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Haines K, Shin GJ, Truong T, Grisel B, Kuchibhatla M, Castillo-Angeles M, Agarwal S, Fernandez-Moure J. The Earlier the Better: Surgical Stabilization of Rib Fractures Associated With Improved Outcomes. J Surg Res 2024; 302:517-524. [PMID: 39178567 DOI: 10.1016/j.jss.2024.07.101] [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: 11/28/2023] [Revised: 07/10/2024] [Accepted: 07/19/2024] [Indexed: 08/26/2024]
Abstract
INTRODUCTION Surgical stabilization of rib fractures (SSRF) has been associated with lower rates of mortality and fewer respiratory complications. This study sought to evaluate the association between SSRF timing and patient outcomes. METHODS This retrospective analysis included patients aged ≥45 y who underwent SSRF in the Trauma Quality Improvement Program database from 2016 to 2020. Primary outcome was incidence of ventilator-assisted pneumonia (VAP). Secondary outcomes included acute respiratory distress syndrome (ARDS), unplanned endotracheal intubation, in-hospital mortality, failure to rescue (FTR) after all major complications, and FTR after severe respiratory complications. Logistic regression models of outcomes on timing to SSRF were fit while controlling for age, gender, body mass index, injury severity score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS Among 4667 patients who received SSRF, average time to SSRF was 4.6 ± 3.2 d. Each additional day to SSRF was associated with increased odds of VAP (odds ratio [OR] 1.07, confidence interval [CI] 1.03-1.11) and intubation (OR 1.10, CI 1.08-1.13). A longer time to SSRF was associated with increased odds of ARDS (OR 1.10, CI 1.05-1.15), while no significant association was observed for in-hospital mortality (OR 0.99, CI 0.93-1.04). A longer time to SSRF was associated with decreased odds of FTR after a major complication (OR 0.90, CI 0.83-0.97) and respiratory complications (OR 0.87, CI 0.78-0.96). CONCLUSIONS For each day that SSRF is delayed, increased odds of VAP, intubation, and ARDS were observed. Prompt intervention is crucial for preventing these complications and improving our ability to rescue patients.
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Affiliation(s)
- Krista Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Gi Jung Shin
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Braylee Grisel
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Maragatha Kuchibhatla
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Manuel Castillo-Angeles
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph Fernandez-Moure
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Haines K, Shin GJ, Truong T, Kuchibhatla M, Moore L, Rice W, Xu R, Swain S, Grisel B, Castillo-Angeles M, Agarwal S, Fernandez-Moure J. Age-Neutral Surgical Stabilization of Rib Fractures: Breaking the Ageism Barrier. J Surg Res 2024; 302:420-427. [PMID: 39153364 DOI: 10.1016/j.jss.2024.07.081] [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: 01/27/2024] [Revised: 07/10/2024] [Accepted: 07/19/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Surgical stabilization of rib fractures (SSRF) is associated with lower rates of mortality and fewer complications. This study evaluates whether the decision to undergo SSRF is associated with age, race, ethnicity, and insurance status and assesses associated clinical outcomes. METHODS This retrospective analysis included patients ≥45 y old with rib fractures who underwent SSRF in the Trauma Quality Improvement Program from 2016 to 2020. Race, ethnicity, and insurance statuses were collected. Age in years was dichotomized into two groups: 45-64 and 65+. Outcomes included ventilator-associated pneumonia, unplanned endotracheal intubation, acute respiratory distress syndrome, in-hospital mortality, failure to rescue (FTR) after major complications, and FTR after respiratory complications. Logistic regression models were fit to evaluate outcomes, controlling for gender, body mass index, Injury Severity Score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS Two thousand eight hundred thirty-nine patients aged 45-64 and 1828 patients aged 65+ underwent SSRF. No significant difference in clinical outcomes was noted between these groups. Analysis showed that the association of SSRF with ventilator-associated pneumonia, unplanned intubation, acute respiratory distress syndrome, in-hospital mortality, FTR after a major complication, or FTR after a respiratory complication did not vary by age (P > 0.05). Black (odds ratio [OR] 0.67; 95% confidence interval [CI]: 0.59-0.77; P < 0.001), Hispanic (OR 0.80; 95% CI: 0.71-0.91; P < 0.001), and Medicaid (OR = 0.85; 95% CI = 0.76-0.95; P = 0.005) patients were less likely to receive SSRF. CONCLUSIONS No differences in clinical outcomes were measured between adults aged 45-64 and ≥65 who underwent SSRF. Older age should not preclude patients from receiving SSRF. Further work is needed to improve underutilization in Black, Hispanic and Medicaid patients.
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Affiliation(s)
- Krista Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Gi Jung Shin
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Maragatha Kuchibhatla
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lauren Moore
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - William Rice
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ruidi Xu
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sonal Swain
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Braylee Grisel
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Manuel Castillo-Angeles
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph Fernandez-Moure
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Hamad DM, Subacius H, Thomas A, Guttman MP, Tillmann BW, Jerath A, Haas B, Nathens AB. A multidimensional approach to identifying high-performing trauma centers across the United States. J Trauma Acute Care Surg 2024; 97:125-133. [PMID: 38480489 DOI: 10.1097/ta.0000000000004313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
INTRODUCTION The differentiators of centers performing at the highest level of quality and patient safety are likely both structural and cultural. We aimed to combine five indicators representing established domains of trauma quality and to identify and describe the structural characteristics of consistently performing centers. METHODS Using American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2020, we evaluated five quality measures across several care domains for adult patients in levels I and II trauma centers: (1) time to operating room for patients with abdominal gunshot wounds and shock, (2) proportion of patients receiving timely venous thromboembolism prophylaxis, (3) failure to rescue (death following a complication), (4) major hospital complications, and (5) mortality. Overall performance was summarized as a composite score incorporating all measures. Centers were ranked from highest to lowest performer. Principal component analysis showed the influence of each indicator on overall performance and supported the composite score approach. RESULTS We identified 272 levels I and II centers, with 28 and 27 centers in the top and bottom 10%, respectively. Patients treated in high-performing centers had significant lower rates of death major complications and failure to rescue, compared with low-performing centers ( p < 0.001). The median time to operating room for gunshot wound was almost half that in high compared with low-performing centers, and rates of timely venous thromboembolism prophylaxis were over twofold greater ( p < 0.001). Top performing centers were more likely to be level I centers and cared for a higher number of severely injured patients per annum. Each indicator contributed meaningfully to the variation in scores and centers tended to perform consistently across most indicators. CONCLUSION The combination of multiple indicators across dimensions of quality sets a higher standard for performance evaluation and allows the discrimination of centers based on structural elements, specifically level 1 status, and trauma center volume. LEVEL OF EVIDENCE Therapeutic /Care Management; Level IV.
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Affiliation(s)
- Doulia M Hamad
- From the Department of Surgery (D.M.H., M.P.G., B.H., A.B.N.), Sunnybrook Health Sciences Center and the University of Toronto; Institute of Health Policy, Management, and Evaluation (D.M.H., A.B.N.), University of Toronto, Toronto, Ontario, Canada; The Society of Thoracic Surgeons (H.S.), Chicago, Illinois; Medical College of Wisconsin (A.T.), Milwaukee, Wisconsin; Interdepartmental Division of Critical Care (B.W.T., B.H.), University of Toronto; Tory Trauma Program (B.W.T., A.B.N.), Sunnybrook Health Sciences Center; Department of Medicine (B.W.T.), Division of Respirology and Critical Care Medicine, University Health Network; Sunnybrook Research Institute (B.W.T., A.J., B.H., A.B.N.), Sunnybrook Health Sciences Centre; Department of Anesthesia (A.J.), Sunnybrook Health Sciences Center University of Toronto; Department of Critical Care Medicine (B.H.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and American College of Surgeons (A.B.N.), Chicago, Illinois
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Taylor SV, Loo GT, Richardson LD, Legome E. Patient Factors Associated With Prolonged Length of Stay After Traumatic Brain Injury. Cureus 2024; 16:e59989. [PMID: 38774459 PMCID: PMC11107954 DOI: 10.7759/cureus.59989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 05/24/2024] Open
Abstract
Background For traumatic brain injury (TBI) survivors, recovery can lead to significant time spent in the inpatient/rehabilitation settings. Hospital length of stay (LOS) after TBI is a crucial metric of resource utilization and treatment costs. Risk factors for prolonged LOS (PLOS) after TBI require further characterization. Methodology We conducted a retrospective analysis of patients with diagnosed TBI at an urban trauma center. PLOS was defined as the 95th percentile of the LOS of the cohort. Patients with and without PLOS were compared using clinical/injury factors. Analyses included descriptive statistics, non-parametric analyses, and multivariable logistic regression for PLOS status. Results The threshold for PLOS was >24 days. In the cohort of 1,343 patients, 77 had PLOS. PLOS was significantly associated with longer mean intensive care unit (ICU) stays (16.4 vs. 1.5 days), higher mean injury severity scores (18.6 vs. 13.8), lower mean Glasgow coma scale scores (11.3 vs. 13.7) and greater mean complication burden (0.7 vs. 0.1). PLOS patients were more likely to have moderate/severe TBI, Medicaid insurance, and were less likely to be discharged home. In the regression model, PLOS was associated with ICU stay, inpatient disposition, ventilator use, unplanned intubation, and inpatient alcohol withdrawal. Conclusions TBI patients with PLOS were more likely to have severe injuries, in-hospital complications, and Medicaid insurance. PLOS was predicted by ICU stay, intubation, alcohol withdrawal, and disposition to inpatient/post-acute care facilities. Efforts to reduce in-hospital complications and expedite discharge may reduce LOS and accompanying costs. Further validation of these results is needed from larger multicenter studies.
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Affiliation(s)
- Shameeke V Taylor
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
- Department of Emergency Medicine, Mount Sinai Morningside, New York, USA
| | - George T Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Lynne D Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Eric Legome
- Department of Emergency Medicine, Mount Sinai Morningside, New York, USA
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Foster N, Martin L, Raby E, Wood FM, Fear M, Pavlos N, Edgar DW. Trauma patient heterotopic ossification diagnosis is associated with increased hospital length of stay. Injury 2024; 55:111328. [PMID: 38428100 DOI: 10.1016/j.injury.2024.111328] [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: 05/02/2023] [Revised: 12/21/2023] [Accepted: 01/14/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Traumatic heterotopic ossification (tHO) refers to the development of extra-skeletal bone in muscle and soft tissues following tissue insult secondary to surgery or trauma. This presents a persistent clinical concern associated with significant patient morbidity and expense to diagnose and treat. Traumatic HO is a substantial barrier to rehabilitation for trauma-injured patients. As such, the development of tHO after burn and other trauma is hypothesised to prolong inpatient length of stay (LOS) and thus increase health care costs. OBJECTIVE To investigate the association between an inpatient tHO diagnosis and hospital LOS in trauma patients. METHODS A retrospective audit of trauma patients over a 14-year period was completed using data from four WA hospitals. Burn and neurological trauma patients diagnosed with tHO as an inpatient (tHO+) and control subjects (tHO-), matched (1:3) by age, gender, and injury severity factors, were identified using medical diagnostic codes. Data relating to patient and injury-related determinants of LOS from tHO+ and tHO- subjects were analysed to model the association of tHO on total hospital length of stay. RESULTS 188 identified patients were hospitalised due to traumatic injury; 47 patients with tHO following burn injury (n = 17), spinal cord injury (n = 13) and traumatic brain injury (n = 17), and 141 control patients. Those who developed tHO during hospitalisation had a significantly higher median LOS than matched trauma patients who did not develop tHO (142 days vs. 61 days). Multivariate regression analyses identified the following independent predictive factors of a prolonged hospital LOS: tHO diagnosis, mechanical ventilation hours, injury to the hip region and thigh area, other ossification disorder, pressure injury, admission to intensive care unit and deep vein thrombosis. Trauma patients diagnosed with tHO during their hospital admission stayed 1.6 times longer than trauma patients matched for injury severity without a tHO diagnosis (IRR 1.56, 95% CI 1.35-1.79, p<0.001). CONCLUSION Traumatic heterotopic ossification is an independent explanatory factor for increased hospital LOS in patients following burns, spinal cord, and traumatic brain injury. Early diagnosis may assist in reducing the impact of tHO on acute hospital stay after trauma.
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Affiliation(s)
- Nichola Foster
- Burn Injury Research Node, Institute for Health Research, School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia 6160, Australia; Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia; Physiotherapy Department, Sir Charles Gairdner Osborne Park Health Care Group, North Metropolitan Health Service, Nedlands, Western Australia 6009, Australia.
| | - Lisa Martin
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Edward Raby
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Mark Fear
- Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
| | - Nathan Pavlos
- School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia 6009, Australia
| | - Dale W Edgar
- Burn Injury Research Node, Institute for Health Research, School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia 6160, Australia; Burn Injury Research Unit, University of Western Australia, Nedlands, Western Australia 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia 6150, Australia; Safety and Quality Unit, Armadale Kalamunda Group Health Service, East Metropolitan Health Service, Mt Nasura, Western Australia 6112, Australia; Fiona Wood Foundation, 11 Robin Warren Dr, Murdoch, Western Australia 6150, Australia
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Silver CM, Thomas AC, Reddy S, Kirkendoll S, Nathens AB, Issa N, Patel PP, Plevin RE, Kanzaria HK, Stey AM. Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America. JAMA Netw Open 2024; 7:e240795. [PMID: 38416488 PMCID: PMC10902734 DOI: 10.1001/jamanetworkopen.2024.0795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024] Open
Abstract
Importance Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures People experiencing homelessness were identified using the TQP's alternate home residence variable. Main Outcomes and Measures Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.
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Affiliation(s)
- Casey M. Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Arielle C. Thomas
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Avery B. Nathens
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nabil Issa
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Purvi P. Patel
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | | | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
| | - Anne M. Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Forssten SP, Ahl Hulme R, Forssten MP, Ribeiro MAF, Sarani B, Mohseni S. Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls. Front Med (Lausanne) 2023; 10:1290201. [PMID: 38152301 PMCID: PMC10751787 DOI: 10.3389/fmed.2023.1290201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/02/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF. Methods Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method. Results A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease. Conclusion When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac risk, and measures of injury severity. This may allow for better identification of at-risk patients, and at the same time resulting in a more equitable allocation of resources.
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Affiliation(s)
- Sebastian Peter Forssten
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden
| | - Rebecka Ahl Hulme
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Marcelo A. F. Ribeiro
- Pontifical Catholic University of São Paulo, São Paulo, Brazil
- Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates
- Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Shahin Mohseni
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
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Becker N, Hammen A, Bläsius F, Weber CD, Hildebrand F, Horst K. Effect of Injury Patterns on the Development of Complications and Trauma-Induced Mortality in Patients Suffering Multiple Trauma. J Clin Med 2023; 12:5111. [PMID: 37568511 PMCID: PMC10420136 DOI: 10.3390/jcm12155111] [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: 06/30/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Patients that suffer from severe multiple trauma are highly vulnerable to the development of complications that influence their outcomes. Therefore, this study aimed to evaluate the risk factors that can facilitate an early recognition of adult patients at risk. The inclusion criteria were as follows: admission to a level 1 trauma center, injury severity score (ISS) ≥ 16 (severe injury was defined by an abbreviated injury score (AIS) ≥ 3) and ≥18 years of age. Injury- and patient-associated factors were correlated with the development of four complication clusters (surgery-related, infection, thromboembolic events and organ failure) and three mortality time points (immediate (6 h after admission), early (>6 h-72 h) and late (>72 h) mortality). Statistical analysis was performed using a Chi-square, Mann-Whitney U test, Cox hazard regression analysis and binominal logistic regression analysis. In total, 383 patients with a median ISS of 24 (interquartile range (IQR) 17-27) were included. The overall mortality rate (27.4%) peaked in the early mortality group. Lactate on admission significantly correlated with immediate and early mortality. Late mortality was significantly influenced by severe head injuries in patients with a moderate ISS (ISS 16-24). In patients with a high ISS (≥25), late mortality was influenced by a higher ISS, older age and higher rates of organ failure. Complications were observed in 47.5% of all patients, with infections being seen most often. The development of complications was significantly influenced by severe extremity injuries, the duration of mechanical ventilation and length of ICU stay. Infection remains the predominant posttraumatic complication. While immediate and early mortality is mainly influenced by the severity of the initial trauma, the rates of severe head injuries influence late mortality in moderate trauma severity, while organ failure remains a relevant factor in patients with a high injury severity.
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Affiliation(s)
- Nils Becker
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Antonia Hammen
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH University Hospital Aachen, 52074 Aachen, Germany
| | - Felix Bläsius
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Christian David Weber
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Klemens Horst
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
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Lopes MCBT, Bustillo RA, Whitaker IY. In-hospital complications after trauma due to road traffic accidents. Eur J Trauma Emerg Surg 2023; 49:1855-1862. [PMID: 37017763 DOI: 10.1007/s00068-023-02264-2] [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: 10/03/2022] [Accepted: 03/28/2023] [Indexed: 04/06/2023]
Abstract
PURPOSE The study aimed to verify the association between in-hospital complications and characterization and clinical variables including hospital care and trauma severity. METHODS This analysis with the prospective cohort data was conducted at a municipal hospital in São Paulo, Brazil, and included participants aged 14 years or older, with traumatic injuries from traffic accidents. Data was collected from January 2015 to July 2016 and included demographics variables, type of traumatic event, clinical parameters, length of stay in the Emergency department and in the Intensive Care Unit, length of hospital stay, survival probability, trauma severity and mortality. RESULTS Of the 327 patients, 25.1% had in-hospital complications and their occurrence was statistically associated with higher mean age, run-overs and higher trauma severity. The length of stay in the emergency room, hospital stay, ICU stay, percentage of deaths, and hospital readmission were higher in patients with complications. The number of complications was correlated with trauma severity, ICU stay, and mortality. CONCLUSION Complications were associated with older age, run-overs, greater trauma severity, length of stay and readmission after hospital discharge.
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Affiliation(s)
| | | | - Iveth Yamaguchi Whitaker
- Universidade Federal de São Paulo, Escola Paulista de Enfermagem, Rua Napoleão de Barros, 754, Sao Paulo, SP, CEP: 04024-002, Brazil
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10
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Sun M, Xu M, Sun J. Risk factor analysis of postoperative complications in patients undergoing emergency abdominal surgery. Heliyon 2023; 9:e13971. [PMID: 36950651 PMCID: PMC10025099 DOI: 10.1016/j.heliyon.2023.e13971] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/05/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023] Open
Abstract
Purpose To investigate the relationship between intraoperative anesthesia-related factors and postoperative complications in patients undergoing emergency abdominal surgery, and to identify risk factors for these postoperative complications. Methods We retrospectively analyzed 942 emergency surgery patients who underwent general anesthesia and emergency abdominal operations at Jiangsu Province Hospital during the period September 2015 to December 2016. Logistic regression analysis was performed to analyze the association between preoperative or intraoperative parameters and postoperative complications. Results Among the 942 patients whose data were analyzed, 226 (24.0%) had major postoperative complications within 30 days after surgery. The most common postoperative complications were respiratory complications (31.8% of those experiencing complications). After adjusting for the role of multiple confounding factors, multivariable analysis showed that the independent risk factors for postoperative complications were patient age (OR 1.648; 95% CI 1.352-2.008), the ASA classification (OR 3.220; 95% CI 2.492-4.162), intraoperative hypotension lasting more than 20 min (OR 2.031; 95% CI 1.256-3.285), intraoperative tachyarrhythmias (OR 2.205; 95% CI 1.114-4.365), and the surgical level (i.e. type and difficulty level) [OR 1.895; 95% CI 1.306-2.750]. Conclusion Prolonged intraoperative hypotension (>20 min) and the occurrence of tachyarrhythmias are independent risk factors for postoperative complications in patients who undergo emergency abdominal surgery. During hemodynamic management of these patients, systolic blood pressure should be controlled to within 20% of the baseline value to reduce the risk of postoperative complications. In addition, a higher patient age, higher ASA grade, and a higher surgical classification level also significantly increase the risk of postoperative complications.
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Affiliation(s)
- Menghan Sun
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 220009, China
| | - Mengmeng Xu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, Anhui Province, 230001, China
| | - Jie Sun
- Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 220009, China
- Department of Anesthesiology, Zhongda Hospital, Medical School, Southeast University, Nanjing Province, 220009, China
- Department of Anesthesiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210029, China
- Corresponding author. Department of Anesthesiology, Zhongda Hospital,School of Medicine,Southeast University, Nanjing, 220009, China.
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11
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McCrum ML, Allen CM, Han J, Iantorno SE, Presson AP, Wan N. Greater spatial access to care is associated with lower mortality for emergency general surgery. J Trauma Acute Care Surg 2023; 94:264-272. [PMID: 36694335 PMCID: PMC10069479 DOI: 10.1097/ta.0000000000003837] [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: 01/26/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions. METHODS A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity. RESULTS A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity. CONCLUSION This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Marta L McCrum
- From the Department of Surgery (M.L.M., S.E.I.), Surgical Population Analysis Research Core (M.L.M.), Statistical Design and Biostatistics Center (C.M.A., A.P.P.), and Department of Geography (J.H., N.W.), The University of Utah, Salt Lake City, Utah
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12
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Computed tomographic bone mineral density is independently associated with adverse in-hospital outcomes in Dutch level-1 trauma patients. Eur J Trauma Emerg Surg 2022; 49:1393-1400. [DOI: 10.1007/s00068-022-02175-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/11/2022] [Indexed: 11/28/2022]
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13
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Lee PT, Krecko LK, Savage S, O'Rourke AP, Jung HS, Ingraham A, Zarzaur BL, Scarborough JE. Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement. J Trauma Acute Care Surg 2022; 93:446-452. [PMID: 35393378 PMCID: PMC9489599 DOI: 10.1097/ta.0000000000003645] [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: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Patrick T Lee
- From the Department of Surgery (P.T.L., L.K.K.), University of Wisconsin School of Medicine and Public Health; and Department of Surgery (S.S., A.P.O., H.S.J., A.I., B.L.Z., J.E.S.), Division of Acute Care and Regional General Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
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14
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Failure to Rescue in Trauma: Early and Late Mortality in Low and High Performing Trauma Centers. J Trauma Acute Care Surg 2022; 93:176-186. [PMID: 35444147 DOI: 10.1097/ta.0000000000003662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Failure to Rescue (FTR) is defined as mortality following a complication. FTR has come under scrutiny as a quality metric to compare trauma centers. In contrast to elective surgery, trauma has an early period of high expected mortality due to injury sequelae rather than a complication. Here, we report FTR in early and late mortality using an externally validated trauma patient database, hypothesizing that centers with higher risk-adjusted mortality rates have higher risk-adjusted FTR rates. METHODS The study included 114,220 patients at 34 Level I and II trauma centers in a statewide quality collaborative (2016-2020) with ISS ≥5. Emergency room deaths were excluded. Multivariate regression models were used to produce center-level adjusted rates for mortality and major complications. Centers were ranked on adjusted mortality rate and divided into quintiles. Early deaths (within 48 hours of presentation) and late deaths (after 48 hours) were analyzed. RESULTS Overall, 6.7% of patients had a major complication and 3.1% died. There was no difference in the mean risk-adjusted complication rate amongst the centers. FTR was significantly different across the quintiles (13.8% at the very low mortality centers vs. 23.4% at the very high mortality centers, p < 0.001). For early deaths, there was no difference in FTR rates amongst the highest and lowest mortality quintiles. For late deaths, there was a twofold increase in the FTR rate between the lowest and highest mortality centers (9.7% vs. 19.3%, p < 0.001), despite no difference in the rates of major complications (5.9% vs. 6.0%, p = 0.42). CONCLUSIONS Low-performing trauma centers have higher mortality rates and lower rates of rescue following major complications. These differences are most evident in patients who survive the first 48 hours after injury. A better understanding of the complications and their role in mortality after 48 hours is an area of interest for quality improvement efforts. LEVEL OF EVIDENCE III.
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15
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Forner D, Noel CW, Guttman MP, Haas B, Enepekides D, Rigby MH, Taylor SM, Nathens AB, Eskander A. Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:4131-4141. [PMID: 35320370 DOI: 10.1007/s00068-022-01950-x] [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: 12/25/2021] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma. METHODS This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized. RESULTS In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile. CONCLUSION Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.
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Affiliation(s)
- David Forner
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christopher W Noel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barbara Haas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Danny Enepekides
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 047, Toronto, ON, M4N 3M5, Canada
| | - Matthew H Rigby
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - S Mark Taylor
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - Avery B Nathens
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Antoine Eskander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Otolaryngology, Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 047, Toronto, ON, M4N 3M5, Canada.
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16
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Horn DL, Mindrinos M, Anderson K, Krishnakumar S, Wang C, Li M, Hollenbach J, O’Keefe GE. HLA-A Locus is Associated With Sepsis and Septic Shock After Traumatic Injury. Ann Surg 2022; 275:203-207. [PMID: 33064392 PMCID: PMC10060028 DOI: 10.1097/sla.0000000000003932] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine whether variation in the HLA region is associated with the development of post-traumatic sepsis and septic shock. BACKGROUND Sepsis-related deaths remain a major source of mortality after traumatic injury. Genetic characteristics may contribute to susceptibility to adverse outcomes including sepsis and septic shock. Recent advances in next-generation sequencing technology now allow comprehensive genotyping of the HLA region. METHODS White adult trauma patients requiring more than 2 days of mechanical ventilation underwent HLA genotyping, and were followed for the development of sepsis and septic shock. Odds ratios (OR) for the associations between our outcomes and HLA variants were estimated, a correction for multiple comparisons was applied, and significant variants were included in regression models adjusting for potential confounders. RESULTS A total of 1184 patients were included. Patients were severely injured (median injury severity score 33); 33% developed sepsis, 6% septic shock, and in-hospital mortality was 14%. An amino acid variant (156Q) within the HLA-A peptide-binding groove was associated with greater odds of sepsis [OR 1.50, (1.18-1.89)]. HLA-A∗02:01 was associated with lower odds of septic shock [OR 0.52, (0.32-0.82)]. These associations remained significant after adjusting for potential confounders. CONCLUSIONS This is the first study to apply next-generation sequencing techniques to evaluate associations between immunogenetic factors and post-traumatic sepsis and septic shock. Associations with class I HLA variants are novel as they implicate adaptive immunity in post-traumatic sepsis. These findings are a step towards developing a panel of genetic markers assessing risk of infection-related complications as we move towards more personalized medicine.
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Affiliation(s)
| | - Michael Mindrinos
- Stanford University, Stanford, California
- Immucor, Peachtree Corners, Georgia
| | | | | | | | - Ming Li
- Immucor, Peachtree Corners, Georgia
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17
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Elsamadicy AA, Sandhu MR, Freedman IG, Koo AB, Hengartner AC, Reeves BC, Havlik J, Sarkozy M, Hong CS, Kundishora AJ, Tuason DA, DiLuna M. Racial Disparities in Health Care Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries. World Neurosurg 2021; 156:e307-e318. [PMID: 34560297 DOI: 10.1016/j.wneu.2021.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to investigate the impact of race on hospital length of stay (LOS) and hospital complications among pediatric patients with cervical/thoracic injury. METHODS A retrospective cohort was performed using the 2017 admission year from 753 facilities utilizing the National Trauma Data Bank. All pediatric patients with cervical/thoracic spine injuries were identified using the ICD-10-CM diagnosis coding system. These patients were segregated by their race, non-Hispanic white (NHW), non-Hispanic black (NHB), non-Hispanic Asian (NHA), and Hispanic (H). Demographic, hospital variable, hospital complications, and LOS data were collected. A linear and logistic multivariate regression analysis was performed to determine the risk ratio for hospital LOS as well as complication rate, respectively. RESULTS A total of 4,125 pediatric patients were identified. NHB cohort had a greater prevalence of cervical-only injuries (NHW: 37.39% vs. NHB: 49.93% vs. NHA: 34.29% vs. H: 38.71%, P < 0.001). While transport accident was most common injury etiology for both cohorts, NHB cohort had a greater prevalence of assault (NHW: 1.53% vs. NHB: 17.40% vs. NHA: 2.86% vs. H: 6.58%, P < 0.001) than the other cohorts. Overall complication rates were significantly higher among NHB patients (NHW: 9.39% vs. NHB: 15.12% vs. NHA: 14.29% vs. H: 13.60%, P < 0.001). Compared with the NHW cohort, NHB, NHA, and H had significantly longer hospital LOS (NHW: 6.15 ± 9.03 days vs. NHB: 9.24 ± 20.78 days vs. NHA: 9.09 ± 13.28 days vs. H: 8.05 ± 11.45 days, P < 0.001). NHB race was identified as a significant predictor of increased LOS on multivariate regression analysis (risk ratio: 1.14, 95% confidence interval: 0.46, 1.82; P = 0.001) but not hospital complications (P = 0.345). CONCLUSIONS Race may significantly impact health care resource utilization following pediatric cervical/thoracic spinal trauma.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Mani R Sandhu
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Chris S Hong
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dominick A Tuason
- Department of Orthopedics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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18
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Raj S, Williams EM, Davis MJ, Abu-Ghname A, Luu BC, Buchanan EP. Cost-effectiveness of Multidisciplinary Care in Plastic Surgery: A Systematic Review. Ann Plast Surg 2021; 87:206-210. [PMID: 34253701 DOI: 10.1097/sap.0000000000002931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multidisciplinary care has been previously shown to improve outcomes for patients and providers alike, fostering interprofessional collaboration and communication. Many studies have demonstrated the beneficial health care outcomes of interdisciplinary care. However, there has been minimal focus on the cost-effectiveness of such care, particularly in the realm of plastic surgery. This is the first systematic review to examine cost savings attributable to plastic surgery involvement in multidisciplinary care. METHODS A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary teams including a plastic surgeon was performed. Included articles reported on cost outcomes directly or indirectly attributable to a collaborative intervention. Explicitly reported cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described. RESULTS A total of 604 articles were identified in the initial query, of which 8 met the inclusion criteria. Three studies reported explicit cost savings from multidisciplinary care, with cost savings ranging from $707 to $26,098 per patient, and 5 studies reported changes in secondary factors such as complication rates and length of stay. All studies ultimately recommended multidisciplinary care, regardless of whether cost savings were achieved. CONCLUSIONS This systematic review of the cost-effectiveness of multidisciplinary plastic surgery care examined both primary cost savings and associated quality outcomes, such as length of stay, complication rate, and resource consumption. Our findings indicate that the inclusion of plastic surgery in team-based care provides both direct and indirect cost savings to all involved parties.
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Affiliation(s)
- Sarth Raj
- From the Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Elizabeth M Williams
- From the Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | | | | | - Bryan C Luu
- From the Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
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19
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Tsai SHL, Osgood GM, Canner JK, Mehmood A, Owodunni O, Su CY, Fu TS, Haut ER. Trauma Center Outcomes After Transition From Level 2 to Level 1: A National Trauma Data Bank Analysis. J Surg Res 2021; 264:499-509. [PMID: 33857794 DOI: 10.1016/j.jss.2021.03.021] [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: 05/16/2020] [Revised: 03/01/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous US-based studies have shown that a trauma center designation of level 1 is associated with improved patient outcomes. However, most studies are cross-sectional, focus on volume-related issues and are direct comparisons between levels. This study investigates the change in patient characteristics when individual trauma centers transition from level 2 to level 1 and whether the patients have similar outcomes during the initial period of the transition. STUDY DESIGN We performed a retrospective cohort study that analyzed hospital and patient records included in the National Trauma Data Bank from 2007 to 2016. Patient characteristics were compared before and after their hospitals transitioned their trauma level. Mortality; complications including acute kidney injury, acute respiratory distress syndrome, cardiac arrest with CPR, deep surgical site infection, deep vein thrombosis, extremity compartment syndrome, surgical site infection, osteomyelitis, pulmonary embolism, and so on; ICU admission; ventilation use; unplanned returns to the OR; unplanned ICU transfers; unplanned intubations; and lengths of stay were obtained following propensity score matching, comparing posttransition years with the last pretransition year. RESULTS Sixteen trauma centers transitioned from level 2 to level 1 between 2007 and 2016. One was excluded due to missing data. After transition, patient characteristics showed differences in the distribution of race, comorbidities, insurance status, injury severity scores, injury mechanisms, and injury type. After propensity score matching, patients treated in a trauma center after transition from level 2 to 1 required significantly fewer ICU admissions and had lower complication rates. However, significantly more unplanned intubations, unplanned returns to the OR, unplanned ICU transfers, ventilation use, surgical site infections, pneumonia, and urinary tract infections and higher mortality were reported after the transition. CONCLUSIONS Trauma centers that transitioned from level 2 to level 1 had lower overall complications, with fewer patients requiring ICU admission. However, higher mortality and more surgical site infections, pneumonia, urinary tract infections, unplanned intubations, and unplanned ICU transfers were reported after the transition. These findings may have significant implications in the planning of trauma systems for administrators and healthcare leaders.
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Affiliation(s)
- Sung Huang Laurent Tsai
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Greg Michael Osgood
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joseph K Canner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amber Mehmood
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Maryland
| | - Oluwafemi Owodunni
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Chun-Yi Su
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tsai-Sheng Fu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Elliott Richard Haut
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Johns Hopkins School of Medicine, Baltimore, Maryland
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20
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Davis MJ, Luu BC, Raj S, Abu-Ghname A, Buchanan EP. Multidisciplinary care in surgery: Are team-based interventions cost-effective? Surgeon 2021; 19:49-60. [PMID: 32220537 DOI: 10.1016/j.surge.2020.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/28/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multidisciplinary care has been shown to improve outcomes for patients, and interprofessional collaboration has been demonstrated to be beneficial for providers. In the field of surgery, although a large number of multidisciplinary care teams have been described, no study to date has examined whether or not these team-based interventions are generally cost-effective. This is the first systematic review to examine cost savings attributable to multidisciplinary care across all surgical fields. METHODS A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary surgical teams was performed. Selected articles reported on cost outcomes directly attributable to a collaborative intervention. Cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described. RESULTS A total of 1421 articles were identified in the initial query, of which 43 met inclusion criteria. Thirty-nine studies (91%) reported multidisciplinary care to be cost effective, with an average cost savings among all studies of $5815 per patient. No significant differences in the amount of savings achieved were found between different intervention subtypes. All studies ultimately recommended (40) or gave mixed reviews (3) of multidisciplinary care, regardless of whether cost savings were achieved. CONCLUSION Multidisciplinary surgical care is beneficial not only in terms of patient and provider outcomes, but also in reference to its cost-effectiveness. Well-designed multidisciplinary teams tend to optimize perioperative care for all involved parties. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.
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Affiliation(s)
- Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Bryan C Luu
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Sarth Raj
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Edward P Buchanan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA.
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21
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Deaths following withdrawal of life-sustaining therapy: Opportunities for quality improvement? J Trauma Acute Care Surg 2020; 89:743-751. [PMID: 32697448 DOI: 10.1097/ta.0000000000002892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mortality is an important trauma center outcome. With many patients initially surviving catastrophic injuries and a growing proportion of geriatric patients, many deaths might occur following withdrawal of life-sustaining therapy (WLST). We utilized the American College of Surgeons Trauma Quality Improvement Program database to explore whether deaths following WLST might be preventable and to evaluate the impact of excluding patients who died following WLST on hospital performance. METHODS A retrospective cohort study was conducted using data derived from American College of Surgeons Trauma Quality Improvement Program. Adult trauma patients treated at Levels I and II centers in 2016 were included. Three cohorts of deceased patients were created to assess differences in hospital performance. The first included all deaths, the second included only those who died without WLST, and the third included deaths without WLST and deaths with WLST where death was preceded by a major complication. Hospitals were ranked based on their observed-to-expected mortality ratio calculated using each of the three decedent cohorts. Outcomes included absolute change in hospital ranking and change in performance outlier status between cohorts. RESULTS We identified 275,939 patients treated at 447 centers who met inclusion criteria. Overall mortality was 6.9% (n = 19,145). Withdrawal of life-sustaining therapy preceded 43.6% (n = 8,343) of deaths and 23% (n = 1,920) of these patients experienced a major complication before death. The median absolute change in hospital performance rank between the first and second cohort was 58 (p < 0.001), between the first and third cohort was 44 (p < 0.001), and between the second and third cohort was 23 (p < 0.001). Hospital performance outlier status changed significantly between cohorts. CONCLUSION The exclusion of patients who die following WLST from benchmarking efforts leads to a major change in hospital ranks. Potentially preventable deaths, such as those following a major complication, should not be excluded. LEVEL OF EVIDENCE Epidemiological study, level III.
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22
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Tignanelli CJ, Watarai B, Fan Y, Petersen A, Hemmila M, Napolitano L, Jarosek S, Charles A. Racial Disparities at Mixed-Race and Minority Hospitals : Treatment of African American Males With High-Grade Splenic Injuries. Am Surg 2020; 87:287-295. [PMID: 32931304 DOI: 10.1177/0003134820947369] [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: 11/16/2022]
Abstract
INTRODUCTION Racial and socioeconomic disparities in health access and outcomes for many conditions is well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American ([AA] vs White) males with high-grade splenic injuries. METHODS Data from the National Trauma Data Bank were utilized from 2007 to 2015; 24 855 AA or White males with high-grade splenic injuries were included. Multilevel mixed-effects regression analysis was used to evaluate disparities in outcomes and resource allocation. RESULTS Mortality was significantly higher for AA males at mixed-race (OR 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI, 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2, P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08). DISCUSSION While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.
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Affiliation(s)
| | - Bradly Watarai
- Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Yunhua Fan
- Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ashley Petersen
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Mark Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lena Napolitano
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephanie Jarosek
- Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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23
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Fernando DT, Berecki-Gisolf J, Newstead S, Ansari Z. The Australian Injury Comorbidity Indices (AICIs) to predict in-hospital complications: A population-based data linkage study. PLoS One 2020; 15:e0238182. [PMID: 32915808 PMCID: PMC7485849 DOI: 10.1371/journal.pone.0238182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/08/2020] [Indexed: 12/21/2022] Open
Abstract
Background Hospital-admitted patients are at risk of experiencing certain adverse outcomes during their hospital-stay. Patients may need to be admitted to the intensive care unit or be placed on the ventilator while there is also a possibility for complications to develop. Pre-existing comorbidity could increase the risk of these outcomes. The Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Measure (ECM), originally derived for mortality outcomes among general medical populations, are widely used for assessing these in-hospital complications even among specific injury populations. This study derived indices to specifically capture the effect of comorbidity on intensive care unit and ventilator use as well as hospital-acquired complications for injury patients. Methods Retrospective data on injury hospital-admissions from July 2012 to June 2014 (161,334 patients) for the state of Victoria, Australia was analysed. Results from multivariable regression analysis were used to derive the Australian Injury Comorbidity Indices (AICIs) for intensive care unit and ventilator hours and hospital-acquired complications. The AICIs, CCI and ECM were validated on data from Victoria and two other Australian states. Results Five comorbidities were significantly associated with intensive care unit hours, two with ventilator hours and fifteen with hospital-acquired complications for hospitalised injury patients. Not all diseases listed in the CCI or ECM were found to be associated with these outcomes. The AICIs performed equally well in terms of predictive ability to the long-listed ECM and in most instances outperformed the CCI. Conclusions Associations between outcomes and comorbidities vary based on the type of outcome measure. The new comorbidity indices developed in this study provide a relevant, parsimonious and up-to-date method to capture the effect of comorbidity on in-hospital complications among admitted injury patients and is better suited for use in that context compared to the CCI and ECM.
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Affiliation(s)
- Dasamal Tharanga Fernando
- Monash University Accident Research Centre, Monash University, Clayton Campus, Clayton, Victoria, Australia
- * E-mail:
| | - Janneke Berecki-Gisolf
- Monash University Accident Research Centre, Monash University, Clayton Campus, Clayton, Victoria, Australia
| | - Stuart Newstead
- Monash University Accident Research Centre, Monash University, Clayton Campus, Clayton, Victoria, Australia
| | - Zahid Ansari
- Victorian Agency for Health Information, Melbourne, Victoria, Australia
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24
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Forner D, Noel CW, Guttman MP, Haas B, Enepekides D, Rigby MH, Nathens AB, Eskander A. Blunt Versus Penetrating Neck Trauma: A Retrospective Cohort Study. Laryngoscope 2020; 131:E1109-E1116. [PMID: 32894596 DOI: 10.1002/lary.29088] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/23/2020] [Accepted: 08/19/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVES/HYPOTHESIS Despite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital-level characteristics that impact these outcomes. STUDY DESIGN Retrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database. METHODS Adult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in-hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level. RESULTS In a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals [0.564, 0.788]), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals [0.880, 0.954]). CONCLUSIONS Blunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury. LEVEL OF EVIDENCE Level 3 Laryngoscope, 131:E1109-E1116, 2021.
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Affiliation(s)
- David Forner
- Division of Otolaryngology - Head & Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Christopher W Noel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Haas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danny Enepekides
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew H Rigby
- Division of Otolaryngology - Head & Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Avery B Nathens
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antoine Eskander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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25
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Shelley JK, Roden-Foreman JW, Vier D, McShan EE, Bennett MM, Jones AL, Warren AM. Relation of length of stay and other hospital variables to posttraumatic stress disorder and depression after orthopedic trauma. Proc AMIA Symp 2020; 34:28-33. [PMID: 33456140 PMCID: PMC7785185 DOI: 10.1080/08998280.2020.1801113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) and depression are common following orthopedic trauma. This study examined the relationship between injury- and hospital-related variables and PTSD and depression at baseline and 12 months after orthopedic trauma. This longitudinal, prospective cohort study examined adult orthopedic trauma patients admitted ≥24 hours to a level I trauma center. Non-English/Spanish-speaking and cognitively impaired patients were excluded. The Primary Care PTSD screen and PTSD Checklist-Civilian version assessed PTSD, and the Patient Health Questionnaire 8-Item assessed depression. Demographic and hospital-related variables were examined (e.g., hospital length of stay, Injury Severity Score, Glasgow Coma Scale). For 160 participants, PTSD prevalence was 23% at baseline and 21% at 12 months. Depression prevalence was 28% at baseline and 29% at 12 months. Ventilation (P = 0.023, P = 0.006) and prolonged length of stay (P = 0.008, P = 0.003) were correlated with baseline PTSD and depression. Injury etiology (P = 0.008) and Injury Severity Score (P = 0.013) were associated with baseline PTSD. Intensive care unit admission (P = 0.016, P = 0.043) was also correlated with PTSD at baseline and 12 months. Ventilation (P = 0.002, P = 0.040) and prolonged length of stay (P < 0.001, P = 0.001) were correlated with 12-month PTSD and depression. Early and continued screenings with potential interventions could benefit patients' physical and mental rehabilitation after orthopedic injury.
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Affiliation(s)
- Jordin K. Shelley
- Division of Trauma, Critical Care, and Acute Care Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Jacob W. Roden-Foreman
- Division of Trauma, Critical Care, and Acute Care Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - David Vier
- Department of Orthopaedic Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Evan Elizabeth McShan
- Division of Trauma, Critical Care, and Acute Care Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Monica M. Bennett
- Office of the Chief Medical Officer, Baylor Scott & White Health, Dallas, Texas
| | - Alan L. Jones
- Department of Orthopaedic Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Ann Marie Warren
- Division of Trauma, Critical Care, and Acute Care Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
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26
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Hecht JP, Han EJ, Brandt MM, Wahl WL. Early Chemoprophylaxis in Severely Injured Trauma Patients Reduces Risk of Venous Thromboembolism. Am Surg 2020; 86:1185-1193. [PMID: 32723180 DOI: 10.1177/0003134820939914] [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] [Indexed: 01/03/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) remains a serious complication for trauma patients. While early VTE prophylaxis has gained traction, the timing of prophylaxis remains uncertain. We hypothesized that VTE prophylaxis within 24 hours of admission would have lower VTE rates and similar rates of adverse events in seriously injured patients. METHODS Trauma patients were included from 32 American College of Surgeons verified Level 1 and 2 trauma centers over a 10-year period. Patients with injury severity score (ISS) <15, death or discharge within 48 hours of arrival, or who received no prophylaxis were excluded. RESULTS 14 096 patients received VTE prophylaxis with an ISS of ≥15. Patients given prophylaxis at <24 hours had fewer VTE events and trended toward fewer serious in-hospital complications. Mortality and return to the operating room were similar across groups. Hospital and intensive care unit length of stay in the <24 hours prophylaxis group was significantly shorter when VTE prophylaxis was initiated earlier. CONCLUSIONS In severely injured trauma patients with ISS >15, early VTE prophylaxis within 24 hours significantly reduced the risk of VTE as compared with delayed prophylaxis. Early chemoprophylaxis was found to be efficacious in reducing the incidence of VTE; however, the safety of this practice should be evaluated by future prospective studies.
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Affiliation(s)
- Jason P Hecht
- Inpatient Pharmacy, Saint Joseph Mercy, Ann Arbor, MI, USA
| | - Emily J Han
- Inpatient Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | | | - Wendy L Wahl
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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27
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Tignanelli CJ, Watarai B, Fan Y, Petersen A, Hemmila M, Napolitano L, Jarosek S, Charles A. Racial Disparities at Mixed-Race and Minority Hospitals: Treatment of African American Males With High-Grade Splenic Injuries. Am Surg 2020; 86:441-449. [PMID: 32684029 DOI: 10.1177/0003134820918262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Racial and socioeconomic disparities in health access and outcomes for many conditions are well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American (AA) versus white males with high-grade splenic injuries. METHODS Data from the National Trauma Data Bank was utilized from 2007 to 2015. A total of 24 855 AA or white males with high-grade splenic injuries were included. Multilevel mixed effects regression analysis was used to evaluate disparities in outcomes and resource allocation. RESULTS Mortality was significantly higher for AA males at mixed-race (odds ratio [OR] 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2; P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08). DISCUSSION While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.
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Affiliation(s)
| | - Bradly Watarai
- Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Yunhua Fan
- Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ashley Petersen
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Mark Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lena Napolitano
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephanie Jarosek
- Department of Urology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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28
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Redefining the Trauma Triage Matrix: The Role of Emergent Interventions. J Surg Res 2020; 251:195-201. [DOI: 10.1016/j.jss.2019.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 11/23/2022]
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Kashkooe A, Yadollahi M, Pazhuheian F. What factors affect length of hospital stay among trauma patients? A single-center study, Southwestern Iran. Chin J Traumatol 2020; 23:176-180. [PMID: 32171653 PMCID: PMC7296356 DOI: 10.1016/j.cjtee.2020.01.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 12/18/2019] [Accepted: 01/05/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Trauma is a major health concern. Length of hospital stay (LOS) has been targeted as an important metric to assess trauma care. This study aims to evaluate the risk factors that affect LOS among trauma patients in a trauma center in Southwestern Iran. METHODS This cross-sectional study was conducted on patients admitted to Rajaee Trauma Center, Shiraz, Iran between January 1, 2018 and December 30, 2018. The inclusion criteria were age above 15 years and having traffic accident injuries, including car, motorcycle and pedestrian injury mechanisms. The exclusion criteria were existing diseases including cardiovascular, cerebral, renal, and pulmonary diseases prior to this study, dead upon arrival or within 48 h after admission, and stay at the hospital for less than 6 h. The risk variables analyzed for prolonged LOS were age, gender, mechanism of traffic accident injury, infection during hospital stay, type of injury, injury severity score, surgery during hospitalization, and survival. Poisson regression was performed to evaluate the partial effects of each covariate on trauma hospitalization (≥3 days as longer stay). RESULTS This study was conducted on 14,054 patients with traffic accident injury and the mean age was (33.89 ± 15.78) years. Additionally, 74.35% of the patients were male, with male to female ratio of 2.90. The result of Poisson regression indicated that male patients, higher age, combination of thoracic injuries, onset of infected sites, and surgery patients were more susceptible to have a longer LOS. Considering the site of injury, patients with face injuries followed by those with thorax injuries had the highest means of LOS (3.74 days and 3.36 days, respectively). Simultaneous existence of surgical intervention and infection in a patient had the greatest impact on prolonged LOS. CONCLUSION This study identified that age, gender, mechanism of injury, infection, type of injury, survival, and ISS could lead to prolongation of LOS, but the affect can be reduced by eliminating modifiable risk factors.
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Affiliation(s)
- Ali Kashkooe
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahnaz Yadollahi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Forough Pazhuheian
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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30
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Killien EY, Mills B, Vavilala MS, Watson RS, OʼKeefe GE, Rivara FP. Association between age and acute respiratory distress syndrome development and mortality following trauma. J Trauma Acute Care Surg 2020; 86:844-852. [PMID: 30633097 DOI: 10.1097/ta.0000000000002202] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Improved understanding of the relationship between patient age and acute respiratory distress syndrome (ARDS) development and mortality following traumatic injury may help facilitate generation of new hypotheses about ARDS pathophysiology and the role of novel treatments to improve outcomes across the age spectrum. METHODS We conducted a retrospective cohort study of trauma patients included in the National Trauma Data Bank who were admitted to an intensive care unit from 2007 to 2016. We determined ARDS incidence and mortality across eight age groups for the entire 10-year study period and by year. We used generalized linear Poisson regression models adjusted for underlying mortality risk (injury mechanism, Injury Severity Score, admission Glasgow Coma Scale score, admission heart rate, and admission hypotension). RESULTS Acute respiratory distress syndrome occurred in 3.1% of 1,297,190 trauma encounters. Acute respiratory distress syndrome incidence was lowest among pediatric patients and highest among adults aged 35 to 64 years. Acute respiratory distress syndrome mortality was highest among patients 80 years or older (43.9%), followed by 65 to 79 years (30.6%) and 4 years or younger (25.3%). The relative risk of mortality associated with ARDS was highest among the pediatric age groups, with an adjusted relative risk (aRR) of 2.06 (95% confidence interval [CI], 1.72-2.70) among patients 4 years or younger compared with an aRR of 1.51 (95% CI, 1.42-1.62) for the entire cohort. Acute respiratory distress syndrome mortality increased over the 10-year study period (aRR, 1.03 per year; 95% CI, 1.02-1.05 per year), whereas all-cause mortality decreased (aRR, 0.98 per year; 95% CI, 0.98-0.99 per year). CONCLUSIONS While ARDS development following traumatic injury was most common in middle-aged adults, patients 4 years or younger and 65 years or older with ARDS experienced the highest burden of mortality. Children 4 years or younger were disproportionately affected by ARDS relative to their low underlying mortality following trauma that was not complicated by ARDS. Acute respiratory distress syndrome-associated mortality following trauma has worsened over the past decade, emphasizing the need for new prevention and treatment strategies. LEVEL OF EVIDENCE Prognostic/epidemiological study, level III.
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Affiliation(s)
- Elizabeth Y Killien
- From the Harborview Injury Prevention and Research Center (E.Y.K., B.M., M.S.V., G.E.O., F.P.R.), University of Washington, Seattle, Washington; Division of Pediatric Critical Care Medicine, Department of Pediatrics (E.Y.K., R.S.W.), University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine (M.S.V.), University of Washington, Seattle, Washington; Center for Child Health, Behavior, and Development (R.S.W., F.P.R.), Seattle Children's Research Institute, Seattle, Washington; Department of Surgery (G.E.O.), University of Washington, Seattle, Washington; Division of General Pediatrics, Department of Pediatrics (F.P.R.), University of Washington, Seattle, Washington
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31
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Abe T, Komori A, Shiraishi A, Sugiyama T, Iriyama H, Kainoh T, Saitoh D. Trauma complications and in-hospital mortality: failure-to-rescue. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:223. [PMID: 32414401 PMCID: PMC7226721 DOI: 10.1186/s13054-020-02951-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/07/2020] [Indexed: 12/25/2022]
Abstract
Background Reducing medical errors and minimizing complications have become the focus of quality improvement in medicine. Failure-to-rescue (FTR) is defined as death after a surgical complication, which is an institution-level surgical safety and quality metric that is an important variable affecting mortality rates in hospitals. This study aims to examine whether complication and FTR are different across low- and high-mortality hospitals for trauma care. Methods This was a retrospective cohort study performed at trauma care hospitals registered at Japan Trauma Data Bank (JTDB) from 2004 to 2017. Trauma patients aged ≥ 15 years with injury severity score (ISS) of ≥ 3 and those who survived for > 48 h after hospital admission were included. The hospitals in JTDB were categorized into three groups by standardized mortality rate. We compared trauma complications, FTR, and in-hospital mortality by a standardized mortality rate (divided by the institute-level quartile). Results Among 184,214 patients that were enrolled, the rate of any complication was 12.7%. The overall mortality rate was 3.7%, and the mortality rate among trauma patients without complications was only 2.8% (non-precedented deaths). However, the mortality rate among trauma patients with any complications was 10.2% (FTR). Hospitals were categorized into high- (40 facilities with 44,773 patients), average- (72 facilities with 102,368 patients), and low- (39 facilities with 37,073 patients) mortality hospitals, using the hospital ranking of a standardized mortality rate. High-mortality hospitals showed lower ISS than low-mortality hospitals [10 (IQR, 9–18) vs. 11 (IQR, 9–20), P < 0.01]. Patients in high-mortality hospitals showed more complications (14.2% vs. 11.2%, P < 0.01), in-hospital mortality (5.1% vs. 2.5%, P < 0.01), FTR (13.6% vs. 7.4%, P < 0.01), and non-precedented deaths (3.6% vs. 1.9%, P < 0.01) than those in low-mortality hospitals. Conclusions Unlike reports of elective surgery, complication rates and FTR are associated with in-hospital mortality rates at the center level in trauma care.
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Affiliation(s)
- Toshikazu Abe
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan. .,Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | | | - Takehiro Sugiyama
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan.,Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Takako Kainoh
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Daizoh Saitoh
- Department of Traumatology and Emergency Medicine, National Defense Medical College, Tokorozawa, Japan
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Roussas A, Masjedi A, Hanna K, Zeeshan M, Kulvatunyou N, Gries L, Tang A, Joseph B. Number and Type of Complications Associated With Failure to Rescue in Trauma Patients. J Surg Res 2020; 254:41-48. [PMID: 32408029 DOI: 10.1016/j.jss.2020.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/28/2020] [Accepted: 04/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma. METHODS We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR. RESULTS A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications. CONCLUSIONS Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly. LEVEL OF EVIDENCE Level III Prognostic.
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Affiliation(s)
- Adam Roussas
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Aaron Masjedi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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Liu D, Namas RA, Vodovotz Y, Peitzman AB, Simmons RL, Yuan H, Mi Q, Billiar TR. Unsupervised Clustering Analysis Based on MODS Severity Identifies Four Distinct Organ Dysfunction Patterns in Severely Injured Blunt Trauma Patients. Front Med (Lausanne) 2020; 7:46. [PMID: 32161760 PMCID: PMC7053419 DOI: 10.3389/fmed.2020.00046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/30/2020] [Indexed: 12/11/2022] Open
Abstract
Purpose: We sought to identify a MODS score parameter that highly correlates with adverse outcomes and then use this parameter to test the hypothesis that multiple severity-based MODS clusters could be identified after blunt trauma. Methods: MOD score across days (D) 2-5 was subjected to Fuzzy C-means Clustering Analysis (FCM) followed by eight Clustering Validity Indices (CVI) to derive organ dysfunction patterns among 376 blunt trauma patients admitted to the intensive care unit (ICU) who survived to discharge. Thirty-one inflammation biomarkers were assayed (Luminex™) in serial blood samples (3 samples within the first 24 h and then daily up to D 5) and were analyzed using Two-Way ANOVA and Dynamic Network analysis (DyNA). Results: The FCM followed by CVI suggested four distinct clusters based on MOD score magnitude between D2 and D5. Distinct patterns of organ dysfunction emerged in each of the four clusters and exhibited statistically significant differences with regards to in-hospital outcomes. Interleukin (IL)-6, MCP-1, IL-10, IL-8, IP-10, sST2, and MIG were elevated differentially over time across the four clusters. DyNA identified remarkable differences in inflammatory network interconnectivity. Conclusion: These results suggest the existence of four distinct organ failure patterns based on MOD score magnitude in blunt trauma patients admitted to the ICU who survive to discharge.
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Affiliation(s)
- Dongmei Liu
- Department of Cardiology, Third Xiangya Hospital of Central South University, Changsha, China
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rami A. Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Andrew B. Peitzman
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Richard L. Simmons
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Hong Yuan
- Department of Cardiology, Third Xiangya Hospital of Central South University, Changsha, China
| | - Qi Mi
- Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Silva CDLN, Lopes MCBT, Thomaz RR, Whitaker IY. Mortalidade de motociclistas com lesões traumáticas resultantes de acidentes de trânsito na cidade de São José dos Campos, em 2015: estudo de coorte. EPIDEMIOLOGIA E SERVIÇOS DE SAÚDE 2020. [DOI: 10.1590/s1679-49742020000500003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo: Analisar fatores associados à mortalidade por lesões traumáticas entre motociclistas. Métodos: Coorte prospectiva, conduzida no Hospital Municipal de São José dos Campos, Brasil, 2015. Foram incluídos motociclistas com lesões traumáticas, ≥14 anos de idade, hospitalizados. Analisaram-se as variáveis sociodemográficas do acidente e da hospitalização, por modelo de regressão de Poisson, apresentando-se risco relativo (RR) e intervalos de confiança de 95% (IC95%). Resultados: Entre 190 motociclistas, 161 (84,7%), jovens do sexo masculino, revelaram 422 (41,8%) lesões em extremidades inferiores e superiores. A incidência de óbito foi maior na medida do aumento da gravidade do trauma, fisiológica (RR=9,67 [IC95% 1,46;64,26]; e RR=4,71 [IC95% 1,36;16,26]) e anatômica (RR=31,49 [IC95% 3,72;266,38]); e mostrou-se menor em até uma semana de internação (RR=0,39 [IC95% 0,15;0,98]). Conclusão: A gravidade do trauma e o tempo de internação associaram-se ao óbito de motociclistas, mas novos estudos devem ser conduzidos para confirmar esses achados e analisar essas relações mais detalhadamente.
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Morbidity and Mortality Among Critically Injured Children With Acute Respiratory Distress Syndrome. Crit Care Med 2019; 47:e112-e119. [PMID: 30379667 DOI: 10.1097/ccm.0000000000003525] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate morbidity and mortality among critically injured children with acute respiratory distress syndrome. DESIGN Retrospective cohort study. SETTING Four-hundred sixty Level I/II adult or pediatric trauma centers contributing to the National Trauma Data Bank. PATIENTS One hundred forty-six thousand fifty-eight patients less than 18 years old admitted to an ICU with traumatic injury from 2007 to 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed in-hospital mortality and need for postdischarge care among patients with and without acute respiratory distress syndrome and hospital resource utilization and discharge disposition among survivors. Analyses were adjusted for underlying mortality risk (age, Injury Severity Score, serious brain or chest injury, and admission heart rate and hypotension) and year, transfer status, and facility trauma level designation. Acute respiratory distress syndrome occurred in 2,590 patients (1.8%). Mortality was 20.0% among acute respiratory distress syndrome patients versus 4.3% among nonacute respiratory distress syndrome patients, with an adjusted relative risk of 1.76 (95% CI, 1.52-2.04). Postdischarge care was required in an additional 44.8% of acute respiratory distress syndrome patients versus 16.0% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.59; 2.87-4.49), with only 35.1% of acute respiratory distress syndrome patients discharging to home versus 79.8% of patients without acute respiratory distress syndrome. Acute respiratory distress syndrome mortality did not change over the 10-year study period (adjusted relative risk, 1.01/yr; 0.96-1.06) nor did the proportion of acute respiratory distress syndrome patients requiring postdischarge care (adjusted relative risk, 1.04/yr; 0.97-1.11). Duration of ventilation, ICU stay, and hospital stay were all significantly longer among acute respiratory distress syndrome survivors. Tracheostomy placement occurred in 18.4% of acute respiratory distress syndrome survivors versus 2.1% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.10; 2.59-3.70). CONCLUSIONS Acute respiratory distress syndrome development following traumatic injury in children is associated with significantly increased risk of morbidity and mortality, even after adjustment for injury severity and hemodynamic abnormalities. Outcomes have not improved over the past decade, emphasizing the need for new therapeutic interventions, and prevention strategies for acute respiratory distress syndrome among severely injured children.
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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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Elevations in Circulating sST2 Levels Are Associated With In-Hospital Mortality and Adverse Clinical Outcomes After Blunt Trauma. J Surg Res 2019; 244:23-33. [PMID: 31279260 DOI: 10.1016/j.jss.2019.05.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/09/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Soluble suppression of tumorigenicity 2 (sST2), a decoy receptor for interleukin (IL)-33, has emerged as a novel biomarker in various disease processes. Recent studies have elucidated the role of the sST2/IL-33 complex in modulating the balance of Th1/Th2 immune responses after tissue stress. However, the role of sST2 as a biomarker after traumatic injury remains unclear. To address this, we evaluated serum sST2 correlations with mortality and in-hospital adverse outcomes as endpoints in blunt trauma patients. METHODS We retrospectively analyzed clinical and biobank data of 493 blunt trauma victims 472 survivors (mean age: 48.4 ± 0.87; injury severity score [ISS]: 19.6 ± 0.48) and 19 nonsurvivors (mean age: 58.8 ± 4.5; ISS: 23.3 ± 2.1) admitted to the intensive care unit. Given the confounding impact of age on the inflammatory response, we derived a propensity-matched survivor subgroup (n = 19; mean age: 59 ± 3; ISS: 23.4 ± 2) using an IBM SPSS case-control matching algorithm. Serial blood samples were obtained from all patients (3 samples within the first 24 h and then once daily from day [D] 1 to D5 after injury). sST2 and twenty-nine inflammatory biomarkers were assayed using enzyme-linked immunosorbent assay and Luminex, respectively. Two-way analysis of variance on ranks was used to compare groups (P < 0.05). Spearman rank correlation was performed to determine the association of circulating sST2 levels with biomarker levels and in-hospital clinical outcomes. RESULTS Circulating sST2 levels of the nonsurvivor cohort were statistically significantly elevated at 12 h after injury and remained elevated up to D5 when compared either to the overall 472 survivor cohort or a matched 19 survivor subcohort. Admission sST2 levels obtained from the first blood draw after injury in the survivor cohort correlated positively with admission base deficit (correlation coefficient [CC] = 0.1; P = 0.02), international normalized ratio (CC = 0.1, P = 0.03), ISS (CC = 0.1, P = 0.008), and the average Marshall multiple organ dysfunction score between D2 and D5 (CC = 0.1, P = 0.04). Correlations with ISS revealed a positive correlation of ISS with plasma sST2 levels across the mild ISS (CC = 0.47, P < 0.001), moderate ISS (CC = 0.58, P < 0.001), and severe ISS groups (CC = 0.63, P < 0.001). Analysis of biomarker correlations in the matched survivor group over the initial 24 h after injury showed that sST2 correlates strongly and positively with IL-4 (CC = 0.65, P = 0.002), IL-5 (CC = 0.57, P = 0.01), IL-21 (CC = 0.52, P = 0.02), IL-2 (CC = 0.51, P = 0.02), soluble IL-2 receptor-α (CC = 0.5, P = 0.02), IL-13 (CC = 0.49, P = 0.02), and IL-17A (CC = 0.48, P = 0.03). This was not seen in the matched nonsurvivor group. sST2/IL-33 ratios were significantly elevated in nonsurvivors and patients with severe injury based on ISS ≥ 25. CONCLUSIONS Elevations in serum sST2 levels are associated with poor clinical trajectories and mortality after blunt trauma. High sST2 coupled with low IL-33 associates with severe injury, mortality, and worse clinical outcomes. These findings suggest that sST2 could serve as an early prognostic biomarker in trauma patients and that sustained elevations of sST2 could contribute to a detrimental suppression of IL-33 bioavailability in patients with high injury severity.
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Incidence of post-traumatic pneumonia in poly-traumatized patients: identifying the role of traumatic brain injury and chest trauma. Eur J Trauma Emerg Surg 2019; 46:11-19. [PMID: 31270555 PMCID: PMC7223163 DOI: 10.1007/s00068-019-01179-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/24/2019] [Indexed: 11/21/2022]
Abstract
Purpose Traumatic brain injury (TBI) and chest trauma are common injuries in severely injured patients. Both entities are well known to be associated with severe post-traumatic complications, including pneumonia, a common complication with a significant impact on the further clinical course. However, the relevance of TBI, chest trauma and particularly their combination as risk factors for the development of pneumonia and its impact on outcomes are not fully elucidated. Methods A retrospective analysis of poly-traumatized patients treated between 2010 and 2015 at a level I trauma centre was performed. Inclusion criteria were: Injury Severity Score ≥ 16 and age ≥ 18 years. TBI and chest trauma were classified according to the Abbreviated Injury Scale. Complications (i.e. acute respiratory distress syndrome (ARDS), multi-organ dysfunction syndrome (MODS) and pneumonia) were documented by a review of the medical records. The primary outcome parameter was in-hospital mortality. Results Over the clinical course, 19.9% of all patients developed pneumonia, and in-hospital mortality was 25.3%. Pneumonia (OR 5.142, p = 0.001) represented the strongest independent predictor of in-hospital mortality, followed by the combination of chest injury and TBI (OR 3.784, p = 0.008) and TBI (OR 3.028, p = 0.010). Chest injury alone, the combination of chest injury and TBI, and duration of ventilation were independent predictors of pneumonia [resp. OR 4.711 (p = 0.004), OR 4.193 (p = 0.004), OR 1.002 (p < 0.001)]. Conclusions Chest trauma alone and especially its combination with TBI represent high-risk injury patterns for the development of pneumonia, which forms the strongest predictor of mortality in poly-traumatized patients.
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Do outcomes in emergency general surgery vary for minority patients based on surgeons’ racial/ethnic case mix? Am J Surg 2019; 218:42-46. [DOI: 10.1016/j.amjsurg.2019.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 11/09/2018] [Accepted: 01/07/2019] [Indexed: 01/24/2023]
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Naeem Z, McCormack JE, Huang EC, Vosswinkel JA, Shapiro MJ, Zarlasht F, Jawa RS. Impact of Type and Number of Complications on Mortality in Admitted Elderly Blunt Trauma Patients. J Surg Res 2019; 241:78-86. [PMID: 31015071 DOI: 10.1016/j.jss.2019.03.031] [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: 10/05/2018] [Revised: 02/01/2019] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Advanced age and comorbidities are recognized risk factors for adverse outcomes in elderly trauma patients. However, the contribution of the number and type of complications to in-hospital mortality in elderly blunt trauma admissions has not been extensively studied. METHODS A retrospective review of the trauma registry at a level 1 trauma center for blunt trauma patients age ≥65 y hospitalized for at least 2 d between 2010 and 2015. RESULTS There were 2467 admissions, with a median age of 81 y and median injury severity score of 9. The most common mechanism of injury was a low-level fall. Approximately 19.6% of admissions had a complication: 11.1% major complications, 8.6% other complications. The in-hospital mortality rate was significantly different (P < 0.001) among the three groups at 16.1% of major complications group, 7.1% of other, and 2.1% of no complications (P < 0.001). On multivariate logistic regression, each major complication increased the odds for in-hospital mortality by 1.59-fold. CONCLUSIONS Complications are not infrequent in elderly blunt trauma admissions, despite a generally lower energy mechanism of injury. Each major complication is associated with increased odds of mortality. Multifaceted interventions for prevention and mitigation of complications are indicated.
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Affiliation(s)
- Zaina Naeem
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Jane E McCormack
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Marc J Shapiro
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Fnu Zarlasht
- Division of Geriatric Medicine, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York.
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The value of failure to rescue in determining hospital quality for pediatric trauma. J Trauma Acute Care Surg 2019; 87:794-799. [PMID: 30830048 DOI: 10.1097/ta.0000000000002240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In adult trauma patients, high- and low-mortality trauma hospitals have similar rates of major complications but differ based on failure to rescue (mortality following a major complication), which has become a marker of hospital quality. The aim of this study is to examine whether failure to rescue is also an appropriate hospital quality indicator in pediatric trauma. METHODS Children younger than 15 years were identified in the 2007 to 2014 National Trauma Databank research data sets. Hospitals were classified as a high, average or low mortality based on risk-adjusted observed-to-expected in-hospital mortality ratios using the modified Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and failure to rescue. RESULTS Of 125,057 children, 31,600 were treated at low-mortality outlier hospitals, and 7,014 at high-mortality outlier hospitals. Low-mortality hospitals had a lower rate of major complications compared with high-mortality hospitals (0.5% [low] vs. 0.8% [high]; adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.61-0.83; p < 0.01) and a lower failure-to-rescue rate (17.6% [low] vs. 24.1% [high]; adjusted OR, 0.53 [high; 95% CI 0.34-0.83; p < 0.01]). When patients who died within 48 hours were excluded, low-mortality hospitals had a lower complication rate (OR, 0.81; 95% CI, 0.68, 0.96; p = 0.02), but similar failure-to-rescue rate compared to high-mortality hospitals. There was no correlation between trauma verification level and hospital mortality status based on the model. CONCLUSION For pediatric trauma patients, mortality is more strongly associated with major complication rate than with failure to rescue. Thus, failure to rescue does not appear to be the key driver of hospital quality in this population as it does in the adult trauma population. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Variability in management of blunt liver trauma and contribution of level of American College of Surgeons Committee on Trauma verification status on mortality. J Trauma Acute Care Surg 2019; 84:273-279. [PMID: 29194321 DOI: 10.1097/ta.0000000000001743] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients who sustain blunt liver trauma and are treated at an American College of Surgeons Committee on Trauma-verified Level I trauma center have an overall lower risk of mortality compared with patients admitted to a level II trauma center. However, elements contributing to these differences are unknown. We hypothesize that practice variation exists between trauma centers in management of blunt liver injury. Our objective is to identify practice variations and their effect on clinical outcomes. METHODS Data from a statewide collaborative quality initiative for trauma were used. The data set contains information from 29 American College of Surgeons Committee on Trauma verified Levels I and II trauma centers from 2011 to 2016. Propensity score matching was used to create cohorts of patients treated at Levels I or II trauma centers. The 1:1 matched cohorts were used to compare in-hospital mortality, management strategy, complications, intensive care unit (ICU) and hospital length of stay, and failure to rescue. RESULTS Four hundred fifty-four patients with grade 3 or higher blunt liver injury were included. Patients treated at level II trauma centers had higher in-hospital mortality than those treated at Level I trauma centers (15.4% vs 8.8%, p = 0.03). Level II trauma centers used angiography less compared with Level I centers (p = 0.007) and admitted significantly fewer patients to the ICU (p = 0.002). The ICU status was associated with reduced mortality (7.2% vs 23.9%, p < 0.001). Despite a lower rate of overall complications, Level II trauma centers were more likely to fail in rescuing their patients (p = 0.045). CONCLUSION Admission with a high-grade liver injury to a Level II trauma center is associated with increased in-hospital mortality. Level II trauma centers were less likely to use angiography or admit high-grade liver injuries to the ICU. This variation in practice may lead to the inability to rescue critically ill patients. Future research should investigate contributors to underutilization of resources for patients with high-grade liver injuries. LEVEL OF EVIDENCE Care management, level IV.
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Yucel N, Ozturk Demir T, Derya S, Oguzturk H, Bicakcioglu M, Yetkin F. Potential Risk Factors for In-Hospital Mortality in Patients with Moderate-to-Severe Blunt Multiple Trauma Who Survive Initial Resuscitation. Emerg Med Int 2018; 2018:6461072. [PMID: 30595921 PMCID: PMC6282151 DOI: 10.1155/2018/6461072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/11/2018] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION The aim was to identify risk factors that influence in-hospital mortality for patients with moderate-to-severe blunt multiple trauma (BMT) who survive initial resuscitation. METHODS The prospective study involved 195 adult patients with BMT who were admitted to a referral hospital's emergency department (ED) between May 1, 2015, and May 31, 2016. RESULTS Forty-three (22%) of the 195 patients died in hospital. Multivariate analysis identified low blood pH (odds ratio [OR] 6.580, 95% confidence interval [CI] 1.12-38.51), high serum lactate level (OR 1.041, 95% CI 1.01-1.07), high ISS (OR 1.109, 95% CI 1.06-1.16), high APACHE II score (OR 1.189, 95% CI 1.07-1.33), traumatic brain injury (TBI) (OR 4.358, 95% CI 0.76-24.86), severe hemorrhage (OR 5.314, 95% CI 1.07-26.49), and coagulopathy (OR 5.916, 95% CI 1.17-29.90) as useful predictors of acute in-hospital mortality. High ISS (OR 1.047, 95% CI 1.02-1.08), TBI (OR 8.922, 95% CI 2.57-31.00), sepsis (OR 4.956, 95% CI 1.99-12.36), acute respiratory distress syndrome (ARDS) (OR 8.036, 95% CI 1.85-34.84), respiratory failure (OR 9.630, 95% CI 2.64-35.14), renal failure (OR 74.803, 95% CI 11.34-493.43), and multiple organ failure [MOF] (OR 10.415, 95% CI 4.48-24.24) were risk factors for late in-hospital mortality. High Glasgow Coma Scale (GCS) was a good predictor for survival at 2, 7, and 28 or more days of hospitalization (OR 0.708 and 95% CI 0.56-0.09; OR 0.835 and 95% CI 0.73-0.95; OR 0.798 and 95% CI 0.71-0.90, resp.). CONCLUSION Several factors signal poor short-term outcome for patients who present to the ED with moderate-to-severe BMT: low blood pH, high serum lactate level, presence of TBI, severe hemorrhage, coagulopathy, organ failure (respiratory, renal, and MOF), and ARDS. For this patient group, ISS and APACHE II scores might be helpful for stratifying by mortality risk, and GCS might be a good predictor for survival.
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Affiliation(s)
- Neslihan Yucel
- Department of Emergency Medicine, Inonu University, School of Medicine, Malatya, Turkey
| | - Tuba Ozturk Demir
- Department of Emergency Medicine, Inonu University, School of Medicine, Malatya, Turkey
| | - Serdar Derya
- Department of Emergency Medicine, Inonu University, School of Medicine, Malatya, Turkey
| | - Hakan Oguzturk
- Department of Emergency Medicine, Inonu University, School of Medicine, Malatya, Turkey
| | - Murat Bicakcioglu
- Department of Anesthesiology and Reanimation, Inonu University, School of Medicine, Malatya, Turkey
| | - Funda Yetkin
- Department of Infectious Disease and Clinical Microbiology, Inonu University, School of Medicine, Malatya, Turkey
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Lystad RP, Bierbaum M, Curtis K, Braithwaite J, Mitchell R. Unwarranted clinical variation in the care of children and young people hospitalised for injury: a population-based cohort study. Injury 2018; 49:1781-1786. [PMID: 30017178 DOI: 10.1016/j.injury.2018.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/29/2018] [Accepted: 07/09/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Injury is a leading cause of death and disability among children and young people. Recovery may be negatively affected by unwarranted clinical variation such as representation to an emergency department (ED), readmission to a hospital, and mortality. The aim of this study was to examine unwarranted clinical variation across providers of care of children and young people who were hospitalised for injury in New South Wales (NSW). MATERIALS AND METHODS Retrospective population-based cohort study using linked ED, hospital, and mortality data of all children and young people aged ≤25 years who were injured and hospitalised during 1 January 2010-30 June 2014 in NSW. Unwarranted clinical variation across providers was examined using three indicators. That is, for each hospital that treated ≥100 cases per year, risk standardised ratios were calculated with 95% and 99.8% confidence limits using the number of observed and expected events of (1) representations to ED within 72 h, (2) unplanned readmissions to hospital within 28 days, and (3) all-cause mortality within 30 days. RESULTS There were 189,990 injury-related hospitalisations of children and young people. Of these, 4.4% represented to an ED, 8.7% were readmitted to hospital, and 0.2% died. Of the 45 public hospitals that treated ≥100 cases per year, higher than expected rates of ED representations, hospital readmissions, and mortality were observed in eleven, six, and two hospitals, respectively. CONCLUSION The rates of ED representations, hospital readmissions, and mortality among children and young people hospitalised for injury in NSW were similar to the rates reported in other countries. However, unwarranted clinical variation across public hospitals was observed for all three indicators. These findings suggest that by improving routine follow-up support services post-discharge for children and young people and their families, it may be possible to reduce unwarranted clinical variation and improve health outcomes.
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Affiliation(s)
- Reidar P Lystad
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
| | - Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Kate Curtis
- Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Akande M, Minneci PC, Deans KJ, Xiang H, Cooper JN. Association of Medicaid Expansion Under the Affordable Care Act With Outcomes and Access to Rehabilitation in Young Adult Trauma Patients. JAMA Surg 2018; 153:e181630. [PMID: 29874372 DOI: 10.1001/jamasurg.2018.1630] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trauma is the leading cause of death and disability among young adults in the United States. Young adults are also the age group most likely to be uninsured. Implementation of Medicaid expansion through the Affordable Care Act (ACA) has increased insurance coverage, but its associations with trauma care and outcomes among young adults nationwide remain unknown. We examined whether Medicaid expansion, in its first year, was associated with changes in insurance coverage and improved outcomes in young adults hospitalized for traumatic injury. Objective To assess the associations of ACA Medicaid expansion with insurance coverage, in-hospital mortality, failure to rescue, access to rehabilitation, and unplanned readmissions among hospitalized young adult trauma patients across many US states. Design, Setting, and Participants We used the Healthcare Cost and Utilization Project State Inpatient Databases to examine changes in insurance coverage and risk adjusted outcomes among young adults (age 19 to 44 years) who were hospitalized for injuries before and after Medicaid expansion and open enrollment occurred (2012-2013 vs 2014) in 11 US states that expanded Medicaid through the ACA. We also performed difference-in-difference analyses to compare these changes between 3 expansion states and 3 non-expansion states within the same geographic region. Results Of the 141 187 trauma patients hospitalized across 11 Medicaid expansion states, 43 871 (31.1%) were women, and the mean (SD) age was 31.4 (7.6) years. Medicaid expansion was associated with an increase in Medicaid coverage from 16 229 individuals (16.7%) to 15 358 individuals (34.9%) (difference: 18.2% [95% CI, 16.5%-20.0%]; P < .001), a decrease in lack of insurance from 27 016 individuals (27.8%) to 5589 individuals (12.7%) (difference: -15.1% [95% CI, -16.8% to -13.5%]; P < .001), and an increase in discharge to rehabilitation from 9220 individuals (11.4%) to 4736 individuals (12.6%) (difference: 1.16% [95% CI, 0.55%-1.77%]; P < .001). We found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions. Similar results were found when 3 of these states were compared with 3 geographically and demographically similar states that had not enacted Medicaid expansion. Conclusions and Relevance The first year of implementation of Medicaid expansion and open enrollment across 11 selected US states was associated with significant increases in Medicaid coverage, reductions in uninsured rates, and increased access to postdischarge rehabilitation among young adults hospitalized for injury. However, this study found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions.
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Affiliation(s)
- Manzilat Akande
- Department of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Katherine J Deans
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Shah AA, Zogg CK, Rehman A, Latif A, Zafar H, Shakoor A, Wasif N, Chapital AB, Riviello R, Ashfaq A, Williams M, Cornwell EE, Haider AH. Disparate outcomes of global emergency surgery - A matched comparison of patients in developed and under-developed healthcare settings. Am J Surg 2018; 215:1029-1036. [PMID: 29807633 DOI: 10.1016/j.amjsurg.2018.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 02/28/2018] [Accepted: 05/11/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Access to surgical care is an essential element of health-systems strengthening. This study aims to compare two diverse healthcare settings in South Asia and the United States (US). METHODS Patients at the Aga Khan University Hospital (AKUH), Pakistan were matched to patients captured in the US Nationwide Inpatient Sample (US-NIS) from 2009 to 2011. Risk-adjusted differences in mortality, major morbidity, and LOS were compared using logistic and generalized-linear (family gamma, link log) models after coarsened-exact matching. RESULTS A total of 2,244,486 patients (n = 4867 AKUH; n = 2,239,619 US-NIS) were included. Of those in the US-NIS, 990,963 (42.5%) were treated at urban-teaching hospitals, 332,568 (14.3%) in rural locations. Risk-adjusted odds of reported mortality were higher for Pakistani patients (OR[95%CI]: 3.80[2.68-5.37]), while odds of reported complications were lower (OR[95%CI]: 0.56[0.48-0.65]). No differences were observed in LOS. The difference in outcomes was less pronounced when comparing Pakistani patients to American rural patients. CONCLUSION These results demonstrate significant reported morbidity, mortality differences between healthcare systems. Comparative assessments such as this will inform global health policy development and support.
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Affiliation(s)
- Adil A Shah
- Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA; Division of General Surgery, Mayo Clinic, Phoenix, AZ, USA; Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Cheryl K Zogg
- Yale University, School of Medicine, New-Haven, CT, USA; Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Abdul Rehman
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Asad Latif
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hasnain Zafar
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Amarah Shakoor
- Charleston Area Medical Center, West Virginia University, Charleston, WV, USA
| | - Nabil Wasif
- Division of General Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Robert Riviello
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Awais Ashfaq
- Department of Cardiothoracic Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - Mallory Williams
- Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA
| | - Edward E Cornwell
- Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA.
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Effects of Medicaid expansion on disparities in trauma care and outcomes in young adults. J Surg Res 2018; 228:42-53. [PMID: 29907229 DOI: 10.1016/j.jss.2018.02.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/08/2018] [Accepted: 02/27/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Racial/ethnic and socioeconomic disparities in trauma care and outcomes among young adults are well documented. As the Patient Protection and Affordable Care Act Medicaid expansion has increased insurance coverage among young adults, we aimed to investigate its impact on disparities in insurance coverage and outcomes among hospitalized young adult trauma patients. MATERIALS AND METHODS We used the healthcare cost and utilization project state inpatient databases to examine changes in insurance coverage and risk-adjusted outcomes from before (2012-2013) to after (2014) Medicaid expansion among young adults (age 19-44) hospitalized for injury across 11 Medicaid expansion states. Changes were compared across racial/ethnic and community-level income groups. We also compared changes in disparities between three expansion and three nonexpansion states in the US south. RESULTS In the first year of Medicaid expansion, non-Hispanic black trauma patients experienced a large decrease in uninsurance (34.3%-14.2%, P < 0.01), reducing the disparity in uninsurance between non-Hispanic black and non-Hispanic white patients (P < 0.05). There were no differences across racial/ethnic groups in changes in in-hospital mortality, failure to rescue, discharge to rehabilitation, or 30-d unplanned readmissions. Socioeconomic disparities in discharge to rehabilitation decreased (1.63% versus 0.06% increase among patients from the lowest and highest income communities, P < 0.05). In contrast, in the selected southern states, Medicaid expansion was associated with the introduction of a disparity in discharge to inpatient rehabilitation between Hispanics and non-Hispanic whites. CONCLUSIONS Medicaid expansion, in its first year, decreased racial and socioeconomic disparities in uninsurance and socioeconomic disparities in access to rehabilitation.
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Aljerian N, Alhaidar S, Alothman A, AlJohi W, Albaqami FA, Alghnam SA. Association between the mode of transport and in-hospital medical complications in trauma patients: findings from a level-I trauma center in Saudi Arabia. Ann Saudi Med 2018; 38:8-14. [PMID: 29419523 PMCID: PMC6074188 DOI: 10.5144/0256-4947.2018.8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Saudi Arabia, injury is the leading cause of death. Even if nonfatal, the impact of injuries on population health is enormous, as thousands of young patients suffer permanent disabilities every year. Unlike in developed countries, private transportation (PT) is a common means to transport trauma patients. Outcome differences between patients transported via PT relative to emergency medical services (EMS) has not been previously explored. OBJECTIVES To evaluate the association between transportation mode and in-hospital complications among trauma patients. DESIGN Retrospective. SETTING Tertiary care center. PATIENTS AND METHODS The study included all patients (>=16 years), who were admitted following trauma. MAIN OUTCOME MEASURES The main outcome in the study was the occurrence of any medical complications including stroke, sepsis, myocardial infarction, pulmonary embolism, pneumonia, renal failure, acute respiratory distress syndrome, and cardiac arrest. RESULTS The 493 patients were relatively young (over two-thirds of the sample were 45 years old or younger) and over half the population sustained injuries due traffic crashes. More than half (58%) of patients arrived via private transportation. Regression analyses revealed that in-hospital complications following injuries were significantly lower among those who arrived via PT. However, after incorporating propensity score matching, we found no difference in hospital complications (OR=0.55, 95% CI 0.25-1.17). CONCLUSION Multiple factors may influence this unexpected finding, such as distance to health care set.tings, the belief that PT is faster or lack of knowledge of the EMS contact number. Further efforts are needed to raise awareness of the importance of using EMS to transport trauma patients to hospitals. Prevention programs to reduce traffic crashes may facilitate reduction in traumatic injuries and associated complications. LIMITATIONS Retrospective and conducted in one center only.
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Affiliation(s)
| | | | | | | | | | - Suliman Abdullah Alghnam
- Dr. Suliman Abdulah Alghnam Population Health, King Abdullah International Research Center, PO Box 22490, Riyadh 11426, Saudi Arabia T: +966-539468887, , ORCID: http://orcid.org/0000-0001-5817-0481
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