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Wintz D, Schaffer KB, Hites JJ, Wybourn C, Bui EH, Langness S, Hamel M, Wright K, Frey JR. GIFTS: Geriatric Intensive Functional Therapy Sessions-for the older trauma patient. J Trauma Acute Care Surg 2024; 97:197-204. [PMID: 38051122 DOI: 10.1097/ta.0000000000004224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Considering resources for comprehensive geriatric care, it would be beneficial for geriatric trauma patients (GTPs) and medical patients to be comanaged in one program focusing on ancillary therapeutics (AT): physical therapy, occupational therapy, speech language pathology, respiratory therapy, and sleep wake hygiene. This pilot study describes outcomes of GTPs in a hospital-wide program focused on geriatric-specific AT. METHODS Geriatric trauma patients and geriatric patients were screened by program coordinator for enrollment at one Level II trauma center from August 2021 to December 2022. Enrolled patients (EPs) were admitted to trauma or medicine floors and received repetitive AT with attention to sleep wake hygiene throughout hospitalization and compared with similar nonenrolled patients (NEPs). Excluded patients had any of the following: indication of geriatric syndrome with a fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) score of 5, no frailty with a FRAIL score of 0, comfort focused plans, or arrived from skilled care. Retrospective chart review of demographics and outcomes was completed for both EPs and NEPs. RESULTS A total of 224 EPs (28 trauma [TR]) were compared with 574 NEPs (148 TR). Enrolled patients showed shorter length of stay (mean, 3.8 vs. 6.1; p = 0.0001), less delirium (3.1% vs. 9.6%, p = 0.00222), less time to ambulation (13 hours vs. 39 hours, p = 0.0005), and higher likelihood to discharge home (56% vs. 27%, p < 0.0001) as compared with NEPs. The median FRAIL score was 3 for both groups. Enrolled medical patients ambulated the soonest at 11 average hours, compared with 23 hours for enrolled trauma patients and 39 hours for NEPs. There were zero delirium events among enrolled trauma patients; 25% was found among nonenrolled trauma patients ( p = 0.00288). CONCLUSION Despite a small trauma cohort, results support feasibility to include GTPs in hospital-wide programs with geriatric-specific AT. Mobility and cognitive strategies may improve opportunities to avoid delirium, decrease length of stay, and influence more frequent disposition to home. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Diane Wintz
- From the Sharp HealthCare, Sharp Memorial Hospital Trauma and Acute Care Surgery, San Diego, California
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Agoubi LL, Reimel BA, Maine RG, O’Connell KM, Maier RV, McIntyre LK. Intensive care unit readmission in injured older adults: Modifiable risk factors and implications. J Trauma Acute Care Surg 2024; 96:813-819. [PMID: 37926991 PMCID: PMC11043003 DOI: 10.1097/ta.0000000000004203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Prior evaluations of intensive care unit (ICU) readmission among injured older adults have inconsistently identified risk factors, with findings limited by use of subanalyses and small sample sizes. This study aimed to identify risk factors for and implications of ICU readmission in injured older adults. METHODS This retrospective, single-center cohort study was conducted at a high-volume Level 1 trauma center and included injured older adult patients (65 years or older) requiring at least one ICU admission during hospitalization between 2013 and 2018. Patients who died <48 hours of admission were excluded. Exposures included patient demographics and clinical factors. The primary outcome was ICU readmission. Multivariable regression was used to identify risk factors for ICU readmission. RESULTS A total of 6,691 injured adult trauma patients were admitted from 2013 to 2018, 55.4% (n = 3,709) of whom were admitted to the ICU after excluding early deaths. Of this cohort, 9.1% (n = 339) were readmitted to the ICU during hospitalization. Readmitted ICU patients had a higher median Injury Severity Score (21 [interquartile range, 14-26] vs. 16 [interquartile range, 10-24]), with similar mechanisms of injury between the two groups. Readmitted ICU patients had a significantly higher mortality (19.5%) compared with single ICU admission patients (9.9%) ( p < 0.001) and higher rates of developing any complication, including delirium (61% vs. 30%, p < 0.001). On multivariable analysis, the factors associated with the highest risk of readmission were delirium (Relative Risk, 2.6; 95% confidence interval, 2.07-3.26) and aspiration (Relative Risk, 3.04; 95% confidence interval, 1.67-5.54). More patients in the single ICU admission cohort received comfort-focused care at the time of their death as compared with the ICU readmission cohort (93% vs. 85%, p = 0.035). CONCLUSION Readmission to the ICU is strongly associated with higher mortality for injured older adults. Efforts targeted at preventing respiratory complications and delirium in the geriatric trauma population may decrease the rates of ICU readmission and related mortality risk. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Lauren L. Agoubi
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Beth Ann Reimel
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Rebecca G. Maine
- Department of Surgery, University of Washington, Seattle, WA, USA
| | | | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Lisa K. McIntyre
- Department of Surgery, University of Washington, Seattle, WA, USA
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Xu X, Zheng Q, Wei S, Chen Y, Hu X. Follow-up analysis of quality of life in elderly patients with bone trauma: a longitudinal observational study. BMC Geriatr 2023; 23:606. [PMID: 37759165 PMCID: PMC10538243 DOI: 10.1186/s12877-023-04325-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The quality of life (QoL) of elderly patients with bone trauma is significantly decreased and is affected by many complex factors. This study aims to conduct a half-year follow-up survey to clarify QoL and its influencing factors in elderly patients with bone trauma in order to provide targeted care measures for elderly patients with bone trauma. METHODS This was a longitudinal observational study. We used the 36-Item Short Form Health Survey (SF-36) to investigate and evaluate the QoL of 100 patients with bone trauma at the time of hospital discharge and 1 month, 3 months, and 6 months after discharge. Our previous study confirmed that the SF-36 had higher reliability and validity for evaluating the QoL of elderly patients with bone trauma. At the same time, we also investigated the age, gender, location of bone trauma, and destination after discharge of those patients. Those factors that might affect the QoL of elderly patients with bone trauma were identified by univariate and multivariate analyses. RESULTS The total physiological function, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health scores of elderly patients with bone trauma gradually increased from the time of discharge to 1 month, 3 months, and 6 months after discharge, and there were significant differences (p < 0.001). However, there was no significant difference in the general health score in the different periods (P = 0.095). The total QoL scores also significantly differed (F = 118.61, P < 0.001) at the time of discharge (335.252 ± 127.572) and 1 month (285.149 ± 112.827), 3 months (479.344 ± 153.663), and 6 months after discharge (544.396 ± 166.536). The univariate analysis results showed that the location of bone trauma (P < 0.005) and the destination after discharge (P < 0.001) were the main factors affecting QoL in different periods. The results of the multivariate analysis showed that the location of bone trauma was an important factor affecting QoL (P < 0.005 in different periods). Whether to undergo surgery was a factor affecting the patients' long-term QoL (P < 0.005 at 6 months after discharge). CONCLUSIONS Although the QoL of elderly patients with bone trauma gradually improves after injury, their recovery time is long, and the influencing factors are complex. Follow-up services should continue for at least six months for these patients, and comprehensive treatment and long-term rehabilitation services should be provided.
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Affiliation(s)
- Xiaofeng Xu
- Division of Vascular Surgery, Department of General Surgery, Innovation Center of Nursing Research and Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - Qixiang Zheng
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - Siying Wei
- West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - Yongmei Chen
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiuying Hu
- Innovation Center of Nursing Research and Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, China.
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Goswami J, MacArthur TA, Ramachandran D, Mahony C, Howick AS, Price-Troska T, Thompson RJ, Spears GM, Bailey KR, Patnaik MS, Passos JF, Park MS, Ferrer A. TELOMERE LENGTH OF PERIPHERAL BLOOD MONONUCLEAR CELLS IS ASSOCIATED WITH DISCHARGE DISPOSITION IN OLDER TRAUMA PATIENTS. Shock 2023; 59:327-333. [PMID: 36427074 PMCID: PMC10505495 DOI: 10.1097/shk.0000000000002059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction: Little is known regarding peripheral blood mononuclear cell telomere length (PBMC-TL) and response to traumatic injury. The objective of this study was to characterize the role of PBMC-TL in coagulation and clinical outcomes after injury. Methods: Plasma and buffy coats were prospectively collected from trauma patients and healthy volunteers. DNA was purified and PBMC-TL quantified by quantitative polymerase chain reaction. Thrombin generation kinetics were expressed as lag time (in minutes), peak height (in nanometers), time to peak (in minutes), and endogenous thrombin potential (in nM × min). Results are in median and quartiles [Q1, Q3]. P < 0.05 was considered significant (Wilcoxon rank sum testing). Results: Forty-two younger patients (21 [20, 22] years, 69% were male) and 39 older patients (62 [61, 64] years, 79% were male) were included. There was no significant difference in Clinical Frailty Scores between groups. Younger patients had longer total PBMC-TL (0.40 Mb [0.30, 0.49] vs. 0.29 Mb [0.23, 0.33], P < 0.001) and longer average PBMC-TL per chromosome (4.3 kb [3.3, 5.3] vs. 3.2 kb [2.5, 3.7], P < 0.001). When older patients were stratified by 50th percentile of PBMC-TL, there were no differences in thrombin generation; however, those with shorter telomeres were less likely to be discharged home (29% vs. 77%, P = 0.004). Older patients in the bottom quartile of PBMC-TL had shorter lag time (2.78 min [2.33, 3.00] vs. 3.33 min [3.24, 3.89], P = 0.030) and were less likely to be discharged home (22% vs. 90%, P = 0.006) than those in the top quartile of PBMC-TL. Multivariable logistic regression models revealed both increased age and shorter PBMC-TL to be independent predictors of discharge disposition other than home. Conclusion: In older trauma patients, shorter PBMC-TL is associated with accelerated initiation of thrombin generation and lower likelihood of being discharged to home.
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Affiliation(s)
- Julie Goswami
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
- Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, 125 Paterson St., New Brunswick, NJ 08901
| | - Taleen A. MacArthur
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Dhanya Ramachandran
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Cillian Mahony
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Annelise S. Howick
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Tammy Price-Troska
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Riley J. Thompson
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Grant M. Spears
- Clinical Statistics and Biostatistics, Department of Health Sciences Research, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Kent R. Bailey
- Clinical Statistics and Biostatistics, Department of Health Sciences Research, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Mrinal S. Patnaik
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Joao F. Passos
- Department of Physiology and Biomedical Engineering, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
- Robert and Arlene Kogod Center for Aging, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Myung S. Park
- Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
| | - Alejandro Ferrer
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, 200 1 St. SW, Rochester, MN 55905
- Center for Individualized Medicine, Mayo Clinic 200 1 St SW, Rochester, MN 55905
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Kishawi SK, Adomshick VJ, Halkiadakis PN, Wilson K, Petitt JC, Brown LR, Claridge JA, Ho VP. Development of Imaging Criteria for Geriatric Blunt Trauma Patients. J Surg Res 2023; 283:879-888. [PMID: 36915016 PMCID: PMC11299230 DOI: 10.1016/j.jss.2022.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury. METHODS Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value. RESULTS We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis. CONCLUSIONS Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.
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Affiliation(s)
- Sami K Kishawi
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Victoria J Adomshick
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Penelope N Halkiadakis
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Keira Wilson
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Jordan C Petitt
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio; Case Western Reserve University, Department of Population and Quantitative Health Sciences, Cleveland, Ohio.
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Callum J, Tresierra S, Woolley T. Major haemorrhage: putting evidence into practice. Br J Haematol 2022; 198:619-622. [PMID: 35687759 DOI: 10.1111/bjh.18246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/01/2022] [Accepted: 05/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Steven Tresierra
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Thomas Woolley
- Anaesthetics and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
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Factors Associated with In-Patient Mortality in the Rapid Assessment of Adult Earthquake Trauma Patients. Prehosp Disaster Med 2022; 37:299-305. [PMID: 35466904 DOI: 10.1017/s1049023x22000693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To date, there is limited evidence for health care providers regarding the determinants of early assessment of poor outcomes of adult in-patients due to earthquakes. This study aimed to explore factors related to early assessment of adult earthquake trauma patients (AETPs). METHODS The data on 29,933 AETPs in the West China Earthquake Patients Database (WCEPD) were analyzed retrospectively. Then, 37 simple variables that could be obtained rapidly upon arrival at the hospital were collected. The least absolute shrinkage and selection operator (LASSO) regression analyses were performed. A nomogram was then constructed. RESULTS Nine independent mortality-related factors that contributed to AETP in-patient mortality were identified. The variables included age (OR:1.035; 95%CI, 1.027-1.044), respiratory rate ([RR]; OR:1.091; 95%CI, 1.050-1.133), pulse rate ([PR]; OR:1.028; 95%CI, 1.020-1.036), diastolic blood pressure ([DBP]; OR:0.96; 95%CI, 0.950-0.970), Glasgow Coma Scale ([GCS]; OR:0.666; 95%CI, 0.643-0.691), crush injury (OR:3.707; 95%CI, 2.166-6.115), coronary heart disease ([CHD]; OR:4.025; 95%CI, 1.869-7.859), malignant tumor (OR:4.915; 95%CI, 2.850-8.098), and chronic kidney disease ([CKD]; OR:5.735; 95%CI, 3.209-10.019). CONCLUSIONS The nine mortality-related factors for ATEPs, including age, RR, PR, DBP, GCS, crush injury, CHD, malignant tumor, and CKD, could be quickly obtained on hospital arrival and should be the focal point of future earthquake response strategies for AETPs. Based on these factors, a nomogram was constructed to screen for AETPs with a higher risk of in-patient mortality.
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Failure to Rescue in Trauma: Early and Late Mortality in Low and High Performing Trauma Centers. J Trauma Acute Care Surg 2022; 93:176-186. [PMID: 35444147 DOI: 10.1097/ta.0000000000003662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Failure to Rescue (FTR) is defined as mortality following a complication. FTR has come under scrutiny as a quality metric to compare trauma centers. In contrast to elective surgery, trauma has an early period of high expected mortality due to injury sequelae rather than a complication. Here, we report FTR in early and late mortality using an externally validated trauma patient database, hypothesizing that centers with higher risk-adjusted mortality rates have higher risk-adjusted FTR rates. METHODS The study included 114,220 patients at 34 Level I and II trauma centers in a statewide quality collaborative (2016-2020) with ISS ≥5. Emergency room deaths were excluded. Multivariate regression models were used to produce center-level adjusted rates for mortality and major complications. Centers were ranked on adjusted mortality rate and divided into quintiles. Early deaths (within 48 hours of presentation) and late deaths (after 48 hours) were analyzed. RESULTS Overall, 6.7% of patients had a major complication and 3.1% died. There was no difference in the mean risk-adjusted complication rate amongst the centers. FTR was significantly different across the quintiles (13.8% at the very low mortality centers vs. 23.4% at the very high mortality centers, p < 0.001). For early deaths, there was no difference in FTR rates amongst the highest and lowest mortality quintiles. For late deaths, there was a twofold increase in the FTR rate between the lowest and highest mortality centers (9.7% vs. 19.3%, p < 0.001), despite no difference in the rates of major complications (5.9% vs. 6.0%, p = 0.42). CONCLUSIONS Low-performing trauma centers have higher mortality rates and lower rates of rescue following major complications. These differences are most evident in patients who survive the first 48 hours after injury. A better understanding of the complications and their role in mortality after 48 hours is an area of interest for quality improvement efforts. LEVEL OF EVIDENCE III.
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