1
|
Hosseinpour H, Nelson A, Bhogadi SK, Magnotti LJ, Alizai Q, Colosimo C, Hage K, Ditillo M, Anand T, Joseph B. Should We Keep or Transfer Our Severely Injured Geriatric Patients to Higher Levels of Care? J Surg Res 2024; 300:15-24. [PMID: 38795669 DOI: 10.1016/j.jss.2024.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 02/21/2024] [Accepted: 03/16/2024] [Indexed: 05/28/2024]
Abstract
INTRODUCTION Interfacility transfer to higher levels of care is becoming increasingly common. This study aims to evaluate the association between transfer to higher levels of care and prolonged transfer times with outcomes of severely injured geriatric trauma patients compared to those who are managed definitively at lower-level trauma centers. METHODS Severely injured (Injury Severity Score >15) geriatric (≥60 y) trauma patients in the 2017-2018 American College of Surgeons Trauma Quality Improvement Program database managing at an American College of Surgeons/State Level III trauma center or transferring to a level I or II trauma center were included. Outcome measures were 24-h and in-hospital mortality and major complications. RESULTS Forty thousand seven hundred nineteen patients were identified. Mean age was 75 ± 8 y, 54% were male, 98% had a blunt mechanism of injury, and the median Injury Severity Score was 17 [16-21]. Median transfer time was 112 [79-154] min, and the most common transport mode was ground ambulance (82.3%). Transfer to higher levels of care within 90 min was associated with lower 24-h mortality (adjusted odds ratio [aOR]: 0.493, P < 0.001) and similar odds of in-hospital mortality as those managed at level III centers. However, every 30-min delay in transfer time beyond 90 min was progressively associated with increased odds of 24-h (aOR: 1.058, P < 0.001) and in-hospital (aOR: 1.114, P < 0.001) mortality and major complications (aOR: 1.127, P < 0.001). CONCLUSIONS Every 30-min delay in interfacility transfer time beyond 90 min is associated with 6% and 11% higher risk-adjusted odds of 24-h and in-hospital mortality, respectively. Estimated interfacility transfer time should be considered while deciding about transferring severely injured geriatric trauma patients to a higher level of care.
Collapse
Affiliation(s)
- Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Kati Hage
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
| |
Collapse
|
2
|
Jones B, Dicker B, Howie G, Todd V. Review article: Emergency medical services transfer of severe traumatic brain injured patients to a neuroscience centre: A systematic review. Emerg Med Australas 2024; 36:187-196. [PMID: 38263532 DOI: 10.1111/1742-6723.14375] [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: 09/21/2023] [Revised: 12/06/2023] [Accepted: 01/01/2024] [Indexed: 01/25/2024]
Abstract
Patients with severe traumatic brain injuries require urgent medical attention at a hospital. We evaluated whether transporting adult patients with a severe traumatic brain injury (TBI) to a Neuroscience Centre is associated with reduced mortality. We reviewed studies published between 2010 and 2023 on severe TBI in adults (>18 years) using Medline, CINAHL, Google Scholar and Cochrane databases. We focused on mortality rates and the impact of transferring patients to a Neuroscience Centre, delays to neurosurgery and EMS triage accuracy. This review analysed seven studies consisting of 53 365 patients. When patients were directly transported to a Neuroscience Centre, no improvement in survivability was demonstrated. Subsequently, transferring patients from a local hospital to a Neuroscience Centre was significantly associated with reduced mortality in one study (adjusted odds ratio: 0.79, 95% confidence interval: 0.64-0.96), and 24-h (relative risk [RR]: 0.31, 0.11-0.83) and 30-day (RR: 0.66, 0.46-0.96) mortality in another. Patients directly transported to a Neuroscience Centre were more unwell than those taken to a local hospital. Subsequent transfers increased time to CT scanning and neurosurgery in several studies, although these were not statistically significant. Additionally, EMS could accurately triage. None of the included studies demonstrated statistically significant findings indicating that direct transportation to a Neuroscience Centre increased survivability for patients with severe traumatic brain injuries. Subsequent transfers from a non-Neuroscience Centre to a Neuroscience Centre reduced mortality rates at 24 h and 30 days. Further research is required to understand the differences between direct transport and subsequent transfers to Neuroscience Centres.
Collapse
Affiliation(s)
- Ben Jones
- Paramedicine Research Unit, Paramedicine Department, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Bridget Dicker
- Paramedicine Research Unit, Paramedicine Department, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
- Clinical Audit and Research Team, Hato Hone St John, Auckland, New Zealand
| | - Graham Howie
- Paramedicine Research Unit, Paramedicine Department, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Verity Todd
- Paramedicine Research Unit, Paramedicine Department, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
- Clinical Audit and Research Team, Hato Hone St John, Auckland, New Zealand
| |
Collapse
|
3
|
Spering C, Bieler D, Ruchholtz S, Bouillon B, Hartensuer R, Lehmann W, Lefering R, Düsing H. Evaluation of the interhospital patient transfer after implementation of a regionalized trauma care system (TraumaNetzwerk DGU ®) in Germany. Front Med (Lausanne) 2023; 10:1298562. [PMID: 38034545 PMCID: PMC10684689 DOI: 10.3389/fmed.2023.1298562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/11/2023] [Indexed: 12/02/2023] Open
Abstract
Purpose The aim of the study was to evaluate how many patients are being transferred between trauma centers and and their characteristics in the 2006 initiated TraumaNetzwerk DGU® (TNW). We further investigated the time point of transfer and differences in outcome, compared to patients not being transferred. We wanted to know how trauma centers judged the performance of the TNW in transfer. Method (1) We analyzed the data of the TraumaRegister DGU® (TR-DGU) from 2014-2018. Included were patients that were treated in German trauma centers, maximum AIS (MAIS) >2 and MAIS 2 only in case of admission on ICU or death of the patient. Patients being transferred were compared to patients who were not. Characteristics were compared, and a logistic regression analysis performed to identify predictive factors. (2) We performed a survey in the TNW focussing on frequency, timing and communication between hospitals and improvement through TNW. Results Study I analyzed 143,195 patients from the TR-DGU. Their mean ISS was 17.8 points (SD 11.5). 56.4% were admitted primarily to a Level-I, 32.2% to a Level-II and 11.4% to a Level-III Trauma Center. 10,450 patients (7.9%) were transferred. 3,667 patients (22.7%) of the admitted patients of Level-III Center and 5,610 (12.6%) of Level-II Center were transferred, these patients showed a higher ISS (Level-III: 18.1 vs. 12.9; Level-II: 20.1 vs. 15.8) with more often a severe brain injury (AIS 3+) (Level-III: 43.6% vs. 13.1%; Level-II: 53.2% vs. 23.8%). Regression analysis showed ISS 25+ and severe brain injury AIS 3+ are predictive factors for patients needing a rapid transfer. Study II: 215 complete questionnaires (34%) of the 632 trauma centers. Transfers were executed within 2 h after the accident (Level-III: 55.3%; Level-II: 25.0%) and between 2-6 h (Level-III: 39.5%; Level-II: 51.3%). Most trauma centers judged that implementation of TNW improved trauma care significantly (Level III: 65.0%; Level-II: 61.4%, Level-I: 56.7%). Conclusion The implementation of TNW has improved the communication and quality of comprehensive trauma care of severely injured patients within Germany. Transfer is mostly organized efficient. Predictors such as higher level of head injury reveal that preclinical algorithm present a potential of further improvement.
Collapse
Affiliation(s)
- C. Spering
- Department of Trauma Surgery, Orthopedics and Plastic Surgery, Göttingen University Medical Center, Göttingen, Germany
| | - D. Bieler
- Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Medical School, Düsseldorf, Germany
- Department of Orthopaedics and Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - S. Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - B. Bouillon
- Department of Trauma Surgery, Orthopedics and Sports Traumatology, University of Witten/Herdecke, Cologne, Germany
| | - R. Hartensuer
- Center for Orthopaedics, Trauma Surgery, Hand Surgery and Sports Medicine, Surgical Clinic II, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - W. Lehmann
- Department of Trauma Surgery, Orthopedics and Plastic Surgery, Göttingen University Medical Center, Göttingen, Germany
| | - R. Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - H. Düsing
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | | |
Collapse
|
4
|
Sriramka B, Mallik D, Nanda S. Entangled Circuit during Transport of Patient. Indian J Crit Care Med 2023; 27:774-775. [PMID: 37908435 PMCID: PMC10613866 DOI: 10.5005/jp-journals-10071-24531] [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: 11/02/2023] Open
Abstract
How to cite this article: Sriramka B, Mallik D, Nanda S. Entangled Circuit during Transport of Patient. Indian J Crit Care Med 2023;27(10):774-775.
Collapse
Affiliation(s)
- Bhavna Sriramka
- Department of Anaesthesia and Critical Care, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
| | - Diptimayee Mallik
- Department of Anaesthesia and Critical Care, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
| | - Sivani Nanda
- Department of Anaesthesia and Critical Care, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
| |
Collapse
|
5
|
Gil-Jardiné C, Payen JF, Bernard R, Bobbia X, Bouzat P, Catoire P, Chauvin A, Claessens YE, Douay B, Dubucs X, Galanaud D, Gauss T, Gauvrit JY, Geeraerts T, Glize B, Goddet S, Godier A, Le Borgne P, Rousseau G, Sapin V, Velly L, Viglino D, Vigue B, Cuvillon P, Frasca D, Claret PG. Management of patients suffering from mild traumatic brain injury 2023. Anaesth Crit Care Pain Med 2023; 42:101260. [PMID: 37285919 DOI: 10.1016/j.accpm.2023.101260] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To develop a multidisciplinary French reference that addresses initial pre- and in-hospital management of a mild traumatic brain injury patient. DESIGN A panel of 22 experts was formed on request from the French Society of Emergency Medicine (SFMU) and the French Society of Anaesthesiology and Critical Care Medicine (SFAR). A policy of declaration and monitoring of links of interest was applied and respected throughout the process of producing the guidelines. Similarly, no funding was received from any company marketing a health product (drug or medical device). The expert panel had to respect and follow the Grade® (Grading of Recommendations Assessment, Development and Evaluation) methodology to evaluate the quality of the evidence on which the recommendations were based. Given the impossibility of obtaining a high level of evidence for most of the recommendations, it was decided to adopt a "Recommendations for Professional Practice" (RPP) format, rather than a Formalized Expert Recommendation (FER) format, and to formulate the recommendations using the terminology of the SFMU and SFAR Guidelines. METHODS Three fields were defined: 1) pre-hospital assessment, 2) emergency room management, and 3) emergency room discharge modalities. The group assessed 11 questions related to mild traumatic brain injury. Each question was formulated using a PICO (Patients Intervention Comparison Outcome) format. RESULTS The experts' synthesis work and the application of the GRADE® method resulted in the formulation of 14 recommendations. After two rounds of rating, strong agreement was obtained for all recommendations. For one question, no recommendation could be made. CONCLUSION There was strong agreement among the experts on important, transdisciplinary recommendations, the purpose of which is to improve management practices for patients with mild head injury.
Collapse
Affiliation(s)
- Cédric Gil-Jardiné
- Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin, Service des Urgences-Adultes, Population Health, INSERM U1219, équipe aHeAD, Université de Bordeaux, Bordeaux, France.
| | - Jean-François Payen
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Rémy Bernard
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Xavier Bobbia
- Montpellier University, UR UM 103 (IMAGINE), Department of Emergency Medicine, CHU Montpellier, Montpellier, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Pierre Catoire
- Emergency Consultant, Academic Clinical Fellow (Pitié-Salpétrière University, General Emergency Department, Paris) - Tactical Ultrasound Course for Ukraine (TUSC-UA) Course Director - Mehad, France
| | - Anthony Chauvin
- Service d'Accueil des Urgences/SMUR, CHU Lariboisière, Université de Paris - Inserm U942 MASCOT, Université de Paris, Paris, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse Grace, Avenue Pasteur, MC-98002, Monaco
| | - Bénédicte Douay
- SMUR/Service des Urgences, Hôpital Beaujon, AP-HP Nord, Clichy, France
| | - Xavier Dubucs
- Emergency Departement, Centre Hospitalo-Universitaire de Toulouse, Place du Docteur Baylac, 31300 Toulouse, France
| | - Damien Galanaud
- Service de Neuroradiologie, GH Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, University Grenoble Alpes, F-38000 Grenoble, France
| | - Jean-Yves Gauvrit
- Service de Neuroradiologie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Thomas Geeraerts
- Pole Anesthesie Réanimation et INSERM Tonic, CHU de Toulouse et Universite Toulouse 3, Toulouse, France
| | - Bertrand Glize
- PMR Department, CHU de Bordeaux, ACTIVE Team, BPH INSERM U1219, University of Bordeaux, France
| | - Sybille Goddet
- Samu-21, CHU de Dijon, SAU-Smur, CH du Creusot, Dijon, France
| | - Anne Godier
- Université Paris Cité, APHP, Hôpital Européen Georges Pompidou, Service d'anesthésie Réanimation and Inserm UMRS_1140, Paris, France
| | - Pierrick Le Borgne
- Emergency Department, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000 Strasbourg, France - INSERM UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), Faculté de Médecine, Université de Strasbourg, 4 rue Kirschleger, 67085 Strasbourg Cedex, France
| | | | - Vincent Sapin
- Service de Biochimie et de Génétique Moléculaire, Centre de Biologie, CHU de Clermont-Ferrand, France
| | - Lionel Velly
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Damien Viglino
- University Grenoble-Alpes, Emergency Department, CHU Grenoble-Alpes, Grenoble, France - HP2 Laboratory INSERM U1300, Grenoble, France
| | - Bernard Vigue
- Département d'Anesthésie Réanimation, Hôpital Universitaire de Bicêtre, Le Kremlin Bicêtre, France
| | - Philippe Cuvillon
- EA 2992 IMAGINE, Prévention et Prise en Charge de la Défaillance Circulatoire des Patients en état de Choc, Anaesthesiology Department, CHU Nîmes, University Montpellier, 30000 Nîmes, France
| | - Denis Frasca
- Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France, Service d'Anesthésie, Réanimation et Médecine Péri-Opératoire, CHU de Poitiers, France, INSERM U1246, Methods in Patients-Centered Outcomes and Health Research - SPHERE, Nantes, France
| | | |
Collapse
|
6
|
Kameda-Smith MM, Pond GR, Seow H. Rurality index score and pediatric neuro-oncological outcome in Ontario. J Neurosurg Pediatr 2023; 31:275-281. [PMID: 36640100 DOI: 10.3171/2022.12.peds22446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/09/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Rapid access to neurosurgical decisions and definitive management are vital for the outcome of neurocritical patients. There are unique challenges associated with the provision of services required to maintain critical infrastructure for rural citizens. Given that a relationship between rurality, marginalization, and health outcomes has been identified as associated with higher mortality rates and higher rates of many diseases, the authors studied whether worse clinical outcomes were associated with rurality in pediatric neuro-oncological disease. METHODS Using linked administrative databases, the authors retrospectively analyzed a population-based cohort of patients diagnosed with a pediatric brain tumor between 1996 and 2017 in Ontario, Canada. The main variable of interest was the Rurality Index for Ontario (RIO; larger value denotes more rural); the main outcome was survival, while controlling for surgery and tumor type. RESULTS Of the 1428 patients included, 53.9% were male. Overall survival of all the children (controlling for surgery and tumor type) at 1, 5, and 10 years was 84.7%, 65.1%, and 58.4%, respectively. A total of 11.5% were classified as living in a rural area of Ontario. The distance to the nearest pediatric neurosurgical hospital ranged from 25.6 to 167.4 km. The RIO score was 0 in 38.7% of children, and the majority of patients had a RIO score < 40. A higher RIO score was not a significant factor (continuous p = 0.12/ordinal p = 0.18) associated with length of follow-up, indicating that rurality was not significantly linked to compliance with clinical follow-up. CONCLUSIONS Rurality of the region in which pediatric neuro-oncological patients reside was not associated with patient outcome (HR 0.83, p = 0.39).
Collapse
Affiliation(s)
| | | | - Hsien Seow
- 3Oncology, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
7
|
Gilmartin S, Brent L, Hanrahan M, Dunphy M, Deasy C. A retrospective review of patients who sustained traumatic brain injury in Ireland 2014-2019. Injury 2022; 53:3680-3691. [PMID: 36167689 DOI: 10.1016/j.injury.2022.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/30/2022] [Accepted: 09/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the most significant cause of death and disability resulting from major trauma. The aim of this study is to describe the demographics of TBI patients, the current pathways of care and outcomes in the Republic of Ireland from 2014 to 2019. METHODS We performed a retrospective review of all TBI patients meeting inclusion criteria in Ireland's Major Trauma Audit (MTA) from 2014 to 2019. Severe TBI was defined as an abbreviated injury scale (AIS) ≥3 and GCS ≤8. RESULTS During the study period, 30,891 patients sustained major trauma meeting inclusion criteria for MTA, of which 7,393 (23.9%) patients met the inclusion criteria for TBI; 1,025 (13.9%) were classified as severe. The median age was 60.6 years (IQR 36.9-78.0), 54.3 years (32.8-73.4) for males and 71.7 years (50.0-83.0) for females (p<0.001). Of patients with severe TBI, 185 (18.0%) were brought direct to a neurosurgical centre, 389 (37.9%) were transferred to a neurosurgical centre and 321 (31.3%) had a neurosurgical intervention performed. In patients sustaining severe TBI, older patients (Adjusted OR, 0.96,95% CI 0.95-0.97) and patients requiring another surgery (OR 0.31, 95%CI 0.18-0.53) were less likely to be secondarily transferred to a neurosurgical centre. There were 47 (4.6%) patients with severe TBI discharged to rehabilitation. The 30-day mortality in Ireland was 11.6% in all TBI patients and 45.5% in severe TBI patients. Older patients and patients with higher ISS had a higher chance of death. Male patients, patients treated in neurosurgical centre, patients who had neurosurgery or non-neurosurgical surgery had a higher chance of survival. CONCLUSION This population-based study bench marks the 'as is' for patients with TBI in Ireland. We found that presently in Ireland, the mortality rate from severe TBI appears to be higher than that reported in international literature, and only a minority of severe TBI patients are brought directly from the incident to a neurosurgical centre. The new major trauma system should focus on providing effective and efficient access to neurosurgical, neuro-critical and neuro-rehabilitative care for patients who sustain TBI.
Collapse
Affiliation(s)
- Stephen Gilmartin
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland.
| | - Louise Brent
- Major Trauma Audit, National Office of Clinical Audit, Ireland
| | | | - Michael Dunphy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Conor Deasy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland; Major Trauma Audit, National Office of Clinical Audit, Ireland
| |
Collapse
|
8
|
Patterson KN, Nordin A, Beyene TJ, Onwuka A, Bergus K, Horvath KZ, Sribnick EA, Thakkar RK. Implementation of a Level 1 Neuro Trauma Activation at a Tertiary Pediatric Trauma Center. J Surg Res 2022; 275:308-317. [DOI: 10.1016/j.jss.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/08/2021] [Accepted: 02/10/2022] [Indexed: 11/16/2022]
|
9
|
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]
|
10
|
Pomponio MK, Khan IS, Evans LT, Simmons NE, Ball PA, Ryken TC, Hong J. Association between interhospital transfer and increased in-hospital mortality in patients with spinal epidural abscesses. Spine J 2022; 22:921-926. [PMID: 35017053 DOI: 10.1016/j.spinee.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/30/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) is an uncommon yet serious infection, associated with significant morbidity and mortality. Patients diagnosed with SEA often require surgical interventions or critical care services that are not available at community hospitals and are therefore transferred to tertiary care centers. Little is known about the effects of interhospital transfer on acute outcomes for patients with SEA. PURPOSE To study the effects of interhospital transfer on acute outcomes for patients with SEA. STUDY DESIGN Cross sectional analysis using the 2009 to 2017 National Inpatient Sample (NIS). PATIENT SAMPLE Using the 2009 to 2017 NIS, we identified cases of SEA using ICD, Ninth, or Tenth Revision diagnosis codes 324.1 & G06.1. OUTCOME MEASURES Our primary endpoint was in hospital mortality. METHODS The association between interhospital transfer and inpatient mortality was assessed using multivariable logistic regression to adjust for potential covariates. Patient and hospital factors associated with interhospital transfer were assessed in a secondary analysis. RESULTS A total of 21.5% of patient with SEA were treated after transfer from another hospital. After adjusting for covariates, those who presented after transfer had higher odds of death during hospitalization (OR: 1.51, 95% CI 1.27-1.78, p<.001). Transferred patients were significantly more likely to live in rural communities (11.4 % vs. 5.3 % for nontransferred patients). CONCLUSIONS Interhospital transfer, which occurred more frequently in patients from rural hospitals, was associated with death even after controlling for disease severity. Addressing healthcare delivery disparities across the US, including across the rural-urban spectrum, will require better understanding of the observed increased mortality of interhospital transfer as a preventable source of in-hospital mortality for SEA.
Collapse
Affiliation(s)
- Maria K Pomponio
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road Hanover, NH 03755, USA
| | - Imad S Khan
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Linton T Evans
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Nathan E Simmons
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Perry A Ball
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Timothy C Ryken
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Jennifer Hong
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| |
Collapse
|
11
|
Kotwal T, Fluck T, Valsraj K. Bed management in psychiatry: ensuring that the patient perspective is not forgotten. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2021.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARYBed management and the transfer of patients is an area of clinical care that is frequently overlooked. Often, the lack of discussion leads to the patient perspective being ignored and to transfers to new hospitals without appropriate handovers, both to the detriment of patient outcomes. This article reflects on the real-world consequences of the bed management systems used within the UK's National Health Service (NHS), using the example of a patient in psychiatric services.
Collapse
|
12
|
Sewalt CA, Gravesteijn BY, Menon D, Lingsma HF, Maas AIR, Stocchetti N, Venema E, Lecky FE. Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study. Scand J Trauma Resusc Emerg Med 2021; 29:113. [PMID: 34348784 PMCID: PMC8340517 DOI: 10.1186/s13049-021-00930-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00930-1.
Collapse
Affiliation(s)
- Charlie Aletta Sewalt
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Benjamin Yaël Gravesteijn
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Anesthesiology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Esmee Venema
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - Fiona E Lecky
- Center for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | |
Collapse
|
13
|
Grevfors N, Lindblad C, Nelson DW, Svensson M, Thelin EP, Rubenson Wahlin R. Delayed Neurosurgical Intervention in Traumatic Brain Injury Patients Referred From Primary Hospitals Is Not Associated With an Unfavorable Outcome. Front Neurol 2021; 11:610192. [PMID: 33519689 PMCID: PMC7839281 DOI: 10.3389/fneur.2020.610192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/03/2020] [Indexed: 01/29/2023] Open
Abstract
Background: Secondary transports of patients suffering from traumatic brain injury (TBI) may result in a delayed management and neurosurgical intervention, which is potentially detrimental. The aim of this study was to study the effect of triaging and delayed transfers on outcome, specifically studying time to diagnostics and neurosurgical management. Methods: This was a retrospective observational cohort study of TBI patients in need of neurosurgical care, 15 years and older, in the Stockholm Region, Sweden, from 2008 throughout 2014. Data were collected from pre-hospital and in-hospital charts. Known TBI outcome predictors, including the protein biomarker of brain injury S100B, were used to assess injury severity. Characteristics and outcomes of direct trauma center (TC) and those of secondary transfers were evaluated and compared. Functional outcome, using the Glasgow Outcome Scale, was assessed in survivors at 6–12 months after trauma. Regression models, including propensity score balanced models, were used for endpoint assessment. Results: A total of n = 457 TBI patients were included; n = 320 (70%) patients were direct TC transfers, whereas n = 137 (30%) were secondary referrals. In all, n = 295 required neurosurgery for the first 24 h after trauma (about 75% of each subgroup). Direct TC transfers were more severely injured (median Glasgow Coma Scale 8 vs. 13) and more often suffered a high energy trauma (31 vs. 2.9%) than secondary referrals. Admission S100B was higher in the TC transfer group, though S100B levels 12–36 h after trauma were similar between cohorts. Direct or indirect TC transfer could be predicted using propensity scoring. The secondary referrals had a shorter distance to the primary hospital, but had later radiology and surgery than the TC group (all p < 0.001). In adjusted multivariable analyses with and without propensity matching, direct or secondary transfers were not found to be significantly related to outcome. Time from trauma to surgery did not affect outcome. Conclusions: TBI patients secondary transported to a TC had surgical intervention performed hours later, though this did not affect outcome, presumably demonstrating that accurate pre-hospital triaging was performed. This indicates that for selected patients, a wait-and-see approach with delayed neurosurgical intervention is not necessarily detrimental, but warrants further research.
Collapse
Affiliation(s)
- Niklas Grevfors
- Division of Perioperative Medicine and Intensive Care (PMI), Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Division of Perioperative Medicine and Intensive Care (PMI), Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden.,Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden.,Ambulance Medical Service in Stockholm (Ambulanssjukvården i Storstockholm AB), Stockholm, Sweden.,Academic EMS, Stockholm, Sweden
| |
Collapse
|
14
|
Fitschen-Oestern S, Lippross S, Lefering R, Klüter T, Behrendt P, Weuster M, Seekamp A, Dgu T. Missed hand and forearm injuries in multiple trauma patients: An analysis from the TraumaRegister DGU®. Injury 2020; 51:1608-1617. [PMID: 32434714 DOI: 10.1016/j.injury.2020.04.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Multiple trauma patients have a high risk of missed injuries. The main point of our study was to provide new epidemiological data on hand and forearm injuries in multiple trauma with a focus on those that were missed. Therefore, we used the database of the TraumaRegister DGU®. METHODS In this study, we evaluated anonymous data from 139931 patients aged 1-100 years with multiple trauma in the TraumaRegister DGU® of the German Society for Trauma Surgery from 2007 to 2017. Patients with hand and forearm injuries documented during hospital stay were identified and analyzed. We included fractures, dislocations, tendon injuries, nerve injuries and vessel injuries. Patients with missed hand and forearm injuries were compared with patients with primary diagnosed injuries in view of gender, age, ISS, Abbreviated Injury Score (AIS), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), trauma mechanism type of injury, hospital stay, RISC II and mortality rate. Missed injuries were defined as injuries that were recently diagnosed and documented in the intensive care unit (ICU). RESULTS A total of 50459 multiple trauma patients (36.1%) had hand or forearm injuries, and 89472 patients (63.9%) had neither. Patients with hand injuries were younger and were more often involved in car and motorcycle accidents. Severe head trauma was evaluated less frequently, and severe thorax trauma was evaluated more often in patients with hand injuries. The times of diagnosis of hand injuries were documented in 10971 cases. A total of 727 patients (6.6%) with missed hand injuries were registered. The most commonly missed injuries in multiple trauma were 104 carpal fractures/dislocations (11.2%), 195 nerve injuries (25.4%) and 54 tendon injuries (11.4%). Predisposing factors for missing injuries were multiple diagnoses, primary care in the first hospital and direct from emergency room transfer to the ICU. CONCLUSION In contrast to previous findings, severely injured patients, especially those with head injuries and GCS of ≤8, were not predisposed to have missed hand injuries compared to patients without severe head trauma. Special attention should be paid to younger patients after traffic accidents with multiple diagnoses and direct transfer to the ICU.
Collapse
Affiliation(s)
- Stefanie Fitschen-Oestern
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany.
| | - Sebastian Lippross
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Tim Klüter
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
| | - Peter Behrendt
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
| | - Matthias Weuster
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
| | - Andreas Seekamp
- Department of Trauma Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
| | - TraumaRegister Dgu
- Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany
| |
Collapse
|
15
|
Dornbos D, Monson C, Look A, Huntoon K, Smith LGF, Leonard JR, Dhall SS, Sribnick EA. Validation of the Surgical Intervention for Traumatic Injury scale in the pediatric population. J Neurosurg Pediatr 2020; 26:92-97. [PMID: 32276255 DOI: 10.3171/2020.2.peds19474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 02/05/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While the Glasgow Coma Scale (GCS) has been effective in describing severity in traumatic brain injury (TBI), there is no current method for communicating the possible need for surgical intervention. This study utilizes a recently developed scoring system, the Surgical Intervention for Traumatic Injury (SITI) scale, which was developed to efficiently communicate the potential need for surgical decompression in adult patients with TBI. The objective of this study was to apply the SITI scale to a pediatric population to provide a tool to increase communication of possible surgical urgency. METHODS The SITI scale uses both radiographic and clinical findings, including the GCS score on presentation, pupillary examination, and CT findings. To examine the scale in pediatric TBI, a neurotrauma database at a level 1 pediatric trauma center was retrospectively evaluated, and the SITI score for all patients with an admission diagnosis of TBI between 2010 and 2015 was calculated. The primary endpoint was operative intervention, defined as a craniotomy or craniectomy for decompression, performed within the first 24 hours of admission. RESULTS A total of 1524 patients met inclusion criteria for the study during the 5-year span: 1469 (96.4%) were managed nonoperatively and 55 (3.6%) patients underwent emergent operative intervention. The mean SITI score was 4.98 ± 0.31 for patients undergoing surgical intervention and 0.41 ± 0.02 for patients treated nonoperatively (p < 0.0001). The area under the receiver operating characteristic (AUROC) curve was used to examine the diagnostic accuracy of the SITI scale in this pediatric population and was found to be 0.98. Further evaluation of patients presenting with moderate to severe TBI revealed a mean SITI score of 5.51 ± 0.31 in 40 (15.3%) operative patients and 1.55 ± 0.02 in 221 (84.7%) nonoperative patients, with an AUROC curve of 0.95. CONCLUSIONS The SITI scale was designed to be a simple, objective communication tool regarding the potential need for surgical decompression after TBI. Application of this scale to a pediatric population reveals that the score correlated with the perceived need for emergent surgical intervention, further suggesting its potential utility in clinical practice.
Collapse
Affiliation(s)
- David Dornbos
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,2Department of Neurological Surgery, University of Tennessee Health Science Center and Semmes Murphey Clinic, Memphis, Tennessee
| | | | -
- 3Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Andrew Look
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristin Huntoon
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Luke G F Smith
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey R Leonard
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,3Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Sanjay S Dhall
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Eric A Sribnick
- 1Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.,3Division of Pediatric Neurological Surgery, Nationwide Children's Hospital, Columbus, Ohio; and
| |
Collapse
|
16
|
Hamada SR, Delhaye N, Degoul S, Gauss T, Raux M, Devaud ML, Amani J, Cook F, Hego C, Duranteau J, Rouquette A. Direct transport vs secondary transfer to level I trauma centers in a French exclusive trauma system: Impact on mortality and determinants of triage on road-traffic victims. PLoS One 2019; 14:e0223809. [PMID: 31751349 PMCID: PMC6872206 DOI: 10.1371/journal.pone.0223809] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/27/2019] [Indexed: 12/23/2022] Open
Abstract
Background Transporting a severely injured patient directly to a trauma center (TC) is consensually considered optimal. Nevertheless, disagreement persists regarding the association between secondary transfer status and outcome. The aim of the study was to compare adjusted mortality between road traffic trauma patients directly or secondarily transported to a level 1 trauma center (TC) in an exclusive French trauma system with a physician staffed prehospital emergency medical system (EMS). Methods A retrospective cohort study was performed using 2015–2017 data from a regional trauma registry (Traumabase®), an administrative database on road-traffic accidents and prehospital-EMS records. Multivariate logistic regression models were computed to determine the role of the modality of admission on mortality and to identify factors associated with secondary transfer. The primary outcome was day-30 mortality. Results: During the study period, 121.955 victims of road-traffic accident were recorded among which 4412 trauma patients were admitted in the level 1 regional TCs, 4031 directly and 381 secondarily transferred from lower levels facilities. No significant association between all-cause 30-day mortality and the type of transport was observed (Odds ratio 0.80, 95% confidence interval (CI) [0.3–1.9]) when adjusted for potential confounders. Patients secondarily transferred were older, with low-energy mechanism and presented higher head and abdominal injury scores. Among all 947 death, 43 (4.5%) occurred in lower-level facilities. The population-based undertriage leading to death was 0.15%, 95%CI [0.12–0.19]. Conclusion In an exclusive trauma system with physician staffed prehospital care, road-traffic victims secondarily transferred to a TC do not have an increased mortality when compared to directly transported patients.
Collapse
Affiliation(s)
- Sophie Rym Hamada
- Université paris Sud, Department of Anesthesiology and Critical Care, AP-HP, Bicêtre Hôpitaux Universitaires Paris Sud, Le Kremlin Bicêtre, France.,CESP, INSERM, Université paris Sud, UVSQ, Université Paris-Saclay, Paris; CESP, INSERM, Maison de Solenn, Paris, France
| | - Nathalie Delhaye
- Sorbonne Université and Department of Anesthesiology and Critical Care, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière, Paris, France
| | - Samuel Degoul
- Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace, Department of Anesthesiology and Surgical Intensive Care, Mulhouse, France
| | - Tobias Gauss
- Hôpitaux Universitaires Paris Nord Val de Seine, Department of Anesthesiology and Critical Care, AP-HP, Hôpital Beaujon, Clichy, France
| | - Mathieu Raux
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département d'Anesthésie Réanimation, Paris, France
| | | | - Johan Amani
- SAMU 78, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Fabrice Cook
- Université Paris Est, Department of Anesthesiology and Critical Care, APHP, Hôpital Henri Mondor, Créteil, France
| | - Camille Hego
- Hôpitaux Universitaires Paris Nord Val de Seine, Department of Anesthesiology and Critical Care, AP-HP, Beaujon, Clichy, France
| | - Jacques Duranteau
- Université Paris Sud, Department of Anesthesiology and Critical Care, AP-HP, Bicêtre Hôpitaux Universitaires Paris Sud, Le Kremlin Bicêtre, France
| | - Alexandra Rouquette
- CESP, INSERM, Univ. Paris-Sud, UVSQ, Université Paris-Saclay, Paris, France (Postal address: CESP, INSERM, Maison de Solenn, Paris, France.,Bicêtre Hôpitaux Universitaires Paris Sud, Public Health and Epidemiology Department, APHP, Le Kremlin-Bicêtre, France
| | | |
Collapse
|
17
|
Sribnick EA, Lunney M, Wright DW, Allen JW, Hudgins PA, Shi J, Wheeler K, Leonard JR, Dhall SS, Xiangh H. The Surgical Intervention for Traumatic Injury Scale: A Clinical Tool for Traumatic Brain Injury. West J Emerg Med 2019; 20:578-584. [PMID: 31316696 PMCID: PMC6625684 DOI: 10.5811/westjem.2019.4.41802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/25/2019] [Accepted: 04/05/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction There is no widely used method for communicating the possible need for surgical intervention in patients with traumatic brain injury (TBI). This study describes a scoring system designed to communicate the potential need for surgical decompression in TBI patients. The scoring system, named the Surgical Intervention for Traumatic Injury (SITI), was designed to be objective and easy to use. Methods The SITI scale uses radiographic and clinical findings, including the Glasgow Coma Scale Score, pupil examination, and findings noted on computed tomography. To examine the scale, we used the patient database for the Progesterone for the Treatment of Traumatic Brain Injury III (ProTECT III) trial, and retrospectively applied the SITI scale to these patients. Results Of the 871 patients reviewed, 164 (18.8%) underwent craniotomy or craniectomy, and 707 (81.2%) were treated nonoperatively. The mean SITI score was 5.1 for patients who underwent surgery and 2.5 for patients treated nonoperatively (P<0.001). The area under the receiver operating characteristic curve was 0.887. Conclusion The SITI scale was designed to be a simple, objective, clinical decision tool regarding the potential need for surgical decompression after TBI. Application of the SITI scale to the ProTECT III database demonstrated that a score of 3 or more was well associated with a perceived need for surgical decompression. These results further demonstrate the potential utility of the SITI scale in clinical practice.
Collapse
Affiliation(s)
- Eric A Sribnick
- Nationwide Children's Hospital, Division of Neurosurgery, Columbus, Ohio.,The Ohio State University, Department of Neurosurgery, Columbus, Ohio
| | - Michael Lunney
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - David W Wright
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Jason W Allen
- Emory University, Department of Radiology and Imaging Sciences, Atlanta, Georgia
| | - Patricia A Hudgins
- Emory University, Department of Radiology and Imaging Sciences, Atlanta, Georgia
| | - Junxin Shi
- Nationwide Children's Hospital, Center for Pediatric Trauma Research, Columbus, Ohio
| | - Krista Wheeler
- Nationwide Children's Hospital, Center for Pediatric Trauma Research, Columbus, Ohio
| | - Jeffrey R Leonard
- Nationwide Children's Hospital, Division of Neurosurgery, Columbus, Ohio.,The Ohio State University, Department of Neurosurgery, Columbus, Ohio
| | - Sanjay S Dhall
- University of California, San Francisco, Department of Neurosurgery, San Francisco, California
| | - Henry Xiangh
- Nationwide Children's Hospital, Center for Pediatric Trauma Research, Columbus, Ohio
| |
Collapse
|
18
|
Kuhn EN, Warmus BA, Davis MC, Oster RA, Guthrie BL. Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service: A Pilot Study. Neurosurgery 2017; 79:541-8. [PMID: 27489167 DOI: 10.1227/neu.0000000000001378] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Thousands of neurosurgical emergencies are transferred yearly to tertiary care facilities to assume a higher level of care. Several studies have examined how neurosurgical transfers influence patient outcomes, but characteristics of potentially avoidable transfers have yet to be investigated. OBJECTIVE To identify whether potentially avoidable transfers represent a significant portion of transfers to a tertiary neurosurgical facility. METHODS In this cohort study, we evaluated 916 neurosurgical patients transferred to a tertiary care facility over a 2-year period. Transfers were classified as potentially avoidable when no neurosurgical diagnostic test, intervention, or intensive monitoring was deemed necessary (n = 180). The remaining transfers were classified as justifiable (n = 736). The main outcomes and measures were age, sex, diagnosis, insurance status, intervention, distance of transfer, length of hospital and intensive care unit stay, mortality, discharge disposition, and cost. RESULTS Nearly 20% of transfers were identified as being potentially avoidable. Although some of these patients had suffered devastating, irrecoverable neurological insults, many had innocuous conditions that did not require transfer to a higher level of care. Justifiable transfers tend to involve patients with nontraumatic intracranial hemorrhage and cranial neoplasm. Both groups were admitted to the intensive care unit at the same rate (approximately 70% of patients). Finally, the direct transportation cost of potentially avoidable transfers was $1.46 million over 2 years. CONCLUSION This study identified the frequency and expense of potentially avoidable transfers. There is a need for closer examination of the clinical and financial implications of potentially avoidable transfers. ABBREVIATIONS CI, confidence intervalIQR, interquartile rangeJT, justifiable transferOR, odds ratioPAT, potentially avoidable transferUAB, University of Alabama at Birmingham.
Collapse
Affiliation(s)
- Elizabeth N Kuhn
- ‡Department of Neurological Surgery, §Medical Scientist Training Program, and ¶Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | | |
Collapse
|
19
|
Fakhry SM, Ferguson PL, Johnson EE, Wilson DA. Hospitalization in low-level trauma centres after severe traumatic brain injury: review of a population-based emergency department data base. Brain Inj 2017; 31:1486-1493. [PMID: 28980837 DOI: 10.1080/02699052.2017.1376762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To achieve the best possible recovery, individuals with severe TBI should be treated at Level I/II trauma centres (I/II TC). Increased morbidity and mortality can result when injured patients are admitted to facilities that may not have the appropriate resources or expertise to treat the injury. The purpose of this study was to estimate the proportion of severe TBI visits resulting in hospitalization in lower-level trauma centres (OTH) and evaluate the characteristics associated with such hospitalizations. METHODS The 2012 National Emergency Department Sample (NEDS) data set was analysed. Weighted descriptive analysis and multivariable logistic regression were used to describe the association of hospitalization in OTH with demographic, clinical and hospital characteristics. RESULTS Of visits for severe TBI, 112 208 were admitted to I/II TC and 43 294 admitted to OTH. The adjusted odds of hospitalization in OTH were higher for isolated TBI, falls, women, in those with ≥3 chronic conditions and increasing age. CONCLUSIONS An estimated 19.5% of visits for severe TBI resulted in hospitalization in OTH. These findings show the need to further evaluate the relationship between sex, age and mechanism of injury to inform efforts to appropriately triage individuals with TBI to ensure the best possible recovery.
Collapse
Affiliation(s)
- Samir M Fakhry
- a Trauma Service, Division of General Surgery, Department of Surgery , Medical University of South Carolina , Charleston , SC , USA
| | - Pamela L Ferguson
- a Trauma Service, Division of General Surgery, Department of Surgery , Medical University of South Carolina , Charleston , SC , USA
| | - Emily E Johnson
- b College of Nursing , Medical University of South Carolina , Charleston , SC , USA
| | - Dulaney A Wilson
- a Trauma Service, Division of General Surgery, Department of Surgery , Medical University of South Carolina , Charleston , SC , USA.,c Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
| |
Collapse
|
20
|
Fishe JN, Psoter KJ, Klein BL, Anders JF. Retrospective Evaluation of Risk Factors for Pediatric Secondary Transport. PREHOSP EMERG CARE 2017; 22:41-49. [PMID: 28657816 DOI: 10.1080/10903127.2017.1339748] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Emergency medical services (EMS) typically transports patients to the nearest emergency department (ED). After initial presentation, children who require specialized care must undergo secondary transport, exposing them to additional risks and delaying definitive treatment. EMS direct transport protocols exist for major trauma and certain adult medical conditions, however the same cannot be said for pediatric medical conditions or injuries that do not meet trauma center criteria ('minor trauma'). To explore the utility of such future protocols, we sought to first describe the pediatric secondary transport population and examine prehospital risk factors for secondary transport. METHODS Pediatric secondary transport patients aged 0-18 years were identified. Patients meeting state EMS trauma protocol criteria or who were clinically unstable were excluded. Data were abstracted by chart review of EMS, community hospital ED, and specialty hospital records. Patients were compared to control patients with similar conditions who did not require secondary transport. RESULTS This study identified 211 medical or minor trauma pediatric secondary transport patients between 2013 and 2014. The three most prevalent conditions were seizure (n = 52), isolated orthopedic injury (n = 49), and asthma/respiratory distress (n = 27). Increased odds of secondary transport for seizure patients were associated with administration of supplemental oxygen, glucose measurement, and online medical direction; for isolated orthopedic injuries, online medical direction; and for asthma/respiratory distress, administration of supplemental oxygen, and online medical direction. Decreased odds of secondary transport for seizure patients were associated with a higher GCS; for isolated orthopedic injuries, increased age and oxygen saturation; and for asthma/respiratory distress, administration of albuterol only. CONCLUSIONS Children with seizures, isolated orthopedic injuries, and asthma/respiratory distress comprised the majority of the medical or minor trauma pediatric secondary transport population. Each of those conditions had specific risk factors for secondary transport. This study's results provide information to guide future prospective studies and the development of direct transport protocols for those populations.
Collapse
|
21
|
Nishijima DK, Gaona SD, Waechter T, Maloney R, Bair T, Blitz A, Elms AR, Farrales RD, Howard C, Montoya J, Bell JM, Faul M, Vinson DR, Garzon H, Holmes JF, Ballard DW. Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion. Ann Emerg Med 2017; 70:127-138.e6. [PMID: 28238499 DOI: 10.1016/j.annemergmed.2016.12.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/08/2016] [Accepted: 12/14/2016] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. METHODS This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. RESULTS Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). CONCLUSION Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.
Collapse
Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA.
| | - Samuel D Gaona
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
| | | | - Ric Maloney
- Sacramento Metropolitan Fire Department, Sacramento, CA
| | - Troy Bair
- Cosumnes Community Services District Fire Department, Elk Grove, CA
| | - Adam Blitz
- American Medical Response, Sacramento, CA
| | - Andrew R Elms
- Kaiser Permanente South Sacramento Medical Center, Sacramento, CA
| | | | | | | | | | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, GA
| | - David R Vinson
- Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | | | - James F Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
| | | | | |
Collapse
|
22
|
Development of a multi stakeholder partnership to improve access to and delivery of neurosurgical services in Ontario. Health Policy 2016; 121:207-214. [PMID: 27913054 DOI: 10.1016/j.healthpol.2016.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 11/12/2016] [Accepted: 11/16/2016] [Indexed: 11/24/2022]
Abstract
Neurosurgical emergencies require expedient access to definitive care at neurosurgical centers. Neurosurgical resources in province of Ontario are highly centralized, and subsequently, most patients with neurosurgical emergencies will present to non-neurosurgical centers. From 2000-2010, metrics demonstrated the organization of neurosurgical resources might not be optimal. In response to this a program entitled Provincial Neurosurgery Ontario (PNO)- was formed to address these issues in cooperation with neurosurgeons, hospitals and the provincial government. PNO worked with multiple stakeholders to implement interventions to not only prevent out of country transfer, but to also improve the flow of neurosurgical patients in the province and potentially improve outcome. The main interventions undertaken by PNO were: 1) implementation and development of a province-wide tele-radiology system; 2) development of neurosurgery as a provincially-funded program; 3) significant outreach to non-neurosurgical centers; and 4) specialized funding packages for highly specialized level care. This report provides background on the challenges faced by neurosurgery in the province of Ontario and the process developed to address these challenges. Finally, we describe the impact provincial strategies have had on improving access to emergency neurosurgical care in the Ontario.
Collapse
|
23
|
Abstract
The intra- and inter-hospital patient transfer is an important aspect of patient care which is often undertaken to improve upon the existing management of the patient. It may involve transfer of patient within the same facility for any diagnostic procedure or transfer to another facility with more advanced care. The main aim in all such transfers is maintaining the continuity of medical care. As the transfer of sick patient may induce various physiological alterations which may adversely affect the prognosis of the patient, it should be initiated systematically and according to the evidence-based guidelines. The key elements of safe transfer involve decision to transfer and communication, pre-transfer stabilisation and preparation, choosing the appropriate mode of transfer, i.e., land transport or air transport, personnel accompanying the patient, equipment and monitoring required during the transfer, and finally, the documentation and handover of the patient at the receiving facility. These key elements should be followed in each transfer to prevent any adverse events which may severely affect the patient prognosis. The existing international guidelines are evidence based from various professional bodies in developed countries. However, in developing countries like India, with limited infrastructure, these guidelines can be modified accordingly. The most important aspect is implementation of these guidelines in Indian scenario with periodical quality assessments to improve the standard of care.
Collapse
Affiliation(s)
- Ashish Kulshrestha
- Department of Anaesthesia and Intensive Care, Vardan Multispecialty Hospital, Garhi Sikrod, NH-58, Meerut Road, Ghaziabad, Uttar Pradesh, India
| | - Jasveer Singh
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| |
Collapse
|
24
|
Schwindling L, Ragoschke-Schumm A, Kettner M, Helwig S, Manitz M, Roumia S, Lesmeister M, Grunwald IQ, Fassbender K. Prehospital Imaging-Based Triage of Head Trauma with a Mobile Stroke Unit: First Evidence and Literature Review. J Neuroimaging 2016; 26:489-93. [PMID: 27159772 DOI: 10.1111/jon.12355] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/29/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND An ambulance equipped with a computed tomography (CT) scanner, point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit [MSU]) has been shown to enable delivery of thrombolysis to stroke patients at the emergency site, thereby significantly decreasing time to treatment. However, the MSU frequently assesses patients with cerebral disorders other than stroke. For some of these disorders, prehospital CT scanning may also be beneficial. METHODS Our institution manages a program investigating prehospital stroke treatment of patients with neurological emergencies. We assessed a patient with head trauma for whom prehospital CT scanning and laboratory tests allowed cause-based triage to the most appropriate hospital. We examined implications of this case for clinical practice in light of a literature review. RESULTS The MSU was dispatched to assess a 74-year-old woman with suspected head trauma or stroke, found lying on the floor with a left frontal laceration. Her Glasgow Coma Scale score was 13, apart from drowsiness she exhibited no neurologic deficit. A CT scan ruled out intracranial hemorrhage and skull fracture. On the basis of these prehospital diagnostic findings, the patient was taken to the nearest primary care hospital rather than to a trauma center with neurosurgery facilities. CONCLUSION Patients with neurologic disorders other than stroke, such as traumatic brain injury, may also benefit from prehospital CT studies. This case report and the results of our analysis of the literature support the potential benefit of prehospital imaging in correctly triaging patients with suspected traumatic brain injury to the appropriate target hospital.
Collapse
Affiliation(s)
- L Schwindling
- Department of Neurology, Saarland University, Homburg, Germany
| | | | - M Kettner
- Department of Neurology, Saarland University, Homburg, Germany
| | - S Helwig
- Department of Neurology, Saarland University, Homburg, Germany
| | - M Manitz
- Department of Neurology, Saarland University, Homburg, Germany
| | - S Roumia
- Institute of Neuroradiology, Saarland University, Homburg, Germany
| | - M Lesmeister
- Department of Neurology, Saarland University, Homburg, Germany
| | - I Q Grunwald
- Neuroscience Department, Anglia Ruskin University, Chelmsford, Essex, UK
| | - K Fassbender
- Department of Neurology, Saarland University, Homburg, Germany
| |
Collapse
|
25
|
Faul M, Xu L, Sasser SM. Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults. PREHOSP EMERG CARE 2016; 20:594-600. [PMID: 26986195 DOI: 10.3109/10903127.2016.1149651] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups. METHODS Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes. RESULTS Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means. CONCLUSION Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI.
Collapse
|
26
|
Abstract
BACKGROUND Hypobaric hypoxemia is a well-known risk of aeromedical evacuation (AE). Validating patients as safe to fly includes assessment of oxygenation status as well as oxygen-carrying capability (hemoglobin). The incidence and severity of hypoxemia during AE of noncritically injured casualties have not been studied. METHODS Subjects deemed safe to fly by the validating flight surgeon were monitored with pulse oximetry from the flight line until arrival at definitive care. All subjects were US military personnel or contractors following traumatic injuries. Noninvasive oxygen saturation (SpO2), pulse rate, and noninvasive hemoglobin were measured every 5 seconds and recorded to electronic memory. Patient demographics and physiologic data were collected by chart abstraction from the Air Force Form 3899, patient movement record. The incidence and duration of hypoxemic events (SpO2 < 90%) and critical hypoxemic events were determined (SpO2 < 85%). RESULTS Sixty-one casualties were evaluated during AE from Bagram Air Base to Landstuhl Regional Medical Center. The mean (SD) age was 26.2 (6) years, Injury Severity Score (ISS) was 8 (11), and mean SpO2 before AE was 96% (2%). The mean (SD) transport time was 9.3 (1.3) hours. Patients were monitored before AE for a brief period, yielding a total recording time of 10.28 hours. The mean (SD) hemoglobin at the time of enrollment was 13.2 (3.5) g/dL (9.4-18.0 g/dL). Hypoxemia (SpO2 < 90%) was seen in 55 (90%) of 61 subjects. The mean duration of SpO2 less than 90% was 44 minutes. The mean (SD) change in SpO2 from baseline to mean in-flight SpO2 was 4% (1.2%). Thirty-four patients (56%) exhibited an SpO2 less than 85% for 11.7 (15) minutes. CONCLUSION Hypoxemia is a common event during AE of casualties. In patients with infection and concussion or mild traumatic brain injury, this could have long-term consequences. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level V.
Collapse
|
27
|
Barmparas G, Cooper Z, Haider AH, Havens JM, Askari R, Salim A. The elderly patient with spinal injury: treat or transfer? J Surg Res 2015; 202:58-65. [PMID: 27083948 DOI: 10.1016/j.jss.2015.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 11/23/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The purpose of this investigation was to delineate whether elderly patients with spinal injuries benefit from transfers to higher level trauma centers. METHODS Retrospective review of the National Trauma Data Bank 2007 to 2011, including patients > 65 (y) with any spinal fracture and/or spinal cord injury from a blunt mechanism. Patients who were transferred to level I and II centers from other facilities were compared to those admitted and received their definitive treatment at level III or other centers. RESULTS Of 3,313,117 eligible patients, 43,637 (1.3%) met inclusion criteria: 19,588 (44.9%) were transferred to level I-II centers, and 24,049 (55.1%) received definitive treatment at level III or other centers. Most of the patients (95.8%) had a spinal fracture without a spinal cord injury. Transferred patients were more likely to require an intensive care unit admission (48.5% versus 36.0%, P < 0.001) and ventilatory support (16.1% versus 13.3%, P < 0.001). Mortality for the entire cohort was 7.7% (8.6% versus 7.1%, P < 0.001) and significantly higher, at 21.7% for patients with a spinal cord injury (22.3% versus 21.0%, P < 0.001). After adjusting for all available covariates, there was no difference in the adjusted mortality between patients transferred to higher level centers and those treated at lower level centers (adjusted odds ratio [95% confidence interval]: 1.05 [0.95-1.17], P = 0.325). CONCLUSIONS Transfer of elderly patients with spinal injuries to higher level trauma centers is not associated with improved survival. Future studies should explore the justifications used for these transfers and focus on other outcome measures such as functional status to determine the potential benefit from such practices.
Collapse
Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zara Cooper
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Adil H Haider
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joaquim M Havens
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Reza Askari
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
28
|
Corcostegui SP, Beaume S, Prunet B, Cotte J, Nguyen C, Mathais Q, Vinciguerra D, Meaudre E, Kaiser E. Impact de la mise en place d’une filière régionale de traumatologie sur l’activité d’un centre référent. ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0580-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
29
|
Merali Z, Sharma S, MacDonald RD, Massicotte EM. Emergent and Urgent Transfers to Neurosurgical Centers in Ontario. PREHOSP EMERG CARE 2015; 20:245-53. [PMID: 26529260 DOI: 10.3109/10903127.2015.1086847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Critically ill neurosurgical patients require expedient access to neurosurgical centers (NC) to improve outcome. In regionalized health systems patients are often initially evaluated at a non-neurosurgical center (NNC) and are subsequently transferred to a NC using air or ground vehicles. We sought to identify barriers to accessing a NC for critically ill patients by analyzing interfacility transfer times and referral patterns in the province of Ontario. A retrospective observational analysis was undertaken. The cohort included patients in Ontario with emergent and urgent neurologic pathologies who underwent transfer from a NNC to NC between January 1, 2011 and December 31, 2013. Timing, clinical, and geographic data were collected for each transfer. We identified 1103 emergent/urgent transfers. The median transfer time to a NC was 3.4 h (IQR -2.2, 3.8) and varied by the geographic region of origin. A total of 17% of the patients bypassed a closer NC during transfer to their destination NC. Transfers that bypassed a closer NC travelled further (101 miles vs. 296 miles, p < 0.001), took longer (3.1 h vs. 3.9 h, p < 0.001), and in some regions were associated with a higher risk of in-transit clinical decline (3.0% vs. 8.3%, p < 0.05) when compared with transfers that ended at the closest NC. Regionalization of neurosurgical services in Ontario has led to heavy reliance upon patient transfers to maintain continuity of care. Access to a NC varied across the province, which may represent regional differences in neurosurgical bed availability, resource limitations at smaller NCs, or environmental factors. Our descriptions of referral patterns and transport times can guide health system planning in Ontario and similar jurisdictions in the United States and Canada.
Collapse
|
30
|
Juratli T, Stephan S, Stephan A, Sobottka S. Akutversorgung des Patienten mit schwerem Schädel-Hirn-Trauma. Anaesthesist 2015; 64:159-74. [DOI: 10.1007/s00101-014-2337-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
31
|
Sethi D, Subramanian S. When place and time matter: How to conduct safe inter-hospital transfer of patients. Saudi J Anaesth 2014; 8:104-13. [PMID: 24665250 PMCID: PMC3950432 DOI: 10.4103/1658-354x.125964] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inter-hospital transfer (IHT) of patients is often needed for diagnostic or therapeutic interventions. However, the transfer process carries its own risks as a poorly and hastily conducted transfer could lead to adverse events. In this article, we have reviewed literature on the key elements of IHT process including pre-transfer patient stabilization. We have also discussed various modes of transfer, physiological effects of transfer, possible adverse events and how to avoid or mitigate these. Even critically ill-patients can be transported safely by experienced and trained personnel using appropriate equipment. The patient must be maximally stabilized prior to transfer though complete optimization may be possible only at the receiving hospital. Ground or air transport may be employed depending on the urgency, feasibility and availability. Meticulous pre-transfer check and adherence to standard protocols during the transfer will help keep the entire process smooth and event free. The transport team should be trained to anticipate and manage any possible adverse events, medical or technical, during the transfer. Coordination between the referring and receiving hospitals would facilitate prompt transfer to the definitive destination avoiding delay at the emergency or casualty. Documentation of the transfer process and transfer of medical record and investigation reports are important for maintaining continuity of medical care and for medico-legal purposes.
Collapse
Affiliation(s)
- Divya Sethi
- Department of Anesthesiology, Employees’ State Insurance Cooperation, Postgraduate Institute of Medical Sciences and Research, Indraprastha University, New Delhi, India
| | - Shalini Subramanian
- Department of Anesthesiology, Employees’ State Insurance Cooperation, Postgraduate Institute of Medical Sciences and Research, Indraprastha University, New Delhi, India
| |
Collapse
|
32
|
Charbit J, Capdevila X. [A French regional network for management of severe trauma patients: the pelvic ring injury model]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2013; 32:823-824. [PMID: 24209987 DOI: 10.1016/j.annfar.2013.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- J Charbit
- Département d'anesthésie et réanimation Lapeyronie, centre régional d'accueil des polytraumatisés et réanimation polyvalente, CHU de Montpellier, Hôpital Lapeyronie, route de Ganges, 34295 Montpellier cedex 5, France.
| | | |
Collapse
|
33
|
Harvey J, West A. The right scan, for the right patient, at the right time: The reorganization of major trauma service provision in England and its implications for radiologists. Clin Radiol 2013; 68:871-86. [DOI: 10.1016/j.crad.2013.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 01/02/2013] [Accepted: 01/08/2013] [Indexed: 12/30/2022]
|
34
|
Franschman G, Andriessen TMJC, Boer C, Van der Naalt J, Horn J, Haitsma I, Vos PE. Physician-based emergency medical service deployment characteristics in severe traumatic brain injury: a Dutch multicenter study. Injury 2013; 44:1232-6. [PMID: 23816167 DOI: 10.1016/j.injury.2013.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 05/24/2013] [Accepted: 06/01/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prehospital guidelines advise advanced life support in all patients with severe traumatic brain injury (TBI). In the Netherlands, it is recommended that prehospital advanced life support is particularly provided by a physician-based helicopter emergency medical service (P-HEMS) in addition to paramedic care (EMS). Previous studies have however shown that a substantial part of severe TBI patients is exclusively treated by an EMS team. In order to better understand this phenomenon, we evaluated P-HEMS deployment characteristics in severe TBI in a multicenter setting. METHODS The database included patient demographics, prehospital and injury severity parameters and determinants of EMS or EMS/P-HEMS dispatch in 334 patients with severe TBI admitted to level 1 trauma centres in the Netherlands. RESULTS P-HEMS was deployed in 62% of patients with severe TBI. Patients treated by the P-HEMS had a higher injury severity score (29 (20-38)) vs. (25 (16-30); P<0.001), more frequently required blood product transfusions (41% vs. 29%; P=0.03) and recurrently suffered from TBI with extracranial injuries (33% vs. 6%; P<0.001) than patients solely treated by an EMS. The prehospital endotracheal intubation rate was higher in the P-HEMS group in isolated TBI (93% vs. 19%; P<0.001) or TBI with extracranial injuries (96% vs. 43%; P<0.001) compared to the EMS group. In the EMS group, more patients were secondary referred to a level 1 trauma centre (32% vs. 4%; P<0.001 vs. P-HEMS). Despite higher injury severity levels in P-HEMS patients, 6-month mortality rates were similar among groups, irrespective of the presence of extracranial injuries in addition to TBI. Deployment of P-HEMS estimated 52% and 72% (P<0.001) in urban and rural regions, respectively, with comparable endotracheal intubation rates among regions. CONCLUSIONS This study shows that a physician-based HEMS was more frequently deployed in patients with severe TBI in the presence of extracranial injuries, and in rural trauma regions. Treatment of severe TBI patients by a paramedic EMS only was associated with a higher incidence of secondary referrals to a level I trauma centre. Our data support adjustment of local prehospital guidelines for patients with severe TBI to the geographical context.
Collapse
Affiliation(s)
- G Franschman
- Department of Anesthesiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
35
|
Williams T, Finn J, Fatovich D, Jacobs I. Outcomes of different health care contexts for direct transport to a trauma center versus initial secondary center care: a systematic review and meta-analysis. PREHOSP EMERG CARE 2013; 17:442-57. [PMID: 23845080 DOI: 10.3109/10903127.2013.804137] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Within a trauma system, pre-hospital care is the first step in managing the trauma patient. Timely and appropriate transport of the injured patient to the most appropriate facility is important. Many trauma systems mandate that serious trauma cases are transported directly to a level I trauma center unless transfer to a closer hospital is deemed necessary to resuscitate and stabilize the patient prior to onward transfer to definitive care. Statistical and clinical heterogeneity is often high and is likely to be influenced by the heath care context. METHODS We conducted a systematic review and meta-analysis to compare patient outcomes for patients with serious trauma transported directly to a Level I/II trauma center ('direct' group) to those transported to a healthcare facility before transfer to the Level I/ II trauma center ('transfer' group). A search of bibliographic databases and secondary sources that focus on trauma was made. Studies were grouped by region: United States of America, Canada, Europe, Asia, Australia and New Zealand and South Africa. RESULTS The review included 43,554 patients from the 30 studies that met the selection criteria. Heterogeneity of the studies was high (I(2) 71%) overall but low for European, Asian, and Australian and New Zealand studies. There was considerable variation between studies in the structure, policies and practices of the respective trauma systems. The effect of "directness" on patient outcomes was inconsistent. CONCLUSION The current research evidence does not support nor refute a position that all serious trauma patients be routinely transported directly to a level I/II trauma center. As this is a complex issue, local health-care context and injury profile influence trauma policy and practice.
Collapse
Affiliation(s)
- Teresa Williams
- Faculty of Health Sciences, Curtin University, Perth, Western Australia.
| | | | | | | |
Collapse
|
36
|
HESSELFELDT R, STEINMETZ J, JANS H, JACOBSSON MB, ANDERSEN DL, BUGGESKOV K, KOWALSKI M, PRÆST M, ØLLGAARD L, HÖIBY P, RASMUSSEN LS. Impact of a physician-staffed helicopter on a regional trauma system: a prospective, controlled, observational study. Acta Anaesthesiol Scand 2013; 57:660-8. [PMID: 23289798 PMCID: PMC3652037 DOI: 10.1111/aas.12052] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This study aims to compare the trauma system before and after implementing a physician-staffed helicopter emergency medical service (PS-HEMS). Our hypothesis was that PS-HEMS would reduce time from injury to definitive care for severely injured patients. METHODS This was a prospective, controlled, observational study, involving seven local hospitals and one level I trauma centre using a before and after design. All patients treated by a trauma team within a 5-month period (1 December 2009-30 April 2010) prior to and a 12-month period (1 May 2010-30 April 2011) after implementing a PS-HEMS were included. We compared time from dispatch of the first ground ambulance to arrival in the trauma centre for patients with Injury Severity Score (ISS) > 15. Secondary end points were the proportion of secondary transfers and 30-day mortality. RESULTS We included 1788 patients, of which 204 had an ISS > 15. The PS-HEMS transported 44 severely injured directly to the trauma centre resulting in a reduction of secondary transfers from 50% before to 34% after implementation (P = 0.04). Median delay for definitive care for severely injured patients was 218 min before and 90 min after implementation (P < 0.01). The 30-day mortality was reduced from 29% (16/56) before to 14% (21/147) after PS-HEMS (P = 0.02). Logistic regression showed PS-HEMS had an odds ratio (OR) for survival of 6.9 compared with ground transport. CONCLUSIONS Implementation of a PS-HEMS was associated with significant reduction in time to the trauma centre for severely injured patients. We also observed significantly reduced proportions of secondary transfers and 30-day mortality.
Collapse
Affiliation(s)
- R. HESSELFELDT
- Department of Anaesthesia Section 4231 Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - J. STEINMETZ
- Helicopter Emergency Medical Service Ringsted Denmark
| | - H. JANS
- Department of Emergency Medicine Køge Hospital Køge Denmark
| | | | - D. L. ANDERSEN
- Department of Emergency Medicine Slagelse Hospital Slagelse Denmark
| | - K. BUGGESKOV
- Department of Emergency Medicine Holbæk Hospital Holbæk Denmark
| | - M. KOWALSKI
- Department of Anaesthesia Roskilde Hospital Roskilde Denmark
| | - M. PRÆST
- Department of Anaesthesia Nykøbing Falster Hospital Nykøbing Falster Denmark
| | - L. ØLLGAARD
- Department of Emergency Medicine Næstved Hospital Næstved Denmark
| | - P. HÖIBY
- Department of Forensic Medicine Section of Forensic Pathology Copenhagen University Copenhagen Denmark
| | - L. S. RASMUSSEN
- Department of Anaesthesia Section 4231 Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| |
Collapse
|