In-hospital Complications in Trauma Patients According to Injury Severity

Morbidity and Mortality of Trauma Patients 55 and Older: A Study of Nontrauma Risk Factors

Introduction: The American College of Surgeons (ACS) recommends that special considerations be made during triage of trauma patients aged ≥55 due to an observed increase in morbidity and mortality in this population. The geriatric population aged ≥65 represents 30% of all trauma patients. Our objective was to assess which pre-existing conditions (PECs) are associated with worse outcomes in trauma patients aged ≥55. Methods: Study population was selected from the local trauma registry (2020-22). Bi-variate analysis compared PEC status with outcomes controlling for each Injury Severity Score (ISS) category. Injury Severity Score was defined as mild (1-8), moderate (9-15), severe (16-24), and critical (≥25). Results: A total of 5,168 patients were identified (54.9% female, 56.7% age ≥75, 49.1% mild injury). Patients who had chronic renal failure (CRF) were at increased odds of mortality after adjusting for mild (adjusted odds ratio [aOR]: 2.63), moderate (aOR: 2.97), severe (aOR: 2.84), and critical (aOR: 2.62) injuries. Patients who had cirrhosis or congestive heart failure (CHF) were at increased odds of mortality after adjusting for mild (aOR: 3.03, 1.61), moderate (aOR: 3.63, 2.14), and severe (aOR: 3.46, 1.93) injuries, respectively. In addition, there was a relationship between having chronic obstructive pulmonary disease (COPD), dementia, anticoagulant therapy, or diabetes with unplanned intensive care unit (ICU) admission and development of acute kidney injury (AKI). Discussion: There is an association between certain pre-exiting conditions and worse outcomes. Early identification of these factors could provide a foundation for better interdisciplinary management, prevention of complications and associated mortality.

In-hospital complications of work-related musculoskeletal injuries

BACKGROUND, OBJECTIVES

Work-related musculoskeletal (MSK) injuries are a major contributor to morbidity worldwide and frequently result in hospitalisation. Hospital complications are common, costly, and largely preventable, but relevant data is required to address this. This study aimed to identify the incidence and factors associated with in-hospital complications of work-related MSK injuries.

METHODS

This study is based on work-related MSK hospital admission data from Victorian Admitted Episodes Database, 2016-2022. Complications were identified based on ICD-10-AM coding using CHADx (Classification of Hospital Acquired Diagnoses). Negative binomial and logistic regression analyses were performed to identify factors related to in-hospital complications.

RESULTS

In-hospital complications occurred in 6.3 % of work-related MSK injury admissions. In the adjusted models, ages ≥45 years, female sex, and area-level disadvantage were associated with in-hospital complications. Stay at public (vs private) hospitals, comorbidity, emergency admissions, and general anaesthesia were also associated. Complication rates were higher in hospitalised workers with direct head, neck, and trunk injuries and cumulative MSK disorders than those with direct extremities injuries and acute MSK conditions. The most common complications were cardiovascular, gastrointestinal complications and adverse drug events.

CONCLUSION

This study identified patient, injury and hospital-related characteristics associated with in-hospital complications of work-related MSK injuries for informing prevention strategies and risk estimation by hospital staff and workers' compensation schemes. The results demonstrate a sizable rate of complications given the relatively young and healthy study population.

Frequency of posttrauma complications during hospital admission and their association with Injury Severity Score

OBJECTIVE

Multiple trauma is associated with a remarkable risk of in-hospital complications, which harm healthcare services and patients. This study aimed to assess the incidence of posttrauma complications, their relationship with poor outcomes, and the effect of the Injury Severity Score (ISS) on their occurrence.

METHODS

This retrospective cohort study was conducted at a pair of trauma centers, between January 2020 and December 2022. All hospitalized adult patients with multiple trauma were included in this study. Multivariable logistic regression was used to identify factors related to posttrauma complications.

RESULTS

Among 727 multiple trauma patients, 90 (12.4%) developed in-hospital complications. The most frequent complications were pneumonia (4.8%), atelectasis (3.7%), and superficial surgical site infection (2.5%). According to multivariable logistic regression, ISS, the length of stay in the intensive care unit (ICU), the length of stay in the hospital, and mortality were significantly associated with complications. The complication rate increased by 17% with every single-unit increase in ISS (adjusted odds ratio [OR], 1.17; 95% confidence interval [CI], 1.00-1.38). Per every 1-day increase in the ICU or hospital stay, the complication rate increased by 65% (adjusted OR, 1.65; 95% CI, 1.00-2.73) and 20% (adjusted OR, 1.20; 95% CI, 1.03-1.41), respectively. Posttrauma complications were also significantly more common in patients with mortality (adjusted OR, 163.30; 95% CI, 3.04-8,779.32). In multiple trauma patients with a higher ISS, the frequency, severity, and number of complications were significantly increased.

CONCLUSION

In-hospital complications in multiple trauma patients are frequent and associated with poor outcomes and mortality. ISS is an important factor associated with posttrauma complications.

Patient-reported Anxiety Scores Are Associated With Lower Physical Function in Patients Experiencing Orthopaedic Trauma

BACKGROUND

The outcomes of orthopaedic trauma are not solely determined by injury severity or surgical treatment. Studies of numerous orthopaedic outcomes have found that psychosocial factors are also important. Symptoms of anxiety have been linked to long-term pain and disability. Although the existence of a relationship between psychosocial factors and functional outcomes is accepted across multiple disciplines, quantification of this association in patients who have experienced orthopaedic trauma has remained limited. Measuring the anxiety experienced by these individuals and the association with long-term functional outcomes remain poorly understood.

QUESTIONS/PURPOSES

(1) Is there an association between early postoperative anxiety symptoms and late recovery of self-reported physical function in patients with orthopaedic trauma? (2) What was the impact of other factors such as demographic variables and comorbidities on late recovery physical function scores, and how did the magnitude of these factors compare with the association with anxiety score? (3) Did patients who presented as trauma activations differ regarding their anxiety symptoms and late-recovery self-reported physical function?

METHODS

A total of 1550 patients with lower extremity fractures and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and physical function scores treated between January 1, 2014, and January 1, 2021, at an academic Level I trauma center in North America were assessed. We performed a bivariate regression between the initial PROMIS anxiety and physical function, as well as a multivariate regression including age, gender, BMI, and American Society of Anesthesiologists class to control for potential confounding variables. In a subgroup of 787 patients presenting as trauma activations, we performed a separate regression including Injury Severity Score.

RESULTS

PROMIS anxiety was associated with decreased late-recovery physical function (β = -2.64 [95% CI -3.006 to -2.205]; p < 0.001). The relationship between PROMIS anxiety and physical function remained after controlling for confounding variables in our overall cohort (β = -2.54 [95% CI -2.93 to -2.15]; p < 0.001) and in the trauma activation cohort (β = -2.71 [95% CI -3.19 to -2.23]; p < 0.001). Age and American Society of Anesthesiologists score were associated with worse PROMIS physical function scores, while being a man was associated with better PROMIS physical function scores (age: β= -1.26 [95% CI -1.50 to -1.02]; American Society of Anesthesiologists class: β=-2.99 [95% CI -3.52 to -2.46]; men: β = 0.95 [95% CI 0.16 to 1.75]). There were no differences in initial anxiety symptoms or late-recovery physical function between patients who presented as trauma activations and those who did not. Injury Severity Scores were independently associated with worse function (β = -1.45 [95% CI -2.11 to -0.79].

CONCLUSION

Initial patient self-reported anxiety is negatively associated with patient-reported physical function at the final follow-up interval in a broad cohort of patients with orthopaedic lower extremity injuries undergoing surgery. Identifying patients with high initial PROMIS anxiety scores may allow us to determine which patients will report lower functional scores at the final follow-up. Future investigations could focus on the effect of psychosocial interventions such as cognitive behavioral therapy and mindfulness on functional scores.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Race and Insurance Status Disparities in Post-discharge Disposition After Hospitalization for Major Trauma

BACKGROUND

Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to examine the discharge practices among trauma centers in the US and to identify factors that may influence post-hospital disposition.

METHODS

A retrospective analysis of trauma patients using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2007-2017. Primary study outcome was hospital disposition (including long term care facility [LTC], others). Secondary outcomes included: Intensive Care Unit (ICU)-length of stay (LOS), complications, others).

RESULTS

6 899 538 patients were analyzed. Odds of LTC discharge was significantly higher for Black patients (aOR = 1.30, 95% CI:1.24-1.37), abbreviated injury score (AIS) ≥3 (aOR = 4.22, 95% CI: 4.05-4.39), and higher injury severity score (ISS) (aOR = 9.41, 95% CI:9.03-9.80). Significantly more self-pay patients were discharged home compared to other insurance types (P < .0001). Significantly longer hospital- and ICU-LOS were experienced by those who had an AIS ≥3 (hospital: 4.8 days (±7.1) vs. 7.9 (±10.1); ICU: 4.6 (±6.9) vs. 5.9 (±7.9), P < .0001) and had a high ISS (hospital: 4.5 days (±5.9) vs. 16.8 (±17.9); ICU: 3.6 (±5.0) vs. 10.2 (±11.5), P < .0001).

CONCLUSIONS

Patient race, insurance status, and injury severity were predictive of post-hospitalization care discharge. Self-pay and Black patients were less likely to be discharged to secondary care facilities. These findings have the potential to improve in-hospital patient management and predict discharge secondary care needs, and necessitate the need for future research to investigate the extent of inequalities in access to trauma care.

Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement

BACKGROUND

Prevention of hospital-acquired conditions (HACs) is a focus of trauma center quality improvement. The relative contributions of various HACs to postinjury hospital outcomes are unclear. We sought to quantify and compare the impacts of six HACs on early clinical outcomes and resource utilization in hospitalized trauma patients.

METHODS

Adult patients from the 2013 to 2016 American College of Surgeons Trauma Quality Improvement Program Participant Use Data Files who required 5 days or longer of hospitalization and had an Injury Severity Score of 9 or greater were included. Multiple imputation with chained equations was used for observations with missing data. The frequencies of six HACs and five adverse outcomes were determined. Multivariable Poisson regression with log link and robust error variance was used to produce relative risk estimates, adjusting for patient-, hospital-, and injury-related factors. Risk-adjusted population attributable fractions estimates were derived for each HAC-outcome pair, with the adjusted population attributable fraction estimate for a given HAC-outcome pair representing the estimated percentage decrease in adverse outcome that would be expected if exposure to the HAC had been prevented.

RESULTS

A total of 529,856 patients requiring 5 days or longer of hospitalization were included. The incidences of HACs were as follows: pneumonia, 5.2%; urinary tract infection, 3.4%; venous thromboembolism, 3.3%; surgical site infection, 1.3%; pressure ulcer, 1.3%; and central line-associated blood stream infection, 0.2%. Pneumonia demonstrated the strongest association with in-hospital outcomes and resource utilization. Prevention of pneumonia in our cohort would have resulted in estimated reductions of the following: 22.1% for end organ dysfunction, 7.8% for mortality, 8.7% for prolonged hospitalization, 7.1% for prolonged intensive care unit stay, and 6.8% for need for mechanical ventilation. The impact of other HACs was comparatively small.

CONCLUSION

We describe a method for comparing the contributions of HACs to outcomes of hospitalized trauma patients. Our findings suggest that trauma program improvement efforts should prioritize pneumonia prevention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Immunologic response in patients with polytrauma

Purpose

It is now known that traumatic injury initiates a complex and dynamic immune response on the first day. It is believed that in patients with polytrauma, these immune responses contribute to the development of infectious complications. Therefore, understanding the immune response to trauma is critical to improving patient outcomes through the development of new therapies and improved resuscitation strategies. The purpose of this study is to examine the parameters of immunity in patients with severe polytrauma at the stages of surgical treatment (the nearest post-traumatic period and long-term periods) in the absence and presence of purulent-inflammatory complications.

Methods

We retrospectively enrolled 188 patients after severely injured trauma and 210 control group at two Level-1 Trauma Centers. Peripheral blood was collected upon presentation to the hospital and at the following time points: 1, 3, 7, 14, 21, 30, 60 and 90 days, and daily during intensive care unit admission. T-lymphocytes analyses performed using a Beckman Coulter EPICS XL flow cytometer (USA) with monoclonal antibodies (Immunotech, France). Analyses of protein levels of cytokines/chemokines, immunoglobulins, and circulating immune complexes was using ELISA.

Results

Under the influence of trauma, the content of T lymphocytes decreased due to the population of T-helpers. However, the number of B lymphocytes increased. The most pronounced activation of humoral immunity was observed by the 30th day of the post-traumatic period. Concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-a), interleukin-10 (IL-10) on day 1 after injury were the highest. Later, in the post-traumatic period, a gradual decrease in the initially elevated cytokines was noted.

Conclusions

As we continue to extrapolate new information on immune response factors associated with polytrauma, we will be better equipped to develop new therapeutic strategies to treat this serious clinical and social problem. In addition, individually adjusted immune control is an important interactive concept in polytrauma management.

Trauma Quality Indicators' usage limitations in severe trauma patients

PURPOSE

to analyze the relation between Trauma Quality Indicators (QI) and death, as well as clinical adverse events in severe trauma patients.

METHODS

analysis of data collected in the Trauma Register between 2014-2015, including patients with Injury Severity Score (ISS) > 16, reviewing the QI: (F1) Acute subdural hematoma drainage > 4 hours with Glasgow Coma Scale (GCS) <9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours; (F4) Admission-laparotomy time greater than 60 min in hemodynamically instable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time > 6 hours; (F10) Surgery > 24 hours. T the chi-squared and Fisher tests were used to calculate statistical relevance, considering p<0.05 as relevant.

RESULTS

127 patients were included, whose ISS ranged from 17 to 75 (28.8 + 11.5). There were adverse events in 80 cases (63%) and 29 died (22.8%). Twenty-six patients had some QI compromised (20.6%). From the 101 patients with no QI, 22% died, and 7 of 26 patients with compromised QI (26.9%) (p=0.595). From the patients with no compromised QI, 62% presented some adverse event. From the patients with any compromised QI, 18 (65.4%) had some adverse event on clinical evolution (p=0.751).

CONCLUSION

the QI should not be used as death or adverse events predictors in severe trauma patients.

Postmortem Analysis of Fall Victims According to Age Groups: A Comparative Study

Fall represents an important cause of death and its relation with the population aging evidences the need of a broad analysis considering different aspects associated with its occurrence. The objective of this study was to compare fatal victims due to unintentional fall among adults, young olds, olds, and oldest olds, according to sociodemographic data, characteristics, and severity of the trauma. This study is a cross-sectional, comparative study analyzing autopsy reports of fatal victims due to fall, admitted to the Medical Legal Institute of Sao Paulo, Sao Paulo, Brazil, in 2015. The following age groups were: adults (≥18 and <60 years), young olds (≥60 and <70 years), olds (≥70 and <80 years), and oldest olds (≥80 years). The Pearson's χ, Fisher's exact, Kruskal-Wallis, and Dunn tests were applied to compare the groups, with a significance level of 5%. Regarding the 469 fatalities analyzed (57.8% males, mean age: 71.3 ± 18.2 years), there was a higher frequency of oldest olds (43.5%), ground-level falls (70.1%), femoral fractures (35.0%), and delayed deaths (79.6%) due to posttraumatic complications (57.2%). Adults, young olds, olds, and oldest olds differed significantly (p ≤ .005) in relation to the total of analyzed variables, with a special remark on the differences between the age extremes. High frequencies of femoral fractures and delayed deaths due to complications of treatment in low-severity fall victims, especially those older than 70 years, make it necessary to improve fall prevention programs in the older adults and to create a line of care for this population.

Incidence, Risk Factors, and Outcomes of Ventilator-Associated Pneumonia in Traumatic Brain Injury: A Meta-analysis

Ventilator-associated pneumonia (VAP) is one of the most severe complications in patients with traumatic brain injury (TBI) and is considered a risk factor for poor outcomes. However, the incidence of VAP among patients with TBI reported in studies varies widely. What is more, the risk factors and outcomes of VAP are controversial. This study estimates the incidence, risk factors, and outcomes of VAP in patients with TBI and provides evidence for prevention and treatment. PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched from the earliest records to May 2018. Data involving the incidence, risk factors, and outcomes were extracted for meta-analysis. The results showed that the incidence of VAP was 36% (95% confidence interval (CI) 31-41%); risk factors analyses showed that smoking [odds ratio (OR) 2.13; 95% CI 1.16-3.92], tracheostomy (OR 9.55; 95% CI 3.24-28.17), blood transfusion on admission (OR 2.54; 95% CI 1.24-5.18), barbiturate infusion (OR 3.52; 95% CI 1.68-7.40), injury severity score (OR 4.65; 95% CI 1.96-7.34), and head abbreviated injury scale (OR 2.99; 95% CI 1.66-5.37) were related to the occurrence of VAP. When patients developed VAP, mechanical ventilation time (OR 5.45; 95% CI 3.78-7.12), ICU length of stay (OR 6.85; 95% CI 4.90-8.79), and hospital length of stay (OR 10.92; 95% CI 9.12-12.72) were significantly increased. However, VAP was not associated with an increased risk of mortality (OR 1.28; 95% CI 0.74-2.21). VAP is common in patients with TBI. It is affected by a series of factors and has a poor prognosis.

The Importance of Place of Residence on Hospitalized Outcomes for Severely Injured Trauma Patients: A Trauma Registry Analysis

PURPOSE

Socioecological factors are understudied in relation to trauma patients' outcomes. This study investigated the association of neighborhood socioeconomic disadvantage (SED) and remoteness of residence on acute length of hospital stay days (ALSD) and inpatient mortality.

METHODS

A retrospective cohort study was conducted on adults hospitalized for major trauma in a Level 1 trauma center in southeast Queensland from 2014 to 2017. Neighborhood SED and remoteness indices were linked to individual patient variables. Step-wise multivariable negative binomial regression and proportional hazards regression analyses were undertaken, adjusting for injury and patient factors. Outcomes were ALSD and inpatient mortality.

FINDINGS

We analyzed 1,025 patients. Statistically significant increased hazard of inpatient mortality was found for older age (HR 3.53, 95% CI: 1.77-7.11), injury severity (HR 5.27, 95% CI: 2.78-10.02), remoteness of injury location (HR 1.75, 95% CI: 1.06-2.09), and mechanisms related to intentional self-harm or assault (HR 2.72, 95% CI: 1.48-5.03,). Excess mortality risk was apparent for rural patients sustaining less severe injuries (HR 4.20, 95% CI: 1.35-13.10). Increased risk for longer ALSD was evident for older age (RR 1.35, 95% CI: 1.07-1.71), head injury (RR 1.39, 95% CI: 1.19-1.62), extremity injuries (RR 1.82, 95% CI: 1.55-2.14), and higher injury severity scores (ISS) (RR 1.51, 95%: CI: 1.29-1.76).

CONCLUSIONS

Severely injured rural trauma patients are more likely to be socioeconomically disadvantaged and sustain injuries predisposing them to worse hospital outcomes. Further research is needed to understand more about care pathways and factors influencing the severity, mechanism and clinical consequences of rural-based traumatic injuries.