuracies in predicting 30-day mortality, respectively. The STTGMA risk categories significantly stratified the proportions of orthopedic trauma patients who required intensive care unit (ICU) admissions, major and minor complications, and the length of stay (LOS). The odds of ICU admissions, major and minor complications, and the median difference in the LOS increased across the risk categories in a dose-response pattern. STTGMAHE exhibited an excellent level of accuracy in identifying middle-aged and geriatric trauma patients at risk of 30-day mortality and unfavorable clinical trajectories.
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Garwe T, Newgard CD, Stewart K, Wan Y, Cody P, Cutler J, Acharya P, Albrecht RM. Enhancing utility of interfacility triage guidelines using machine learning: Development of the Geriatric Interfacility Trauma Triage score. J Trauma Acute Care Surg 2023; 94:546-553. [PMID: 36404409 PMCID: PMC10038832 DOI: 10.1097/ta.0000000000003846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Undertriage of injured older adults to tertiary trauma centers (TTCs) has been demonstrated by many studies. In predominantly rural regions, a majority of trauma patients are initially transported to nontertiary trauma centers (NTCs). Current interfacility triage guidelines do not highlight the hierarchical importance of risk factors nor do they allow for individual risk prediction. We sought to develop a transfer risk score that may simplify secondary triage of injured older adults to TTCs. METHODS This was a retrospective prognostic study of injured adults 55 years or older initially transported to an NTC from the scene of injury. The study used data reported to the Oklahoma State Trauma Registry between 2009 and 2019. The outcome of interest was either mortality or serious injury (Injury Severity Score, ≥16) requiring an interventional procedure at the receiving facility. In developing the model, machine-learning techniques including random forests were used to reduce the number of candidate variables recorded at the initial facility. RESULTS Of the 5,913 injured older adults initially transported to an NTC before subsequent transfer to a TTC, 32.7% (1,696) had the outcome of interest at the TTC. The final prognostic model (area under the curve, 75.4%; 95% confidence interval, 74-76%) included the following top four predictors and weighted scores: airway intervention (10), traffic-related femur fracture (6), spinal cord injury (5), emergency department Glasgow Coma Scale score of ≤13 (5), and hemodynamic support (4). Bias-corrected and sample validation areas under the curve were 74% and 72%, respectively. A risk score of 7 yields a sensitivity of 78% and specificity of 56%. CONCLUSION Secondary triage of injured older adults to TTCs could be enhanced by use of a risk score. Our study is the first to develop a risk stratification tool for injured older adults requiring transfer to a higher level of care. LEVEL OF EVIDENCE Prognostic and Epidemiolgical; Level III.
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Affiliation(s)
- Tabitha Garwe
- Department of Surgery, University of Oklahoma Health Sciences Center
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center
| | - Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kenneth Stewart
- Department of Surgery, University of Oklahoma Health Sciences Center
| | - Yang Wan
- Emergency Systems Division, Oklahoma State Department of Health
| | | | - James Cutler
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center
| | - Pawan Acharya
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center
| | - Roxie M. Albrecht
- Department of Surgery, University of Oklahoma Health Sciences Center
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6
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Newgard CD, Fischer PE, Gestring M, Michaels HN, Jurkovich GJ, Lerner EB, Fallat ME, Delbridge TR, Brown JB, Bulger EM. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg 2022; 93:e49-e60. [PMID: 35475939 PMCID: PMC9323557 DOI: 10.1097/ta.0000000000003627] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
This work details the process of developing the updated field triage guideline, the supporting evidence, and the final version of the 2021 National Guideline for the Field Triage of Injured Patients.
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Affiliation(s)
- Craig D. Newgard
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Peter E. Fischer
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mark Gestring
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Holly N. Michaels
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Gregory J. Jurkovich
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - E. Brooke Lerner
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mary E. Fallat
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Theodore R. Delbridge
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Joshua B. Brown
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Eileen M. Bulger
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - the Writing Group for the 2021 National Expert Panel on Field Triage
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
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7
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Barrett JW, Williams J, Griggs J, Skene S, Lyon R. What are the demographic and clinical differences between those older adults with traumatic brain injury who receive a neurosurgical intervention to those that do not? A systematic literature review with narrative synthesis. Brain Inj 2022; 36:841-849. [PMID: 35767716 DOI: 10.1080/02699052.2022.2093398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES This review aimed to identify the demographic and clinical differences between those older adults admitted directly under neurosurgical care and those that were not, and whether EMS clinicians could use these differences to improve patient triage. METHODS The authors searched for papers that included older adults who had suffered a TBI and were either admitted directly under neurosurgical care or were not. Titles and abstracts were screened, shortlisting potentially eligible papers before performing a full-text review. The Newcastle-Ottawa Scale was used to assess the risk of bias. RESULTS A total of nine studies were eligible for inclusion. A high abbreviated injury score head, Marshall score or subdural hematoma greater than 10 mm were associated with neurosurgical care. There were few differences between those patients who did and did not receive neurosurgical intervention. CONCLUSIONS Absence of guidelines and clinician bias means that differences between those treated aggressively and conservatively observed in the literature are fraught with bias. Further work is required to understand which patients would benefit from an escalation of care and whether EMS can identify these patients so they are transported directly to a hospital with the appropriate services on-site.
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Affiliation(s)
- Jack W Barrett
- Department of Research and Development, South East Coast Ambulance Service NHS Foundation Trust, Nexus House, Crawley, UK.,Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - Julia Williams
- Department of Research and Development, South East Coast Ambulance Service NHS Foundation Trust, Nexus House, Crawley, UK.,School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Joanna Griggs
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK.,Department of Research and Innovation, Air Ambulance Kent, Surrey, Sussex, Surrey, UK
| | - Simon Skene
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
| | - Richard Lyon
- Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK.,Department of Research and Innovation, Air Ambulance Kent, Surrey, Sussex, Surrey, UK
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van Gool MH, van Roozendaal LM, Vissers YLJ, van den Broek R, van Vugt R, Meesters B, Pijnenburg AM, Hulsewé KWE, de Loos ER. VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases. Gen Thorac Cardiovasc Surg 2022; 70:985-992. [PMID: 35657504 DOI: 10.1007/s11748-022-01830-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest. METHODS From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported. RESULTS VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury. CONCLUSIONS Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.
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Affiliation(s)
| | | | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Raoul van Vugt
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Berend Meesters
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Karel W E Hulsewé
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Erik R de Loos
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands.
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Alqurashi N, Alotaibi A, Bell S, Lecky F, Body R. The diagnostic accuracy of prehospital triage tools in identifying patients with traumatic brain injury: A systematic review. Injury 2022; 53:2060-2068. [PMID: 35190184 DOI: 10.1016/j.injury.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/04/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prehospital care providers are usually the first responders for patients with traumatic brain injury (TBI). Early identification of patients with TBI enables them to receive trauma centre care, which improves outcomes. Two recent systematic reviews concluded that prehospital triage tools for undifferentiated major trauma have low accuracy. However, neither review focused specifically on patients with suspected TBI. Therefore, we aimed to systematically review the existing evidence on the diagnostic performance of prehospital triage tools for patients with suspected TBI. METHODS A comprehensive search of the current literature was conducted using Medline, EMBASE, CINAHL Plus and the Cochrane library (inception to 1st June 2021). We also searched Google Scholar, OpenGrey, pre-prints (MedRxiv) and dissertation databases. We included all studies published in English language evaluating the accuracy of prehospital triage tools for TBI. We assessed methodological quality and risk of bias using a modified Quality Assessment of Diagnostic Studies (QUADAS-2) tool. Two reviewers independently performed searches, screened titles and abstracts and undertook methodological quality assessments. Due to the heterogeneity in the population of interest and prehospital triage tools used, a narrative synthesis was undertaken. RESULTS The initial search identified 1787 articles, of which 8 unique eligible studies met the inclusion criteria (5 retrospective, 2 prospective, 1 mixed). Overall, sensitivity of triage tools studied ranged from 19.8% to 87.9% for TBI identification. Specificity ranged from 41.4% to 94.4%. Two decision tools have been validated more than once: HITS-NS (2 studies, sensitivity 28.3-32.6%, specificity 89.1-94.4%) and the Field Triage Decision Scheme (4 studies, sensitivity 19.8-64.5%, specificity 77.4%-93.1%). Existing tools appear to systematically under-triage older patients. CONCLUSION Further efforts are needed to improve and optimise prehospital triage tools. Consideration of additional predictors (e.g., biomarkers, clinical decision aids and paramedic judgement) may be required to improve diagnostic accuracy.
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Affiliation(s)
- Naif Alqurashi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK; Department of Accidents and Trauma, Prince Sultan bin Abdelaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia.
| | - Ahmed Alotaibi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Trust, Bolton, BL1 5DD, UK.
| | - Fiona Lecky
- University of Sheffield, School of Health and Related Research, Sheffield, UK.
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK; Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK.
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10
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Harthi N, Goodacre S, Sampson F, Alharbi R. Research priorities for prehospital care of older patients with injuries: scoping review. Age Ageing 2022; 51:afac108. [PMID: 35604804 PMCID: PMC9126200 DOI: 10.1093/ageing/afac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 01/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There is increasing recognition of the importance of prehospital trauma care for older patients, but little systematic research to guide practice. We aimed to review the published evidence on prehospital trauma care for older patients, determine the scope of existing research and identify research gaps in the literature. METHODS We undertook a systematic scoping review guided by the Arksey and O'Malley framework and reported in line with the PRISMA-ScR checklist. A systematic search was conducted of Scopus, CINAHL, MEDLINE, PubMed and Cochrane library databases to identify articles published between 2001 and 2021. Study selection criteria were applied independently by two reviewers. Data were extracted, charted and summarised from eligible articles. A data-charting form was then developed to facilitate thematic analysis. Narrative synthesis then involved identifying major themes and subthemes from the data. RESULTS We identified and reviewed 65 studies, and included 25. We identified five categories: 'field triage', 'ageing impacts', 'decision-making', 'paramedic' awareness' and 'paramedic's behaviour'. Undertriage and overtriage (sensitivity and specificity) were commonly cited as poorly investigated field-triage subthemes. Ageing-related physiologic changes, comorbidities and polypharmacy were the most widely researched. Inaccurate decision-making and poor early identification of major injuries were identified as potentially influencing patient outcomes. CONCLUSION This is the first study reviewing the published evidence on prehospital trauma care for older patients and identifying research priorities for future research. Field-triage tools, paramedics' knowledge about injuries in the older population, and understanding of paramedics' negative behaviours towards older patients were identified as key research priorities.
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Affiliation(s)
- Naif Harthi
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
- Faculty of Applied Medical Sciences, Jazan University, Jazan City, Saudi Arabia
| | - Steve Goodacre
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
| | - Fiona Sampson
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
| | - Rayan Alharbi
- Faculty of Applied Medical Sciences, Jazan University, Jazan City, Saudi Arabia
- School of Nursing and Midwifery, La Trobe University, Melbourne City, Australia
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11
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Charles Sifford M, Dailey R, Reif R, Hutchison M, Mason C, Kimbrough K, Davis B, Bhavaraju A, Jensen HK, Robertson R, Taylor J, Beck W, Sexton K. CDC field triage criteria accurately predicts outcomes in high impact trauma. J Inj Violence Res 2022; 14:115-124. [PMID: 35137693 PMCID: PMC9115808 DOI: 10.5249/jivr.v14i1.1650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 01/26/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The precision of emergency medical services (EMS) triage criteria dictates whether an injured patient receives appropriate care. The trauma triage protocol is a decision scheme that groups patients into triage categories of major, moderate and minor. We hypothesized that there is a difference between trauma triage category and injury severity score (ISS). METHODS This retrospective, observational study was conducted to investigate a difference between trauma triage category and ISS. Bivariate analysis was used to test for differences between the subgroup means. The differences between the group means on each measure were analyzed for direction and statistical significance using ANOVA for continuous variables and chi square tests for categorical variables. Logistic and linear regressions were performed to evaluate factors predicting mortality, ICU length of stay. RESULTS With respect to trauma triage category, our findings indicate that minor and moderate triage categories are similar with respect to ISS, GCS, ICU LOS, hospital LOS, and mortality. However, after excluding for low impact injuries (falls), differences between the minor and moderate categories were evident when comparing to ISS, GCS, ICU LOS, and hospital LOS. Additionally, after excluding for low impact injures, ISS, ICU LOS, and hospital stay were found to correlate well with trauma triage category. CONCLUSIONS In this retrospective, observational study significant differences were not seen when comparing ISS with the trauma triage categories of moderate and minor during our initial analysis. However, a difference was found after excluding for low impact injuries. These findings suggest that CDC criteria accurately predicts outcomes in high impact trauma.
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Affiliation(s)
- Mason Charles Sifford
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - R. Dailey
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - R. Reif
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - M. Hutchison
- b Metropolitan Emergency Medical Services, Little Rock, AR, USA.
| | - C. Mason
- b Metropolitan Emergency Medical Services, Little Rock, AR, USA.
| | - K. Kimbrough
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - B. Davis
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - A. Bhavaraju
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - H. K Jensen
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - R. Robertson
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - J. Taylor
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - W.C. Beck
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Kevin Sexton
- a Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Kevin W. Sexton: MD, Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences (UAMS), Little Rock, AR 72205. Tel: 501-686-7000; (Sexton KW.). https://orcid.org/0000-0002-1460-9867
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12
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Jung MK, von Ehrlich-Treuenstätt GVR, Jung AL, Keil H, Grützner PA, Schneider NRE, Kreinest M. Evaluation of external stabilization of type II odontoid fractures in geriatric patients-An experimental study on a newly developed cadaveric trauma model. PLoS One 2021; 16:e0260414. [PMID: 34843595 PMCID: PMC8629171 DOI: 10.1371/journal.pone.0260414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022] Open
Abstract
Background Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar. Methods Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed. Results The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion (p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced (p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced (p = 0.0137) from 48° to 18°. Conclusions In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending.
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Affiliation(s)
- Matthias K. Jung
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | | | - Andreas L. Jung
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Holger Keil
- Clinic for Trauma and Orthopaedic Surgery, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Paul A. Grützner
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | | | - Michael Kreinest
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwigshafen on the Rhine, Germany
- * E-mail:
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13
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The Impact of Age on Predictive Performance of National Early Warning Score at Arrival to Emergency Departments: Development and External Validation. Ann Emerg Med 2021; 79:354-363. [PMID: 34742589 DOI: 10.1016/j.annemergmed.2021.09.434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/17/2021] [Accepted: 09/24/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE To investigate how age affects the predictive performance of the National Early Warning Score (NEWS) at arrival to the emergency department (ED) regarding inhospital mortality and intensive care admission. METHODS International multicenter retrospective cohorts from 2 Danish and 3 Dutch ED. Development cohort: 14,809 Danish patients aged ≥18 years with at least systolic blood pressure or pulse measured from the Danish Multicenter Cohort. External validation cohort: 50,448 Dutch patients aged ≥18 years with all vital signs measured from the Netherlands Emergency Department Evaluation Database (NEED). Multivariable logistic regression was used for model building. Performance was evaluated overall and within age categories: 18 to 64 years, 65 to 80 years, and more than 80 years. RESULTS In the Danish Multicenter Cohort, a total of 2.5% died inhospital, and 2.8% were admitted to the ICU, compared with 2.8% and 1.6%, respectively, in the NEED. Age did not add information for the prediction of intensive care admission but was the strongest predictor for inhospital mortality. For NEWS alone, severe underestimation of risk was observed for persons above 80 while overall Area Under Receiver Operating Characteristic (AUROC) was 0.82 (confidence interval [CI] 0.80 to 0.84) in the Danish Multicenter Cohort versus 0.75 (CI 0.75 to 0.77) in the NEED. When combining NEWS with age, underestimation of risks was eliminated for persons above 80, and overall AUROC increased significantly to 0.86 (CI 0.85 to 0.88) in the Danish Multicenter Cohort versus 0.82 (CI 0.81 to 0.83) in the NEED. CONCLUSION Combining NEWS with age improved the prediction performance regarding inhospital mortality, mostly for persons aged above 80, and can potentially improve decision policies at arrival to EDs.
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14
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In-Hospital Clinical Outcomes in Patients with Fragility Fractures of the Lumbar Spine, Thoracic Spine, and Pelvic Ring: A Comparison of Data before and after Certification as a DGU® Geriatric Trauma Centre. Medicina (B Aires) 2021; 57:medicina57111197. [PMID: 34833415 PMCID: PMC8617676 DOI: 10.3390/medicina57111197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: The implementation of orthogeriatric co-management (OGCM) reflects the demand for interdisciplinary collaborations due to the increasing comorbidities of geriatric trauma patients. This study aimed to assess clinical in-hospital outcomes in lumbar spine, thoracic spine, and pelvic ring fragility fracture patients before and after the implementation of a Geriatric Trauma Centre (GTC) certified by the German Trauma Society (DGU®). Materials and Methods: In this observational, retrospective cohort study, geriatric trauma patients (>70 years of age) were stratified into either a pre-GTC group (hospital admission between 1 January 2012 and 31 December 2013) or a post-GTC group (hospital admission between 1 January 2017 and 31 December 2018). Patients’ pre-injury medical complexity was measured by ASA class (American Society of Anaesthesiologists classification), the use of anticoagulant medication, and the ACCI (Age-adjusted Charlson Comorbidity Index). Outcome parameters were patients’ in-hospital length of stay (LOS) and mortality rates, as well as new in-hospital findings and diagnoses. Further, the necessity of deviation from initial management plans due to complications was assessed using the Adapted Clavien–Dindo Scoring System in Trauma (ACDiT score of ≥1). Results: Patients in the post-GTC group (n = 111) were older (median age 82.0 years) compared to the pre-GTC group (n = 108, median age 80.0 years, p = 0.016). No differences were found in sex, body mass index, ASA class, or ACCI (all p > 0.05). Patients in the post-GTC group used vitamin K antagonists or direct oral anticoagulants more frequently (21.3% versus 10.8%). The incidence of non-surgical treatment and mortality was comparable between groups, while LOS tended to be shorter in the post-GTC group (7.0 days versus 9.0 days, p = 0.076). In the post-GTC group, the detection of urinary tract infections (UTI) increased (35.2% versus 16.2%, p = 0.001), and the delirium diagnoses tended to increase (13.0% versus 6.3%, p = 0.094), while an ACDiT score of ≥1 was comparable between groups (p = 0.169). Conclusions: In this study including lumbar spine, thoracic spine, and pelvic ring geriatric fragility fractures, patients in the post-GTC group were more medically complex. More UTIs and the tendency for increased delirium detection was observed in the post-GTC group, likely due to improved diagnostic testing. Nonetheless, the necessity of deviation from initial management plans (ACDiT score of ≥1) was comparable between groups, potentially a positive result of OGCM.
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15
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Eichinger M, Robb HDP, Scurr C, Tucker H, Heschl S, Peck G. Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review. Scand J Trauma Resusc Emerg Med 2021; 29:100. [PMID: 34301281 PMCID: PMC8305876 DOI: 10.1186/s13049-021-00922-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/14/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group. METHODS AND FINDINGS A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review. CONCLUSIONS Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.
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Affiliation(s)
- Michael Eichinger
- Major Trauma and Cutrale Perioperative and Ageing Group, Imperial College Healthcare NHS Trust, London, UK
| | - Henry Douglas Pow Robb
- Academic Clinical Fellow in General Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Cosmo Scurr
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | | | - Stefan Heschl
- Department of Cardiac, Thoracic and Vascular Anaesthesiology and Intensive Care, Medical University Hospital, Graz, Austria
| | - George Peck
- Cutrale Peri-operative and Ageing Group, Imperial College London, London, UK
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16
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Alshibani A, Alharbi M, Conroy S. Under-triage of older trauma patients in prehospital care: a systematic review. Eur Geriatr Med 2021; 12:903-919. [PMID: 34110604 PMCID: PMC8463357 DOI: 10.1007/s41999-021-00512-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/05/2021] [Indexed: 01/07/2023]
Abstract
Aim The systematic review aimed to assess the under-triage rate for older trauma patients in prehospital care and its impact on their outcomes. Findings Older trauma patients were significantly under-triaged in prehospital care and the benefits of triaging these patients to Tauma Centres (TCs) are still uncertain. Current triage criteria and developed geriatric-specific criteria lacked acceptable accuracy and when patients met the criteria, they had a low chance of being transported to TCs. Message Future worldwide research is needed to assess the following aspects: (1) the accuracy of current trauma triage criteria, (2) developing more accurate triage criteria, (3) destination compliance rates for patients meeting the triage criteria, (4) factors leading to destination non-compliance and their impact on outcomes, and (5) the benefits of TC access for older trauma patients. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00512-5. Background It is argued that many older trauma patients are under-triaged in prehospital care which may adversely affect their outcomes. This systematic review aimed to assess prehospital under-triage rates for older trauma patients, the accuracy of the triage criteria, and the impact of prehospital triage decisions on outcomes. Methods A computerised literature search using MEDLINE, Scopus, and CINHAL databases was conducted for studies published between 1966 and 2021 using a list of predetermined index terms and their associated alternatives. Studies which met the inclusion criteria were included and critiqued using the Critical Appraisal Skills Programme tool. Due to the heterogeneity of the included studies, narrative synthesis was used in this systematic review. Results Of the 280 identified studies, 23 met the inclusion criteria. Current trauma triage guidelines have poor sensitivity to identify major trauma and the need for TC care for older adults. Although modified triage tools for this population have improved sensitivity, they showed significantly decreased specificity or were not applied to all older people. The issue of low rates of TC transport for positively triaged older patients is not well understood. Furthermore, the benefits of TC treatment for older patients remain uncertain. Conclusions This systematic review showed that under-triage is an ongoing issue for older trauma patients in prehospital care and its impact on their outcomes is still uncertain. Further high-quality prospective research is needed to assess the accuracy of prehospital triage criteria, the factors other than the triage criteria that affect transport decisions, and the impact of under-triage on outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00512-5.
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Affiliation(s)
- Abdullah Alshibani
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, LE1 7HA, UK. .,Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Meshal Alharbi
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, LE1 7HA, UK
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17
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Alshibani A, Banerjee J, Lecky F, Coats TJ, Alharbi M, Conroy S. New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults. Open Access Emerg Med 2021; 13:117-135. [PMID: 33814934 PMCID: PMC8009532 DOI: 10.2147/oaem.s297850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/26/2021] [Indexed: 12/22/2022] Open
Abstract
Caring for older people is an important part of prehospital practice, including appropriate triage and transportation decisions. However, prehospital triage criteria are designed to predominantly assess injury severity or high-energy mechanism which is not the case for older people who often have injuries compounded by multimorbidity and frailty. This has led to high rates of under-triage in this population. This narrative review aimed to assess aspects other than triage criteria to better understand and improve prehospital triage decisions for older trauma patients. This includes integrating frailty assessment in prehospital trauma triage, which was shown to predict adverse outcomes for older trauma patients. Furthermore, determining appropriate outcome measures and the benefits of Major Trauma Centers (MTCs) for older trauma patients should be considered in order to direct accurate and more beneficial prehospital trauma triage decisions. It is still not clear what are the appropriate outcome measures that should be applied when caring for older trauma patients. There is also no strong consensus about the benefits of MTC access for older trauma patients with regards to survival, in-hospital length of stay, discharge disposition, and complications. Moreover, looking into factors other than triage criteria such as distance to MTCs, patient or relative choice, training, unfamiliarity with protocols, and possible ageism, which were shown to impact prehospital triage decisions but their impact on outcomes has not been investigated yet, should be more actively assessed and investigated for this population. Therefore, this paper aimed to discuss the available evidence around frailty assessment in prehospital care, appropriate outcome measures for older trauma patients, the benefits of MTC access for older patients, and factors other than triage criteria that could adversely impact accurate prehospital triage decisions for older trauma patients. It also provided several suggestions for the future.
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Affiliation(s)
- Abdullah Alshibani
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.,Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Jay Banerjee
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.,University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, University of Sheffield, Sheffield, UK
| | - Timothy J Coats
- University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Meshal Alharbi
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
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18
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Alshibani A, Singler B, Conroy S. Towards improving prehospital triage for older trauma patients. Z Gerontol Geriatr 2021; 54:125-129. [PMID: 33507358 DOI: 10.1007/s00391-021-01844-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/05/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The proportion of older adults with major trauma is increasing. High-quality care for this population requires accurate and effective prehospital trauma triage decisions. OBJECTIVE Anatomical and physiological changes with age, comorbidities, and medication use for older adults may affect the accuracy of prehospital trauma triage. MATERIAL AND METHODS This narrative review focusses on age-related anatomical and physiological changes, comorbidities, and medication use for older adults with an emphasis on their impact on the accuracy of prehospital trauma triage tools. It also addresses the efforts to develop alternative triage criteria to reduce undertriage. RESULTS Age-related anatomical and physiological changes, comorbidities, and medication use were shown to affect physiological responses to injury and mechanism of injury for older people. Current triage tools poorly predicted injury severity. Geriatric-specific physiological measures and comorbidities significantly improved sensitivity with much lower specificity. Assessing anticoagulant or antiplatelet use in head injury notably improved sensitivity to identify traumatic intracranial hemorrhage, neurosurgery or death with modest decrease in specificity. CONCLUSION Improving prehospital providers' knowledge about the challenges of assessing older people with trauma may reduce undertriage. Assessing frailty could help in improving prehospital providers' judgments. Future research is needed to improve triage decisions for this population.
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Affiliation(s)
- Abdullah Alshibani
- Department of Health Sciences, College of Life Sciences, University of Leicester, LE1 7HA, Leicester, UK.
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Boris Singler
- Zweckverband für Rettungsdienst und Feuerwehralarmierung, Hauptmarkt 16, 90403, Nürnberg, Germany
- Klinik Hallerwiese/Cnopfsche Kinderklinik, Sankt-Johannis-Mühlgasse 19, 90419, Nürnberg, Germany
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, LE1 7HA, Leicester, UK
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Halvachizadeh S, Gröbli L, Berk T, Jensen KO, Hierholzer C, Bischoff-Ferrari HA, Pfeifer R, Pape HC. The effect of geriatric comanagement (GC) in geriatric trauma patients treated in a level 1 trauma setting: A comparison of data before and after the implementation of a certified geriatric trauma center. PLoS One 2021; 16:e0244554. [PMID: 33428650 PMCID: PMC7799827 DOI: 10.1371/journal.pone.0244554] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/13/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Improvements in life expectancy imply that an increase of geriatric trauma patients occurs. These patients require special attention due to their multiple comorbidity issues. The aim of this study was to assess the impact of the implementation of geriatric comanagement (GC) on the allocation and clinical outcome of geriatric trauma patients. METHODS This observational cohort study aims to compare the demographic development and the clinical outcome in geriatric trauma patients (aged 70 years and older) before and after implementation of a certified geriatric trauma center (GC). Geriatric trauma patients admitted between January 1, 2010 and December 31, 2010 were stratified to group pre-GC and admissions between January 1, 2018 and December 31, 2018 to Group post-GC. We excluded patients requiring end-of-life treatment and those who died within 24 h or due to severe traumatic brain injury. Outcome parameters included demographic changes, medical complexity (measured by American Society of Anaesthesiology Score (ASA) and Charlson Comorbidity Index (CCI)), in-hospital mortality and length of hospitalization. RESULTS This study includes 626 patients in Group pre-GC (mean age 80.3 ± 6.7 years) and 841 patients in Group post-GC (mean age 81.1 ± 7.3 years). Group pre-GC included 244 (39.0%) males, group post-GC included 361 (42.9%) males. The mean CCI was 4.7 (± 1.8) points in pre-GC and 5.1 (± 2.0) points in post-GC (p <0.001). In Group pre-GC, 100 patients (16.0%) were stratified as ASA 1 compared with 47 patients (5.6%) in Group post-GC (p <0.001). Group pre-GC had significantly less patients stratified as ASA 3 or higher (n = 235, 37.5%) compared with Group post-GC (n = 389, 46.3%, p <0.001). Length of stay (LOS) decreased significantly from 10.4 (± 20.3) days in Group pre-GC to 7.9 (±22.9) days in Group post-GC (p = 0.011). The 30-day mortality rate was comparable amongst these groups (pre-GC 8.8% vs. post-GC 8.9%). CONCLUSION This study appears to support the implementation of a geriatric trauma center, as certain improvements in the patient care were found: Despite a higher CCI and a higher number of patients with higher ASA classifications, Hospital LOS, complication rates and mortality did were not increased after implementation of the CG. The increase in the case numbers supports the fact that a higher degree of specialization leads to a response by admitting physicians, as it exceeded the expectable trend of demographic ageing. We feel that a larger data base, hopefully in a multi center set up should be undertaken to verify these results.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University Hospital Zurich, Zurich, Switzerland
- * E-mail:
| | | | - Till Berk
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Christian Hierholzer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
| | - Heike A. Bischoff-Ferrari
- Department of Geriatric Medicine, University Hospital Zurich, Zurich, Switzerland
- Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Waid City Hospital Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- University Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University Hospital Zurich, Zurich, Switzerland
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Fröhlich M, Caspers M, Lefering R, Driessen A, Bouillon B, Maegele M, Wafaisade A. Do elderly trauma patients receive the required treatment? Epidemiology and outcome of geriatric trauma patients treated at different levels of trauma care. Eur J Trauma Emerg Surg 2019; 46:1463-1469. [PMID: 31844920 DOI: 10.1007/s00068-019-01285-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE In an ageing society, geriatric trauma displays an increasing challenge in trauma care. Due to comorbidities and reduced physiologic reserves, these patients might benefit from an immediate specialised care. The current study aims to clarify the prevalence and outcome of geriatric trauma depending on the level of the primary trauma centre. METHODS Data sets of 124,641 patients entered in the TR-DGU between 2009 and 2016 were included. Geriatric trauma was defined above 65 years and ISS ≥ 9. Analysing the prevalence, the age structure of all trauma cases registered in 2014 was compared to demographic data of the German Federal Statistical Office. Differences in injury pattern, in-hospital care and outcome between the primary levels of care were analysed. RESULTS In comparison to their share of population, geriatric patients are highly overrepresented in the TR-DGU. Despite minor injury mechanisms, severe head injuries are common. A tendency to under-triage can be observed, as level II and III trauma centres receive a higher percentage of older patients. Nevertheless, there is no effect on the mortality. 10% of these patients require an early transfer to a higher levelled trauma centres mainly due to severe head and spine injuries. Surprisingly, pre-clinical available signs such as GCS or blood pressure were not altered in these patients. CONCLUSION Patients above the age of 65 years represent a second group with high risk for traumatic injuries besides younger adults. Despite low-energy trauma mechanisms, these patients are prone to suffer from severe injuries, which require specialised care. Current admission practice appears adequate, as pre-clinical available symptoms did not correlate with injuries that demanded an early inter-hospital transfer. Specialised geriatric triage scores might further improve admission practice.
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Affiliation(s)
- Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany. .,Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.
| | - Michael Caspers
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Arne Driessen
- Department of Orthopedics, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Bertil Bouillon
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
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Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. A comparison of major trauma patient transport destination in metropolitan Perth, Western Australia. Australas Emerg Care 2019; 23:90-96. [PMID: 31668941 DOI: 10.1016/j.auec.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/25/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite evidence of a lower risk of death, major trauma patients are not always transported to Trauma Centres. This study examines the characteristics and outcomes of major trauma patients between transport destinations. METHODS A retrospective cohort study of major trauma patients (Injury Severity Score >15) transported by ambulance was undertaken. Cases were divided into transport destination groups: (1) Direct, those transported to the Trauma Centre directly from the scene; (2) Indirect, those transported to another hospital prior to Trauma Centre transfer and (3) Non-transfers, those transported to a non-Trauma Centre and never subsequently transferred. Median and interquartile range (IQR) were used to describe the groups and differences were assessed using the Kruskal-Wallis test for continuous variables and Pearson chi-square for categorical. RESULTS A total of 1625 patients were included. The median age was oldest in the non-transfers cohort (72 years IQR 46-84). This group had the highest proportion of falls from standing and head injuries (n = 298/400, 75%, p < 0.001). The non-transfers had the highest proportion of 30-day mortality (n = 134/400, 34%). CONCLUSIONS There were significant differences between the groups with older adults, falls and head injuries over-represented in the non-transfer group. Considering the ageing population, trauma systems will need to adapt.
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Affiliation(s)
- Elizabeth Brown
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia.
| | - Paul Bailey
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Daniel Fatovich
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Emergency Medicine, Royal Perth Hospital, University of Western Australia, Bentley, WA, Australia; Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, WA, Australia.
| | - Gavin Pereira
- School of Public Health, Curtin University, Bentley, WA, Australia; Telethon Kids Institute, WA, Australia.
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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Techar K, Nguyen A, Lorenzo RM, Yang S, Thielen B, Cain-Nielsen A, Hemmila MR, Tignanelli CJ. Early Imaging Associated With Improved Survival in Older Patients With Mild Traumatic Brain Injuries. J Surg Res 2019; 242:4-10. [DOI: 10.1016/j.jss.2019.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/17/2019] [Accepted: 04/03/2019] [Indexed: 01/07/2023]
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Crash Telemetry-Based Injury Severity Prediction is Equivalent to or Out-Performs Field Protocols in Triage of Planar Vehicle Collisions. Prehosp Disaster Med 2019; 34:356-362. [PMID: 31322099 DOI: 10.1017/s1049023x19004515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION With the increasing availability of vehicle telemetry technology, there is great potential for Advanced Automatic Collision Notification (AACN) systems to improve trauma outcomes by detecting patients at-risk for severe injury and facilitating early transport to trauma centers. METHODS National Automotive Sampling System Crashworthiness Data System (NASS-CDS) data from 1999-2013 were used to construct a logistic regression model (injury severity prediction [ISP] model) predicting the probability that one or more occupants in planar, non-rollover motor vehicle collisions (MVCs) would have Injury Severity Score (ISS) 15+ injuries. Variables included principal direction of force (PDOF), change in velocity (Delta-V), multiple impacts, presence of any older occupant (≥55 years old), presence of any female occupant, presence of right-sided passenger, belt use, and vehicle type. The model was validated using medical records and 2008-2011 crash data from AACN-enabled Michigan (USA) vehicles identified from OnStar (OnStar Corporation; General Motors; Detroit, Michigan USA) records. To compare the ISP to previously established protocols, a literature search was performed to determine the sensitivity and specificity of first responder identification of ISS 15+ for MVC occupants. RESULTS The study population included 924 occupants in 836 crash events. The ISP model had a sensitivity of 72.7% (95% Confidence Interval [CI] 41%-91%) and specificity of 93% (95% CI 92%-95%) for identifying ISS 15+ occupants injured in planar MVCs. The current standard 2006 Field Triage Decision Scheme (FTDS) was 56%-66% sensitive and 75%-88% specific in identifying ISS 15+ patients. CONCLUSIONS The ISP algorithm comparably is more sensitive and more specific than current field triage in identifying MVC patients at-risk for ISS 15+ injuries. This real-world field study shows telemetry data transmitted before dispatch of emergency medical systems can be helpful to quickly identify patients who require urgent transfer to trauma centers.
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Garwe T, Stewart KE, Newgard CD, Stoner JA, Sacra JC, Cody P, Oluborode B, Albrecht RM. Survival Benefit of Treatment at or Transfer to a Tertiary Trauma Center among Injured Older Adults. PREHOSP EMERG CARE 2019; 24:245-256. [PMID: 31211622 DOI: 10.1080/10903127.2019.1632997] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: It is well established that seriously injured older adults are under-triaged to tertiary trauma centers. However, the survival benefit of tertiary trauma centers (TC) compared to a non-tertiary trauma centers (Non-TCs) remains unclear for this patient population. Using improved methodology and a larger sample, we hypothesized that there was a difference in hospital mortality between injured older adults treated at TCs and those treated at Non-TCs. Methods: This was a retrospective cohort study of injured older adults (> =55 years) reported to the Oklahoma statewide trauma registry between 2005 and 2014. The outcome of interest was 30-day in-hospital mortality and the exposure variable of interest was level of definitive trauma care (TC vs Non-TC). Overall survival benefit of treatment at a TC as well as the survival benefit of transferring injured older adults to a TC were evaluated using multivariable survival analyses as well as propensity score-adjusted analyses. Results: Of the 25,288 patients eligible for analysis, 43% (10,927) were treated at TCs. Multivariable Cox regression analyses revealed effect modification by age group and time. After adjusting for potential confounders within the age strata, overall, patients treated at TCs were significantly less likely to die within 7 days of admission and this effect was stronger for patients aged 55-64 years (HR 0.41, 95% CI 0.31-0.52) compared to those > =65 years (HR 0.62, 95% CI 0.55-0.70). Overall survival benefit of TCs beyond 7 days was also observed (HR 0.68, 95% CI 0.56-0.83). Similarly, for the survival benefit of transferring injured older adults, after adjusting for the propensity to be transferred and other confounders, transfer to a TC was associated with lower 30-day mortality both for patients less than 65 years old (HR 0.36, 95% CI: 0.27-0.49) and those 65 years and older (HR 0.55, 95% CI: 0.48-0.64). Conclusions: Our results suggest a survival benefit for injured older adults treated at TCs. This benefit was also observed for patients transferred from non-tertiary trauma centers. Further research should focus on identifying specific subgroups of patients who would especially benefit from this level of care to minimize trauma triage inefficiencies.
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Meagher AD, Lin A, Mandell SP, Bulger E, Newgard C. A Comparison of Scoring Systems for Predicting Short- and Long-term Survival After Trauma in Older Adults. Acad Emerg Med 2019; 26:621-630. [PMID: 30884022 DOI: 10.1111/acem.13727] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/18/2019] [Accepted: 03/12/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30-day mortality using an empirically derived scoring system from available data and to compare it with current prognostic scoring systems. METHODS This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. We matched data from EMS to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30-day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson Comorbidity Index (CCI), modified frailty index, geriatric trauma outcome score (GTOS), GTOS II, and Injury Severity Score (ISS). RESULTS There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the geriatric trauma risk indicator (GTRI; emergent airway or CCI ≥ 2), had 87.2% sensitivity (95% confidence interval [CI] = 83.0% to 91.5%) and 30.6% specificity (95% CI = 29.3% to 31.9%) for 30-day mortality (area under the receiving operating characteristic curve [AUROC] = 0.589, 95% CI = 0.566 to 0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI). CONCLUSIONS Older, injured adults transported by EMS to a large variety of trauma and nontrauma hospitals were more likely to die within 30 days if they required emergent airway management or had a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high-risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive.
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Affiliation(s)
- Ashley D. Meagher
- Division of Trauma and Critical Care Department of Surgery University of Washington Seattle WA
- Division of General Surgery Department of Surgery Indiana University Indianapolis IN
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
| | - Samuel P. Mandell
- Division of Trauma and Critical Care Department of Surgery University of Washington Seattle WA
| | - Eileen Bulger
- Division of Trauma and Critical Care Department of Surgery University of Washington Seattle WA
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
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Amoako J, Evans S, Brown NV, Khaliqdina S, Caterino JM. Identifying Predictors of Undertriage in Injured Older Adults After Implementation of Statewide Geriatric Trauma Triage Criteria. Acad Emerg Med 2019; 26:648-656. [PMID: 30661273 DOI: 10.1111/acem.13695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/02/2019] [Accepted: 01/11/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to identify factors associated with transport of injured older adults meeting statewide geriatric trauma triage criteria to a trauma center. METHODS An observational retrospective cohort study using the 2009 to 2011 Ohio Trauma Registry. Subjects were adults ≥ 70 years old who met Ohio's geriatric triage criteria for trauma center transport by emergency medical services. We created multivariable logistic regression models to identify predictors of initial and ultimate (e.g., interfacility transfer) transport to a Level I or II trauma center and to a Level I, II, or III center. RESULTS Of 10,411 subjects, 47% were initially and 59% were ultimately transported to a Level I or II trauma center with rates of 66 and 74%, respectively, for transport to a Level I, II, or III center. For initial transport to a Level I or II center, age 80 to 89 (odds ratio [OR] = 0.89), age ≥ 90 (OR = 0.76), and either only a Level 3 (OR = 0.3) or no trauma center (OR = 0.11) in county of residence had decreased odds of transport, while male sex (OR = 1.38), black race (OR = 2.07), Injury Severity Score (ISS) 10-15 (OR = 1.99), ISS > 15 (OR = 2.85), and Glasgow Coma Scale score < 9 (OR = 2.11) had increased odds. Results were similar for ultimate transport to a Level I or II center. Analyzing transport to a Level I, II, or III center demonstrated similar results except a Level III trauma center in county of residence was associated with increased odds (OR = 2.00 for initial and 2.21 for ultimate) of transport to a Level I, II, or III center. CONCLUSIONS We identified factors independently associated with failure to transport injured older adults to trauma centers in statewide data collected after adoption of geriatric triage criteria. Lack of a trauma center in the county of residence remained a factor even in analyses that included ultimate transport.
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Affiliation(s)
- Jeffrey Amoako
- The Ohio State University College of Medicine; The Ohio State University Wexner Medical Center; Columbus OH
| | - Sara Evans
- University of Cincinnati College of Medicine; Cincinnati OH
| | - Nicole V. Brown
- Center for Biostatistics; The Ohio State University Wexner Medical Center; Columbus OH
| | - Salman Khaliqdina
- Department of Emergency Medicine; The Ohio State University Wexner Medical Center; Columbus OH
| | - Jeffrey M. Caterino
- Department of Emergency Medicine; The Ohio State University Wexner Medical Center; Columbus OH
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Ringen AH, Gaski IA, Rustad H, Skaga NO, Gaarder C, Naess PA. Improvement in geriatric trauma outcomes in an evolving trauma system. Trauma Surg Acute Care Open 2019; 4:e000282. [PMID: 31245616 PMCID: PMC6560476 DOI: 10.1136/tsaco-2018-000282] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/14/2019] [Accepted: 02/28/2019] [Indexed: 01/07/2023] Open
Abstract
Background The elderly trauma patient has increased mortality compared with younger patients. During the last 15 years, initial treatment of severely injured patients at Oslo University Hospital Ulleval (OUHU) has changed resulting in overall improved outcomes. Whether this holds true for the elderly trauma population needs exploration and was the aim of the present study. Methods We performed a retrospective study of 2628 trauma patients 61 years or older admitted to OUHU during the 12-year period, 2002-2013. The population was stratified based on age (61-70 years, 71-80 years, 81 years and older) and divided into time periods: 2002-2009 (P1) and 2010-2013 (P2). Multiple logistic regression models were constructed to identify clinically relevant core variables correlated with mortality and trauma team activation rate. Results Crude mortality decreased from 19% in P1 to 13% in P2 (p<0.01) with an OR of 0.77 (95 %CI 0.65 to 0.91) when admitted in P2. Trauma team activation rates increased from 53% in P1 to 72% in P2 (p<0.01) with an OR of 2.16 (95% CI 1.93 to 2.41) for being met by a trauma team in P2. Mortality increased from 10% in the age group 61-70 years to 26% in the group above 80 years. Trauma team activation rates decreased from 71% in the age group 61-70 years to 50% in the age group older than 80 years. Median ISS were 17 in all three age groups and in both time periods. Discussion Development of a multidisciplinary dedicated trauma service is associated with increased trauma team activation rate as well as survival in geriatric trauma patients. As expected, mortality increased with age, although inversely related to the likelihood of being met by a trauma team. Trauma team activation should be considered for all trauma patients older than 70 years. Level of evidence Level IV.
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Affiliation(s)
- Amund Hovengen Ringen
- Department of Anesthesia, Oslo University Hospital Ulleval, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Iver Anders Gaski
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Hege Rustad
- Department of GI-Surgery, Oslo University Hospital Ulleval, Oslo, Norway
| | - Nils Oddvar Skaga
- Department of Anesthesia, Oslo University Hospital Ulleval, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Paal Aksel Naess
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
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Hon S, Gaona SD, Faul M, Holmes JF, Nishijima DK. How Well Do EMS Providers Predict Intracranial Hemorrhage in Head-Injured Older Adults? PREHOSP EMERG CARE 2019; 24:8-14. [PMID: 30895835 DOI: 10.1080/10903127.2019.1597954] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. Methods: This was a prospective observational cohort study conducted with five EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, "What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?" Responses were recorded as ordinal categories (<1%, 1-5%, >5-10%, >10-50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. Results: Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64-85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1-85.5%) and a specificity of 41.5% (37.7-45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1-3) was poorly sensitive (26.3%, 95% CI 17.7-37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9-99.3%) but poorly specific (12.9%, 95% CI 10.4-15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0-80.0%; specificity 35.3%, 95% CI 31.6-38.3%). Conclusions: As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included.
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Taylor BN, Rasnake N, McNutt K, McKnight CL, Daley BJ. Rapid Ground Transport of Trauma Patients: A Moderate Distance From Trauma Center Improves Survival. J Surg Res 2018; 232:318-324. [DOI: 10.1016/j.jss.2018.06.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/05/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
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van Rein EA, van der Sluijs R, Houwert RM, Gunning AC, Lichtveld RA, Leenen LP, van Heijl M. Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible? Am J Emerg Med 2018; 36:1060-1069. [DOI: 10.1016/j.ajem.2018.01.055] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022] Open
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Underbrink L, Dalton AT, Leonard J, Bourg PW, Blackmore A, Valverde H, Candlin T, Caputo LM, Duran C, Peckham S, Beckman J, Daruna B, Furie K, Hopgood D. New Immobilization Guidelines Change EMS Critical Thinking in Older Adults With Spine Trauma. PREHOSP EMERG CARE 2018; 22:637-644. [PMID: 29405797 DOI: 10.1080/10903127.2017.1423138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The impact of immobilization techniques on older adult trauma patients with spinal injury has rarely been studied. Our advisory group implemented a change in the immobilization protocol used by emergency medical services (EMS) professionals across a region encompassing 9 trauma centers and 24 EMS agencies in a Rocky Mountain state using a decentralized process on July 1, 2014. We sought to determine whether implementing the protocol would alter immobilization methods and affect patient outcomes among adults ≥60 years with a cervical spine injury. METHODS This was a 4-year retrospective study of patients ≥60 years with a cervical spine injury (fracture or cord). Immobilization techniques used by EMS professionals, patient demographics, injury characteristics, and in-hospital outcomes were compared before (1/1/12-6/30/14) and after (7/1/14-12/31/15) implementation of the Spinal Precautions Protocol using bivariate and multivariate analyses. RESULTS Of 15,063 adult trauma patients admitted to nine trauma centers, 7,737 (51%) were ≥60 years. Of those, 237 patients had cervical spine injury and were included in the study; 123 (51.9%) and 114 (48.1%) were transported before and after protocol implementation, respectively. There was a significant shift in the immobilization methods used after protocol implementation, with less full immobilization (59.4% to 28.1%, p < 0.001) and an increase in the use of both a cervical collar only (8.9% to 27.2%, p < 0.001) and not using any immobilization device (15.5% to 31.6%, p = 0.003) after protocol implementation. While the proportion of patients who only received a cervical collar increased after implementing the Spinal Precautions Protocol, the overall proportion of patients who received a cervical collar alone or in combination with other immobilization techniques decreased (72.4% to 56.1%, p = 0.01). The presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was similar before and after protocol implementation; in-hospital mortality (adjusted odds ratio = 0.56, 95% confidence interval: 0.24-1.30, p = 0.18) was similar post-protocol implementation after adjusting for injury severity. CONCLUSIONS There were no differences in neurologic deficit or patient disposition in the older adult patient with cervical spine trauma despite changes in spinal restriction protocols and resulting differences in immobilization devices.
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