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Rafieezadeh A, Zangbar B, Zeeshan M, Gandhi C, Al-Mufti F, Jehan F, Kirsch J, Rodriguez G, Samson D, Prabhakaran K. Predictors of mortality after craniotomy for geriatric traumatic brain injury. Injury 2024; 55:111585. [PMID: 38704345 DOI: 10.1016/j.injury.2024.111585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/02/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy. METHODS We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08. RESULTS We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all). CONCLUSIONS Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome. LEVEL OF EVIDENCE Level III retrospective study.
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Affiliation(s)
- Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States.
| | - Muhammad Zeeshan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Chirag Gandhi
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Fawaz Al-Mufti
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Faisal Jehan
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Gabriel Rodriguez
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - David Samson
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Kartik Prabhakaran
- Westchester Medical Center, New York Medical College, Valhalla, NY, United States
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Kelly ML, Stuart M, Zouki J, Long B, Sabat N, Clark CR, Donaldson E, Colbran RE. General surgeon performed emergency craniotomies in regional Queensland hospitals: a 20-year state-wide study on patient outcomes. ANZ J Surg 2024; 94:585-590. [PMID: 38553955 DOI: 10.1111/ans.18911] [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: 10/27/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Traumatic brain injuries account for up to 50% of trauma related deaths and if surgical intervention is indicated, consensus suggests a maximum of 4 hours to surgical decompression. The occurrence and outcomes of craniotomies performed by non-neurosurgeons in regional Queensland hospitals have never been reported previously in the literature. METHODS A retrospective review was performed at all regional Queensland hospitals without an on-site neurosurgical service from January 2001 to December 2022 to identify patients undergoing emergency craniotomy. Data recorded included basic demographics, history of anti-coagulant use, mechanism of injury, type of haemorrhage, Glasgow Coma Score and Glasgow Outcome Scale (GOS) on discharge. Radiological parameters measured included midline shift and maximal coronal depth of haematoma. The primary aim of this study was to assess the clinical and radiological outcomes of patients who underwent a craniotomy performed by general surgeons. RESULTS Over the past 20 years there have been 23 emergency decompressive procedures (one excluded) performed in regional Queensland. Preoperative imaging demonstrated 9 extradural haematomas and 13 subdural haematomas. Six of 17 transferred cases required reoperation after transfer to a neurosurgical centre. Survival was observed in 9 of 22 cases, with 'good' functional outcome (GOS ≥3) observed in 7 cases. In no cases were rurally performed burr holes effective. DISCUSSION Qualitatively, a larger craniotomy may be associated with better clinical and radiological outcomes. Although rare occurrences, our results demonstrate that general surgeon performed craniotomies are frequently efficacious in producing radiological and/or clinical improvement and should be considered as a potentially lifesaving procedure.
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Affiliation(s)
- Madeleine Louise Kelly
- Department of General Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Michael Stuart
- Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Jason Zouki
- Department of General Surgery, Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Brittany Long
- Department of General Surgery, Cairns Hospital, Cairns, Queensland, Australia
| | - Nestor Sabat
- Department of General Surgery, Mackay Hospital, Mackay, Queensland, Australia
| | - Claudia Rose Clark
- Department of General Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Eric Donaldson
- Department of General Surgery, Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Rachel Emily Colbran
- Department of General Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Haseeb A, Oduoye MO, Jawed I. Letter to the editor "effect of continuous hypertonic saline infusion on clinical outcomes in patients with traumatic brain injury". Neurosurg Rev 2024; 47:96. [PMID: 38413416 DOI: 10.1007/s10143-024-02331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan.
| | | | - Inshal Jawed
- Department of Medicine, Dow University of Health Sciences, Mission Rd, Karachi, Sindh, Pakistan
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Mouchtouris N, Luck T, Yudkoff C, Locke K, Momin A, Khanna O, Andrews C, Gonzalez G, Harrop J, Shah SO, Jallo J. Ventriculostomy Associated with Reduced Mortality in Severe Traumatic Brain Injury Compared to Parenchymal ICP Monitoring: A Propensity Score-Adjusted Analysis. World Neurosurg 2023; 178:e445-e452. [PMID: 37495098 DOI: 10.1016/j.wneu.2023.07.096] [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: 07/02/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND There is a lack of data on whether intracranial pressure (ICP)-guided therapy with an intraparenchymal fiberoptic monitor (IPM) or an external ventricular drain (EVD) leads to superior outcomes. Our goal is to determine the relationship between ICP-guided therapy with an EVD or IPM and mortality. METHODS Retrospective analysis of severe traumatic brain injury cases that required IPM or EVD placement for ICP-guided therapy from January 1, 2010 to December 31, 2020. The data were obtained from the Pennsylvania Trauma Systems Foundation registry. RESULTS A total of 2305 patients met the inclusion criteria, with 1048 (45.5%) IPM and 1257 (54.5%) EVD placed. Inpatient mortality occurred in 337 (32.2%) and 334 (26.6%) patients in the IPM and EVD cohorts, respectively (P = 0.003). Even among those treated medically only, inpatient mortality occurred in 171 (30.8%) of those with an IPM and in 100 (23.4%) of those with an EVD (P = 0.010). Multivariable logistic regression analysis showed that older age (odds ratio [OR] 1.03, P < 0.001), lower Glasgow Coma Scale (GCS) score (OR 1.16, P < 0.001), requiring surgery (OR 1.22, P = 0.049), and an IPM (OR 1.40, P = 0.001) were significant predictors of mortality. Propensity score-adjusted analysis using inverse probability of treatment weighted method revealed a 28% decrease in mortality and a 14% decrease in length of hospital stay with EVD use when adjusting for age, sex, GCS, Injury Severity Score, surgery, and Hispanic ethnicity. CONCLUSIONS A significant mortality benefit was associated with the use of EVD compared to IPM. This mortality benefit was observed regardless of whether patients required surgery or not.
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Affiliation(s)
- Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
| | - Trevor Luck
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Clifford Yudkoff
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Katherine Locke
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Arbaz Momin
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Carrie Andrews
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Glenn Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Syed Omar Shah
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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Van Ditshuizen JC, Rojer LA, Van Lieshout EM, Bramer WM, Verhofstad MH, Sewalt CA, Den Hartog D. Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis. J Trauma Acute Care Surg 2023; 94:877-892. [PMID: 36726194 PMCID: PMC10208644 DOI: 10.1097/ta.0000000000003890] [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: 09/22/2022] [Revised: 12/20/2022] [Accepted: 01/01/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trauma networks have multiple designated levels of trauma care. This classification parallels concentration of major trauma care, creating innovations and improving outcome measures. OBJECTIVES The objective of this study is to assess associations of level of trauma care with patient outcomes for populations with specific severe injuries. METHODS A systematic literature search was conducted using six electronic databases up to April 19, 2022 (PROSPERO CRD42022327576). Studies comparing fatal, nonfatal clinical, or functional outcomes across different levels of trauma care for trauma populations with specific severe injuries or injured body region (Abbreviated Injury Scale score ≥3) were included. Two independent reviewers included studies, extracted data, and assessed quality. Unadjusted and adjusted pooled effect sizes were calculated with random-effects meta-analysis comparing Level I and Level II trauma centers. RESULTS Thirty-five studies (1,100,888 patients) were included, of which 25 studies (n = 443,095) used for meta-analysis, suggesting a survival benefit for the severely injured admitted to a Level I trauma center compared with a Level II trauma center (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06-1.25). Adjusted subgroup analysis on in-hospital mortality was done for patients with traumatic brain injuries (OR, 1.23; 95% CI, 1.01-1.50) and hemodynamically unstable patients (OR, 1.09; 95% CI, 0.98-1.22). Hospital and intensive care unit length of stay resulted in an unadjusted mean difference of -1.63 (95% CI, -2.89 to -0.36) and -0.21 (95% CI, -1.04 to 0.61), respectively, discharged home resulted in an unadjusted OR of 0.92 (95% CI, 0.78-1.09). CONCLUSION Severely injured patients admitted to a Level I trauma center have a survival benefit. Nonfatal outcomes were indicative for a longer stay, more intensive care, and more frequently posthospital recovery trajectories after being admitted to top levels of trauma care. Trauma networks with designated levels of trauma care are beneficial to the multidisciplinary character of trauma care. LEVEL OF EVIDENCE Systematic review and meta-analysis; Level III.
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Matthews L, Kelly E, Fleming A, Byerly S, Fischer P, Molyneaux I, Kerwin A, Howley I. An Analysis of Injured Patients Treated at Level 1 Trauma Centers Versus Other Centers: A Scoping Review. J Surg Res 2023; 284:70-93. [PMID: 36549038 DOI: 10.1016/j.jss.2022.11.062] [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: 06/03/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Trauma systems continue to evolve to create the best outcomes possible for patients who have undergone traumatic injury. OBJECTIVE This review aims to evaluate the existing research on outcomes based on field triage to a Level 1 trauma center (L1TC) compared to other levels of hospitals and nontrauma centers. METHODS A structured literature search was conducted using PubMed, CINAHL, Embase, and the Cochrane Database. Studies analyzing measures of morbidity, mortality, and cost after receiving care at L1TCs compared to lower-level trauma centers and nontrauma centers in the United States and Canada were included. Three independent reviewers reviewed abstracts, and two independent reviewers conducted full-text review and quality assessment of the included articles. RESULTS Twelve thousand five hundred fourteen unique articles were identified using the literature search. 61 relevant studies were included in this scoping review. 95.2% of included studies were national or regional studies, and 96.8% were registry-based studies. 72.6% of included studies adjusted their results to account for injury severity. The findings from receiving trauma care at L1TCs vary depending on severity of injury, type of injury sustained, and patient characteristics. Existing literature suffers from limitations inherent to large de-identified databases, making record linkage between hospitals impossible. CONCLUSIONS This scoping review shows that the survival benefit of L1TC care is largest for patients with the most severe injuries. This scoping review demonstrates that further research using high-quality data is needed to elucidate more about how to structure trauma systems to improve outcomes for patients with different severities of injuries and in different types of facilities.
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Affiliation(s)
- Lynley Matthews
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Emma Kelly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew Fleming
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Peter Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ian Molyneaux
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew Kerwin
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Isaac Howley
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Plurad DS, Geesman G, Sheets NW, Chawla-Kondal B, Ayutyanont N, Mahmoud A. A Contemporary Analysis of the Effect of Trauma Center Verification Level on Mortality in Severe Injury. Am Surg 2023; 89:286-292. [PMID: 34060924 DOI: 10.1177/00031348211023437] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Literature demonstrates increased mortality for the severely injured at a Level II vs. Level I center. Our objective is to reevaluate the impact of trauma center verification level on mortality for patients with an Injury Severity Score (ISS) > 15 utilizing more contemporary data. We hypothesize that there would be no mortality discrepancy. STUDY DESIGN Utilizing the ACS Trauma Quality Program Participant Use File admission year 2017, we identified severely injured (ISS >15) adult (age >15 years) patients treated at an ACS-verified Level I or Level II center. We excluded patients who underwent interfacility transfer. Logistic regression was performed to determine adjusted associations with mortality. RESULTS There were 63 518 patients included, where 43 680 (68.8%) were treated at a Level I center and 19 838 (31.2%) at a Level II. Male gender (70.1%) and blunt injuries (92.0%) predominated. Level I admissions had a higher mean ISS [23.8 (±8.5) vs. 22.9 (±7.8), <.001], while Level II patients were older [mean age (y) 52.3 (±21.6) vs. 48.6 (±21.0), <.001] with multiple comorbidities (37.7% vs. 34.9%, <.001). Adjusted mortality between Level I and II centers was similar (12.0% vs. 11.8%, .570). CONCLUSIONS Despite previous findings, mortality outcomes are similar for severely injured patients treated at a Level I vs. Level II center. We theorize that this relates to mandated Level II resourcing as defined by an updated American College of Surgeons verification process.
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Affiliation(s)
- David S Plurad
- HCA Healthcare, Nashville, TN, USA.,Section of Trauma, 43951Riverside Community Hospital, Riverside, CA, USA
| | - Glenn Geesman
- HCA Healthcare, Nashville, TN, USA.,Section of General Surgery, 43951Riverside Community Hospital, Riverside, CA, USA
| | - Nicholas W Sheets
- HCA Healthcare, Nashville, TN, USA.,Section of Trauma, 43951Riverside Community Hospital, Riverside, CA, USA
| | - Bhani Chawla-Kondal
- HCA Healthcare, Nashville, TN, USA.,Section of Trauma, 43951Riverside Community Hospital, Riverside, CA, USA
| | | | - Ahmed Mahmoud
- HCA Healthcare, Nashville, TN, USA.,Section of General Surgery, 43951Riverside Community Hospital, Riverside, CA, USA
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Li J, Zhang X, Su H, Qu Y, Piao M. Investigation of the Effects of Large Bone Flap Craniotomy on Cerebral Hemodynamics, Intracranial Infection Rate, and Nerve Function in Patients with Severe Craniocerebral Trauma. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2681278. [PMID: 36101799 PMCID: PMC9462990 DOI: 10.1155/2022/2681278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/11/2022] [Accepted: 06/17/2022] [Indexed: 11/17/2022]
Abstract
In order to explore the clinical value of large bone flap craniotomy, the effects of standard large bone flap craniotomy on cerebral hemodynamic indexes, incidence of postoperative intracranial infection, and neurological function in patients with severe craniocerebral trauma are investigated. 89 patients with severe craniocerebral trauma admitted from January 2020 to June 2021 are analyzed retrospectively. All patients are divided into a large craniotomy group (n = 45) and control group (n = 44) according to different surgical methods. The large craniotomy group is treated with large craniotomy decompression, and the control group is treated with traditional craniotomy decompression. The incidence of intracranial infection in each group is recorded, and NIHSS is applied to observe the neurological function recovery of 2 groups before and 1 month after operation. Besides, the patients are followed up after surgery and the Kaplan-Meier survival curve is obtained to compare the survival rate of patients in the two groups. It is clearly evident that the two surgical methods have certain clinical efficacy in the treatment of patients with severe craniocerebral trauma. Comparatively, the large craniotomy can further improve brain blood supply and improve neurological function recovery. Also, it can obtain low incidence of postoperative adverse reactions and intracranial infection.
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Affiliation(s)
- JiNan Li
- Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China
| | - XinLi Zhang
- Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China
| | - Hang Su
- Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China
| | - YaNan Qu
- Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China
| | - Meixuan Piao
- Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China
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Koruga N, Soldo Koruga A, Rončević R, Turk T, Kopačin V, Kretić D, Rotim T, Rončević A. Telemedicine in Neurosurgical Trauma during the COVID-19 Pandemic: A Single-Center Experience. Diagnostics (Basel) 2022; 12:diagnostics12092061. [PMID: 36140463 PMCID: PMC9497489 DOI: 10.3390/diagnostics12092061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Telemedicine is a rapid tool that reduces the time until treatment for patients, which is especially useful for neurosurgical trauma. The aim of our study was to evaluate the use of telemedicine in neurosurgery during the COVID-19 pandemic compared with the pre-pandemic era. We assessed the utilization of telemedicine at the Department of Neurosurgery at University Hospital Center Osijek in Croatia over a timespan of one year prior to the COVID-19 pandemic and the first year of the pandemic, starting with the date of first lockdown in Croatia. For each time period, the total number of consults and specific clinical inquiries were recorded and adequately grouped as well as comprehensive patient characteristics. There were 336 consults in the pre-pandemic period and 504 in the pandemic period. The number of trauma-related consults during COVID-19 measures was significantly higher than the pre-pandemic era (288 and 138, respectively, p < 0.0001). Neurosurgical trauma patients requiring consults in the pandemic period were significantly older than before the pandemic (64.9 ± 18.5 and 60.6 ± 19.1, respectively, p = 0.03). Significantly, the number of admissions to our center and urgent surgeries did not significantly differ between these periods. Telemedicine is a cost-effective tool in the neurosurgical evaluation of patients, especially for trauma. The COVID-19 pandemic accelerated telemedicine implementation and improved neurosurgical trauma treatments.
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Affiliation(s)
- Nenad Koruga
- Department of Neurosurgery, University Hospital Center Osijek, 31000 Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
| | - Anamarija Soldo Koruga
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Neurology, University Hospital Center Osijek, 31000 Osijek, Croatia
| | - Robert Rončević
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Center Osijek, 31000 Osijek, Croatia
| | - Tajana Turk
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Center Osijek, 31000 Osijek, Croatia
| | - Vjekoslav Kopačin
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Center Osijek, 31000 Osijek, Croatia
| | - Domagoj Kretić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Center Osijek, 31000 Osijek, Croatia
| | - Tatjana Rotim
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Center Osijek, 31000 Osijek, Croatia
| | - Alen Rončević
- Department of Neurosurgery, University Hospital Center Osijek, 31000 Osijek, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Correspondence: ; Tel.: +385-98-1698481
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Campbell M, Zagel AL, Ortega H, Kreykes N, Tu A, Linabery AM, Plasencia L, Krause E, Bergmann KR. Quality Indicators for Children With Traumatic Brain Injury After Transition to an American College of Surgeons Level I Pediatric Trauma Center. Pediatr Emerg Care 2022; 38:e329-e336. [PMID: 33109937 DOI: 10.1097/pec.0000000000002276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare quality indicators, including frequency of acute surgical and emergent interventions, and resource utilization before and after American College of Surgeons (ACS) level I trauma verification among children with moderate or severe traumatic brain injury (TBI). METHODS This is a retrospective review of patients younger than 18 years treated for moderate or severe TBI, as determined by International Classification of Disease codes. Our institution obtained ACS level I trauma verification in 2013. Outcomes during the pre-ACS (June 2003-May 2008), interim (June 2008-May 2013), and post-ACS (June 2013-May 2018) periods were compared via nonparametric tests. Tests for linear trend were conducted using Cochran-Armitage tests for categorical data and by linear regression for continuous variables. RESULTS There were 677 children with moderate or severe TBIs (pre-ACS, 125; interim, 198; post-ACS, 354). Frequency of any surgical intervention increased significantly in the post-ACS period (12.2%) compared with interim (5.1%) and pre-ACS periods (5.6%, P = 0.007). More children in the post-ACS period required intracranial pressure monitoring (P = 0.017), external ventricular drain placement (P = 0.003), or endotracheal intubation (P = 0.001) compared with interim and pre-ACS periods. There was no significant change in time to operating room (P = 0.514), frequency of decompression (P = 0.096), or time to decompression (P = 0.788) between study periods. The median time to head CT decreased significantly in the post-ACS period (26 minutes; interquartile range [IQR], 9-60) compared with interim (36 minutes; IQR, 21-69) and pre-ACS periods (53 minutes; IQR, 36-89; P < 0.001). Frequency of repeat head computed tomography decreased significantly in the post-ACS period (30.2%) compared with interim (56.1%) and pre-ACS periods (64.0%, Ptrend = 0.044). CONCLUSIONS Transition to an ACS level I trauma verification was associated with improvements in quality indicators for children with moderate or severe TBI.
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Affiliation(s)
- Maryellen Campbell
- From the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | | | | | | | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Giugni A, Gamberini L, Carrara G, Antiga L, Brissy O, Buldini V, Calamai I, Csomos A, De Luca A, Ferri E, Fleming JM, Gradisek P, Kaps R, Kyprianou T, Lagomarsino S, Lazar I, Martino C, Mikaszewska-Sokolewicz M, Montis A, Nardai G, Nattino G, Nattino G, Paci G, Portolani L, Xirouchaki N, Chieregato A, Bertolini G. Hospitals with and without neurosurgery: a comparative study evaluating the outcome of patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med 2021; 29:158. [PMID: 34727955 PMCID: PMC8561979 DOI: 10.1186/s13049-021-00959-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/22/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND We leveraged the data of the international CREACTIVE consortium to investigate whether the outcome of traumatic brain injury (TBI) patients admitted to intensive care units (ICU) in hospitals without on-site neurosurgical capabilities (no-NSH) would differ had the same patients been admitted to ICUs in hospitals with neurosurgical capabilities (NSH). METHODS The CREACTIVE observational study enrolled more than 8000 patients from 83 ICUs. Adult TBI patients admitted to no-NSH ICUs within 48 h of trauma were propensity-score matched 1:3 with patients admitted to NSH ICUs. The primary outcome was the 6-month extended Glasgow Outcome Scale (GOS-E), while secondary outcomes were ICU and hospital mortality. RESULTS A total of 232 patients, less than 5% of the eligible cohort, were admitted to no-NSH ICUs. Each of them was matched to 3 NSH patients, leading to a study sample of 928 TBI patients where the no-NSH and NSH groups were well-balanced with respect to all of the variables included into the propensity score. Patients admitted to no-NSH ICUs experienced significantly higher ICU and in-hospital mortality. Compared to the matched NSH ICU admissions, their 6-month GOS-E scores showed a significantly higher prevalence of upper good recovery for cases with mild TBI and low expected mortality risk at admission, along with a progressively higher incidence of poor outcomes with increased TBI severity and mortality risk. CONCLUSIONS In our study, centralization of TBI patients significantly impacted short- and long-term outcomes. For TBI patients admitted to no-NSH centers, our results suggest that the least critically ill can effectively be managed in centers without neurosurgical capabilities. Conversely, the most complex patients would benefit from being treated in high-volume, neuro-oriented ICUs.
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Affiliation(s)
- Aimone Giugni
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Lorenzo Gamberini
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Greta Carrara
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | | | - Obou Brissy
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | - Virginia Buldini
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Italo Calamai
- Anesthesia and Intensive Care Unit, AUSL Toscana Centro, San Giuseppe Hospital, Empoli, Florence, Italy
| | - Akos Csomos
- Hungarian Army Medical Center, Budapest, Hungary
| | - Alessandra De Luca
- Neurointensive Care Unit, Department of Anesthesia and Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Enrico Ferri
- Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital, Bologna, Italy
| | - Joanne M Fleming
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | - Primoz Gradisek
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Rafael Kaps
- General Hospital Novo Mesto, Novo Mesto, Slovenia
| | - Theodoros Kyprianou
- University of Nicosia Medical School, Nicosia, Cyprus
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Silvia Lagomarsino
- Neurointensive Care Unit, Department of Anesthesia and Intensive Care Unit, AOU Careggi, Florence, Italy
| | - Isaac Lazar
- Pediatric Intensive Care Unit, Soroka Medical Center and The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Costanza Martino
- Anesthesia and Intensive Care Unit, AUSL Romagna, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Andrea Montis
- Department of Neurorehabilitation, ASSL Oristano, ATS Sardegna, Oristano, Italy
| | - Gabor Nardai
- Department of Anaesthesiology and Intensive Care, Péterfy Hospital and Trauma Centre, Budapest, Hungary
| | - Giovanni Nattino
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy.
| | - Giuseppe Nattino
- Intensive Care Unit, Azienda Socio Sanitaria Territoriale di Lecco, Lecco, Italy
| | - Giulia Paci
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
| | - Laila Portolani
- Anesthesia and Intensive Care Unit, AUSL Romagna, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Arturo Chieregato
- Neurointensive Care Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Guido Bertolini
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Villa Camozzi, Via G.B. Camozzi 3, 24020, Ranica, Bergamo, Italy
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12
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Sewalt CA, Gravesteijn BY, Nieboer D, Steyerberg EW, Den Hartog D, Van Klaveren D. Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers. BMC Emerg Med 2021; 21:93. [PMID: 34362302 PMCID: PMC8344140 DOI: 10.1186/s12873-021-00487-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 07/26/2021] [Indexed: 12/16/2022] Open
Abstract
Background Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. Methods We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. Results We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92–0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). Conclusions Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00487-3.
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Affiliation(s)
- Charlie A Sewalt
- Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands. .,Trauma Research Unit, Department of Surgery, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands.
| | - Benjamin Y Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands
| | - David Van Klaveren
- Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands
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Barami K, Pemberton J, Banerjee A, London J, Bandy W. A Retrospective Analysis of Intracranial Pressure Monitoring and Outcomes in Adults after Severe Traumatic Brain Injury at Kaiser Permanente Trauma Centers. Perm J 2021; 25. [PMID: 35348072 DOI: 10.7812/tpp/20.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The role of intracranial pressure (ICP) monitoring in improving outcomes after severe traumatic brain injury especially at level II trauma centers remains controversial. A retrospective analysis was undertaken to assess the impact of ICP monitoring on mortality and long-term functional outcome in adults after severe traumatic brain injury at level II trauma centers. METHODS The data were extracted from the Kaiser Permanente trauma database. Inclusion criteria were adults (≥ 18 years) with severe traumatic brain injury (Glasgow Coma Scale score, < 9) admitted to 2 level II trauma centers in Northern California from 2014 to 2019. RESULTS Of 199 patients, 58 (29.1%) underwent ICP monitoring. The monitored subgroup was significantly younger (< 65 years), had lower Glasgow Coma Scale scores (3-5), underwent cranial procedures (craniotomy or decompressive craniectomy) more often, and had greater injury severity scores (≥ 15). Despite monitored patients being more severely injured, there was no significant difference in mortality or 6-month favorable outcomes between monitored and nonmonitored patients, including patients who underwent cranial procedures. Increased monitoring frequency and reduction in overall mortality was seen throughout the study period yet with a parallel reduction in both groups. CONCLUSION ICP monitoring may not impact in-patient mortality or long-term outcomes at level II trauma centers. Improved outcomes may be more related to identifying patients who may benefit from ICP-guided therapy rather than simply increasing the overall use of it. Last, our pattern of care and outcomes are comparable to level I trauma centers and our findings may serve as a benchmark for future studies.
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Affiliation(s)
- Kaveh Barami
- Department of Neurosurgery, Kaiser Vacaville, Vacaville, CA
| | | | - Amit Banerjee
- Department of Neurosurgery, Kaiser Sacramento, Sacramento, CA
| | - Jason London
- Department of Trauma Surgery, Kaiser South Sacramento, Sacramento, CA
| | - William Bandy
- Department of Trauma Surgery, Kaiser Vacaville, Vacaville, CA
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Baron RB, Neifert SN, Martini ML, Maragkos GA, McNeill IT, Lamb C, Rasouli JJ, Caridi JM. A Comparison of Outcomes for Spinal Trauma Patients at Level I and Level II Centers. Clin Spine Surg 2021; 34:153-157. [PMID: 33044272 DOI: 10.1097/bsd.0000000000001074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective analysis of a national database. OBJECTIVE To characterize the spine trauma population, describe trauma center (TC) resources, and compare rates of outcomes between the American College of Surgeons (ACS) level I and level II centers. SUMMARY OF BACKGROUND DATA Each year, thousands of patients are treated for spinal trauma in the United States. Although prior analyses have explored postsurgical outcomes for patients with trauma, no study has evaluated these metrics for spinal trauma at level I and level II TCs. MATERIALS AND METHODS The ACS Trauma Quality Improvement Program was queried for all spinal trauma cases between 2013 and 2015, excluding polytrauma cases, patients discharged within 24 hours, data from TCs without a designated level, and patients transferred for treatment. RESULTS Although there were similar rates of severe spine traumas (Abbreviated Injury Scale≥3) at ACS level I and level II centers (P=0.7), a greater proportion of level I patients required mechanical ventilation upon emergency department arrival (P=0.0002). Patients at level I centers suffered from higher rates of infectious complications, including severe sepsis (0.58% vs. 0.31%, P=0.02) and urinary tract infections (3.26% vs. 2.34%, P=0.0009). Intensive care unit time (1.90 vs. 1.65 days, P=0.005) and overall length of stay (8.37 days vs. 7.44 days, P<0.0001) was higher at level I TCs. Multivariate regression revealed higher adjusted overall complication rates at level II centers (odds ratio, 1.15, 95% confidence interval, 1.06-1.24; P<0.001), but no difference in mortality (odds ratio, 1.18; 95% confidence interval, 0.92-1.52; P>0.10). CONCLUSIONS ACS level I TCs possess larger surgical staff and are more likely to be academic centers. Patients treated at level I centers experience fewer overall complications but have a greater incidence of infectious complications. Mortality rates are not statistically different.
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Affiliation(s)
- Rebecca B Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Plurad D, Geesman G, Sheets N, Chawla-Kondal B, Mahmoud A. A Re-Evaluation of the Effect of Trauma Center Verification Level on the Early Risk of Death in Hemodynamically Unstable Patients. Cureus 2021; 13:e14462. [PMID: 33996322 PMCID: PMC8118090 DOI: 10.7759/cureus.14462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Studies show increased early and overall mortality at level II compared to level I trauma centers in hemodynamically unstable patients. We hypothesize there is no mortality difference between level I and level II centers applying more contemporary data. Study design Utilizing the 2017 Trauma Quality Program Participant Use File (TQP-PUF), we identified adult patients (age >14 years) who presented to an American College of Surgeons (ACS) verified level I or II center with hypotension (systolic blood pressure [SBP] < 90 mmHg). Logistic regression was performed to identify adjusted associations with mortality. Results A total of 7,264 patients met the inclusion criteria, of whom most were males (4,924 [67.8%]) with blunt trauma (5,924 [81.6%]) being predominated. Mean admission SBP was 73.2 (±13.0) mmHg. There were 1,097 (15.1%) deaths. Level I admissions (4,931 (67.9%]) were more likely male (3,389 [68.7%] vs. 1,535 [65.8]; p=0.012), non-white (3,119 [63.3%] vs. 1,664 [71.3%]; p<0.001), a victim of penetrating trauma (933 [18.9%] vs. 385 [16.5%]; p=0.015), and more severely injured (mean Injury Severity Score: 19.3 [±15] vs. 16.7 [±13.7]; p<0.001). Level II admissions (2,333 [32.1%]) were older (46.8 [±18.5] vs. 50.3 [±20.1] years; p<0.001) with more co-morbidities (mean Charlson Comorbidity Index: 1.43 [±2] vs. 1.77 [±2.2]; p<0.001). Adjusted mortality between level I and II admissions was similar (766 [15.5%] vs. 331 [14.2%]; p=0.918). Early hourly mortality also did not differ. Conclusion There is no overall or hourly mortality discrepancy between ACS-verified level I and II centers for patients presenting with hypotension. This potentially relates to the use of more contemporary data gathered after implementation of updated verification requirements.
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Affiliation(s)
- David Plurad
- Trauma and Acute Care Surgery, Riverside Community Hospital, Riverside, USA
| | - Glenn Geesman
- General Surgery, Riverside Community Hospital, Riverside, USA
| | - Nicholas Sheets
- Trauma and Acute Care Surgery, Riverside Community Hospital, Riverside, USA
| | | | - Ahmed Mahmoud
- General Surgery, Riverside Community Hospital, Riverside, USA
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16
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Plurad DS, Geesman G, Mahmoud A, Sheets N, Chawla‐Kondal B, Ayutyanont N, Ghostine S, Guldner G. The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer. Acad Emerg Med 2021; 28:292-299. [PMID: 33010085 DOI: 10.1111/acem.14145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/14/2020] [Accepted: 09/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous literature demonstrates increased mortality for traumatic brain injury (TBI) with transfer to a Level II versus Level I trauma center. Our objective was to determine the effect of the most recent American College of Surgeons-Committee on Trauma (ACS-COT) "Resources for the Optimal Care of the Injured Patient" resources manual ("The Orange Book") on outcomes after severe TBI after interfacility transfer to Level I versus Level II center. METHODS Utilizing the Trauma Quality Program Participant Use File of the American College of Surgeons admission year 2017, we identified patients with isolated TBI undergoing interfacility transfer to either Level I or Level II trauma center. Logistic regression was performed to determine independent associations with mortality. RESULTS There were 10,268 (71.6%) transferred to a Level I center and 4,025 (28.4%) were transferred to a Level II center. They were mostly male (61.4%) with a mean ± SD age of 61 ± 20.8 years. Mean Injury Severity Score was 16.3 ± 6.3 and most were injured in a single-level fall (51.5%). Patients transferred to a Level I center were less likely to be White (82.3% vs. 84.7%, 0.002) and more likely to have sustained penetrating trauma (2.7% vs. 1.6%, <0.001). The incidence of severe TBI (Glasgow Coma Scale [GCS] = 3-8) was similar (9.3% vs. 8.3%, 0.068). On logistic regression, severity of TBI predicted death; however, there was no difference in adjusted mortality outcome with admission to a Level II versus a Level I center (0.998 [0.836-1.192], 0.985). CONCLUSIONS There is no mortality discrepancy in patients with isolated TBI transferred to a Level II versus Level I center despite previous contrary evidence and thus no reason to bypass a Level II in favor of a Level I. This relative improvement potentially relates to the new requirements as defined in the latest version of the ACS-COT's resources manual.
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Affiliation(s)
- David S. Plurad
- From HCA Healthcare
- the Section of Trauma Riverside Community Hospital Riverside CAUSA
| | - Glenn Geesman
- From HCA Healthcare
- the Section of General Surgery Riverside Community Hospital Riverside CAUSA
| | - Ahmed Mahmoud
- From HCA Healthcare
- the Section of General Surgery Riverside Community Hospital Riverside CAUSA
| | - Nicholas Sheets
- From HCA Healthcare
- the Section of Trauma Riverside Community Hospital Riverside CAUSA
| | - Bhani Chawla‐Kondal
- From HCA Healthcare
- the Section of Trauma Riverside Community Hospital Riverside CAUSA
| | | | - Samer Ghostine
- and the Department Neurosurgery Services University of California–Riverside Riverside CAUSA
| | - Gregory Guldner
- and the Department Emergency Medicine Riverside Community Hospital Riverside CAUSA
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Jenkins PC, Newgard CD. The Effect of Trauma Center Verification on Outcomes of Traumatic Brain Injury Patients Undergoing Interfacility Transfer. Acad Emerg Med 2021; 28:375-376. [PMID: 33258185 DOI: 10.1111/acem.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Peter C. Jenkins
- Department of Surgery Indiana University School of Medicine Indianapolis INUSA
| | - Craig D. Newgard
- Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland ORUSA
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18
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Jakob DA, Benjamin ER, Cremonini C, Demetriades D. Management and outcomes of severe pelvic fractures in level I and II ACS verified trauma centers. Am J Surg 2020; 222:227-233. [PMID: 33131692 DOI: 10.1016/j.amjsurg.2020.10.031] [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: 09/03/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the management strategies and outcomes of isolated severe pelvic fractures in level I and II ACS verified trauma centers. METHODS ACS-TQIP database study, including patients with blunt, isolated severe pelvic facture (AIS 3-5). RESULTS 2629 level I and 1277 level II patients were included. Early blood product transfusion was significantly higher, pharmacological VTE prophylaxis significantly lower and ICU length of stay significantly longer in level II centers (p < 0.001). On multivariate analysis, treatment at level II centers was independently associated with increased overall complications, specifically ARDS, but not mortality. CONCLUSIONS In isolated severe pelvic fractures there was a significantly higher use of early blood products, less VTE pharmacological prophylaxis, longer ICU length of stay and higher overall complications and ARDS in level II centers. Blood product utilization and pharmacological VTE prophylaxis are potential areas of quality improvement in level II centers.
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Affiliation(s)
- Dominik A Jakob
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County University of Southern California Medical Center, University of Southern California Los Angeles, CA, 90033, USA.
| | - Elizabeth R Benjamin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County University of Southern California Medical Center, University of Southern California Los Angeles, CA, 90033, USA.
| | - Camilla Cremonini
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County University of Southern California Medical Center, University of Southern California Los Angeles, CA, 90033, USA.
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County University of Southern California Medical Center, University of Southern California Los Angeles, CA, 90033, USA.
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Livingston JK, Grigorian A, Kuza C, Galvin K, Joe V, Chin T, Bernal N, Nahmias J. No Difference in Mortality Between Level I and II Trauma Centers for Combined Burn and Trauma. J Surg Res 2020; 256:528-535. [PMID: 32799001 DOI: 10.1016/j.jss.2020.07.007] [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: 02/17/2020] [Revised: 06/22/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Trauma patients with burn injuries have higher morbidity and mortality rates compared with patients who solely experience burn or trauma injuries. There is a paucity of data regarding burn-trauma (BT) patient outcomes at level I (LI) trauma centers compared with level II (LII) centers. We hypothesized that BT patients at LI trauma centers have lower mortality rates than those at LII trauma centers. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for patients aged ≥18 y who had BT injuries. Patients treated at an LI were compared with those at an LII center with a primary outcome of in-hospital mortality. Secondary outcomes included hospital length of stay (LOS) and intensive care unit (ICU) LOS. A multivariable logistic regression analysis was used to identify factors associated with all-cause mortality. RESULTS From 1971 BT patients, 1540 (78%) were treated at an LI trauma center, and 431 (22%) at an LII center. Compared with LII centers, LI BT patients had a longer median LOS (10 versus 7 d; P < 0.001) and ICU LOS (5 versus 4 d; P < 0.001). Both LI and LII centers had similar mortality rates (8.5% versus 7.0%; P = 0.300). On multivariable analysis, receiving care at an LI trauma center was not associated with decreased mortality (odds ratio 0.79, 95% confidence interval 0.42-1.48; P = 0.456). CONCLUSIONS We report that LI trauma center BT patients had an increased hospital and ICU LOS compared with those at LII centers. However, there was no significant difference in mortality between patients cared for at LI and LII trauma centers in risk-adjusted models.
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Affiliation(s)
| | - Areg Grigorian
- Department of Surgery, University of California Irvine, Orange, California
| | - Catherine Kuza
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Katie Galvin
- Department of Surgery, University of California Irvine, Orange, California
| | - Victor Joe
- Department of Surgery, University of California Irvine, Orange, California
| | - Theresa Chin
- Department of Surgery, University of California Irvine, Orange, California
| | - Nicole Bernal
- Department of Surgery, University of California Irvine, Orange, California
| | - Jeffry Nahmias
- Department of Surgery, University of California Irvine, Orange, California.
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Plurad DS, Geesman G, Mahmoud A, Sheets N, Chawla-Kondal B, Ayutyanont N, Ghostine S. The effect of trauma center verification level on traumatic brain injury outcome after implementation of the Orange Book. Am J Surg 2020; 221:637-641. [PMID: 33390245 DOI: 10.1016/j.amjsurg.2020.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/14/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous literature demonstrates mortality discrepancies at Level II vs. Level I centers in patients with isolated Traumatic Brain Injury (TBI). Our hypothesis is that the implementation of the 2014 version of the resources manual ("the Orange Book") is associated with an elimination of this outcome disparity. METHODS Utilizing the Trauma Quality Program Participant Use File for 2017, we compared TBI outcomes at ACS Level I vs. Level II centers. RESULTS 39,764 records met inclusion criteria where 25,382 (63.8%) were admitted to a Level I center. Level I patients were younger (56.4 vs.59.1 years, p < 0.001) and less likely to have been injured in a single level fall (39.5%vs.45.5%, p < 0.001). The incidence of severe TBI (11.3%vs.10.3%, p < 0.001) was more common. Adjusted mortality at a Level II vs. Level I center were similar [7.8% vs. 8.4%, 0.669]. CONCLUSIONS Implementation of 2014 version of the ACS resources manual is associated with improved TBI associated mortality in ACS Level II centers relative to their Level I counterparts.
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