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Omondi MP. Epidemiology of orthopedic injuries among inpatients admitted at a tertiary teaching and referral hospital in Kenya: a retrospective cross-sectional study. BMC Musculoskelet Disord 2024; 25:670. [PMID: 39192255 DOI: 10.1186/s12891-024-07793-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 08/16/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Orthopedic injuries are serious and continue to be a concern for healthcare systems worldwide. Approximately 90% of the estimated traumatic injuries occur in low- and middle-income countries. In Kenya, there is a dearth of information on orthopedic injury patterns that could be used to prioritize injury prevention measures and to help hospital management teams allocate resources appropriately. The purpose of this study was to determine the epidemiology of orthopedic injuries admitted to Kenyatta National Hospital. METHODS This was a retrospective cross-sectional study. Overall, 720 charts were reviewed. Data were analyzed using frequency distribution, pearson chi-square test and logistic regression. RESULTS Overall, 85% were aged 15-64 years. Approximately 80% were male, married or single. Patients with primary or secondary education composed 72%. Road traffic accidents (59.4%) and falls (24.7%) were the most common mechanisms of injury. A total of 99.9% of the inpatients were Kenyans. Open injuries were 40.1%. Lower limb (67.4%) and upper limb (26.9%) injuries were the most common. Inpatients aged 15-24 years were 74% less likely to have upper limb injuries than those aged 0-14 years (p = 0.023). However, those aged 15-24 years were 19.250 times more likely to have spine injuries than those aged 0-14 years (p = 0.008). Males were 68.6% and 51.2% less likely to have pelvic injury and comorbidities, respectively, than females (p < 0.001). Patients with secondary and tertiary education were 2.016 (p = 0.003) and 2.3 (p < 0.001) times more likely to have upper limb injuries, respectively, than those with no or preschool education. Similarly, those with tertiary education were 2.079 times more likely to have comorbidities than those with no or preschool education (p = 0.017). CONCLUSION Most of the inpatients with orthopedic injuries were young, male involved in Road traffic accidents and therefore Kenya National Transport and Safety Authority needs to enforce road safety measures to reduce road carnage. Those with higher education and children were more likely to have upper limb injuries. Females were more likely to have pelvic injuries and co-morbidities. Lower and upper limb injuries were the most common injuries and this should guide resource allocation in management of orthopedic injuries.
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Omondi MP, Mwangi Chege J, Ong’ang’o H, Sitati FC. Effect of enforcement of the national referral guidelines on patterns of orthopedic admissions to Kenyatta National Hospital, Kenya: Pre-post intervention study. PLoS One 2024; 19:e0290195. [PMID: 39137196 PMCID: PMC11321550 DOI: 10.1371/journal.pone.0290195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/07/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Inappropriate utilization of higher-level health facilities and ineffective management of referral processes in resource-limited settings are becoming increasingly a concern in health care management in developing countries. This is characterized by self-referral and frequent bypassing of the nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. On July 1, 2021, Kenyatta National Hospital (KNH) enforced the Kenya Health Sector Referral Implementation Guidelines, 2014, which required patients to receive approval from the KNH referral office and a formal referral letter to be admitted at KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by the Kenya 2010 Constitution and KNH legal statue of 1987. OBJECTIVE To determine the effect of enforcing the national referral guidelines on patterns of orthopaedic admissions to the KNH. This was a pre-post intervention study. Data abstraction was done for 459 and 446 charts before and after the enforcement of the national referral guidelines, respectively. RESULTS Enforcement of the national referral guidelines reduced the proportion of walk-in admissions from 54.9% to 45.1%, while the proportion of facility referrals increased from 46.6% to 53.4% (p = 0.013). The percentage of non-trauma orthopaedic admissions doubled from 12.0% to 22.4% (p<0.001). There was also an increase in admissions through the Outpatient Clinic and Corporate Outpatient Clinic. The proportion of emergency admissions declined, while that of elective admissions increased. The increase in elective cases was mainly driven by the increase in female admissions with active insurance cover, tertiary education, non-trauma-related conditions and older age groups. However, the use of official formal written referral letters did not change despite the enforcement of the national referral guidelines. CONCLUSION The enforcement of the national referral guidelines reduced the proportion of walk-ins' admissions to KNH. While the enforcement of the national referral guidelines had no effect on the use of official formal written referral letters, it did limit access and utilization of inpatient orthopedic services for young male patients with no active insurance cover and in need of emergency orthopedic care.
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Affiliation(s)
| | - Joseph Mwangi Chege
- Orthopedics Unit, Department of Surgery, University of Nairobi, Nairobi, Kenya
| | | | - Fred Chuma Sitati
- Orthopedics Unit, Department of Surgery, University of Nairobi, Nairobi, Kenya
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Jones RP. A New Approach for Understanding International Hospital Bed Numbers and Application to Local Area Bed Demand and Capacity Planning. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:1035. [PMID: 39200645 PMCID: PMC11353596 DOI: 10.3390/ijerph21081035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 09/02/2024]
Abstract
Three models/methods are given to understand the extreme international variation in available and occupied hospital bed numbers. These models/methods all rely on readily available data. In the first, occupied beds (rather than available beds) are used to measure the expressed demand for hospital beds. The expressed occupied bed demand for three countries was in the order Australia > England > USA. Next, the age-standardized mortality rate (ASMR) has dual functions. Less developed countries/regions have low access to healthcare, which results in high ASMR, or a negative slope between ASMR versus available/occupied beds. In the more developed countries, high ASMR can also be used to measure the 'need' for healthcare (including occupied beds), a positive slope among various social (wealth/lifestyle) groups, which will include Indigenous peoples. In England, a 100-unit increase in ASMR (European Standard population) leads to a 15.3-30.7 (feasible range) unit increase in occupied beds per 1000 deaths. Higher ASMR shows why the Australian states of the Northern Territory and Tasmania have an intrinsic higher bed demand. The USA has a high relative ASMR (for a developed/wealthy country) because healthcare is not universal in the widest sense. Lastly, a method for benchmarking the whole hospital's average bed occupancy which enables them to run at optimum efficiency and safety. English hospitals operate at highly disruptive and unsafe levels of bed occupancy, manifesting as high 'turn-away'. Turn-away implies bed unavailability for the next arriving patient. In the case of occupied beds, the slope of the relationship between occupied beds per 1000 deaths and deaths per 1000 population shows a power law function. Scatter around the trend line arising from year-to-year fluctuations in occupied beds per 1000 deaths, ASMR, deaths per 1000 population, changes in the number of persons hidden in the elective, outpatient and diagnostic waiting lists, and local area variation in births affecting maternity, neonatal, and pediatric bed demand. Additional variation will arise from differences in the level of local funding for social care, especially elderly care. The problems associated with crafting effective bed planning are illustrated using the English NHS as an example.
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Affiliation(s)
- Rodney P Jones
- Healthcare Analysis & Forecasting, Wantage OX12 0NE, Oxfordshire, UK
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Velez DR, Duncan AJ, Zreik K. Traumatic Brain Injury Patients Admitted on High-Census Days Receive Less Critical Care and Have an Increased Risk for Delirium. Cureus 2024; 16:e65957. [PMID: 39221291 PMCID: PMC11365572 DOI: 10.7759/cureus.65957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION The utilization of healthcare services in a growing population has raised concerns about its impact on clinical outcomes. Studies have shown that increased hospital census is associated with higher admission rates and unnecessary consults, tests, and procedures in various areas of healthcare. Traumatic brain injuries (TBIs), a significant concern due to their potential for long-term disabilities, are commonly encountered in intensive care units (ICUs) and are a leading cause of patient mortality. Despite extensive research on various aspects of TBI, the effect of the patient census on TBI outcomes remains unexplored. This study aims to investigate the relationship between healthcare provider patient census and clinical outcomes in TBI patients at a level I trauma center. METHODS A retrospective review was conducted from 2017 to 2022. The mean number of patients per day in the trauma service was determined, with patients below this average considered to be present on low-census days and those above it on high-census days. Patient demographics, mechanisms of injury, vital signs, TBI severity, and associated injuries were analyzed. Adjusted regression analyses were conducted. RESULTS Over the study period, 1,527 TBI patients were identified. Demographics were similar between patients admitted on high- and low-census days. Patients with moderate TBI were 30% less likely to be admitted to the ICU on high-census days, whereas there was no difference in ICU admission for patients with mild or severe TBI. Delirium was significantly higher in patients admitted on high-census days compared to those on low-census days. This was further identified to be predominantly driven by patients with mild TBI admitted on high-census days. CONCLUSION While most outcomes remained consistent, significant rates of delirium were found in our mild TBI patients admitted on high-census days suggesting the need for additional factors in the evaluation of these patients on admission. This study also reveals potential under-triage in moderate TBI patients on high-census days as they had significantly lower rates of ICU admission. These findings emphasize the need for further investigations to optimize patient care strategies within the context of fluctuating healthcare system demands.
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Affiliation(s)
- David R Velez
- Department of General Surgery, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Anthony J Duncan
- Department of General Surgery, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Khaled Zreik
- Department of Trauma and Acute Care Surgery, Sanford Medical Center Fargo, Fargo, USA
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Brahmbhatt VV, Leonard M, Burns B. Evaluating Staffing Guidelines Using Trauma Volume by Season, Day, and Time of Day at a Level 1 Trauma Center in Rural Appalachia. Cureus 2024; 16:e61429. [PMID: 38953080 PMCID: PMC11215934 DOI: 10.7759/cureus.61429] [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: 02/27/2024] [Accepted: 05/30/2024] [Indexed: 07/03/2024] Open
Abstract
Background Trauma is regarded as randomly occurring, but patterns exist for trauma volume which are useful in staffing guidelines and resource allocation. Literature on trauma admissions volume has been centered around geographically/climatically diverse centers and has often not considered many different temporal factors at once. Additionally, studies on trauma volume and staffing centered around rural or southern Trauma 1 centers were largely absent in the literature. Based on this, a study on our Trauma 1 center was deemed appropriate. Objective The objective of this study was to determine significant trends in trauma admissions and use this information to assess current staffing. This assessment was conducted through a retrospective analysis of patients admitted to the emergency department at our center. Methodology The retrospective data analysis study was conducted using data obtained locally and then subsequently uploaded onto the National Trauma Data Bank (NTDB). Patients included all trauma activations and consults to the trauma team above the age of 18. We analyzed the data by season, day, and time of admission to identify trends. Chi-square analysis was used to establish significance in comparing groups (day of the week, hour of day, and season of the year). Factors such as Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and length of stay (hospital days) were used to determine patterns of trauma severity. Results A total of 15,418 patients (8,307 males, 7,111 females) were analyzed in the dataset. The mean ISS was 8.14, and the mean GCS was 14.22. Weekends had significantly greater trauma volume than weekdays (P < 0.05). Motor vehicle collision (MVC), motorcycle, bicycle, and all-terrain vehicle (ATV) traumas were all significantly greater in summer. Bicycle and ATV trauma were significantly lowest in winter (P < 0.05). Admissions began to rise at 7 am and peaked at 5 pm. ISS, GCS, and hospital days did not significantly differ based on all groups assessed. Variation in trauma peak time across days of the week was insignificant. Our study discovered key findings in the form of increased trauma patient volume in summer, weekends, and between the hours of 1 and 9 pm. Our project found that the current staffing presents a mismatch in terms of addressing periods of high trauma. Staffing is lower on weekends, and there are conflicting administrative tasks scheduled during peak trauma hours (1-7 pm). This could be addressed by adjusting shift schedules to align better with periods of high trauma, such as increasing the workforce on weekends and decreasing it on weekdays. During summer months, adding additional float shift staff may help to better address the peak trauma volume. Conclusions Currently, there is evidence to suggest that high trauma times correspond with times of low staffing. Based on our study, there was evidence to show that low staffing periods corresponded with high trauma times. This volume-to-staffing mismatch may contribute to underlying problems such as long wait times, overworked providers, and ED overcrowding. Future studies may choose to focus on quality differences and wait times, aiming to quantify the effect of the mismatch of resources on patient volume.
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Affiliation(s)
| | | | - Bracken Burns
- Surgery, East Tennessee State University, Johnson City, USA
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Skladman R, Tadisina KK, Bettlach CR, Currie KB, Tanaka SA, Mackinnon SE, Fox IK, Sacks JM, Pet MA. The Yearly Periodicity of Operative Upper Extremity Trauma: A Retrospective Study of "Trauma Season". Plast Reconstr Surg 2024; 153:101e-111e. [PMID: 37189241 DOI: 10.1097/prs.0000000000010689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Upper extremity (UE) trauma requiring operative care increases during the summer and fall months, which the authors colloquially refer to as "trauma season." METHODS CPT databases were queried for codes related to acute UE trauma at a single level-1 trauma center. Monthly CPT code volume was tabulated for 120 consecutive months and average monthly volume was calculated. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed data set to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in four age groups. RESULTS A total of 11,084 CPT codes were included. Monthly trauma-related CPT volume was highest in July through October and lowest in December through February. Time-series analysis revealed yearly oscillation in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming yearly periodicity. Multivariable modeling revealed R 2 attributable to periodicity of 0.53 ( P < 0.01). Periodicity was strongest in younger populations and weaker in older populations. R 2 was 0.44 for ages 0 to 17, 0.35 for ages 18 to 44, 0.26 for ages 45 to 64, and 0.11 for ages 65 and older. CONCLUSIONS Operative UE trauma volumes peak in the summer and early fall and reach a winter nadir. Periodicity accounts for 53% of trauma volume variability. The authors' findings have implications for allocation of operative block time and personnel and expectation management over the course of the year.
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Affiliation(s)
- Rachel Skladman
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Kashyap K Tadisina
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Carrie R Bettlach
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Kelly B Currie
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Shoichiro A Tanaka
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Susan E Mackinnon
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Ida K Fox
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Justin M Sacks
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Mitchell A Pet
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
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Beiriger J, Lu L, Silver D, Brown JB. Impact of patient, system, and environmental factors on utilization of air medical transport after trauma. J Trauma Acute Care Surg 2024; 96:62-69. [PMID: 37789517 PMCID: PMC10841710 DOI: 10.1097/ta.0000000000004153] [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: 10/05/2023]
Abstract
BACKGROUND Air medical transport (AMT) improves outcomes for severely injured patients. The decision to fly patients is complex and must consider multiple factors. Our objective was to evaluate the interaction between geography, patient and environmental factors, and emergency medical services (EMS) system resources on AMT after trauma. We hypothesize that significant geographic variation in AMT utilization will be associated with varying levels of patient, environmental, and EMS resources. METHODS Patients transported by EMS in the Pennsylvania state trauma registry 2000 to 2017 were included. We used our previously developed Air Medical Prehospital Triage (AMPT; ≥2 points triage to AMT) score and Geographic Emergency Medical Services Index (GEMSI; higher indicates more system resources) as measures for patient factors and EMS resources, respectively. A mixed-effects logistic regression model determined the association of AMT utilization with patient, system, and environmental variables. RESULTS There were 195,354 patients included. Fifty-five percent of variation in AMT utilization was attributed to geographic differences. Triage to AMT by the AMPT score was associated with nearly twice the odds of AMT utilization (adjusted odds ratio, 1.894; 95% confidence interval, 1.765-2.032; p < 0.001). Each 1-point increase in GEMSI was associated with a 6.1% reduction in odds of AMT (0.939; 0.922-0.957; p < 0.001). Younger age, rural location, and more severe injuries were also associated with increased odds of AMT ( p < 0.05). When categorized by GEMSI level, the AMPT score and patient factors were more important for predicting AMT utilization in the middle tercile (moderate EMS resources) compared with the lower (low EMS resources) and higher tercile (high EMS resources). Weather, season, time-of-day, and traffic were all associated with AMT utilization ( p < 0.05). CONCLUSION Patient, system, and environmental factors are associated with AMT utilization, which varies geographically and by EMS/trauma system resource availability. A more comprehensive approach to AMT triage could reduce variation and allow more tailored efforts toward optimizing resource allocation and outcomes. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Jamison Beiriger
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Liling Lu
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - David Silver
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
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Beyene RT, Stonko DP, Gondek SP, Morrison JJ, Dennis BM. Identifying temporal variations in burn admissions. PLoS One 2023; 18:e0286154. [PMID: 37289792 PMCID: PMC10249893 DOI: 10.1371/journal.pone.0286154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/10/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Variations in admission patterns have been previously identified in non-elective surgical services, but minimal data on the subject exists with respect to burn admissions. Improved understanding of the temporal pattern of burn admissions could inform resource utilization and clinical staffing. We hypothesize that burn admissions have a predictable temporal distribution with regard to the time of day, day of week, and season of year in which they present. STUDY DESIGN A retrospective, cohort observational study of a single burn center from 7/1/2016 to 3/31/2021 was performed on all admissions to the burn surgery service. Demographics, burn characteristics, and temporal data of burn admissions were collected. Bivariate absolute and relative frequency data was captured and plotted for all patients who met inclusion criteria. Heat-maps were created to visually represent the relative admission frequency by time of day and day of week. Frequency analysis grouped by total body surface area against time of day and relative encounters against day of year was performed. RESULTS 2213 burn patient encounters were analyzed, averaging 1.28 burns per day. The nadir of burn admissions was from 07:00 and 08:00, with progressive increase in the rate of admissions over the day. Admissions peaked in the 15:00 hour and then plateaued until midnight (p<0.001). There was no association between day of week in the burn admission distribution (p>0.05), though weekend admissions skewed slightly later (p = 0.025). No annual, cyclical trend in burn admissions was identified, suggesting that there is no predictable seasonality to burn admissions, though individual holidays were not assessed. CONCLUSION Temporal variations in burn admissions exist, including a peak admission window late in the day. Furthermore, we did not find a predictable annual pattern to use in guiding staffing and resource allocation. This differs from findings in trauma, which identified admission peaks on the weekends and an annual cycle that peaks in spring and summer.
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Affiliation(s)
- Robel T. Beyene
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Stephen P. Gondek
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jonathan J. Morrison
- Mayo Clinic Division of Vascular and Endovascular Surgery, Rochester, MN, United States of America
| | - Bradley M. Dennis
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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Banks KC, Mooney CM, Borthwell R, Victorino K, Coutu S, Mazzolini K, Dzubnar J, Browder TD, Victorino GP. Racial Disparities Among Trauma Patients During the COVID-19 Pandemic. J Surg Res 2023; 281:89-96. [PMID: 36137357 PMCID: PMC9420714 DOI: 10.1016/j.jss.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/03/2022] [Accepted: 08/20/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Given the disparate effects of the COVID-19 pandemic on people of color, we hypothesized that patients of color experienced a disproportionate increase in trauma during the COVID-19 pandemic. MATERIALS AND METHODS We compared trauma patients arriving in the 3 y before our statewide stay-at-home mandate on March 20, 2020 (PRE) to those arriving in the year afterward (POST). In addition to race/ethnicity, we assessed patient demographics and other clinical variables. Chi-squared, Fisher's exact, and Mann-Whitney U tests were used for univariate analyses. A multivariable logistic regression was performed to assess for associations with mortality. RESULTS During the study period, 8583 patients were included in the PRE group and 2883 were included in the POST group. There were increases in penetrating trauma (PRE 14.7%, POST 23.1%; P < 0.001) and mortality rates (PRE 3.20%, POST 4.60%; P < 0.001). From PRE to POST, the percentage of Black patients increased from 35.0% to 38.3% (P = 0.01) and the percentage of Hispanic patients increased from 19.2% to 23.0% (P < 0.001). After a multivariable analysis, Asian patients experienced an independent increase in mortality from PRE to POST (odds ratio 2.00, 95% confidence interval 1.13-3.54, P = 0.02). CONCLUSIONS Penetrating trauma and mortality rates increased during the pandemic. There was a simultaneous increase in the percentage of Black and Hispanic trauma patients. Asian patient mortality increased significantly after the start of the pandemic independent of other variables. Identifying racial/ethnic disparities is the first step in finding ways to improve dissimilar outcomes.
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Affiliation(s)
- Kian C Banks
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California.
| | - Colin M Mooney
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Rachel Borthwell
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Kealia Victorino
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Sophia Coutu
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Kirea Mazzolini
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Jessica Dzubnar
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Timothy D Browder
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
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Omondi MP, Mwangi JC, Sitati FC, Onga'ngo H. Patterns of orthopedic and trauma admissions to a tertiary teaching and referral health facility in Kenya: Chart review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001425. [PMID: 37195922 DOI: 10.1371/journal.pgph.0001425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/12/2023] [Indexed: 05/19/2023]
Abstract
Tertiary hospitals in resource-limited countries should treat referred patients but in reality, are the first level of care for the vast majority of patients. As a result, the tertiary facility effectively functions as a primary health care facility. The urban phenomenon of widespread self-referral is associated with low rates of formal referral from peripheral health facilities. The study objective was to determine the patterns of orthopaedic and trauma admissions to Kenyatta National Hospital. This was descriptive study design. 905 patient charts were reviewed in 2021. The mean age was 33.8 years (SD 16.5) with range of 1-93 years. Majority 66.3% were between 25-64 years with those above 65 years being 40 (4.4%). Children 0-14 years comprised 10.9% of the admissions. Of the 905 admissions, 80.7% were accident and trauma-related admissions while 17.1% were non-trauma related admissions. About 50.1% were facility referrals while 49.9% were walk-ins. Majority of admissions were through Accident and Emergency Department 78.1%, Corporate Outpatient Care 14.9% and orthopedic Clinic 7.0%. About 78.7% were emergency admissions while 20.8% were elective admissions. Approximately 48.5% were due to Road Traffic Accidents and 20.9% due to falls. Close to 44.8% were casual workers and 20.2% unemployed. About 34.0% attained primary education and 35.0% secondary education. About 33.2% of female admissions were due to non-trauma conditions as compared to male admissions (12.8%) (p<0.001). Admissions for those aged 25-64 years were 3.5 more likely to have emergency admission as compared to those aged 0-14 years. Male were 65.1% less likely to have elective admissions compared to female (p<0.001). Whereas lower limb injuries and non-trauma related conditions were the most commonly admitted conditions, Lower limb injury and spine cases were mostly facility referred while non-trauma conditions were walk-in patients. Vast majority (89.2%) of admissions were from Nairobi Metropolitan region.
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Affiliation(s)
| | | | | | - Herbert Onga'ngo
- Department of Orthopedics, Kenyatta National Hospital, Nairobi, Kenya
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Skladman R, Tadisina KK, Chi J, Nguyen DC, Patel K, Pet MA. Facial Trauma Operative Volume Demonstrates Consistent and Significant Yearly Periodicity. J Oral Maxillofac Surg 2022; 81:424-433. [PMID: 36587931 DOI: 10.1016/j.joms.2022.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE Facial trauma requiring operative care increases during the summer and fall months, which is colloquially referred to as trauma season. The purpose of this study is to determine if there is a quantifiable and statistically significant yearly periodicity of operative facial trauma volume. MATERIALS AND METHODS To confirm the existence and quantify the magnitude of trauma season, we conducted a retrospective cohort study. The Plastic Surgery divisional billing database was queried for Current Procedural Terminology (CPT) codes related to acute facial trauma. The outcome variable is monthly CPT code volume and calendar month is the predictor. Monthly CPT volume was tabulated for 120 consecutive months. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed dataset to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability (R2) attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in 4 age groups. Patient identifiers, demographic information, surgeon, and date of surgery were collected as covariates. RESULTS One thousand six hundred fifty eight CPT codes obtained through Plastic Surgery billing records were included. Mean age at presentation was 32.5 ± 16.3 years (range = 85.05). Monthly trauma-related CPT volume was highest in June-September and lowest in December-February. Time series analysis revealed yearly oscillation, in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming the presence of yearly periodicity. Multivariable linear modeling revealed R2 attributable to periodicity of 0.23 (P = .008). Periodicity was strongest in younger populations and weaker in older populations. R2 = 0.25 for ages 0-17, R2 = 0.18 for ages 18-44, R2 = 0.16 for ages 45-64, and R2 = 0.034 for ages ≥ 65. CONCLUSION Operative facial trauma volumes peak in the summer and early fall and reach a winter nadir. This periodicity is statistically significant and accounts for 23% of overall trauma volume variability at our Level 1 trauma hospital. Younger patients drive the majority of this effect. Our findings have implications for operative block time and personnel allocation, in addition to expectation management over the course of the year.
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Affiliation(s)
- Rachel Skladman
- Post-Doctoral Research Fellow, Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University, St. Louis, MO
| | - Kashyap K Tadisina
- Fellow, Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University, St. Louis, MO
| | - John Chi
- Associate Professor, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Washington University, St. Louis, MO
| | - Dennis C Nguyen
- Assistant Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University, St. Louis, MO
| | - Kamlesh Patel
- Associate Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University, St. Louis, MO
| | - Mitchell A Pet
- Assistant Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University, St. Louis, MO.
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12
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Wells JM, Rodean J, Cook L, Sills MR, Neuman MI, Kornblith AE, Jain S, Hirsch AW, Goyal MK, Fleegler EW, DeLaroche AM, Aronson PL, Leonard JC. Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19. Pediatrics 2022; 150:188520. [PMID: 35836331 DOI: 10.1542/peds.2021-054545] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To describe the epidemiology of pediatric injury-related visits to children's hospital emergency departments (EDs) in the United States during early and later periods of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS We conducted a cross-sectional study using the Pediatric Health Information System, an administrative database to identify injury-related ED visits at 41 United States children's hospitals during the SARS-CoV-2 pandemic period (March 15, 2020 to March 14, 2021) and a 3 year comparator period (March 15-March 14, 2017-2020). For these 2 periods, we compared patient characteristics, injury type and severity, primary discharge diagnoses, and disposition, stratified by early (March 15, 2020 to June 30, 2020), middle (July 1, 2020 to October 31, 2020), and late (November 1, 2020 to March 14, 2021) pandemic periods. RESULTS Overall, ED injury-related visits decreased by 26.6% during the first year of the SARS-CoV-2 pandemic, with the largest decline observed in minor injuries. ED injury-related visits resulting in serious-critical injuries increased across the pandemic (15.9% early, 4.9% middle, 20.6% late). Injury patterns with the sharpest relative declines included superficial injuries (41.7% early) and sprains/strains (62.4% early). Mechanisms of injury with the greatest relative increases included (1) firearms (22.9% early; 42.8% middle; 37% late), (2) pedal cyclists (60.4%; 24.9%; 32.2%), (3) other transportation (20.8%; 25.3%; 17.9%), and (4) suffocation/asphyxiation (21.4%; 20.2%; 28.4%) and injuries because of suicide intent (-16.2%, 19.9%, 21.8%). CONCLUSIONS Pediatric injury-related ED visits declined in general. However, there was a relative increase in injuries with the highest severity, which warrants further investigation.
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Affiliation(s)
- Jordee M Wells
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Lawrence Cook
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Marion R Sills
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron E Kornblith
- Departments of Emergency Medicine and Pediatrics, University of California San Francisco, San Francisco, California
| | - Shobhit Jain
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Alexander W Hirsch
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Monika K Goyal
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, District of Columbia
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy M DeLaroche
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Paul L Aronson
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Julie C Leonard
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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13
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Antonini M, Hinwood M, Paolucci F, Balogh ZJ. The Epidemiology of Major Trauma During the First Wave of COVID-19 Movement Restriction Policies: A Systematic Review and Meta-analysis of Observational Studies. World J Surg 2022; 46:2045-2060. [PMID: 35723706 PMCID: PMC9208248 DOI: 10.1007/s00268-022-06625-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND The objective of this systematic review is to investigate changes in the epidemiology of major trauma presentations during the implementation of movement restriction measures to manage the first wave of the SARS-CoV-2 (COVID-19) pandemic. METHODS A systematic search in six databases, as well as a search of grey literature was performed from January 2020 to August 2021. Estimates were pooled using random-effects meta-analysis. The certainty of evidence was rated according to the GRADE approach. The review is reported using both PRISMA guideline and the MOOSE checklist. RESULTS In total, 35 studies involving 36,987 patients were included. The number of major trauma admissions overall decreased during social movement restrictions (-24%; p < 0.01; 95% CI [-0.31; -0.17]). A pooled analysis reported no evidence of a change in the severity of trauma admissions (OR:1.17; 95%CI [0.77, 1.79], I2 = 77%). There was no evidence for a change in mortality during the COVID-19 period (OR:0.94, 95%CI [0.80,1.11], I2 = 53%). There was a statistically significant reduction in motor vehicle trauma (OR:0.70; 95%CI [0.61, 0.81], I2 = 91%) and a statistically significant increase in admissions due to firearms and gunshot wounds (OR:1.34; 95%CI [1.11, 1.61], I2 = 73%) and suicide attempts and self-harm (OR:1.41; 95%CI [1.05, 1.89], I2 = 39%). CONCLUSIONS AND RELEVANCE Although evidence continues to emerge, this systematic review reports some decrease in absolute major trauma volume with unchanged severity and mortality during the first wave of COVID-19 movement restriction policies. Current evidence does not support the reallocation of highly specialised trauma professionals and trauma resources. Registration PROSPERO ID CRD42020224827.
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Affiliation(s)
- Marcello Antonini
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia
| | - Madeleine Hinwood
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia
- Medical Research Institute, Lookout Road, New Lambton Heights, NSW, 2305, Australia
| | - Francesco Paolucci
- Newcastle Business School, University of Newcastle, Hunter St &, Auckland St, Newcastle, NSW, 2300, Australia
- Department of Sociology and Business Law, University of Bologna, Strada Maggiore 45, 40126, Bologna, Italy
| | - Zsolt J Balogh
- School of Medicine and Public Health, University of Newcastle, University Dr, Callaghan, NSW, 2308, Australia.
- Division of Surgery, John Hunter Hospital, Locked Bag No. 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia.
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14
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Van Essen D, Vergouwen M, Sayre EC, White NJ. Orthopaedic trauma on the weekend: Longer surgical wait times, and increased after-hours surgery. Injury 2022; 53:1999-2004. [PMID: 35331476 DOI: 10.1016/j.injury.2022.03.010] [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: 02/03/2022] [Accepted: 03/06/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients. METHODS All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression. RESULTS Weekends were associated with increased surgical wait times (8.9%, p<0.001) despite decreased surgical trauma volumes (9.1%, p<0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p<0.001). Surgical wait times increased midweek and remained high until Saturday. CONCLUSION With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.
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Affiliation(s)
- Darren Van Essen
- Section of Orthopaedics, Cumming School of Medicine, University of Calgary, 2500 University Drive, NW T2N 1N4, Calgary, AB, Canada
| | - Martina Vergouwen
- Section of Orthopaedics, Cumming School of Medicine, University of Calgary, 2500 University Drive, NW T2N 1N4, Calgary, AB, Canada
| | - Eric C Sayre
- Arthritis Research Canada, 5591 Number 3 Rd, V6 × 2C7, Richmond, BC, Canada
| | - Neil J White
- Section of Orthopaedics, Cumming School of Medicine, University of Calgary, 2500 University Drive, NW T2N 1N4, Calgary, AB, Canada.
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15
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Stanisce L, Fisher AH, Choi BY, Newman A, Wang JL, Koshkareva Y. How Did the COVID-19 Pandemic Affect Trends in Facial Trauma? Craniomaxillofac Trauma Reconstr 2022; 15:132-138. [PMID: 35633770 PMCID: PMC8941287 DOI: 10.1177/19433875211022574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Study Design: Retrospective cohort analysis. Objective: To examine the impact the COVID-19 pandemic and its accompanying societal measures had on the incidence, characteristics, and management of maxillofacial traumatic injuries. Methods: This cohort analysis compared facial trauma injuries presenting to the highest-volume Level I Trauma Center in New Jersey, USA from January 1 to July 31 in 2020 and 2019. Differences in demographics, mechanisms, and interventions were compared between the pandemic period (March 16–July 31, 2020) and the equivalent pre-pandemic date period in 2019 using X2, Fishers Exact, and Mann–Whitney U testing. Results: In total, 616 subjects were included. The daily incidence of facial trauma consults during the 2020 pandemic (1.81 ± 1.1) decreased compared to 2019 (2.15 ± 1.3) (p = 0.042). During the outbreak, there was an increase in the proportion of subjects with positive urine drug screens (21.5% vs. 12.2%; p = 0.011) and injuries related to domestic violence (10.2% vs. 4.5%; p = 0.023). Patients were 30% less likely to be transferred from local hospitals (RR, 0.70 [0.53–0.93]; p = 0.014). Although subjects had a 25% increased risk of presenting with injuries deemed procedural (RR, 1.25 [95% CI, 1.05–1.56]; p = 0.048), a greater proportion were discharged with operative procedures scheduled as outpatients (16.0% vs. 4.9%; p = 0.005). Conclusions: The COVID-19 pandemic has impacted both the epidemiology and management of maxillofacial traumatic injuries, perhaps secondary to modifications in personal and community behaviors or the effects on healthcare systems in our region.
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Affiliation(s)
- Luke Stanisce
- Division of Otolaryngology—Head and Neck Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Alec H. Fisher
- Division of Plastic and Reconstructive Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Bo Young Choi
- Cooper Medical School at Rowan University, Camden, NJ, USA
| | - Andrew Newman
- Division of Plastic and Reconstructive Surgery, Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School at Rowan University, Camden, NJ, USA
| | - Ju Lin Wang
- Cooper Medical School at Rowan University, Camden, NJ, USA
- Division of Trauma Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Yekaterina Koshkareva
- Division of Otolaryngology—Head and Neck Surgery, Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School at Rowan University, Camden, NJ, USA
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16
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Velez D, Gerberding A, Ahmeti M. SUNBURN: a protocol for delivering bad news in trauma and acute care surgery. Trauma Surg Acute Care Open 2022; 7:e000851. [PMID: 35224205 PMCID: PMC8830305 DOI: 10.1136/tsaco-2021-000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/26/2022] [Indexed: 11/04/2022] Open
Abstract
IntroductionThe delivery of bad news can be one of the most challenging tasks in surgery. There are numerous barriers specific to trauma and acute care surgery (TRACS) that make these conversations more difficult. Prior protocols have all been designed for oncology and primary care with poorer application to TRACS. The lack of guidance for leading these conversations in TRACS led us to develop the SUNBURN protocol. It draws elements from prior protocols and discards the irrelevant aspects and pays particular attention to the TRACS-specific concerns.SUNBURN protocolStep 1: S–Set Up; Step 2: U–Understand Perceptions; Step 3: N–Notify (‘Warning Shot’); Step 4: B–Brief Narrative and Break Bad News; Step 5: U–Understand Emotions; Step 6: R–Respond; Step 7: N–Next Steps.ConclusionThis protocol can provide a framework to help guide and ease the delivery of bad news in TRACS.
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Affiliation(s)
- David Velez
- Department of Surgery, University of North Dakota, Grand Forks, North Dakota, USA
| | - Andrea Gerberding
- Department of Surgery, University of North Dakota, Grand Forks, North Dakota, USA
| | - Mentor Ahmeti
- Department of Surgery, University of North Dakota, Grand Forks, North Dakota, USA
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17
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Patel N, Harfouche M, Stonko DP, Elansary N, Scalea TM, Morrison JJ. Factors Associated With Increased Mortality in Severe Abdominopelvic Injury. Shock 2022; 57:175-180. [PMID: 34468423 DOI: 10.1097/shk.0000000000001851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Associated injuries are thought to increase mortality in patients with severe abdominopelvic trauma. This study aimed to identify clinical factors contributing to increased mortality in patients with severe abdominopelvic trauma, with the hypothesis that a greater number of concomitant injuries would result in increased mortality. METHODS This was a retrospective review of the Trauma Quality Improvement Program (TQIP) database of patients ≥ 18 years with severe abdominopelvic trauma defined as having an abdominal Abbreviated Injury Score (AIS) ≥ 3 with pelvic fractures and/or iliac vessel injury (2015-2017). Primary outcome was in-hospital mortality based on concomitant body region injuries. Secondary outcomes included mortality at 6 h, 6 to 24 h, and after 24 h based on concomitant injuries, procedures performed, and transfusion requirements. RESULTS A total of 185,257 patients were included in this study. Survivors had more severely injured body regions than non-survivors (4 vs. 3, P < 0.001). Among those who died within 6 h, 28.5% of patients required a thoracic procedure and 43% required laparotomy compared to 6.3% and 22.1% among those who died after 24 h (P < 0.001). Head AIS ≥ 3 was the only body region that significantly contributed to overall mortality (OR 1.26, P < 0.001) along with laparotomy (OR 3.02, P < 0.001), neurosurgical procedures (2.82, P < 0.001) and thoracic procedures (2.28, P < 0.001). Non-survivors who died in < 6 h and 6-24 h had greater pRBC requirements than those who died after 24 h (15.5 and 19.5 vs. 8 units, P < 0.001). CONCLUSION Increased number of body regions injured does not contribute to greater mortality. Uncontrolled noncompressible torso hemorrhage rather than the burden of concomitant injuries is the major contributor to the high mortality associated with severe abdominopelvic injury.
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Affiliation(s)
- Neerav Patel
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Melike Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - David P Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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18
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Zarkowsky DS, Stonko DP. Artificial intelligence's role in vascular surgery decision-making. Semin Vasc Surg 2021; 34:260-267. [PMID: 34911632 DOI: 10.1053/j.semvascsurg.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/28/2022]
Abstract
Artificial intelligence (AI) is the next great advance informing medical science. Several disciplines, including vascular surgery, use AI-based decision-making tools to improve clinical performance. Although applied widely, AI functions best when confronted with voluminous, accurate data. Consistent, predictable analytic technique selection also challenges researchers. This article contextualizes AI analyses within evidence-based medicine, focusing on "big data" and health services research, as well as discussing opportunities to improve data collection and realize AI's promise.
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Affiliation(s)
- Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado School of Medicine, 12615 E 17(th) Place, AO1, Aurora, CO, 80045.
| | - David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
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19
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Mazzolini K, Dzubnar J, Kwak H, Banks K, Mooney C, Tang A, Cohan C, Browder T. An Epidemic Within the Pandemic: The Rising Tide of Trauma DuringCOVID-19. J Surg Res 2021; 272:139-145. [PMID: 34971837 PMCID: PMC8654586 DOI: 10.1016/j.jss.2021.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 10/14/2021] [Accepted: 11/25/2021] [Indexed: 11/16/2022]
Abstract
Background In the age of COVID-19 and enforced social distancing, changes in patterns of trauma were observed but poorly understood. Our aim was to characterize traumatic injury mechanisms and acuities in 2020 and compare them with previous years at our level I trauma center. Material and methods Patients with trauma triaged in 2016 through 2020 from January to May were reviewed. Patient demographics, level of activation (1 versus 2), injury severity score, and mechanism of injury were collected. Data from 2016 through 2019 were combined, averaged by month, and compared with data from 2020 using chi-squared analysis. Results During the months of interest, 992 patients with trauma were triaged in 2020 and 4311 in 2016-2019. The numbers of penetrating and level I trauma activations in January-March of 2020 were similar to average numbers for the same months during 2016 through 2019. In April 2020, there was a significant increase in the incidence of penetrating trauma compared with the prior 4-year average (27% versus 16%, P < 0.002). Level I trauma activations in April 2020 also increased, rising from 17% in 2016 through 2019 to 32% in 2020 (P < 0.003). These findings persisted through May 2020 with similarly significant increases in penetrating and high-level trauma. Conclusions In the months after the initial spread of COVID-19, there was a perceptible shift in patterns of trauma. The significant increase in penetrating and high-acuity trauma may implicate a change in population dynamics, demanding a need for thoughtful resource allocation at trauma centers nationwide in the context of a global pandemic.
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Affiliation(s)
- Kirea Mazzolini
- Department of Surgery, University of California San Francisco, San Francisco, California.
| | - Jessica Dzubnar
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Hyunjee Kwak
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Kian Banks
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Colin Mooney
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Annie Tang
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Caitlin Cohan
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Timothy Browder
- Department of Surgery, University of California San Francisco, San Francisco, California
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20
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Stonko DP, Etchill EW, Giuliano KA, DiBrito SR, Eisenson D, Heinrichs T, Morrison JJ, Haut ER, Kent AJ. Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly Trauma Patients. Am Surg 2021; 87:1760-1765. [PMID: 34727744 DOI: 10.1177/00031348211054072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity. METHODS The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS 614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality (P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality (P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4). CONCLUSIONS Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.
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Affiliation(s)
- David P Stonko
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Department of Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Eric W Etchill
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Department of Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Katherine A Giuliano
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Department of Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Sandra R DiBrito
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Department of Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Daniel Eisenson
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Department of Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | | | | | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Armstrong Institute for Patient Safety and Quality, 1501Johns Hopkins Medicine, Baltimore, MD, USA.,Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alistair J Kent
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Department of Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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21
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Cameron A, Javidan AP, Nathens AB, Cleghorn G. How prepared are Canadian trauma centres for mass casualty incidents? Injury 2021; 52:2625-2629. [PMID: 34246480 DOI: 10.1016/j.injury.2021.06.017] [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: 01/03/2021] [Revised: 06/07/2021] [Accepted: 06/22/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Mass Casualty Incidents (MCIs) are rare but devastating events that require extensive planning in order to minimize morbidity and mortality. There are two broad categories limiting a hospital's response: physical assets (e.g., critical care beds, operating rooms, food, communication devices) as well as operating procedures (e.g., MCI committees, regional coordination, provider training). The purpose of this study is to provide an examination of MCI preparedness according to these categories in Level 1 Trauma Centre across Canada. METHODS This study surveyed all Level 1 Trauma Centres across Canada in order to assess the physical assets and operating procedures they had in place in the event of a hypothetical MCI on one of the busiest days of the year for trauma care. RESULTS Of the 28 Trauma Centres contacted, 13 completed surveys (46%). Most hospitals had sufficient food (9/13) water (9/13), fuel (7/13), and communication assets (8/13) for a hypothetical MCI. A median of 38 mechanical ventilators could be mobilized. No hospitals mandated physician training for MCIs, and 6/13 centres were certain that they had a Strategic Emergency Management Plan (SEMP). Only 6/13 hospitals had dedicated MCI committees, Overall, 4/13 hospitals had explicit plans developed with community hospitals. CONCLUSION This study demonstrated that physical assets are generally less limiting than operating procedures. Four key areas of potential improvement have been identified: 1) provider training (especially physicians), 2) coordination with small hospitals, 3) mechanical ventilator availability, and 4) MCI committees with explicit Strategic Emergency Management Plans.
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Affiliation(s)
- Andrew Cameron
- University of Toronto Emergency Medicine Residency Training Program, Toronto, ON, Canada.
| | - Arshia P Javidan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Avery B Nathens
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Tory Regional Trauma Program and the Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Graham Cleghorn
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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22
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Using Weather, Lunar Cycles, and Time of Year to Predict Trauma Incidents in an Urban, Level I Pediatric Trauma Center. J Trauma Nurs 2021; 28:84-89. [PMID: 33667202 DOI: 10.1097/jtn.0000000000000565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma patterns in adults are influenced by weather conditions, lunar phases, and time of year. The extent to which these factors contribute to pediatric trauma is unclear. OBJECTIVE The present study aimed to review patients from a single Level I pediatric trauma center to determine the influence of weather, the lunar cycle, and time of year on trauma activity. METHODS A retrospective review of trauma activations (n = 1,932) was conducted from 2015 to 2017. Injury type and general demographics were collected. Weather data and lunar cycles were derived from historical databases. RESULTS Days with no precipitation increased the total number of injuries of all types compared with those with precipitation (p < .001). Blunt and penetrating injuries were more likely to occur during full moons, whereas burn injuries were significantly higher during new moons (p < .001). Blunt trauma was significantly higher in September than all other months, F(11, 1,921) = 4.25, p < .001, whereas January had a significantly higher number of burns than all other months (p < .001). CONCLUSIONS Pediatric trauma trends associated with external factors such as weather, lunar cycles, and time of year can inform hospital staffing decisions in anticipation of likely injuries and help direct injury prevention efforts.
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23
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Maleitzke T, Pumberger M, Gerlach UA, Herrmann C, Slagman A, Henriksen LS, von Mauchenheim F, Hüttermann N, Santos AN, Fleckenstein FN, Rauch G, Märdian S, Perka C, Stöckle U, Möckel M, Lindner T, Winkler T. Impact of the COVID-19 shutdown on orthopedic trauma numbers and patterns in an academic Level I Trauma Center in Berlin, Germany. PLoS One 2021; 16:e0246956. [PMID: 33592046 PMCID: PMC7886210 DOI: 10.1371/journal.pone.0246956] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/28/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic led to the implementation of drastic shutdown measures worldwide. While quarantine, self-isolation and shutdown laws helped to effectively contain and control the spread of SARS-CoV-2, the impact of COVID-19 shutdowns on trauma care in emergency departments (EDs) remains elusive. METHODS All ED patient records from the 35-day COVID-19 shutdown (SHUTDOWN) period were retrospectively compared to a calendar-matched control period in 2019 (CTRL) as well as to a pre (PRE)- and post (POST)-shutdown period in an academic Level I Trauma Center in Berlin, Germany. Total patient and orthopedic trauma cases and contacts as well as trauma causes and injury patterns were evaluated during respective periods regarding absolute numbers, incidence rate ratios (IRRs) and risk ratios (RRs). FINDINGS Daily total patient cases (SHUTDOWN vs. CTRL, 106.94 vs. 167.54) and orthopedic trauma cases (SHUTDOWN vs. CTRL, 30.91 vs. 52.06) decreased during the SHUTDOWN compared to the CTRL period with IRRs of 0.64 and 0.59. While absolute numbers decreased for most trauma causes during the SHUTDOWN period, we observed increased incidence proportions of household injuries and bicycle accidents with RRs of 1.31 and 1.68 respectively. An RR of 2.41 was observed for injuries due to domestic violence. We further recorded increased incidence proportions of acute and regular substance abuse during the SHUTDOWN period with RRs of 1.63 and 3.22, respectively. CONCLUSIONS While we observed a relevant decrease in total patient cases, relative proportions of specific trauma causes and injury patterns increased during the COVID-19 shutdown in Berlin, Germany. As government programs offered prompt financial aid during the pandemic to individuals and businesses, additional social support may be considered for vulnerable domestic environments.
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Affiliation(s)
- Tazio Maleitzke
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Julius Wolff Institute, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Undine A. Gerlach
- Division of Emergency and Acute Medicine, Campus Charité Mitte and Virchow-Klinikum, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Carolin Herrmann
- Institute of Biometry and Clinical Epidemiology, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Slagman
- Division of Emergency and Acute Medicine, Campus Charité Mitte and Virchow-Klinikum, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Louise S. Henriksen
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Nils Hüttermann
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Anabel N. Santos
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Florian N. Fleckenstein
- Berlin Institute of Health (BIH), Berlin, Germany
- Department of Diagnostic and Interventional Radiology, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Sven Märdian
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich Stöckle
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Möckel
- Division of Emergency and Acute Medicine, Campus Charité Mitte and Virchow-Klinikum, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Lindner
- Division of Emergency and Acute Medicine, Campus Charité Mitte and Virchow-Klinikum, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Winkler
- Center for Musculoskeletal Surgery, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Julius Wolff Institute, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Charité –Universitätsmedizin Berlin, Berlin, Germany
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24
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Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury. Can J Neurol Sci 2021; 48:817-825. [PMID: 33431101 DOI: 10.1017/cjn.2021.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes. METHODS Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer. RESULTS Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition. CONCLUSIONS No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.
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Skinner M, Baker J, Heh V, Goodman M, Pritts T, Janowak C. Rib Season: Temporal Variation in Chest Wall Injuries. J Surg Res 2020; 260:129-133. [PMID: 33338889 DOI: 10.1016/j.jss.2020.11.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Trauma to the chest wall is one of the most common injuries suffered. Knowing whether there are regular and reproducible changes in frequency or severity of certain injury types may help resource allocation and improve prevention efforts or outcomes; however, no prior studies have evaluated seasonal variation in chest wall injuries (CWIs). We aimed to determine if CWIs vary annually in a consistent distinct temporal variation. METHODS Using an established traumatic blunt CWI database at a single urban level 1 trauma center, patients with a moderate-to-severe (chest wall Abbreviated Injury Score (AIS) ≥2) CWI were reviewed. A subpopulation of predominant chest wall injury (pCWI) was defined as those with a chest wall AIS ≥3 and no other anatomic region having a higher AIS. Demographics, injury patterns, mechanisms of injury, and AIS were collected in addition to date of injury over a 4-y period. Data were analyzed using descriptive statistics as well as Poisson time-series regression for periodicity. Seasonal comparison of populations was performed using Student's t-tests and Analysis of Variance (ANOVA) with significance assessed at a level of P < 0.05. RESULTS Over a 4-y period nearly 16,000 patients presented with injury, of which 3042 patients were found to have a blunt CWI. Total CWI patients per year from 2014 to 2017 ranged from 571 to 947. Over this period, August had the highest incidence for patients with any CWI, moderate-to-severe injuries, and pCWI. February had the lowest overall injury incidence as well as lowest moderate-to-severe injury incidence. January had the lowest pCWI incidence. Yearly changes followed a quadratic sinusoid model that predicted a peak between incidence, between June and October, and the low season. A low season was found to be December-April. Comparing low to high seasons of injured patient monthly means revealed significant differences: total injuries (69.94 versus 85.56, P = 0.04), moderate to severe (62.25 versus 78.19, P = 0.06), and pCWI (25.25 versus 34.44, P = 0.01). Analysis of injuries by mechanism revealed a concomitant increase in motorcycle collisions during this period. CONCLUSIONS There appears to be a significant seasonal variation in the overall incidence of CWI as well as severe pCWI, with a high-volume injury season in summer months (June-October) and low-volume season in winter (December-April). Motorcycle accidents were the major blunt injury mechanism that changed with this seasonality. These findings may help guide resource utilization and injury prevention.
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Affiliation(s)
- Mitchell Skinner
- Division of Trauma, Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer Baker
- Division of Trauma, Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Victor Heh
- Division of Trauma, Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Michael Goodman
- Division of Trauma, Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Timothy Pritts
- Division of Trauma, Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Christopher Janowak
- Division of Trauma, Department of Surgery, Section of General Surgery, University of Cincinnati, Cincinnati, Ohio.
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Ludwig DC, Nelson JL, Burke AB, Lang MS, Dillon JK. What Is the Effect of COVID-19-Related Social Distancing on Oral and Maxillofacial Trauma? J Oral Maxillofac Surg 2020; 79:1091-1097. [PMID: 33421417 PMCID: PMC7735032 DOI: 10.1016/j.joms.2020.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022]
Abstract
Purpose The purpose of this study was to understand the impact of social distancing policies enacted during the COVID-19 pandemic on the epidemiology of oral and maxillofacial fractures at an urban, Level I trauma center in the United States. Materials and Methods The investigators designed a retrospective cohort study and enrolled a sample of 883 subjects who presented for evaluation of oral and maxillofacial fractures (OMF) between March 1 and June 30 in the years 2018 through 2020. The primary predictor variable was the evaluation of OMF during a period with social distancing policies (2020 – experimental group) or without social distancing policies in place (2018 or 2019 – control group). The primary outcome variables were the facial fracture diagnosis, the abbreviated injury scale (AIS), injury severity score (ISS), and the mechanism of injury. Appropriate univariate and bivariate statistics were computed, and the level of significance was set at P < .05 for all tests. Results The number of subjects presenting with OMF was lower during the period of social distancing (n = 235 in 2020) than during the periods without (2018: n = 330; 2019: n = 318). During the period of social distancing, there were more individuals who presented secondary to assault, whereas fewer individuals presented secondary to falls (P = .05). On average, those who presented in 2020 had more severe oral and maxillofacial injuries (mean AIS = 3.2 ± 1.2 in 2020 vs 3.0 ± 1.1 in 2019 and 3.0 ± 1.1 in 2018. P = .03) and more overall injuries (mean ISS = 20.7 ± 13.1 in 2020 vs 19.2 ± 12.5 in 2019; 17.8 ± 12.8 in 2018. P = .03). Conclusions The investigators found that during the period of social distancing through the COVID-19 pandemic, the number of OMF cases decreased but that the severity of oral and maxillofacial and overall injuries was higher.
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Affiliation(s)
- David C Ludwig
- Resident, Department of Oral and Maxillofacial Surgery, University of Washington, Seattle, WA
| | - J Luke Nelson
- Dental Student, School of Dentistry, University of Washington, Seattle, WA
| | - Andrea B Burke
- Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Melanie S Lang
- Clinical Associate Professor, Department of Oral and Maxillofacial Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Jasjit K Dillon
- Clinical Associate Professor, Program Director, Chief of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, University of Washington, Harborview Medical Center, Seattle, WA.
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Beyer CA, Hopper LD, French CE, Galante JM, Callcut RA. The Effect of California's Stay-at-Home Order on Trauma Patient Volume During the Coronavirus Disease 2019 Pandemic. ANNALS OF SURGERY OPEN 2020; 1:e005. [PMID: 37637445 PMCID: PMC10455284 DOI: 10.1097/as9.0000000000000005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Carl A. Beyer
- From the Department of Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Leslie D. Hopper
- From the Department of Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Casey E. French
- From the Department of Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Joseph M. Galante
- From the Department of Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Rachel A. Callcut
- From the Department of Surgery, University of California Davis Medical Center, Sacramento, CA
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28
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Agorastos A, Olff M. Traumatic stress and the circadian system: neurobiology, timing and treatment of posttraumatic chronodisruption. Eur J Psychotraumatol 2020; 11:1833644. [PMID: 33408808 PMCID: PMC7747941 DOI: 10.1080/20008198.2020.1833644] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Humans have an evolutionary need for a well-preserved internal 'clock', adjusted to the 24-hour rotation period of our planet. This intrinsic circadian timing system enables the temporal organization of numerous physiologic processes, from gene expression to behaviour. The human circadian system is tightly and bidirectionally interconnected to the human stress system, as both systems regulate each other's activity along the anticipated diurnal challenges. The understanding of the temporal relationship between stressors and stress responses is critical in the molecular pathophysiology of stress-and trauma-related diseases, such as posttraumatic stress disorder (PTSD). Objectives/Methods: In this narrative review, we present the functional components of the stress and circadian system and their multilevel interactions and discuss how traumatic stress can affect the harmonious interplay between the two systems. Results: Circadian dysregulation after trauma exposure (posttraumatic chronodisruption) may represent a core feature of trauma-related disorders mediating enduring neurobiological correlates of traumatic stress through a loss of the temporal order at different organizational levels. Posttraumatic chronodisruption may, thus, affect fundamental properties of neuroendocrine, immune and autonomic systems, leading to a breakdown of biobehavioral adaptive mechanisms with increased stress sensitivity and vulnerability. Given that many traumatic events occur in the late evening or night hours, we also describe how the time of day of trauma exposure can differentially affect the stress system and, finally, discuss potential chronotherapeutic interventions. Conclusion: Understanding the stress-related mechanisms susceptible to chronodisruption and their role in PTSD could deliver new insights into stress pathophysiology, provide better psychochronobiological treatment alternatives and enhance preventive strategies in stress-exposed populations.
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Affiliation(s)
- Agorastos Agorastos
- II. Department of Psychiatry, Division of Neurosciences, School of Medicine, Faculty of Medical Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.,VA Center of Excellence for Stress and Mental Health (CESAMH), VA San Diego Healthcare System, San Diego, CA, USA
| | - Miranda Olff
- Department of Psychiatry, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands.,ARQ Psychotrauma Expert Group, Diemen, The Netherlands
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Abdallah HO, Zhao C, Kaufman E, Hatchimonji J, Swendiman RA, Kaplan LJ, Seamon M, Schwab CW, Pascual JL. Increased Firearm Injury During the COVID-19 Pandemic: A Hidden Urban Burden. J Am Coll Surg 2020; 232:159-168.e3. [PMID: 33166665 PMCID: PMC7645281 DOI: 10.1016/j.jamcollsurg.2020.09.028] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/19/2020] [Accepted: 09/24/2020] [Indexed: 01/28/2023]
Abstract
Background Public health measures were instituted to reduce COVID-19 spread. A decrease in total emergency department volume followed, but the impact on injury is unknown. With lockdown and social distancing potentially increasing domicile discord, we hypothesized that intentional injury increased during COVID-19, driven primarily by an increase in penetrating trauma. Study Design A retrospective review of acute adult patient care in an urban Level I trauma center assessed injury patterns. Presenting patient characteristics and diagnoses from 6 weeks pre to 10 weeks post statewide stay-at-home orders (March 16, 2020) were compared, as well as with 2015-2019. Subsets were defined by intentionality (intentional vs nonintentional) and mechanism of injury (blunt vs penetrating). Fisher exact and Wilcoxon tests were used to compare proportions and means. Results There were 357 trauma patients that presented pre stay-at-home order and 480 that presented post stay-at-home order. Pre and post groups demonstrated differences in sex (35.6% vs 27.9% female; p = 0.02), age (47.4 ± 22.1 years vs 42 ± 20.3 years; p = 0.009), and race (1.4% vs 2.3% Asian; 63.3% vs 68.3% Black; 30.5% vs 22.3% White; and 4.8% vs 7.1% other; p = 0.03). Post stay-at-home order mechanism of injury revealed more intentional injury (p = 0.0008). Decreases in nonintentional trauma after adoption of social isolation paralleled declines in daily emergency department visits. Compared with earlier years, 2020 demonstrated a significantly greater proportion of intentional violent injury during the peripandemic months, especially from firearms. Conclusions Unprecedented social isolation policies to address COVID-19 were associated with increased intentional injury, especially gun violence. Meanwhile, emergency department and nonintentional trauma visits decreased. Pandemic-related public health measures should embrace intentional injury prevention and management strategies.
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Affiliation(s)
- Hatem O Abdallah
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cindy Zhao
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elinore Kaufman
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justin Hatchimonji
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert A Swendiman
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
| | - C William Schwab
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Jose L Pascual
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA.
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30
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Dvorak JE, Lester ELW, Maluso PJ, Tatebe LC, Bokhari F. There Is No Weekend Effect in the Trauma Patient. J Surg Res 2020; 258:195-199. [PMID: 33011451 DOI: 10.1016/j.jss.2020.08.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The presence of a "weekend effect", that is, increased morbidity/mortality for patients admitted to the hospital on a weekend, has been reported in numerous studies across many specialties. Postulated causes include reduced weekend staffing, increased time between admission and undergoing procedures/surgery, and decreased subspecialty availability. The aim of this study is to evaluate if a "weekend effect" exists in trauma care in the United States. METHODS Using the 2012-2015 National In-patient Sample database from the Healthcare Cost and Utilization Project, adults with trauma diagnoses who were admitted nonelectively were analyzed. Using logistic and negative binomial regression adjusted for survey-related discharge weights and statistically significant covariables, mortality and length of stay (LOS) were assessed, respectively. Subgroup analysis was conducted using rural, urban teaching, and urban nonteaching hospital-type subgroups. Additional subgroup analysis of patients who required surgery during admission was also performed. RESULTS A total of 22,451 patients were identified, with 3.94% admitted to rural and 81.42% to urban hospitals. Weekend admission did not have a statistically significant difference in adjusted-mortality (OR 0.928; 95% CI 0.858-1.003; P = 0.059) or LOS (IRR 0.978; 95% CI 0.945-1.011; P = 0.199). There was also no statistically significant increase in mortality or LOS for weekend admits in any of the hospital subgroups. CONCLUSIONS There does not appear to be a weekend effect for trauma admission. This may be explained by the nature of trauma care in the United States, in which there is often 24-h in-house coverage regardless of day of the week. Replicating a trauma service coverage schedule may help other services decrease the presence of the weekend effect.
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Affiliation(s)
- Justin E Dvorak
- Department of Trauma and Burns, John H. Stroger, Jr. Hospital of Cook County. Chicago, Illinois.
| | - Erica L W Lester
- Department of Trauma and Burns, John H. Stroger, Jr. Hospital of Cook County. Chicago, Illinois
| | - Patrick J Maluso
- Department of Trauma and Burns, John H. Stroger, Jr. Hospital of Cook County. Chicago, Illinois
| | - Leah C Tatebe
- Department of Trauma and Burns, John H. Stroger, Jr. Hospital of Cook County. Chicago, Illinois
| | - Faran Bokhari
- Department of Trauma and Burns, John H. Stroger, Jr. Hospital of Cook County. Chicago, Illinois
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31
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Hind J, Lahart IM, Jayakumar N, Athar S, Fazal MA, Ashwood N. Seasonal variation in trauma admissions to a level III trauma unit over 10 years. Injury 2020; 51:2209-2218. [PMID: 32703642 DOI: 10.1016/j.injury.2020.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Major trauma centres have improved morbidity and mortality for moderate and severely injured patients. Less injured patients may be treated in facilities less resourced for trauma care. In these units, understanding the variations in injury presentation and treatment over time allows service delivery to be tailored to demand. This study set out to describe seasonal variations in trauma over a 10-year period at a level III trauma unit. MATERIALS AND METHODS Patient demographics, admission frequency, site of injury, season of admission, management, complications, onward transfers, and length of stay were extracted on consecutive patients admitted with traumatic injuries between January 2009 and December 2018 and recorded on a prospectively maintained database. Analysis was undertaken to determine if there were reproducible patterns in trauma presentation across seasons, based on the patient's age and gender, type of injury, management and length of stay. RESULTS There were 13,007 'first admissions' over 10 years, with a mean (SD) age of 55.6 (27.7) years. Admissions were higher in summer (27%) and lower in winter (23.6%) and patients were on average younger in the summer (52.8 years) and older in winter (59.2 years). The proportion of female and male patients remained relatively constant across seasons (CV=6% and 8%, respectively). There was seasonal variation in the incidence of forearm (36%) elbow (19%), and multi-sites injuries (17%) compared with hip and wrist injuries (CV=5% for both). A lower proportion of patients underwent operations in summer (72%) compared with other seasons with winter having the highest at 77%. More patients aged less than 60 years stayed in hospital during winter than summer (13.2% vs. 11.6-12.4%) although often for a day. Patients aged 60 years stayed longer in spring and winter. CONCLUSION The results of this study demonstrate trends in the admission and management of trauma patients to a level III trauma unit. Some of the patterns in admission, treatment and length of stay had not been identified previously. The results can be used to enhance patient care and minimise health care costs by reducing unwarranted variations and enabling service delivery to match the demand in all trauma units.
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Affiliation(s)
- Jamie Hind
- University Hospital of Derby and Burton (Queens Hospital), Belvedere Road, Burton on Trent, DE13 0RB, United Kingdom.
| | - Ian M Lahart
- Faculty of Education, Health, and Wellbeing, University of Wolverhampton, Gorway Road, Walsall, WS1 3BD, United Kingdom
| | - Nithish Jayakumar
- Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, United Kingdom
| | - Sajjad Athar
- University Hospital of Derby and Burton (Queens Hospital), Belvedere Road, Burton on Trent, DE13 0RB, United Kingdom
| | | | - Neil Ashwood
- University Hospital of Derby and Burton (Queens Hospital), Belvedere Road, Burton on Trent, DE13 0RB, United Kingdom
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Seasonal Variation in the Volume of Posterior Spinal Arthrodesis Procedures for Pediatric Scoliosis. Spine (Phila Pa 1976) 2020; 45:1293-1298. [PMID: 32341304 DOI: 10.1097/brs.0000000000003517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of the Healthcare Cost and Utilization Project's Kids' Inpatient Database. OBJECTIVE The aim of this study was to investigate variations in surgical case volume in the US for spinal arthrodesis for pediatric patients with scoliosis. SUMMARY OF BACKGROUND DATA Approximately 38,000 spinal arthrodesis procedures are performed each year in the United States for pediatric patients with scoliosis. Anecdotally, pediatric spine surgeons report performing more scoliosis procedures during summer months and before national holidays than during other periods, but this has not been reported in the literature. A thorough understanding of seasonal variations in surgical volume may guide the allocation of health care resources. METHODS Using the Healthcare Cost and Utilization Project's Kids' Inpatient Database, we identified 32,563 patients aged <21 years with adolescent idiopathic scoliosis (54%), neuromuscular scoliosis (19%), congenital scoliosis (12%), early-onset scoliosis (12%), or scoliosis from other causes (5%) who underwent primary spinal arthrodesis from 2000 through 2016. χ goodness-of-fit tests were used to evaluate seasonal differences in the number of spinal arthrodesis procedures performed. A negative binomial distribution model was used to compare surgical volume by month. Alpha = 0.05. RESULTS We found significant seasonal variation in the volume of spinal arthrodesis procedures performed, which persisted after stratifying by type of scoliosis (all, P < 0.001). For all types of scoliosis, surgical volume was highest during the summer. The 3 months with the highest surgical volumes were June, July, and December. CONCLUSION The number of spinal arthrodesis procedures performed in the United States for pediatric scoliosis peaked significantly during the summer, with the highest volume of surgeries performed during June, July, and December. An understanding of these variations can help hospitals and providers allocate resources appropriately throughout the year according to predictable changes in surgical volume. LEVEL OF EVIDENCE 4.
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Stonko DP, Guillamondegui OD, Fischer PE, Dennis BM. Artificial intelligence in trauma systems. Surgery 2020; 169:1295-1299. [PMID: 32921479 DOI: 10.1016/j.surg.2020.07.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
Local trauma care and regional trauma systems are data-rich environments that are amenable to machine learning, artificial intelligence, and big-data analysis mechanisms to improve timely access to care, to measure outcomes, and to improve quality of care. Pilot work has been done to demonstrate that these methods are useful to predict patient flow at individual centers, so that staffing models can be adapted to match workflow. Artificial intelligence has also been proven useful in the development of regional trauma systems as a tool to determine the optimal location of a new trauma center based on trauma-patient geospatial injury data and to minimize response times across the trauma network. Although the utility of artificial intelligence is apparent and proven in small pilot studies, its operationalization across the broader trauma system and trauma surgery space has been slow because of cost, stakeholder buy-in, and lack of expertise or knowledge of its utility. Nevertheless, as new trauma centers or systems are developed, or existing centers are retooled, machine learning and sophisticated analytics are likely to be important components to help facilitate decision-making in a wide range of areas, from determining bedside nursing and provider ratios to determining where to locate new trauma centers or emergency medical services teams.
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Affiliation(s)
- David P Stonko
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, TN.
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Tverdal C, Aarhus M, Andelic N, Skaansar O, Skogen K, Helseth E. Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway. Inj Epidemiol 2020; 7:45. [PMID: 32867838 PMCID: PMC7461333 DOI: 10.1186/s40621-020-00269-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022] Open
Abstract
Background The vast majority of hospital admitted patients with traumatic brain injury (TBI) will have intracranial injury identified by neuroimaging, requiring qualified staff and hospital beds. Moreover, increased pressure in health care services is expected because of an aging population. Thus, a regular evaluation of characteristics of hospital admitted patients with TBI is needed. Oslo TBI Registry – Neurosurgery prospectively register all patients with TBI identified by neuroimaging admitted to a trauma center for southeast part of Norway. The purpose of this study is to describe this patient population with respect to case load, time of admission, age, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival. Methods Data for 5 years was extracted from Oslo TBI Registry – Neurosurgery. Case load, time of admission, age, sex, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival was compiled and compared. Results From January 1st, 2015 to December 31st, 2019, 2153 consecutive patients with TBI identified by neuroimaging were registered. The admission rate of TBI of all severities has been stable year-round since 2015. Mean age was 52 years (standard deviation 25, range 0–99), and 68% were males. Comorbidities were common; 28% with pre-injury ASA score of ≥3 and 25% used antithrombotic medication. The dominating cause of injury in all ages was falls (55%) but increased with age. Upon admission, the head injury was classified as mild TBI in 46%, moderate in 28%, and severe (Glasgow coma score ≤ 8) in 26%. Case load was stable without seasonal variation. Majority of patients (68%) were admitted during evening, night or weekend. 68% was admitted to intensive care unit. Length of hospital stay was 4 days (median, interquartile range 3–9). 30-day survival for mild, moderate and severe TBI was 98, 94 and 69%, respectively. Conclusions The typical TBI patients admitted to hospital with abnormal neuroimaging were aged 50–79 years, often with significant comorbidity, and admitted outside ordinary working hours. This suggests the necessity for all-hour presence of competent health care professionals.
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Affiliation(s)
- Cathrine Tverdal
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway. .,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Mads Aarhus
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ola Skaansar
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Karoline Skogen
- Department of Neuroradiology, Oslo University Hospital, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Lenart EK, Lewis RH, Sharpe JP, Fischer PE, Croce MA, Magnotti LJ. They only come out at night: Impact of time of day on outcomes after penetrating abdominal trauma. Surg Open Sci 2020; 2:1-4. [PMID: 32803149 PMCID: PMC7419659 DOI: 10.1016/j.sopen.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 10/26/2022] Open
Abstract
Background Patients who present at night following penetrating abdominal trauma are thought to have more severe injuries and increased risk for morbidity and mortality. The current literature is at odds regarding this belief. The purpose of this study was to evaluate time of day on outcomes following laparotomy for penetrating abdominal trauma. Methods Patients undergoing laparotomy following penetrating abdominal trauma over a 12-month period at a level I trauma center were stratified by age, sex, severity of shock, injury, operative complexity, and time of day (DAY = 0700-1900, NIGHT = 1901-0659). Outcomes of damage control laparotomy, ventilator days, intensive care unit length of stay, hospital length of stay, morbidity, and mortality were compared between DAY and NIGHT. Results A total of 210 patients were identified: 145 (69%) comprised NIGHT, and 65 (31%) comprised DAY. Overall mortality was 2.9%. Both injury severity and intraoperative transfusions were increased with NIGHT with no difference in morbidity (37% vs 40%, P = 0.63) or mortality (2.1% vs 4.6%, P = 0.31). Adjusting for sex, time of day, injury severity, and operative complexity, only abdominal abbreviated injury severity (odds ratio 1.46; 95% confidence interval 1.07-1.99, P = .019) and operative transfusions (odds ratio 1.18; 95% confidence interval 1.09-1.28, P < .0001) were identified as independent predictors of damage control laparotomy using multivariable logistic regression (area under the curve 0.96). Conclusion The majority of operative penetrating abdominal trauma occurs at night with increased injury burden, more operative transfusions, and increased use of damage control laparotomy with no difference in morbidity and mortality. Outcomes at a fully staffed and operational trauma center should not be impacted by time of day.
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Affiliation(s)
- Emily K Lenart
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Richard H Lewis
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - John P Sharpe
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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A Call to Arms: Emergency Hand and Upper-Extremity Operations During the COVID-19 Pandemic. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:175-181. [PMID: 32835183 PMCID: PMC7256509 DOI: 10.1016/j.jhsg.2020.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/18/2020] [Indexed: 01/07/2023] Open
Abstract
Purpose Limited data exist regarding volumetric trends and management of upper-extremity emergencies during periods of social restriction and duress, such as the coronavirus disease 2019 pandemic. We sought to study the effect of shelter-in-place orders on emergent operative upper-extremity surgery. Methods All patients undergoing emergent and time-sensitive operations to the finger(s), hand, wrist, and forearm were tracked over an equal number of days before and after shelter-in-place orders at 2 geographically distinct Level I trauma centers. Surgical volume and resources, patient demographics, and injury patterns were compared before and after official shelter-in-place orders. Results A total of 58 patients underwent time-sensitive or emergent operations. Mean patient age was 42 years; mean injury severity score was 9 and median American Society of Anesthesiologist score was 2. There was a 40% increase in volume after shelter-in-place orders, averaging 1.4 cases/d. Indications for surgery included high-energy closed fracture (60%), traumatic nerve injury (19%), severe soft tissue infection (15%), and revascularization of the arm, hand, or digit(s) (15%). High-risk behavior, defined as lawlessness, assault, and high-speed auto accidents, was associated with a significantly greater proportion of operations after shelter-in-place orders (40% vs 12.5%; P < .05). Each institution dedicated an average of 3 inpatient beds and one intensive care unit-capable bed to upper-extremity care daily. Resources used included an average of 115 minutes of daily operating room time and 8 operating room staff or personnel per case. Conclusions Hand and upper-extremity operative volume increased after shelter-in-place orders at 2 major Level I trauma centers across the country, demanding considerable hospital resources. The rise in volume was associated with an increase in high-risk behavior. Type of study/level of evidence Therapeutic IV.
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Dennis BM, Stonko DP, Callcut RA, Sidwell RA, Stassen NA, Cohen MJ, Cotton BA, Guillamondegui OD. Artificial neural networks can predict trauma volume and acuity regardless of center size and geography: A multicenter study. J Trauma Acute Care Surg 2020; 87:181-187. [PMID: 31033899 DOI: 10.1097/ta.0000000000002320] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Trauma has long been considered unpredictable. Artificial neural networks (ANN) have recently shown the ability to predict admission volume, acuity, and operative needs at a single trauma center with very high reliability. This model has not been tested in a multicenter model with differing climate and geography. We hypothesize that an ANN can accurately predict trauma admission volume, penetrating trauma admissions, and mean Injury Severity Score (ISS) with a high degree of reliability across multiple trauma centers. METHODS Three years of admission data were collected from five geographically distinct US Level I trauma centers. Patients with incomplete data, pediatric patients, and primary thermal injuries were excluded. Daily number of traumas, number of penetrating cases, and mean ISS were tabulated from each center along with National Oceanic and Atmospheric Administration data from local airports. We trained a single two-layer feed-forward ANN on a random majority (70%) partitioning of data from all centers using Bayesian Regularization and minimizing mean squared error. Pearson's product-moment correlation coefficient was calculated for each partition, each trauma center, and for high- and low-volume days (>1 standard deviation above or below mean total number of traumas). RESULTS There were 5,410 days included. There were 43,380 traumas, including 4,982 penetrating traumas. The mean ISS was 11.78 (SD = 6.12). On the training partition, we achieved R = 0.8733. On the testing partition (new data to the model), we achieved R = 0.8732, with a combined R = 0.8732. For high- and low-volume days, we achieved R = 0.8934 and R = 0.7963, respectively. CONCLUSION An ANN successfully predicted trauma volumes and acuity across multiple trauma centers with very high levels of reliability. The correlation was highest during periods of peak volume. This can potentially provide a framework for determining resource allocation at both the trauma system level and the individual hospital level. LEVEL OF EVIDENCE Care Management, level IV.
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Affiliation(s)
- Bradley M Dennis
- From the Division of Trauma and Surgical Critical Care, (B.M.D., O.D.G.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Surgery (D.P.S.), The Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery (R.A.C.), University of California San Francisco, San Francisco, California; Department of General Surgery, Iowa Methodist Medical Center (R.A.S.), Des Moines, Iowa; Division of Acute Care Surgery, Department of Surgery, University of Rochester Medical Center (N.A.S.), Rochester, New York; Department of Surgery, Denver Health Medical Center (M.J.C.), Denver, Colorado; and Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Memorial Hermann Hospital/Texas Medical Center (B.A.C.), Houston, Texas
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