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Melhado C, Evans LL, Miskovic A, Subacius H, Nathens AB, Stein DM, Burd RS, Jensen AR. Benchmarking Pediatric Trauma Care in Mixed Trauma Centers: Adult Risk-Adjusted Mortality Is Not a Reliable Indicator of Pediatric Outcomes. J Am Coll Surg 2024; 238:243-251. [PMID: 38059567 DOI: 10.1097/xcs.0000000000000919] [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: 12/08/2023]
Abstract
BACKGROUND Trauma center benchmarking has become standard practice for assessing quality. The American College of Surgeons adult trauma center verification standards do not specifically require participation in a pediatric-specific benchmarking program. Centers that treat adults and children may therefore rely solely on adult benchmarking metrics as a surrogate for pediatric quality. This study assessed discordance between adult and pediatric mortality within mixed trauma centers to determine the need to independently report pediatric-specific quality metrics. STUDY DESIGN A cohort of trauma centers (n = 493, including 347 adult-only, 44 pediatric-only, and 102 mixed) that participated in the American College of Surgeons TQIP in 2017 to 2018 was analyzed. Center-specific observed-to-expected mortality estimates were calculated using TQIP adult inclusion criteria for 449 centers treating adults (16 to 65 years) and using TQIP pediatric inclusion criteria for 146 centers treating children (0 to 15 years). We then correlated risk-adjusted mortality estimates for pediatric and adult patients within mixed centers and evaluated concordance of their outlier status between adults and children. RESULTS The cohort included 394,075 adults and 97,698 children. Unadjusted mortality was 6.1% in adults and 1.2% in children. Mortality estimates had only moderate correlation ( r = 0.41) between adult and pediatric cohorts within individual mixed centers. Mortality outlier status for adult and pediatric cohorts was discordant in 31% (32 of 102) of mixed centers (weighted Kappa statistic 0.06 [-0.11 to 0.22]), with 78% (23 of 32) of discordant centers having higher odds of mortality for children than for adults (6 centers with average adult mortality and high pediatric mortality and 17 centers with low adult mortality and average pediatric mortality, p < 0.01). CONCLUSIONS Adult mortality is not a reliable surrogate for pediatric mortality in mixed trauma centers. Incorporation of pediatric-specific benchmarks should be required for centers that admit children.
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Affiliation(s)
- Caroline Melhado
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
| | - Lauren L Evans
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
| | - Amy Miskovic
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
| | - Haris Subacius
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
| | - Avery B Nathens
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
- Department of Surgery, University of Toronto, Toronto, ON (Nathens)
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Stein)
| | - Randall S Burd
- Division of Burn and Trauma Surgery, Children's National Medical Center, Washington, DC (Burd)
| | - Aaron R Jensen
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
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Fihn SD, Rivara FP. JAMA Network Open-The Year in Review, 2022. JAMA Netw Open 2023; 6:e236253. [PMID: 36929406 DOI: 10.1001/jamanetworkopen.2023.6253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Affiliation(s)
- Stephan D Fihn
- Department of Medicine, University of Washington, Seattle
- Deputy Editor, JAMA Network Open
| | - Frederick P Rivara
- Department of Pediatrics, University of Washington, Seattle
- Editor, JAMA Network Open
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Lau L, Ajzenberg H, Haas B, Wong CL. Trauma in the Aging Population. Emerg Med Clin North Am 2023; 41:183-203. [DOI: 10.1016/j.emc.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Priestap F, Veens J, Vogt K. Transfer status may not be associated with worse outcomes in elderly trauma patients. Injury 2023; 54:1314-1320. [PMID: 36737269 DOI: 10.1016/j.injury.2023.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 01/05/2023] [Accepted: 01/26/2023] [Indexed: 01/30/2023]
Abstract
PURPOSE To compare outcomes of elderly patients who arrive directly to a lead trauma centre to those who are transferred from a peripheral hospital. METHODS This study used a retrospective cohort design and data obtained from the local trauma registry. The study population was patients 65 years and older who presented with an Injury Severity Score (ISS) of 12 or greater, or for whom the trauma team was activated, over a 10-year period. Patients were excluded from the study if they arrived direct from the scene and died within 3 hours of arrival, they were found to have no injuries, or they were directly admitted more than 2 days from the time of injury. Following the use of multiple imputation, multivariable logistic regression analysis was used to evaluate the relationship between in-hospital mortality and directness of transport, while adjusting for potentially confounding variables. RESULTS Of the 1619 patients included in the analyses over half (54.2%) were transported directly from the scene of injury to the lead trauma hospital (LTH). The remaining 45.8% initially presented to a non-tertiary hospital and were later transferred to the LTH. Crude mortality was 18.7% in the direct group and 14.0% in the transfer group (p = 0.015). The unadjusted odds of death for patients arriving to LTH by referral was 0.71 (95% confidence interval, 0.54, 0.93), compared to patients arriving to the LTH directly. After adjustment for age, ISS, presence of severe head injury, Charlson Comorbidity Index, shock, initial GCS, and ICU admission from the emergency department, the mortality risk did not differ significantly for transferred patients compared to those arriving directly (OR = 0.77 (95% confidence interval, 0.54, 1.09). CONCLUSION There was no significant difference in in-hospital mortality between elderly patients transported directly to the trauma centre and those who were transferred from peripheral hospitals.
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Affiliation(s)
- Fran Priestap
- London Health Sciences Centre - Victoria Hospital, 800 Commissioners Rd E., London, Ontario N6A 5W9, Canada.
| | - Juliet Veens
- Huron Perth Health Alliance - Stratford General Hospital, 46 General Hospital Dr., Stratford, Ontario, Canada; Division of Emergency Medicine, Schulich School of Dentistry and Medicine, Western University, London, Ontario, Canada
| | - Kelly Vogt
- London Health Sciences Centre - Victoria Hospital, 800 Commissioners Rd E., London, Ontario N6A 5W9, Canada; Department of Surgery, Schulich School of Dentistry and Medicine, Western University, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
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Reider L, Pollak A, Wolff JL, Magaziner J, Levy JF. National trends in extremity fracture hospitalizations among older adults between 2003 and 2017. J Am Geriatr Soc 2021; 69:2556-2565. [PMID: 34062611 DOI: 10.1111/jgs.17281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States. DESIGN Retrospective longitudinal cohort study. SETTING The 2003-2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals. PARTICIPANTS Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture. MEASUREMENTS Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time. RESULTS Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend < 0.001) and men (3.2%, p trend < 0.001) between 2003 and 2017. This trend was primarily attributed to a decline in low energy femur fractures which accounted for 65% of all fracture hospitalizations. Among older adults with an extremity fracture hospitalization, mortality declined from 5.1% in 2003 to 3.3% in 2017 in men, and from 2.6% to 1.9% in women (p trend < 0.001). High energy fractures were due to falls (53%), motor vehicle accidents (34%), and other high impact injuries (13%). Overall, 12% of extremity fracture hospitalizations were attributed to high-energy injuries: increases were observed among men ages 65-74 (20%; p trend < 0.001) and 75-84 (10%; p trend = 0.013), but not among women of any age. CONCLUSION Observed declines in the incidence of extremity fracture hospitalizations and related mortality are encouraging. However, increasing incidence of fracture hospitalization from high energy injuries among men suggests that older adults with complex injuries will be seen with more prevalence in the future.
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Affiliation(s)
- Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew Pollak
- School of Medicine, Department of Orthopaedics, University of Maryland, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jay Magaziner
- School of Medicine, Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, USA
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Dandan IS, Tominaga GT, Zhao FZ, Schaffer KB, Nasrallah FS, Gawlik M, Bayat D, Dandan TH, Biffl WL. Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients. Trauma Surg Acute Care Open 2021; 6:e000670. [PMID: 34013050 PMCID: PMC8094379 DOI: 10.1136/tsaco-2020-000670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background Overtriage of trauma patients is unavoidable and requires effective use of hospital resources. A 'pit stop' (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost. Methods We performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05. Results There were 994 TAs and 474 TRs in the first 9 months after implementation. TR's preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%. Discussion PS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources. Level of evidence Level II, economic/decision therapeutic/care management study.
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Affiliation(s)
- Imad S Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Gail T Tominaga
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Frank Z Zhao
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Melanie Gawlik
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Dunya Bayat
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Tala H Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Walter L Biffl
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
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Thompson A, Gida S, Nassif Y, Hope C, Brooks A. The impact of frailty on trauma outcomes using the Clinical Frailty Scale. Eur J Trauma Emerg Surg 2021; 48:1271-1276. [PMID: 33682027 PMCID: PMC7937544 DOI: 10.1007/s00068-021-01627-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 02/21/2021] [Indexed: 12/17/2022]
Abstract
Background Population ageing is a worldwide phenomenon; thanks to improvements in medical care and living standards. The Office of National Statistics in the UK predicts that the fastest growing age group in coming decades will be those over 85 years. This is reflected in Trauma Audit and Research Network data, which has highlighted a shift in caseload from a majority of young males to elderly patients at UK Major Trauma Centres (MTC). This study of elderly trauma patients admitted to a UK MTC reviews the links between frailty, using the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), and outcomes from trauma. Methods A retrospective database review of patients > 65 years old admitted to our MTC was performed. We identified 1125 eligible patients of which 729 had a recorded CFS. Those without a CFS were omitted. The primary outcome measured was in-hospital mortality. Secondary measures were Injury Severity Score, length of stay, trauma team activation on arrival and discharge destination. Multivariate regression analyses were performed using STATA v 15. Results Those of CFS 5–9 (frail) were 2.6 times more likely to die than the CFS 1–4 (pre-frail) (OR 2.65, 95% CI 1.47–4.78). The frail group was also 56% less likely to have a trauma call on admission (OR 0.44, 95% CI 0.30–0.65) and 61% less likely to be discharged to their usual place of residence (OR 0.39, 95% CI 0.28–0.55). Conclusion We advocate the use of the Clinical Frailty Scale as a screening tool for frailty in trauma patients, highlighting those at risk of increased length of stay and mortality, subsequently assisting healthcare providers with setting realistic expectations with family members. Level of evidence Level III, prognostic and epidemiological
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Affiliation(s)
- Amari Thompson
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham, NG7 2UH, England, UK.
| | - Sunil Gida
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham, NG7 2UH, England, UK
| | - Yasar Nassif
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham, NG7 2UH, England, UK
| | - Carla Hope
- Royal Derby Hospital, Derby, England, UK
| | - Adam Brooks
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham, NG7 2UH, England, UK
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Palliative care and aggressive interventions after falling: A Nationwide Inpatient Sample analysis. Palliat Support Care 2021; 20:101-106. [PMID: 33663643 DOI: 10.1017/s1478951521000158] [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
OBJECTIVE The purpose of this study is to identify whether there is an opportunity for improvement to provide palliative care services after a serious fall. We hypothesized that (1) palliative care services would be utilized in less than 10% of patients over the age of 65 who fall and (2) more than 20% of patients would receive aggressive life-sustaining treatments (LSTs) prior to death. METHODS Using the 2017 Nationwide Inpatient Sample, we identified patients who were admitted to the hospital with a fall (ICD-10 W00-W19) and were hospitalized at least two days with valid discharge data. Palliative care services (Z51.5) or LSTs (cardiopulmonary resuscitation, ventilation, reintubation, tracheostomy, feeding tube placement, vasopressors, transfusion, total parenteral nutrition, and hemodialysis) were identified with ICD-10 codes. We examined the use of palliative care or LSTs by discharge destination (home, facility, and death). Logistic regression was used to identify factors associated with palliative care. RESULTS In total, 155,241 patients were identified (median 82 years old, interquartile range 74-88); 2.5% died in hospital, and 69.4% were transferred to a facility. Palliative care occurred in 4.5% of patients, and LST occurred in 15.1%. Patients who died were significantly more likely to have had palliative care (50.1% vs. 3.4% of home or facility discharges) and were more likely to have an LST [53.0% vs. 9.8% (home) vs. 15.9% (facility)]. Palliative care was associated with both death [adjusted odds ratio (AOR) 19.84, 95% confidence interval (CI) 18.39-21.41, p < 0.001] and LST (AOR 1.36, 95% CI 1.27-1.46, p < 0.001). SIGNIFICANCE OF RESULTS Palliative care is associated with both death and LST, suggesting that physicians use palliative care as a last resort after aggressive measures have been exhausted. Patients who fall would likely benefit from the early use of palliative care to align future goals of care.
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Hatchimonji JS, Kaufman EJ, Young AJ, Smith BP, Xiong R, Reilly PM, Holena DN. High-Performance Trauma Centers in a Single-State Trauma System : Big Saves or Marginal Gains? Am Surg 2020; 86:766-772. [PMID: 32723186 DOI: 10.1177/0003134820934415] [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
BACKGROUND Trauma centers with low observed:expected (O:E) mortality ratios are considered high performers; however, it is unknown whether improvements in this ratio are due to a small number of unexpected survivors with high mortality risk (big saves) or a larger number of unexpected survivors with moderate mortality risk (marginal gains). We hypothesized that the highest-performing centers achieve that status via larger numbers of unexpected survivors with moderate mortality risk. METHODS We calculated O:E ratios for trauma centers in Pennsylvania for 2016 using a risk-adjusted mortality model. We identified high and low performers as centers whose 95% CIs did not cross 1. We visualized differences between these centers by plotting patient-level observed and expected mortality; we then examined differences in a subset of patients with a predicted mortality of ≥10% using the chi-squared test. RESULTS One high performer and 1 low performer were identified. The high performer managed a population with more blunt injuries (97.2% vs 93.6%, P < .001) and a higher median Injury Severity Score (14 vs 11, P < .001). There was no difference in survival between these centers in patients with an expected mortality of <10% (98.0% vs 96.7%, P = .11) or ≥70% (23.5% vs 10.8%, P = .22), but there was a difference in the subset with an expected mortality of ≥10% (77.5% vs 43.1%, P < .001). CONCLUSIONS Though patients with very low predicted mortality do equally well in high-performing and low-performing centers, the fact that performance seems determined by outcomes of patients with moderate predicted mortality favors a "marginal gains" theory.
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Affiliation(s)
- Justin S Hatchimonji
- 6572 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Andrew J Young
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Brian P Smith
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Ruiying Xiong
- Department of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Daniel N Holena
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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Sheffy N, Tellem R, Bentov I. Anesthetic Challenges in Treating the Older Adult Trauma Patient: an Update. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00378-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cronin PK, Ferrone ML, Marso CC, Stieler EK, Beck AW, Blucher JA, Makhni MC, Simpson AK, Harris MB, Schoenfeld AJ. Predicting survival in older patients treated for cervical spine fractures: development of a clinical survival score. Spine J 2019; 19:1490-1497. [PMID: 31125694 DOI: 10.1016/j.spinee.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Emerging literature has identified the importance of pretreatment health and functional status as influential in the prognostication of survival. A comprehensive, accessible, predictive model for survival following cervical spine fracture has yet to be developed. PURPOSE To develop an accessible and intuitive predictive model for survival in individuals aged 50 and older treated for cervical spine fractures. STUDY DESIGN Retrospective review of records from two tertiary care centers (2009-2016). PATIENT SAMPLE Patients age 50 and older who received operative or nonoperative management for cervical fractures. OUTCOME MEASURES One-year mortality was the primary outcome with 3-month and 2-year mortality considered secondarily. METHODS Multivariable logistic regression was used to identify factors independently associated with mortality. The magnitude and precision of the relationship with 1-year mortality for statistically significant variables determined weighting in the scoring system subsequently developed. Score performance was tested through multivariable regression and bootstrap simulation. In a sensitivity test, the performance of the score developed for 1-year mortality was assessed using figures for the 3-month and 2-year time-points. RESULTS We included 1,758 patients. Mortality rates were 12% at 3 months, 17% at 1 year, and 21% at 2 years. Following multivariable testing age, injury severity score and Glasgow coma scale demonstrated the strongest predictive values for a base score, followed by serum albumin and ambulatory status. The resultant composite score ranged from 0 (base score≤4, albumin≤3.5 g/dL, and dependent/nonambulator at presentation) to a maximum of 4 (base score≥5, albumin>3.5 g/dL, and independent ambulator at presentation). Following multivariable analysis, when compared to patients with a score of 4, significantly increased odds of 1-year mortality were appreciated for those with scores of 3 (odds ratio [OR] 7.35; 95% confidence interval [CI] 3.77, 14.32), 2 (OR 8.43; 95% CI 4.66, 15.25), 1 (OR 17.47; 95% CI 9.81, 31.11), and 0 (OR 26.58; 95% CI 13.87, 50.92). Score performance was unchanged in bootstrap testing and sensitivity analyses. CONCLUSIONS We have developed a useful prognostic utility capable of informing survival in individuals age 50 and older, following cervical spine fractures. The score can be applied to adjust patient expectations, anticipate outcomes, and as an adjunct to decision-making in the postinjury period.
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Affiliation(s)
- Patrick K Cronin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Chase C Marso
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Evan K Stieler
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Aaron W Beck
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Justin A Blucher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Melvin C Makhni
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02214, USA
| | - Andrew J Schoenfeld
- Investigation Performed at Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Trinder MW, Wellman SW, Nasim S, Weber DG. Evaluation of the trauma triage accuracy in a Level 1 Australian trauma centre. Emerg Med Australas 2018; 30:699-704. [PMID: 29888859 DOI: 10.1111/1742-6723.13117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess the rate of undertriage of major trauma patients and to assess factors contributing to undertriage in a modern Australian Level 1 trauma centre. METHODS A retrospective case series of 600 consecutive major trauma (injury severity score [ISS] >15) patients admitted to Royal Perth Hospital (RPH) during 2015 was performed. Data were compiled via the prospectively maintained hospital trauma registry for all patients admitted with a major trauma during the study period. Results were analysed for patient demographics, mechanism and outcomes. The primary outcome of the study was to determine the rate of undertriage of major trauma at RPH by establishing whether or not the trauma team activation page was correctly sent at the time of patient arrival based on hospital criteria. RESULTS The average age of patients in the study population was 46.5 (±21.5) years and the mean ISS was 24.7 (±9.3). The most common mechanism of injury was falls, motor vehicle accidents and motorbike accidents. One hundred and sixty-nine patients (28%) did not have trauma team activation on arrival to the ED. Among these patients, 132 did not fulfil the RPH trauma activation criteria. The remaining 37 patients (6.1%) did meet the criteria and were considered undertriaged. Subgroup analysis showed a statistically significant difference in age between the patients who had trauma team activation (42.7 ± 19.5 years) and those who did not (55.9 ± 23.3 years). CONCLUSION In this cohort of major trauma, a 6.1% undertriage performance of the triage tool was observed. Sub-analysis of the data showed that elderly patients were more likely to be undertriaged.
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Affiliation(s)
- Matthew W Trinder
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Samuel W Wellman
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sana Nasim
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
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Tominaga GT, Dandan IS, Schaffer KB, Nasrallah F, Gawlik R N M, Kraus JF. Trauma resource designation: an innovative approach to improving trauma system overtriage. Trauma Surg Acute Care Open 2017; 2:e000102. [PMID: 29766100 PMCID: PMC5877913 DOI: 10.1136/tsaco-2017-000102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/29/2017] [Accepted: 06/05/2017] [Indexed: 01/07/2023] Open
Abstract
Background Effective triage of injured patients is often a balancing act for trauma systems. As healthcare reimbursements continue to decline,1 innovative programs to effectively use hospital resources are essential in maintaining a viable trauma system. The objective of this pilot intervention was to evaluate a new triage model using 'trauma resource' (TR) as a new category in our existing Tiered Trauma Team Activation (TA) approach with hopes of decreasing charges without adversely affecting patient outcome. Methods Patients at one Level II Trauma Center (TC) over seven months were studied. Patients not meeting American College of Surgeons criteria for TA were assigned as TR and transported to a designated TC for expedited emergency department (ED) evaluation. Such patients were immediately assessed by a trauma nurse, ED nurse, and board-certified ED physician. Diagnostic studies were ordered, and the trauma surgeon (TS) was consulted as needed. Demographics, injury mechanism, time to physician evaluation, time to CT scan, time to disposition, hospital length of stay (LOS), and in-hospital mortality were analyzed. Results Fifty-two of the 318 TR patients were admitted by the TS and were similar to TA patients (N=684) with regard to gender, mean Injury Severity Score, mean LOS and in-hospital mortality, but were older (60.4 vs 47.2 years, p<0.0001) and often involved in a fall injury (52% vs 35%, p=0.0170). TR patients had increased door to physician evaluation times (11.5 vs 0.4 minutes, p<0.0001) and increased door to CT times (76.2 vs 25.9 minutes, p<0.0001). Of the 313 TR patients, 52 incurred charges totaling US$253 708 compared with US$1 041 612 if patients had been classified as TA. Conclusions Designating patients as TR prehospital with expedited evaluation by an ED physician and early TS consultation resulted in reduced use of resources and lower hospital charges without increase in LOS, time to disposition or in-hospital mortality. Level of evidence Level II.
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Affiliation(s)
- Gail T Tominaga
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Imad S Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Fady Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Melanie Gawlik R N
- Trauma Service, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jess F Kraus
- Department of Epidemiology, University of California Los Angeles, Carlsbad, California, USA
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Kaufman EJ, Earl-Royal E, Barie PS, Holena DN. Failure to Rescue after Infectious Complications in a Statewide Trauma System. Surg Infect (Larchmt) 2016; 18:89-98. [PMID: 27912035 DOI: 10.1089/sur.2016.112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The failure to rescue (FTR) rate, the rate of death after a complication, measures a center's ability to identify and manage complications by "rescuing" vulnerable patients. Infectious complications are common after trauma, but risk factors for death after infection are not established. We hypothesized that risk factors would differ for FTR after infectious complications, development of infections, and for development of and death after non-infectious complications. PATIENTS AND METHODS We analyzed trauma registry data for adult patients admitted to all 30 level I and II Pennsylvania trauma centers, 2011-2014. We used multivariable regression to identify risk factors for infection, non-infectious complications, failure to rescue after infection (FTR-I), failure to rescue after non-infectious complications (FTR-N), and death. We compared secondary complication patterns among patients with an index infection. RESULTS Of 95,806 admitted patients, at least one complication developed in 11.2%. Among these, 33.6% had an infection as the first complication. Mortality rates were 3.7% overall, 2.8% in patients with no complications, 7.2% after infection, and 13.5% after non-infectious complications. Urinary tract infection was the most common infection (41.7%), followed by pneumonia (37.5%) and wound infection (6.9%). Risk factors for infection included higher injury severity score (ISS), poor admitting physiology, female gender, cirrhosis, dementia, history of stroke, and drug abuse. Factors associated with FTR-I included male gender (odds ratio [OR] 1.6, 95% confidence interval 1.1-1.2), older age (OR 1.04, 1.03-1.05), increased ISS, cirrhosis, chronic renal insufficiency, and use of anticoagulation or steroids. CONCLUSIONS Infectious complications are common in trauma patients and are an important component of FTR. Risk factors for infection and FTR-I differ and may help identify patients who may benefit from close surveillance and early intervention. Half of all FTR deaths were preceded by only a single complication, highlighting that management of this index complication, along with any secondary complications, may be a fruitful area for intervention.
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Affiliation(s)
- Elinore J Kaufman
- 1 Department of Surgery, New York-Presbyterian Weill Cornell Medical Center , New York, New York (formerly University of Pennsylvania Master's Program in Health Policy)
| | - Emily Earl-Royal
- 2 University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Philip S Barie
- 1 Department of Surgery, New York-Presbyterian Weill Cornell Medical Center , New York, New York (formerly University of Pennsylvania Master's Program in Health Policy)
| | - Daniel N Holena
- 3 Division of Traumatology, Surgical Critical Care and Emergency Surgery , University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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15
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Failure-to-rescue after injury is associated with preventability: The results of mortality panel review of failure-to-rescue cases in trauma. Surgery 2016; 161:782-790. [PMID: 27788924 DOI: 10.1016/j.surg.2016.08.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/02/2016] [Accepted: 08/05/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Failure-to-rescue is defined as the conditional probability of death after a complication, and the failure-to-rescue rate reflects a center's ability to successfully "rescue" patients after complications. The validity of the failure-to-rescue rate as a quality measure is dependent on the preventability of death and the appropriateness of this measure for use in the trauma population is untested. We sought to evaluate the relationship between preventability and failure-to-rescue in trauma. METHODS All adjudications from a mortality review panel at an academic level I trauma center from 2005-2015 were merged with registry data for the same time period. The preventability of each death was determined by panel consensus as part of peer review. Failure-to-rescue deaths were defined as those occurring after any registry-defined complication. Univariate and multivariate logistic regression models between failure-to-rescue status and preventability were constructed and time to death was examined using survival time analyses. RESULTS Of 26,557 patients, 2,735 (10.5%) had a complication, of whom 359 died for a failure-to-rescue rate of 13.2%. Of failure-to-rescue deaths, 272 (75.6%) were judged to be non-preventable, 65 (18.1%) were judged potentially preventable, and 22 (6.1%) were judged to be preventable by peer review. After adjusting for other patient factors, there remained a strong association between failure-to-rescue status and potentially preventable (odds ratio 2.32, 95% confidence interval, 1.47-3.66) and preventable (odds ratio 14.84, 95% confidence interval, 3.30-66.71) judgment. CONCLUSION Despite a strong association between failure-to-rescue status and preventability adjudication, only a minority of deaths meeting the definition of failure to rescue were judged to be preventable or potentially preventable. Revision of the failure-to-rescue metric before use in trauma care benchmarking is warranted.
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16
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Tran J, Jeanmonod D, Agresti D, Hamden K, Jeanmonod RK. Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients. West J Emerg Med 2016; 17:252-7. [PMID: 27330655 PMCID: PMC4899054 DOI: 10.5811/westjem.2016.3.29702] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/08/2016] [Accepted: 03/09/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The National Emergency X-radiography Utilization Study (NEXUS) criteria are used extensively in emergency departments to rule out C-spine injuries (CSI) in the general population. Although the NEXUS validation set included 2,943 elderly patients, multiple case reports and the Canadian C-Spine Rules question the validity of applying NEXUS to geriatric populations. The objective of this study was to validate a modified NEXUS criteria in a low-risk elderly fall population with two changes: a modified definition for distracting injury and the definition of normal mentation. METHODS This is a prospective, observational cohort study of geriatric fall patients who presented to a Level I trauma center and were not triaged to the trauma bay. Providers enrolled non-intoxicated patients at baseline mental status with no lateralizing neurologic deficits. They recorded midline neck tenderness, signs of trauma, and presence of other distracting injury. RESULTS We enrolled 800 patients. One patient fall event was excluded due to duplicate enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range 65-101). The numbers in parenthesis after the negative predictive value represent confidence interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and 10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive (CI [67.9-100]) with a negative predictive value of 100 (98.7-100). CONCLUSION Our study suggests that a modified NEXUS criteria can be safely applied to low-risk elderly falls.
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Affiliation(s)
- John Tran
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Donald Jeanmonod
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | - Darin Agresti
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
| | | | - Rebecca K Jeanmonod
- St. Luke's University Hospital, Department of Emergency Medicine, Bethlehem, Pennsylvania
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Cooper Z, Mitchell SL, Lipsitz S, Harris MB, Ayanian JZ, Bernacki RE, Jha AK. Mortality and Readmission After Cervical Fracture from a Fall in Older Adults: Comparison with Hip Fracture Using National Medicare Data. J Am Geriatr Soc 2015; 63:2036-42. [PMID: 26456855 DOI: 10.1111/jgs.13670] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To examine the prevalence of cervical spine fractures after falls in older Americans, to show changes in recent years, and to compare 12-month outcomes between individuals with cervical and hip fracture after falls. DESIGN Retrospective study of Medicare data from 2007 to 2011. SETTING Acute care hospitals. PARTICIPANTS Individuals aged 65 and older with cervical or hip fracture after a fall. MEASUREMENTS Cervical fracture rate, 12-month mortality, and readmission rate after injury. RESULTS Rates of cervical fracture increased from 4.6 per 10,000 in 2007 to 5.3 per 10,000 in 2011; rates of hip fracture decreased from 77.3 per 10,000 in 2007 to 63.5 per 10,000 in 2011. Participants with cervical fracture with and without spinal cord injury (SCI) were more likely than those with hip fracture to receive treatment at large hospitals (59.4% and 54.1% vs 28.1%, P < .001), teaching hospitals (49.3% and 40.0% vs 13.4%, P < .001), and regional trauma centers (46.3% and 38.5% vs 13.0%, P < .001). Participants with cervical fracture without (24.7%) and with SCI (41.7%) had greater risk-adjusted mortality at 1 year than those with hip fracture (22.7%) (P < .001). By 1 year, 73.4% of participants with cervical fracture with and 59.5% without SCI and 59.3% of those with hip fracture had died or were readmitted to the hospital (P < .001). CONCLUSION Cervical spinal fractures occur in one of every 2,000 Medicare beneficiaries annually and appear to be increasing over time. Participants with cervical fracture had greater mortality than those with hip fracture. Given the increasing prevalence and the poor outcomes in this population, hospitals need to develop processes to improve care for these vulnerable individuals.
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Affiliation(s)
- Zara Cooper
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Medical School of Medicine, Harvard University, Boston, Massachusetts
| | - Susan L Mitchell
- Medical School of Medicine, Harvard University, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mitchel B Harris
- Medical School of Medicine, Harvard University, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - John Z Ayanian
- Division of General Medicine, University of Michigan, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ariadne Labs, Boston, Massachusetts
| | - Ashish K Jha
- T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
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Brooks SE, Mukherjee K, Gunter OL, Guillamondegui OD, Jenkins JM, Miller RS, May AK. Do Models Incorporating Comorbidities Outperform Those Incorporating Vital Signs and Injury Pattern for Predicting Mortality in Geriatric Trauma? J Am Coll Surg 2014; 219:1020-7. [DOI: 10.1016/j.jamcollsurg.2014.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/17/2014] [Accepted: 08/01/2014] [Indexed: 12/21/2022]
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Tiao J, Moore L, Boutin A, Turgeon AF. Establishing consensus on the definition of an isolated hip fracture for trauma system performance evaluation: A systematic review. J Emerg Trauma Shock 2014; 7:209-14. [PMID: 25114432 PMCID: PMC4126122 DOI: 10.4103/0974-2700.136867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/16/2013] [Indexed: 12/01/2022] Open
Abstract
Background: Risk-adjusted mortality is widely used to benchmark trauma center care. Patients presenting with isolated hip fractures (IHFs) are usually excluded from these evaluations. However, there is no standardized definition of an IHF. We aimed to evaluate whether there is consensus on the definition of an IHF used as an exclusion criterion in studies evaluating the performance of trauma centers in terms of mortality. Materials and Methods: We conducted a systematic review of observational studies. We searched the electronic databases MEDLINE, EMBASE, BIOSIS, The Cochrane Library, CINAHL, TRIP Database, and PROQUEST for cohort studies that presented data on mortality to assess the performance of trauma centers and excluded IHF. A standardized, piloted data abstraction form was used to extract data on study settings, IHF definitions and methodological quality of included studies. Consensus was considered to be reached if more than 50% of studies used the same definition of IHF. Results: We identified 8,506 studies of which 11 were eligible for inclusion. Only two studies (18%) used the same definition of an IHF. Three (27%) used a definition based on Abbreviated Injury Scale (AIS) Codes and five (45%) on International Classification of Diseases (ICD) codes. Four (36%) studies had inclusion criteria based on age, five (45%) on secondary injuries, and four (36%) on the mechanism of injury. Eight studies (73%) had good overall methodological quality. Conclusions: We observed important heterogeneity in the definition of an IHF used as an exclusion criterion in studies evaluating the performance of trauma centers. Consensus on a standardized definition is needed to improve the validity of evaluations of the quality of trauma care.
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Affiliation(s)
- Judith Tiao
- Department of Social and Preventive Medicine;, Université Laval, Québec, Canada ; Axe Santé des populations et pratiques optimales en santé (traumatologie-urgence-soins intensifs), Centre de Recherche du CHU de Québec - Hôpital de l'Enfant-Jésus, Université Laval, Québec, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine;, Université Laval, Québec, Canada ; Axe Santé des populations et pratiques optimales en santé (traumatologie-urgence-soins intensifs), Centre de Recherche du CHU de Québec - Hôpital de l'Enfant-Jésus, Université Laval, Québec, Canada
| | - Amélie Boutin
- Axe Santé des populations et pratiques optimales en santé (traumatologie-urgence-soins intensifs), Centre de Recherche du CHU de Québec - Hôpital de l'Enfant-Jésus, Université Laval, Québec, Canada
| | - Alexis F Turgeon
- Axe Santé des populations et pratiques optimales en santé (traumatologie-urgence-soins intensifs), Centre de Recherche du CHU de Québec - Hôpital de l'Enfant-Jésus, Université Laval, Québec, Canada ; Department of Anesthesiology, Division of Critical Care Medicine, Quebec, Canada
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20
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Gomez D, Alali AS, Haas B, Xiong W, Tien H, Nathens AB. Temporal trends and differences in mortality at trauma centres across Ontario from 2005 to 2011: a retrospective cohort study. CMAJ Open 2014; 2:E176-82. [PMID: 25295237 PMCID: PMC4183166 DOI: 10.9778/cmajo.20140007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Care in a trauma centre is associated with significant reductions in mortality after severe injury. However, emerging evidence suggests that outcomes across similarly accredited trauma centres are not equivalent, even after adjusting for case-mix. The primary objective of this analysis was to evaluate secular trends in overall mortality at trauma centres. Secondarily, we explored trauma centre-specific mortality to determine the extent of variation between centres. METHODS Data on 26 421 adults (≥□18 yr) admitted to a trauma centre between 2005 and 2011 were derived from the Ontario Trauma Registry. We used generalized estimating equations to calculate in-hospital mortality over time and hierarchical models to estimate trauma-centre-specific mortality. To quantify variability between centres, we calculated median odds ratios. Adjusted odds of death were calculated for each trauma centre to identify those with higher than expected, average and lower than expected mortality. RESULTS Overall mortality at trauma centres decreased from 13.2% in 2005 to 11.2% in 2009. After adjusting for case mix, the odds of death decreased by approximately 3% a year (95% confidence interval 0%-5%). Trauma centre-specific mortality ranged from 11.4% to 13.1%. After adjusting for case mix, differences in trauma centre-specific mortality were observed (median odds ratio = 1.25), suggesting that the odds of dying could be 1.25-fold greater if the same patient was admitted to 1 randomly selected trauma centre as opposed to another. Differences were most pronounced for patients with isolated head injuries and among older patients as evidenced by higher median odds ratios and the number of outliers. INTERPRETATION We observed a significant improvement over time in the mortality of severely injured patients cared for at Ontario's trauma centres. However, considerable differences in trauma centre-specific mortality were observed. Differences were most pronounced among older injured patients and those with isolated traumatic brain injury. System-wide performance improvement initiatives should target these subgroups.
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Affiliation(s)
- David Gomez
- Department of Surgery and Division of General Surgery, University of Toronto, Toronto, Ont
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Aziz S. Alali
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont
| | - Barbara Haas
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont
| | - Wei Xiong
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Homer Tien
- Department of Surgery and Division of General Surgery, University of Toronto, Toronto, Ont
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Avery B. Nathens
- Department of Surgery and Division of General Surgery, University of Toronto, Toronto, Ont
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
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21
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Staudenmayer K, Lin F, Mackersie R, Spain D, Hsia R. Variability in California triage from 2005 to 2009: a population-based longitudinal study of severely injured patients. J Trauma Acute Care Surg 2014; 76:1041-7. [PMID: 24662870 PMCID: PMC4221245 DOI: 10.1097/ta.0000000000000197] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Timely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage. METHODS We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality. RESULTS The undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001). CONCLUSION This is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Affiliation(s)
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - David Spain
- Department of Surgery, Stanford University School of Medicine
| | - Renee Hsia
- Department of Emergency Medicine, University of California, San Francisco
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Joseph B, Zangbar B, Pandit V, Kulvatunyou N, Haider A, O'Keeffe T, Khalil M, Tang A, Vercruysse G, Gries L, Friese RS, Rhee P. Mortality after trauma laparotomy in geriatric patients. J Surg Res 2014; 190:662-6. [PMID: 24582068 DOI: 10.1016/j.jss.2014.01.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/13/2014] [Accepted: 01/16/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy. METHODS A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006-2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality. RESULTS A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2-4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. CONCLUSIONS Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Bardiya Zangbar
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Viraj Pandit
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Ansab Haider
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'Keeffe
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Mazhar Khalil
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Gary Vercruysse
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Lynn Gries
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Randall S Friese
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
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Harvey J, West A. The right scan, for the right patient, at the right time: The reorganization of major trauma service provision in England and its implications for radiologists. Clin Radiol 2013; 68:871-86. [DOI: 10.1016/j.crad.2013.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 01/02/2013] [Accepted: 01/08/2013] [Indexed: 12/30/2022]
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Abstract
Despite the increasing prevalence of high-energy skeletal trauma in the elderly (i.e., sixty years or older), there is a lack of prospective data regarding best care for these injuries.Elderly patients with multiple injuries are often undertriaged to trauma centers and underresuscitated.Aggressive early resuscitation can improve outcomes in elderly patients who have sustained skeletal trauma.Comanagement by orthopaedic surgeons and geriatricians of elderly patients with skeletal trauma can lead to a lower length of hospital stay, lower readmission rates, shorter time to operation, lower complication rates, and lower mortality.
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Affiliation(s)
- Julie A Switzer
- Division of Orthopaedic Trauma, University of Minnesota-Regions Hospital, 640 Jackson Street, St. Paul, MN 55101, USA.
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25
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Moore L, Stelfox HT, Turgeon AF. Complication rates as a trauma care performance indicator: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R195. [PMID: 23072526 PMCID: PMC3682297 DOI: 10.1186/cc11680] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/14/2012] [Indexed: 12/14/2022]
Abstract
Introduction Information on complication rates is essential to trauma quality improvement efforts. However, it is unclear which complications are the most clinically relevant. The objective of this study was to evaluate whether there is consensus on the complications that should be used to evaluate the performance of acute care trauma hospitals. Methods We searched the Medline, EMBASE, Cochrane Central, CINAHL, BIOSIS, TRIP and ProQuest databases and included studies using at least one nonfatal outcome to evaluate the performance of acute care trauma hospitals. Data were extracted in duplicate using a piloted electronic data abstraction form. Consensus was considered to be reached if a specific complication was used in ≥ 70% of studies (strong recommendation) or in ≥ 50% of studies (weak recommendation). Results Of 14,521 citations identified, 22 were eligible for inclusion. We observed important heterogeneity in the complications used to evaluate trauma care. Seventy-nine specific complications were identified but none were used in ≥ 70% of studies and only three (pulmonary embolism, deep vein thrombosis, and pneumonia) were used in ≥ 50% of studies. Only one study provided evidence for the clinical relevance of complications used and only five studies (23%) were considered of high methodological quality. Conclusion Based on the results of this review, we can make a weak recommendation on three complications that should be used to evaluate acute care trauma hospitals; pulmonary embolism, deep vein thrombosis, and pneumonia. However, considering the observed disparity in definitions, the lack of clinical justification for the complications used, and the low methodological quality of studies, further research is needed to develop a valid and reliable performance indicator based on complications that can be used to improve the quality and efficiency of trauma care.
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Nathens AB, Cryer HG, Fildes J. The American College of Surgeons Trauma Quality Improvement Program. Surg Clin North Am 2012; 92:441-54, x-xi. [DOI: 10.1016/j.suc.2012.01.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Franklin GA, Cannon RW, Smith JW, Harbrecht BG, Miller FB, Richardson JD. Impact of withdrawal of care and futile care on trauma mortality. Surgery 2011; 150:854-60. [PMID: 22000200 DOI: 10.1016/j.surg.2011.07.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 07/18/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND The observed to expected (O:E) mortality based on Injury Severity Scores (ISS) has been used to assess quality of trauma center (TC) care. Injuries in the elderly have increased, and these patients often have advanced directives, on occasion limiting aggressive care even for potentially survivable injuries; unfortunately, there are few data on the impact of these demographic changes on mortality. Additionally, many patients arrive moribund and care provided is likely to be futile. We sought to examine the impact of these situations on TC mortality. METHODS All trauma deaths for 2008-2009 were assessed for ISS, preventability of mortality, potential for survivability, impact of withdrawal of care (WOC), and timing of deaths. RESULTS There were 5433 patients with 347 deaths (6.4%). Deaths occurred more frequently in men (70%) who were older (56.3 years) and had head injuries (70%, Glasgow Coma Scale score of 6.9). The average ISS was high (25.5), but 19% of deaths occurred in minimally injured (ISS < 15). One fifth of all patients who died arrived in or rapidly progressed to cardiac arrest with little to no chance to impact survival. Of the nonsurvivors, 147 (42% of deaths) had WOC at a mean of 1.5 days based on advanced directives (18%) or family desires. Combing WOC and futile care, medical treatment could not have been expected to impact survival in 62% of deaths. CONCLUSION There has been a major shift in the demographics of the injured with a high proportion of elderly and head injured and/or those who have little likelihood of survival. Crude mortality or O:E based on ISS overestimates preventable deaths. Societal factors, presence of advanced directives, and WOC decisions must be considered when assessing TC performance. Although our crude mortality rate was 6.4%, it was only 2.4% in patients we were actually permitted to treat. We suggest a WOC factor should be added to TC data to characterize mortality rates more accurately.
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Affiliation(s)
- Glen A Franklin
- Department of Surgery, University of Louisville, Louisville, KY 40292, USA.
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Variation in quality of care after emergency general surgery procedures in the elderly. J Am Coll Surg 2011; 212:1039-48. [PMID: 21620289 DOI: 10.1016/j.jamcollsurg.2011.03.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 02/05/2011] [Accepted: 03/01/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND The elderly (age ≥65 years) comprise an increasing proportion of patients undergoing emergency general surgery (EGS) procedures and have distinct needs compared with the young. We postulated that the needs of the elderly require different processes of care than those required for the young to assure optimal outcomes. To explore this hypothesis, we evaluated 30-day outcomes following EGS procedures in the young and the elderly and determined whether hospital performance was consistent across these 2 age strata. STUDY DESIGN With data from the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2008), regression models were constructed for serious morbidity and mortality for all patients undergoing EGS procedures and separately for young and elderly patients. These models allowed for estimation of the risk of adverse outcomes associated with advanced age and the generation of hospital-level observed to expected (O/E) ratios. We evaluated the correlation between hospital O/E ratios for the young and the elderly and the concordance of outlier status (hospitals with CIs of O/E ratios excluding 1) with weighted κ across these 2 age groups. RESULTS Among 68,003 procedures at 186 hospitals, elderly patients had a higher crude and adjusted risk for serious morbidity (27.9% versus 9.7%, p < 0.0001; odds ratio 1.17, 95% CI 1.10 to 1.24) and mortality (15.2% versus 2.5%, p < 0.0001; odds ratio 2.29, 95% CI 2.09 to 2.51). When outcomes for elderly versus younger patients were compared, there was fair to moderate agreement on hospital performance for serious morbidity (r = 0.43; κ = 0.30) but not for mortality (r = 0.10; κ = 0.17). CONCLUSIONS Elderly patients are at substantially greater risk for adverse events following EGS procedures. Hospitals had only slight agreement in mortality outcomes in the elderly compared with those in young patients. Processes of care that may account for this disparity should be further investigated.
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