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Shen Y, Orlando A, Fakhry SM. Decline in Explanatory Power of Trauma Mortality Models With Age: Varying Contribution of Glasgow Coma Scale, Injury Severity Score, Comorbidities, and Frailty. J Surg Res 2024; 302:125-133. [PMID: 39096741 DOI: 10.1016/j.jss.2024.07.048] [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: 03/01/2024] [Revised: 06/21/2024] [Accepted: 07/08/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION Adjusting for confounding variables is critical for objective comparison of outcomes. The explanatory power of variables used in adjusted models for injury and their relative utility across age groups has not been well-defined. This study aimed to assess the explanatory power of covariates commonly adjusted in injury research and their relative performance across age groups. METHODS Inpatients 18-100 y (2017-2022) were selected from 90 hospital trauma registries. Patients were grouped into sequential 5-y age blocks. Mortality was defined as the proportion of patients "expired + hospice". Dominance analysis was used to determine the average contribution (McFadden's R2) for covariates commonly included in multivariable logistic regressions. RESULTS Three hundred seventeen-thousand one hundred thirty-six patients were included (51.1% male, mean age: 63, mean injury severity score [ISS]: 9.8, mean Glasgow Coma Scale: 14.3, 93.5% blunt). Total explanatory power (McFadden's R2) for mortality was highest in youngest age group (52.7% in 18-24 group) and decreased with age, with the lowest R2 (19.6%) in 95-100 group. Regardless of age, the Glasgow Coma Scale was the most important covariate (R2 ranging from 9.0% to 20.4%). At age 18-24 y, ISS was a more dominant contributor than Elixhauser Score, but beyond 55 y, Elixhauser Score became more dominant than ISS. CONCLUSIONS The explanatory power of adjustment models including common covariates is limited and varies significantly across age groups, decreasing linearly with age. Adjusting for outcomes using these covariates may limit objective comparisons especially for older adults. Additional research is needed to identify covariates that enhance the explanatory power of adjustment models to allow for more objective comparisons across all ages.
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Affiliation(s)
- Yan Shen
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | - Alessandro Orlando
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | - Samir M Fakhry
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, Tennessee.
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Bulger EM, Bixby PJ, Price MA, Villarreal CL, Moreno AN, Herrera-Escobar JP, Bailey JA, Brasel KJ, Cooper ZR, Costantini TW, Gibran NS, Groner JI, Joseph B, Newgard CD, Stein DM. An executive summary of the National Trauma Research Action Plan. J Trauma Acute Care Surg 2024; 97:315-322. [PMID: 38523118 DOI: 10.1097/ta.0000000000004279] [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: 03/26/2024]
Abstract
ABSTRACT The National Trauma Research Action Plan project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research, the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.
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Affiliation(s)
- Eileen M Bulger
- From the Department of Surgery (E.M.B., N.S.G.), University of Washington, Seattle, Washington; Coalition for National Trauma Research (P.J.B., M.A.P., C.L.V., A.N.M., NTRAP Investigators Group), San Antonio, Texas; Center for Surgery and Public Health (J.P.H.-E., Z.R.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (J.A.B.), Uniformed Services University, Bethesda, Maryland; Department of Surgery (K.J.B., C.D.N.), Oregon Health and Sciences University, Portland, Oregon; Department of Surgery (T.W.C.), University of California - San Diego, San Diego, California; Department of Pediatric Surgery (J.I.G.), Nationwide Children's Hospital, Columbus, Ohio; Department of Surgery (B.J.), University of Arizona, Tucson, Arizona; and Department of Surgery (D.M.S.), University of Baltimore Medical School, Baltimore, Maryland
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Egodage T, Ho VP, Bongiovanni T, Knight-Davis J, Adams SD, Digiacomo J, Swezey E, Posluszny J, Ahmed N, Prabhakaran K, Ratnasekera A, Putnam AT, Behbahaninia M, Hornor M, Cohan C, Joseph B. Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee. Trauma Surg Acute Care Open 2024; 9:e001395. [PMID: 39021732 PMCID: PMC11253746 DOI: 10.1136/tsaco-2024-001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
Background Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation. Methods We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified. Results Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings. Conclusion Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.
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Affiliation(s)
- Tanya Egodage
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Vanessa P Ho
- Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Tasce Bongiovanni
- Surgery, University of San Francisco, San Francisco, California, USA
| | | | - Sasha D Adams
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Jody Digiacomo
- Nassau University Medical Center, East Meadow, New York, USA
| | | | | | - Nasim Ahmed
- Surgery, Division of Trauma, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
| | - Kartik Prabhakaran
- Surgery, Westchester Medical Center Health Network, Valhalla, New York, USA
| | | | | | | | - Melissa Hornor
- Surgery, Loyola University Chicago, Maywood, Illinois, USA
| | - Caitlin Cohan
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bellal Joseph
- The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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Mohseni S, Forssten MP, Mohammad Ismail A, Cao Y, Hildebrand F, Sarani B, Ribeiro MAF. Investigating the link between frailty and outcomes in geriatric patients with isolated rib fractures. Trauma Surg Acute Care Open 2024; 9:e001206. [PMID: 38347893 PMCID: PMC10860062 DOI: 10.1136/tsaco-2023-001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Background Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures. Methods All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding. Results A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001]. Conclusion There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.
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Affiliation(s)
- Shahin Mohseni
- Orebro universitet Fakulteten for medicin och halsa, Orebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City—Mayo Clinic, Abu Dhabi, UAE
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Babak Sarani
- George Washington University, Washington, District of Columbia, USA
| | - Marcelo AF Ribeiro
- Department of Surgery, Sheikh Shakhbout Medical City—Mayo Clinic, Abu Dhabi, UAE
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El-Qawaqzeh K, Magnotti LJ, Hosseinpour H, Nelson A, Spencer AL, Anand T, Bhogadi SK, Alizai Q, Ditillo M, Joseph B. Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes? Injury 2024; 55:110972. [PMID: 37573210 DOI: 10.1016/j.injury.2023.110972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/09/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes. STUDY DESIGN Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017-2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days. RESULTS 110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2-9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05). CONCLUSION Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.
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Affiliation(s)
- Khaled El-Qawaqzeh
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA.
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Costantini TW, Bulger E, Price MA, Haut ER. Research priorities in venous thromboembolism after trauma: Secondary analysis of the National Trauma Research Action Plan. J Trauma Acute Care Surg 2023; 95:762-769. [PMID: 37322589 DOI: 10.1097/ta.0000000000004074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a significant cause of morbidity and mortality during recovery from injury and can result in significant health care costs. Despite advances in the past several decades in our approach to VTE prophylaxis after injury, opportunities exist to improve the delivery and implementation of optimal VTE prophylaxis. Here, we aim to identify consensus research questions related to VTE across all National Trauma Research Action Plan (NTRAP) Delphi expert panels to further guide the research agenda aimed at preventing VTE after injury. METHODS This is a secondary analysis of consensus-based research priorities that were collected using a Delphi methodology by 11 unique NTRAP panels that were charged with unique topic areas across the spectrum of injury care. The database of questions was queried for the keywords "VTE," "venous thromboembo," and "DVT" and then grouped into relevant topic areas. RESULTS There were 86 VTE-related research questions identified across 9 NTRAP panels. Eighty-five questions reached consensus with 24 rated high priority; 60, medium priority; and 1, low priority. Questions related to the timing of VTE prophylaxis (n = 17) were most common, followed by questions related to risk factors for the development of VTE (n = 16), the effects of tranexamic acid on VTE (n = 11), the approach to dosing of pharmacologic prophylaxis (n = 8), and the pharmacologic prophylactic medication choice for optimal VTE prophylaxis (n = 6). CONCLUSION National Trauma Research Action Plan panelists identified 85 consensus-based research questions that should drive dedicated extramural research funding opportunities to support quality studies aimed at optimizing VTE prophylaxis after injury. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Todd W Costantini
- From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.W.C.), UC San Diego School of Medicine, San Diego, California; Division of Trauma, Burns, and Critical Care, Department of Surgery (E.B.), University of Washington, Seattle, Washington; Harborview Medical Center (E.B.), Seattle, Washington; Coalition for National Trauma Research (M.A.P.), San Antonio, Texas; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine, Baltimore, Maryland; and Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Proaño-Zamudio JA, Argandykov D, Renne A, Gebran A, Ouwerkerk JJJ, Dorken-Gallastegi A, de Roulet A, Velmahos GC, Kaafarani HMA, Hwabejire JO. Timing of regional analgesia in elderly patients with blunt chest-wall injury. Surgery 2023; 174:901-906. [PMID: 37582669 DOI: 10.1016/j.surg.2023.07.006] [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: 01/26/2023] [Revised: 06/22/2023] [Accepted: 07/08/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Rib fractures represent a typical injury pattern in older people and are associated with respiratory morbidity and mortality. Regional analgesia modalities are adjuncts for pain management, but the optimal timing for their initiation remains understudied. We hypothesized that early regional analgesia would have similar outcomes to late regional analgesia. METHODS We retrospectively reviewed the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2019. We included patients ≥65 years old admitted with blunt chest wall trauma who received regional analgesia. We divided patients into 2 groups: (1) early regional analgesia (within 24 hours of admission) and (2) late regional analgesia (>24 hours). The outcomes evaluated were ventilator-associated pneumonia, mortality, unplanned intensive care unit admission, unplanned intubation, discharge to home, and duration of stay. Univariable analysis and multivariable logistic regression adjusting for patient and injury characteristics, trauma center level, and respiratory interventions were performed. RESULTS In the study, 2,248 patients were included. The mean (standard deviation) age was 75.3 (6.9), and 52.7% were male. The median injury severity score (interquartile range) was 13 (9-17). The early regional analgesia group had a decreased incidence of unplanned intubation (2.7% vs 5.3%, P = .002), unplanned intensive care unit admission (4.9% vs 8.4%, P < .001), and shorter mean duration of stay (5.5 vs 6.5 days, P = .002). In multivariable analysis, early regional analgesia was associated with decreased odds of unplanned intubation (odds ratio, 0.58; 95% confidence interval, 0.36-0.94; P = .026), unplanned intensive care unit admission (odds ratio, 0.60; 95% confidence interval, 0.041-0.86; P = .006), and increased odds of discharge to home (odds ratio, 1.27; 95% confidence interval, 1.04-1.55; P = .019). After multivariable adjustment, no significant difference was found for ventilator-associated pneumonia or mortality (odds ratio, 0.60; 95% confidence interval, 0.34-1.04; P = .070). CONCLUSION Early regional analgesia initiation is associated with improved outcomes in older people with blunt chest wall injuries. Geriatric trauma care bundles targeting early initiation of regional analgesia can potentially decrease complications and resource use.
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Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Angela Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Joep J J Ouwerkerk
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Amory de Roulet
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Haut ER, Kirby JP, Bailey JA, Phuong J, Gavitt B, Remick KN, Staudenmayer K, Cannon JW, Price MA, Bulger EM. Developing a National Trauma Research Action Plan: Results from the trauma systems and informatics panel Delphi survey. J Trauma Acute Care Surg 2023; 94:584-591. [PMID: 36623269 DOI: 10.1097/ta.0000000000003867] [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: 01/10/2023]
Abstract
BACKGROUND The National Academies of Sciences, Engineering, and Medicine 2016 report on the trauma care system recommended establishing a National Trauma Research Action Plan to strengthen and guide future trauma research. To address this recommendation, the Department of Defense funded a study to generate a comprehensive research agenda spanning the trauma and burn care continuum. Panels were created to conduct a gap analysis and identify high-priority research questions. The National Trauma Research Action Plan panel reported here addressed trauma systems and informatics. METHODS Experts were recruited to identify current gaps in trauma systems research, generate research questions, and establish the priorities using an iterative Delphi survey approach from November 2019 through August 2020. Panelists were identified to ensure heterogeneity and generalizability, including military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: patient/population, intervention, compare/control, and outcome. In subsequent surveys, panelists prioritized each research question on a 9-point Likert scale, categorized as low-, medium-, and high-priority items. Consensus was defined as ≥60% agreement. RESULTS Twenty-seven subject matter experts generated 570 research questions, of which 427 (75%) achieved the consensus threshold. Of the consensus reaching questions, 209 (49%) were rated high priority, 213 (50%) medium priority, and 5 (1%) low priority. Gaps in understanding the broad array of interventions were identified, including those related to health care infrastructure, technology products, education/training, resuscitation, and operative intervention. The prehospital phase of care was highlighted as an area needing focused research. CONCLUSION This Delphi gap analysis of trauma systems and informatics research identified high-priority research questions that will help guide investigators and funding agencies in setting research priorities to continue to work toward Zero Preventable Deaths after trauma. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Elliott R Haut
- From the Division of Acute Care Surgery, Department of Surgery (E.R.H.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; The Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland Acute and Critical Care Surgery (J.P.K.) and Department of Surgery (J.A.B.), Washington University in St. Louis, St. Louis, Missouri Harborview Injury Prevention and Research Center (J.P.), University of Washington, Seattle, Washington Trauma Surgery and Surgical Critical Care (B.G.), University of Cincinnati Medical Center, Cincinnati, Ohio Department of Surgery (K.N.R.), Uniformed Services University School of Medicine, Bethesda, Maryland Department of General Surgery (K.S.), Stanford University, Stanford, California Division of Traumatology, Surgical Critical Care and Emergency Surgery (J.W.C.), University of Pennsylvania, Philadelphia, Pennsylvania The Coalition for National Trauma Research (M.A.P.), San Antonio, Texas Department of Surgery (E.M.B.), University of Washington, Seattle, Washington Coalition for National Trauma Research (NRAP Trauma Systems and Informatics Panel), San Antonio, Texas
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Jarman H, Crouch R, Friend S, Cole E. Establishing the research priorities for major trauma in the United Kingdom: A Delphi study of nurses and allied health professionals. Int Emerg Nurs 2023; 67:101265. [PMID: 36857846 DOI: 10.1016/j.ienj.2023.101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 01/07/2023] [Accepted: 01/20/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Research prioritisation exercises are used to determine which areas of research are important. In major trauma care, nurses and allied health professionals are central to the delivery of evidence-based care but their opinions on research priorities are under-represented in the literature. We aimed to identify the research priorities of major trauma nurses and allied health professionals in the UK. METHODS A three-round electronic Delphi study was conducted in the UK between November 2019 and May 2021. Round one aimed to generate research questions with rounds two and three questions in order of priority. In stages two and three responses were analysed using descriptive statistics to compute frequencies and proportions for the ranking of each question. RESULTS Survey rounds were completed by 180, 100 and 91 respondents respectively. The first round generated 285 statements that were condensed into 71 research questions. Analysis of rankings in subsequent rounds prioritised 54 research questions across themes of adult / children's acute care, psychological care and workforce, training and education. DISCUSSION Nurses and AHPs are well-positioned to determine research priorities in major trauma care. Focusing on these priorities will guide future research and help to build an evidence-base in trauma care.
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Affiliation(s)
- Heather Jarman
- Emergency Department Clinical Research Group, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom.
| | - Robert Crouch
- University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom.
| | - Stephen Friend
- Emergency Department Clinical Research Group, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom.
| | - Elaine Cole
- Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2EA, United Kingdom.
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Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial. J Trauma Acute Care Surg 2023; 94:36-44. [PMID: 36279368 DOI: 10.1097/ta.0000000000003817] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, >0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p < 0.001), and discharge to rehab/SNFs (aOR, 1.98; p < 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p < 0.05). CONCLUSION External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Pivalizza EG, Sen S, Hernandez N. Implementation of a Geriatric Trauma Clinical Pathway. JAMA Surg 2023; 158:104-105. [PMID: 36197660 DOI: 10.1001/jamasurg.2022.4822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Evan G Pivalizza
- Department of Anesthesiology, McGovern Medical School at UT Houston, Houston, Texas
| | - Sudipta Sen
- Department of Anesthesiology, McGovern Medical School at UT Houston, Houston, Texas
| | - Nadia Hernandez
- Department of Anesthesiology, McGovern Medical School at UT Houston, Houston, Texas
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Bass GA, Duffy CC, Kaplan LJ, Sarani B, Martin ND, Ismail AM, Cao Y, Forssten MP, Mohseni S. The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures. Injury 2023; 54:56-62. [PMID: 36402584 DOI: 10.1016/j.injury.2022.11.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/23/2022] [Accepted: 11/10/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture. METHODS All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders. RESULTS 96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome. CONCLUSIONS Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; School of Medical Sciences, Orebro University, Orebro, Sweden; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA
| | - Caoimhe C Duffy
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA
| | - Lewis J Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, USA; Corporal Michael Cresenscz Veterans Affairs Medical Center (CMCVAMC), Philadelphia, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, George Washington University School of Medicine & Health Sciences, Washington D.C., USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | | | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden; Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden.
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