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Beiriger J, Puyana J, Deeb AP, Silver D, Lu L, Boland S, Brown JB. Exploring patient and system factors impacting undertriage of injured patients meeting national field triage guideline criteria. J Trauma Acute Care Surg 2024:01586154-990000000-00779. [PMID: 39093636 DOI: 10.1097/ta.0000000000004407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Trauma systems save lives by coordinating timely and effective responses to injury. However, trauma system effectiveness varies geographically, with worse outcomes observed in rural settings. Prior data suggest that undertriage may play a role in this disparity. Our aim was to explore potential driving factors for decision making among clinicians for undertriaged trauma patients. METHODS We performed a retrospective analysis of the National Emergency Medical Services Information System database among patients who met physiologic or anatomic national field triage guideline criteria for transport to the highest level of trauma center. Undertriage was defined as transport to a non-level I/II trauma center. Multivariable logistic regression was used to determine demographic, injury, and system characteristics associated with undertriage. Undertriaged patients were then categorized into "recognized" and "unrecognized" groups using the documented reason for transport destination to identify underlying factors associated with undertriage. RESULTS A total of 36,094 patients were analyzed. Patients in urban areas were more likely to be transported to a destination based on protocol rather than the closest available facility. As expected, patients injured in urban regions were less likely to be undertriaged than their suburban (adjusted odds ratio [aOR], 2.69; 95% confidence interval [95% CI], 2.21-3.31), rural (aOR, 2.71; 95% CI, 2.28-3.21), and wilderness counterparts (aOR, 3.99; 95% CI, 2.93-5.45). The strongest predictor of undertriage was patient/family choice (aOR, 6.29; 5.28-7.50), followed by closest facility (aOR, 5.49; 95% CI, 4.91-6.13) as the reason for hospital selection. Nonurban settings had over twice the odds of recognizing the presence of triage criteria among undertriaged patients (p < 0.05). CONCLUSION Patients with injuries in nonurban settings and those with less apparent causes of severe injury are more likely to experience undertriage. By analyzing how prehospital clinicians choose transport destinations, we identified patient and system factors associated with undertriage. Targeting these at-risk demographics and contributing factors may help alleviate regional disparities in undertriage. LEVEL OF EVIDENCE Diagnostic; Level IV.
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Affiliation(s)
- Jamison Beiriger
- From the Division of Trauma and General Surgery, Department of Surgery (J.B., J.P., D.S., L.L., S.B., J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Department of Surgery (A.-P.D.), Advent Health, Orlando, Florida
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Cho NY, Vadlakonda A, Curry J, Tran Z, Tillou A, de Virgilio C, Benharash P. Association of rurality with short-term outcomes of peripheral vascular trauma. Surgery 2024; 176:205-210. [PMID: 38614911 DOI: 10.1016/j.surg.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/24/2024] [Accepted: 03/14/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Peripheral vascular trauma is a major contributing factor to long-term disability and mortality among patients with traumatic injuries. However, an analysis focusing on individuals at a high risk of experiencing limb loss due to rural and urban peripheral vascular trauma is lacking. METHOD This was a retrospective analysis of the 2016 to 2020 Nationwide Readmissions Database. Patients (≥18 years) undergoing open or endovascular procedures after admission for peripheral vascular trauma were identified using the 2016 to 2020 Nationwide Readmissions Database. Patients from rural regions were considered Rural, whereas the remainder comprised Urban. The primary outcome of the study was primary amputation. Multivariable regression models were developed to evaluate rurality with outcomes of interest. RESULTS Of 29,083 patients, 4,486 (15.6%) were Rural. Rural were older (41 [28-59] vs 37 [27-54] years, P < .001), with a similar distribution of female sex (23.0 vs 21.3%, P = .09) and transfers from other facilities (2.8 vs 2.5%, P = .34). After adjustment, Rural status was not associated with the odds of mortality (P = .82), with urban as reference. Rural status was, however, associated with greater odds of limb amputation (adjusted odds ratio 1.85, 95% confidence interval 1.47-2.32) and reduced index hospitalization cost by $7,100 (95% confidence interval $3,500-10,800). Additionally, compared to patients from urban locations, rurality was associated with similar odds of non-home discharge and 30-day readmission. Over the study period, the marginal effect of rurality on the risk-adjusted rates of amputation significantly increased (P < .001). CONCLUSION Patients who undergo peripheral vascular trauma management in rural areas appear to increasingly exhibit a higher likelihood of amputation, with lower incremental costs and a lower risk of 30-day readmission. These findings underscore disparities in access to optimal trauma vascular care as well as limited resources in rural regions.
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Affiliation(s)
- Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA. https://twitter.com/NamYong_Cho
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Acute Care Surgery, Department of Surgery, Loma Linda University Health, CA. https://twitter.com/DrZacharyTran
| | - Areti Tillou
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Trauma and Emergency Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Stamey HM, Brou LI, Meyers KR, Yang H, Thackeray-Pflughoft K, Spilman SK. Getting patients to the right level of trauma center after motorcycle crashes in a rural trauma system. Am J Emerg Med 2024; 78:8-11. [PMID: 38181543 DOI: 10.1016/j.ajem.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/08/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE After a motorcycle crash (MCC), emergency medical services (EMS) responders must balance trauma center proximity with clinical needs of patients, which is especially challenging in rural states. The study purpose was to determine if MCC patients treated at lower-level trauma centers (LLTC) experienced higher mortality when compared to patients transported directly to the highest level of trauma care available in the state at Level II trauma centers. PROCEDURES A retrospective study was conducted on MCC patients transported by EMS to Montana hospitals and met registry inclusion criteria in 2020-2021. The first study group included patients initially transported to state-designated trauma centers (equivalent to Level III-V) or non-designated hospitals (LLTC), and the second group included patients transported directly to American College of Surgeon verified Level II trauma centers (L2TC). Secondary transfer was defined as initial transport to a LLTC and subsequent transfer to a L2TC. Primary study outcome was mortality at the L2TC. Chi-square tests and Wilcoxon rank sum tests were used for analysis. FINDINGS In the study period, 337 MCC patients were transported by EMS; 186 (55%) patients were transported to a LLTC while 151 patients (45%) were transported to a L2TC. There were no statistically significant differences in mortality (12% vs 8%, p = 0.30) when comparing secondary transfer patients to patients transported directly to a L2TC. CONCLUSIONS Nearly half of patients initially evaluated at a LLTC required transfer to a higher-level of care. Secondary transfer was not associated with increased mortality.
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Affiliation(s)
- Heather M Stamey
- Intermountain Healthcare St. Vincent, Billings, MT, United States of America
| | - Lina I Brou
- Biostatistical Consultant, Denver, CO, United States of America
| | - Katherine R Meyers
- Intermountain Healthcare St. Vincent, Billings, MT, United States of America.
| | - Hannah Yang
- Montana Department of Public Health and Human Services, Helena, MT, United States of America
| | | | - Sarah K Spilman
- Diligent Research & Consulting, Urbandale, IA, United States of America
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Kumar S, Song J, Reilly PM, Dickinson ET, Buckler DG, Haddad DN, Kaufman E. Crossing the line: access to trauma care across state borders. Trauma Surg Acute Care Open 2024; 9:e001228. [PMID: 38410755 PMCID: PMC10895237 DOI: 10.1136/tsaco-2023-001228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024] Open
Abstract
Objective This study investigates the challenge posed by state borders by identifying the population, injury, and geographic scope of areas of the country where the closest trauma center is out-of-state, and by collating state emergency medical services (EMS) policies relevant to cross-border trauma transport. Methods We identified designated levels I, II, and III trauma centers using data from American Trauma Society. ArcGIS was used to map the distance between US census block groups and trauma centers to identify the geographic areas for which cross-border transport may be most expedient. National Highway Traffic Safety Administration data were queried to quantify the proportion of fatal crashes occurring in the areas of interest. State EMS protocols were categorized by stance on cross-border transport. Results Of 237 596 included US census block groups, 18 499 (7.8%) were closest to an out-of-state designated level I or II trauma center. These census block groups accounted for 6.9% of the US population and 9.5% of all motor vehicle fatalities. With the inclusion of level III trauma centers, the number of US census block groups closest to an out-of-state designated level I, II, or III trauma center decreased to 13 690 (5.8%). These census block groups accounted for 5.1% of the US population and 7.1% of all motor vehicle fatalities. Of the 48 contiguous states, 30 encourage cross-border transport, 2 discourage it, 12 are neutral, and 4 leave it to local discretion. Conclusion Cross-border transport can expedite access to care in at least 5% of US census block groups. While few states discourage this practice, more robust policy guidance could reduce delays and enhance care. Level of Evidence III, Epidemiological.
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Affiliation(s)
- Satvika Kumar
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jamie Song
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Patrick M Reilly
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward T Dickinson
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David G Buckler
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diane N Haddad
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elinore Kaufman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Stamey HM, Meyers KR, Fordham JT, Young KJ, Ott RL, Spilman SK. Access to Trauma Care in a Rural State: A Descriptive Geographic and Demographic Analysis. J Emerg Med 2024; 66:e20-e26. [PMID: 37867034 DOI: 10.1016/j.jemermed.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/10/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Montana is a rural state with limited access to higher-level trauma care; it also has higher injury fatality rates compared with the rest of the country. OBJECTIVES The purpose of this study was to utilize Geographic Information System methodology to assess proximity to trauma care and identify the demographic characteristics of regions without trauma access. METHODS Maptitude® Geographic Information System software (Caliper Corporation, Newton, MA) was used to identify regions in Montana within 60 min of trauma care; this included access to a Level II or Level III trauma center with general surgery capabilities and access to any level of trauma care. Demographic characteristics are reported to identify population groups lacking access to trauma care. RESULTS Of the 1.1 million residents of Montana, 63% of residents live within 60 driving min of a higher-level trauma center, and 83% of residents live within 60 driving min of any level of trauma center. Elderly residents over age 65 years of age and American Indians had reduced access to both higher-level trauma care and any level trauma care. CONCLUSIONS Prompt access to trauma care is significantly lower in Montana than in other parts of the country, with dramatic disparities for American Indians. In a rural state, it is important to ensure that all hospitals are equipped to provide some level of trauma care to reduce these disparities.
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Breeding T, Ngatuvai M, Rosander A, Maka P, Davis J, Knowlton LM, Hoops H, Elkbuli A. Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery. J Trauma Acute Care Surg 2023; 95:806-815. [PMID: 37405809 DOI: 10.1097/ta.0000000000004067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
ABSTRACT This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities. LEVEL OF EVIDENCE Systematic Review; Level IV.
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Affiliation(s)
- Tessa Breeding
- From the Kiran Patel College of Allopathic Medicine (T.B., M.N.), NOVA Southeastern University, Fort Lauderdale, Florida; Arizona College of Osteopathic Medicine, Midwestern University (A.R.), Glendale, Arizona; John A. Burns School of Medicine (P.M.), Honolulu, Hawaii; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (J.D.), The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Trauma and Surgical Critical Care, Department of Surgery (L.M.K.), Stanford University Medical Center, Palo Alto, California; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (H.H.), Oregon Health & Sciences University, Portland, Oregon; Division of Trauma and Surgical Critical Care, Department of Surgery (A.E.), and Department of Surgical Education (A.E.), Orlando Regional Medical Center, Orlando, Florida
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Deeb AP, Teng CY, Peitzman AB, Billiar TR, Sperry JL, Lu L, Beiriger J, Brown JB. Direct Trauma Center Access by Helicopter Emergency Medical Services is Associated With Improved Survival After Severe Injury. Ann Surg 2023; 278:e840-e847. [PMID: 36735480 PMCID: PMC10397363 DOI: 10.1097/sla.0000000000005812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Evaluate the association of survival with helicopter transport directly to a trauma center compared with ground transport to a non-trauma center (NTC) and subsequent transfer. SUMMARY BACKGROUND DATA Helicopter transport improves survival after injury. One potential mechanism is direct transport to a trauma center when the patient would otherwise be transported to an NTC for subsequent transfer. METHODS Scene patients 16 years and above with positive physiological or anatomic triage criteria within PTOS 2000-2017 were included. Patients transported directly to level I/II trauma centers by helicopter were compared with patients initially transported to an NTC by ground with a subsequent helicopter transfer to a level I/II trauma center. Propensity score matching was used to evaluate the association between direct helicopter transport and survival. Individual triage criteria were evaluated to identify patients most likely to benefit from direct helicopter transport. RESULTS In all, 36,830 patients were included. Direct helicopter transport was associated with a nearly 2-fold increase in odds of survival compared with NTC ground transport and subsequent transfer by helicopter (aOR 2.78; 95% CI 2.24-3.44, P <0.01). Triage criteria identifying patients with a survival benefit from direct helicopter transport included GCS≤13 (1.71; 1.22-2.41, P <0.01), hypotension (2.56; 1.39-4.71, P <0.01), abnormal respiratory rate (2.30; 1.36-3.89, P <0.01), paralysis (8.01; 2.03-31.69, P <0.01), hemothorax/pneumothorax (2.34; 1.36-4.05, P <0.01), and multisystem trauma (2.29; 1.08-4.84, P =0.03). CONCLUSIONS Direct trauma center access is a mechanism driving the survival benefit of helicopter transport. First responders should consider helicopter transport for patients meeting these criteria who would otherwise be transported to an NTC.
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Affiliation(s)
- Andrew-Paul Deeb
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Cindy Y. Teng
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Andrew B. Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Timothy R. Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Jason L. Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Liling Lu
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Jamison Beiriger
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
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Johnson RM, Larson NJ, Brown CT, Iyegha UP, Blondeau B, Dries DJ, Rogers FB. American Trauma Care: A System of Systems. Air Med J 2023; 42:318-327. [PMID: 37716800 DOI: 10.1016/j.amj.2023.07.002] [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: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE The benefits of organized trauma systems have been well-documented during 50 years of trauma system development in the United States. Unfortunately, despite this evidence, trauma system development has occurred only sporadically in the 50 states. METHODS The relevant literature related to trauma system design and development was reviewed based on relevance to the study. Information from these sources was summarized into a SWOT (strengths, weaknesses, opportunities, and threats) analysis. RESULTS Strengths discovered were leadership brought forth by the American College of Surgeons Committee on Trauma and meaningful change generated from The National Academy of Sciences, Engineering, and Medicine report addressing the fractionation of the nation's trauma systems, whereas weaknesses included patient outcome disparities due to the lack of a national governing authority, undertriage, underresourced rural trauma, and underfunded trauma research. Opportunities included the creation of level IV trauma centers; telemedicine; the development of rural trauma management courses; air medical transport to bring high-intensity care to the patient, particularly in rural areas; trauma research; and trauma prevention through outreach and educational programs. The following threats were determined: mass casualty incidents, motor vehicle collisions because of the high rate of motor vehicle collision deaths in the United States relative to other developed countries, and underfunded trauma systems. CONCLUSION Much work remains to be done in the development of an American trauma system. Recommendations include implementation of trauma care governance at the federal level; national oversight and support of emergency medical services systems, particularly in rural areas with strict reporting processes for emergency medical services programs; national organization of our mass casualty response; increased federal and state funding allocated to trauma centers; a consistent model for trauma system development; and trauma research.
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Affiliation(s)
| | | | | | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN
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Sung J, Yao A, Antoniou G, Cooksey R, Winters J, Ee M, Williams N. Failure to initiate trauma team activation for patients who meet the criteria in a level 1 paediatric trauma centre: which patients are missing out? ANZ J Surg 2022; 92:2628-2634. [PMID: 35833510 PMCID: PMC9796087 DOI: 10.1111/ans.17906] [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: 03/23/2022] [Revised: 06/10/2022] [Accepted: 07/01/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Trauma team activation (TTA) is paramount in the early hospital management of trauma patients. This study aimed to evaluate factors which contribute to failure to activate the Trauma team for management of paediatric trauma. METHODS A retrospective cohort study of Emergency Department (ED) presentations at the paediatric major trauma hospital in Adelaide, South Australia was conducted over a 16-month period. Data from the hospital's trauma registry, individual case files and digital medical records were evaluated to determine factors that were associated with no TTA. RESULTS During the study period, 617 trauma patients who met Level 1 or Level 2 TTA criteria attended the trauma centre. For 29 (4.7%) of these patients, there was no TTA. Predictors of no TTA included sustaining abdomen and/or pelvis injuries compared to limb injuries (unadjusted odds ratio [OR] = 10.59, 95% confidence interval [CI] 1.98-56.69, P = 0.006), sustaining non-accidental injury (NAI) versus an injury with vehicle involvement (OR = 30.13, 95% CI 6.43-141.21, P < 0.001), and arriving via emergency medical retrieval service compared to private vehicle (OR = 14.23, 95% CI 3.94-51.36, P < 0.001). No patients transferred directly to Paediatric Intensive Care Unit (PICU), or High Dependency Unit (HDU) received an appropriate TTA. CONCLUSION Multiple factors were associated with no TTA in paediatric trauma patients. The results highlight that even in PICU and HDU admissions and transfer patients, vigilant clarification of mechanism of injury and potential for occult injuries should be undertaken to ensure appropriate TTA and improve patient outcome.
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Affiliation(s)
- Jonghoo Sung
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Angela Yao
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Georgia Antoniou
- Department of Orthopaedic SurgeryWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Rebecca Cooksey
- Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia,Department of Paediatric SurgeryWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Jacqueline Winters
- Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia,Department of Paediatric MedicineWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Michael Ee
- Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia,Department of Paediatric SurgeryWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Nicole Williams
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia,Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
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Liu LJW, Crispo JAG, Bach P, Ansell DR, Thibault D, Willis AW, Cragg JJ. Amphetamine-related care in the USA, 2003-2014: cross-sectional analyses examining inpatient trends and factors associated with hospitalisation outcomes. BMJ Open 2022; 12:e059898. [PMID: 36127119 PMCID: PMC9490607 DOI: 10.1136/bmjopen-2021-059898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 08/15/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Although amphetamine use is a growing health problem in the USA, there are limited data on amphetamine-related hospitalisations. The primary objective of our study was to examine trends in amphetamine-related hospitalisations in the USA between 2003 and 2014, including by age and sex. Our secondary objectives were to examine whether demographic, clinical and care setting characteristics were associated with select outcomes of amphetamine-related hospitalisations, including in-hospital mortality, prolonged length of stay and leaving against medical advice. DESIGN, SETTING AND PARTICIPANTS Using the 2003-2014 National Inpatient Sample, we estimated the rate of amphetamine-related hospitalisations for each year in the USA among individuals 18+ years of age, stratified by age and sex. Subgroup analyses examined hospitalisations due to amphetamine causes. Unconditional logistic regression modelling was used to estimate the adjusted odds of admission outcomes for sociodemographic, clinical and hospital indicators. PRIMARY AND SECONDARY OUTCOMES Our primary outcome was amphetamine-related hospitalisations between 2003 and 2014; secondary outcomes included in-hospital mortality, prolonged length of stay and leaving against medical advice. RESULTS Amphetamine-related hospitalisation rates increased from 27 to 69 per 100 000 population between 2003 and 2014. Annual rates were consistently greater among younger (18-44 years) individuals and men. Regional differences were observed, with admission to Western hospitals being associated with increased mortality (adjusted OR, AOR 5.07, 95% CI 1.22 to 21.04) and shorter (0-2 days) lengths of stay (AOR 0.70, 95% CI 0.58 to 0.83) compared with Northeast admissions. Males (AOR 1.26, 95% CI 1.15 to 1.38; compared with females) and self-pay (AOR 2.30, 95% CI 1.90 to 2.79; compared with private insurance) were associated with leaving against medical advice. CONCLUSIONS Increasing rates of amphetamine-related hospitalisation risk being overshadowed by other public health crises. Regional amphetamine interventions may offer the greatest population health benefits. Future studies should examine long-term outcomes among patients hospitalised for amphetamine-related causes.
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Affiliation(s)
- Lisa J W Liu
- Collaboration for Outcomes Research and Evaluation (CORE), The University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - James A G Crispo
- Collaboration for Outcomes Research and Evaluation (CORE), The University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
- Human Sciences Division, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Paxton Bach
- Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Dominique R Ansell
- Emergency Department, Health Sciences North, Sudbury, Ontario, Canada
- Clinical Sciences Division, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Dylan Thibault
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jacquelyn J Cragg
- Collaboration for Outcomes Research and Evaluation (CORE), The University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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Ferre AC, Curtis J, Flippin JA, Claridge JA, Tseng ES, Brown LR, Ho VP. Do new trauma centers provide needed or redundant access? A nationwide analysis. J Trauma Acute Care Surg 2022; 93:347-352. [PMID: 35647793 PMCID: PMC9615221 DOI: 10.1097/ta.0000000000003652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our prior research has demonstrated that increasing the number of trauma centers (TCs) in a state does not reliably improve state-level injury-related mortality. We hypothesized that many new TCs would serve populations already served by existing TCs, rather than in areas without ready TC access. We also hypothesized that new TCs would also be less likely to serve economically disadvantaged populations. METHODS All state-designated adult TCs registered with the American Trauma Society in 2014 and 2019 were mapped using ArcGIS Pro (ESRI Inc., Redlands, CA). Trauma centers were grouped as Level 1 or 2 (Lev12) or Level 3, 4 or 5 (Lev345). We also obtained census tract-level data (73,666 tracts), including population counts and percentage of population below the federal poverty threshold. Thirty-minute drive-time areas were created around each TC. Census tracts were considered "served" if their geographic centers were located within a 30-minute drive-time area to any TC. Data were analyzed at the census tract level. RESULTS A total of 2,140 TCs were identified in 2019, with 256 new TCs and 151 TC closures. Eighty-two percent of new TCs were Levels 3 to 5. Nationwide, coverage increased from 75.3% of tracts served in 2014 to 78.1% in 2019, representing an increased coverage from 76.0% to 79.4% of the population. New TC served 17,532 tracts, of which 87.3% were already served. New Lev12 TCs served 9,100 tracts, of which 91.2% were already served; new Lev345 TCs served 15,728 tracts, of which 85.9% were already served. Of 2,204 newly served tracts, those served by Lev345 TCs had higher mean percentage poverty compared with those served by Lev12 TCs (15.7% vs. 13.2% poverty, p < 0.05). DISCUSSION Overall, access to trauma care has been improving in the United States. However, the majority of new TCs opened in locations with preexisting access to trauma care. Nationwide, Levels 3, 4, and 5 TCs have been responsible for expanding access to underserved populations. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
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Affiliation(s)
- Alexandra C. Ferre
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
- Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Jacqueline Curtis
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH
| | - J. Alford Flippin
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Jeffrey A. Claridge
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Esther S. Tseng
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Laura R. Brown
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
| | - Vanessa P. Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH
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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Edwards GC, Wong SL, Russell MC, Winslow ER, Shaffer VO, Pawlik TM. Society for Surgery of the Alimentary Tract Health Care Quality and Outcomes Committee Webinar: Addressing Disparities. J Gastrointest Surg 2022; 26:997-1005. [PMID: 35318595 DOI: 10.1007/s11605-022-05300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Gretchen C Edwards
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maria C Russell
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Emily R Winslow
- Department of Surgery, Medstar Georgetown Medical Center, Washington, DC, USA
| | - Virginia O Shaffer
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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14
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Wang CJ, Yang TH, Hung KS, Wu CH, Yen ST, Yen YT, Shan YS. Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study. BMC Emerg Med 2021; 21:150. [PMID: 34861821 PMCID: PMC8641219 DOI: 10.1186/s12873-021-00543-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/21/2021] [Indexed: 11/22/2022] Open
Abstract
Background Undertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes. Method This retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed. Results A total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p < 0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076). Conclusion This study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.
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Affiliation(s)
- Chih-Jung Wang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shu-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan.
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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15
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Wu CA, Dutta R, Virk S, Roy N, Ranganathan K. The need for craniofacial trauma and oncologic reconstruction in global surgery. J Oral Biol Craniofac Res 2021; 11:563-567. [PMID: 34430193 DOI: 10.1016/j.jobcr.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022] Open
Abstract
The global burden of surgical disease is concentrated in low- and middle-income countries and primarily consists of injuries and malignancies. While global reconstructive surgery has a long and well-established history, efforts thus far have been focused on addressing congenital anomalies. Craniofacial trauma and oncologic reconstruction are comparatively neglected despite their higher prevalence. This review explores the burden, management, and treatment gaps of craniofacial trauma and head and neck cancer reconstruction in low-resource settings. We also highlight successful alternative treatments used in low-resource settings and pearls that can be learned from these areas.
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Affiliation(s)
| | - Rohini Dutta
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital (Government of India), Mumbai, India.,Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Sargun Virk
- Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Nobhojit Roy
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital (Government of India), Mumbai, India
| | - Kavitha Ranganathan
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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Deeb AP, Phelos HM, Peitzman AB, Billiar TR, Sperry JL, Brown JB. Geospatial assessment of helicopter emergency medical service overtriage. J Trauma Acute Care Surg 2021; 91:178-185. [PMID: 33605701 PMCID: PMC8243854 DOI: 10.1097/ta.0000000000003122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite evidence of benefit after injury, helicopter emergency medical services (HEMS) overtriage remains high. Scene and transfer overtriage are distinct processes. Our objectives were to identify geographic variation in overtriage and patient-level predictors, and determine if overtriage impacts population-level outcomes. METHODS Patients 16 years or older undergoing scene or interfacility HEMS in the Pennsylvania Trauma Outcomes Study were included. Overtriage was defined as discharge within 24 hours of arrival. Patients were mapped to zip code, and rates of overtriage were calculated. Hot spot analysis identified regions of high and low overtriage. Mixed-effects logistic regression determined patient predictors of overtriage. High and low overtriage regions were compared for population-level injury fatality rates. Analyses were performed for scene and transfer patients separately. RESULTS A total of 85,572 patients were included (37.4% transfers). Overtriage was 5.5% among scene and 11.8% among transfer HEMS (p < 0.01). Hot spot analysis demonstrated geographic variation in high and low overtriage for scene and transfer patients. For scene patients, overtriage was associated with distance (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06 per 10 miles; p = 0.04), neck injury (OR, 1.27; 95% CI, 1.01-1.60; p = 0.04), and single-system injury (OR, 1.37; 95% CI, 1.15-1.64; p < 0.01). For transfer patients, overtriage was associated with rurality (OR, 1.64; 95% CI, 1.22-2.21; p < 0.01), facial injury (OR, 1.22; 95% CI, 1.03-1.44; p = 0.02), and single-system injury (OR, 1.35; 95% CI, 1.18-2.19; p < 0.01). For scene patients, high overtriage was associated with higher injury fatality rate (coefficient, 1.72; 95% CI, 1.68-1.76; p < 0.01); low overtriage was associated with lower injury fatality rate (coefficient, -0.73; 95% CI, -0.78 to -0.68; p < 0.01). For transfer patients, high overtriage was not associated with injury fatality rate (p = 0.53); low overtriage was associated with lower injury fatality rate (coefficient, -2.87; 95% CI, -4.59 to -1.16; p < 0.01). CONCLUSION Geographic overtriage rates vary significantly for scene and transfer HEMS, and are associated with population-level outcomes. These findings can help guide targeted performance improvement initiatives to reduce HEMS overtriage. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Andrew-Paul Deeb
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Heather M. Phelos
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Andrew B. Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Timothy R. Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Jason L. Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
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Nederpelt CJ, Mokhtari AK, Alser O, Tsiligkaridis T, Roberts J, Cha M, Fawley JA, Parks JJ, Mendoza AE, Fagenholz PJ, Kaafarani HMA, King DR, Velmahos GC, Saillant N. Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds. J Trauma Acute Care Surg 2021; 90:1054-1060. [PMID: 34016929 DOI: 10.1097/ta.0000000000003155] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. METHODS Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. RESULTS A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. CONCLUSION Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Charlie J Nederpelt
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care (TESSC) (C.J.N., A.K.M., O.A., J.A.F., J.J.P., A.E.M., P.J.F., H.M.A.K., D.R.K., G.C.V., N.S.), Massachusetts General Hospital (MGH), Boston, Massachusetts; Department of Trauma Surgery (C.J.N.), Leiden University Medical Center, Leiden, The Netherlands; Lincoln Laboratory (T.T., J.R., M.C.), Massachusetts Institute of Technology (MIT), Cambridge, Massachusetts; and Center for Outcomes and Patient Safety in Surgery (H.M.A.K), Massachusetts General Hospital (MGH), Boston, Massachusetts
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18
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Deeb AP, Phelos HM, Peitzman AB, Billiar TR, Sperry JL, Brown JB. Making the call in the field: Validating emergency medical services identification of anatomic trauma triage criteria. J Trauma Acute Care Surg 2021; 90:967-972. [PMID: 34016920 PMCID: PMC8243859 DOI: 10.1097/ta.0000000000003168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The National Field Triage Guidelines were created to inform triage decisions by emergency medical services (EMS) providers and include eight anatomic injuries that prompt transportation to a Level I/II trauma center. It is unclear how accurately EMS providers recognize these injuries. Our objective was to compare EMS-identified anatomic triage criteria with International Classification of Diseases-10th revision (ICD-10) coding of these criteria, as well as their association with trauma center need (TCN). METHODS Scene patients 16 years and older in the NTDB during 2017 were included. National Field Triage Guidelines anatomic criteria were classified based on EMS documentation and ICD-10 diagnosis codes. The primary outcome was TCN, a composite of Injury Severity Score greater than 15, intensive care unit admission, urgent surgery, or emergency department death. Prevalence of anatomic criteria and their association with TCN was compared in EMS-identified versus ICD-10-coded criteria. Diagnostic performance to predict TCN was compared. RESULTS There were 669,795 patients analyzed. The ICD-10 coding demonstrated a greater prevalence of injury detection. Emergency medical service-identified versus ICD-10-coded anatomic criteria were less sensitive (31% vs. 59%), but more specific (91% vs. 73%) and accurate (71% vs. 68%) for predicting TCN. Emergency medical service providers demonstrated a marked reduction in false positives (9% vs. 27%) but higher rates of false negatives (69% vs. 42%) in predicting TCN from anatomic criteria. Odds of TCN were significantly greater for EMS-identified criteria (adjusted odds ratio, 4.5; 95% confidence interval, 4.46-4.58) versus ICD-10 coding (adjusted odds ratio 3.7; 95% confidence interval, 3.71-3.79). Of EMS-identified injuries, penetrating injury, flail chest, and two or more proximal long bone fractures were associated with greater TCN than ICD-10 coding. CONCLUSION When evaluating the anatomic criteria, EMS demonstrate greater specificity and accuracy in predicting TCN, as well as reduced false positives compared with ICD-10 coding. Emergency medical services identification is less sensitive for anatomic criteria; however, EMS identify the most clinically significant injuries. Further study is warranted to identify the most clinically important anatomic triage criteria to improve our triage protocols. LEVEL OF EVIDENCE Care management, Level IV; Prognostic, Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Heather M. Phelos
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Andrew B. Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Timothy R. Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Jason L. Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
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Elkbuli A, Sutherland M, Sanchez C, Liu H, Ang D, McKenney M. The Shortage of Trauma Surgeons in the US. Am Surg 2021; 88:280-288. [PMID: 33522266 DOI: 10.1177/0003134820988808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND As the United States (US) population increases, the demand for more trauma surgeons (TSs) will increase. There are no recent studies comparing the TS density temporally and geographically. We aim to evaluate the density and distribution of TSs by state and region and its impact on trauma patient mortality. METHODS A retrospective cohort analysis of the American Medical Association Physician Masterfile (PM), 2016 US Census Bureau, and Centers for Disease Control and Prevention (CDC's) Web-based Injury Statistics Query and Reporting System (WISQARS) to determine TS density. TS density was calculated by dividing the number of TSs per 1 000 000 population at the state level, and divided by 500 admissions at the regional level. Trauma-related mortality by state was obtained through the CDC's WISQARS database, which allowed us to estimate trauma mortality per 100 000 population. RESULTS From 2007 to 2014, the net increase of TS was 3160 but only a net increase of 124 TSs from 2014 to 2020. Overall, the US has 12.58 TSs/1 000 000 population. TS density plateaued from 2014 to 2020. 33% of states have a TS density of 6-10/1 000 000 population, 43% have a density of 10-15, 12% have 15-20, and 12% have a density >20. The Northeast has the highest density of TSs per region (2.95/500 admissions), while the Midwest had the lowest (1.93/500 admissions). CONCLUSION The density of TSs in the US varies geographically, has plateaued nationally, and has implications on trauma patient mortality. Future studies should further investigate causes of the TS shortage and implement institutional and educational interventions to properly distribute TSs across the US and reduce geographic disparities.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Carol Sanchez
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Huazhi Liu
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA.,University of Central Florida, Orlando, FL, USA
| | - Darwin Ang
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA.,University of Central Florida, Orlando, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA.,University of South Florida, Tampa, FL, USA
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