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Coulombe P, Malo C, Robitaille-Fortin M, Nadeau A, Émond M, Moore L, Blanchard PG, Benhamed A, Mercier E. Identification and Management of Pelvic Fractures in Prehospital and Emergency Department Settings. J Surg Res 2024; 300:371-380. [PMID: 38843724 DOI: 10.1016/j.jss.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION This study aims to describe the characteristics of patients with a pelvic fracture treated at a level 1 trauma center, the proportion of prehospital undertriage and the use of pelvic circumferential compression device (PCCD). METHODS This is a retrospective cohort study. Prehospital and inhospital medical records of adults (≥16 y old) with a pelvic fracture who were treated at Hopital de l'Enfant-Jesus-CHU de Québec (Quebec City, Canada), a university-affiliated level 1 trauma center, between September 01, 2017 and September 01, 2021 were reviewed. Isolated hip or pubic ramus fracture were excluded. Data are presented using proportions and means with standard deviations. RESULTS A total of 228 patients were included (males: 62.3%; mean age: 54.6 [standard deviation 21.1]). Motor vehicle collision (47.4%) was the main mechanism of injury followed by high-level fall (21.5%). Approximately a third (34.2%) needed at least one blood transfusion. Compared to those admitted directly, transferred patients were more likely to be male (73.0% versus 51.3%, P < 0.001) and to have a surgical procedure performed at the trauma center (71.3% versus 46.9%, P < 0.001). The proportion of prehospital undertriage was 22.6%. Overall, 17.1% had an open-book fracture and would have potentially benefited from a prehospital PCCD. Forty-six transferred patients had a PCCD applied at the referral hospital of which 26.1% needed adjustment. CONCLUSIONS Pelvic fractures are challenging to identify in the prehospital environment and are associated with a high undertriage of 22.6%. Reducing undertriage and optimizing the use of PCCD are key opportunities to improve care of patients with a pelvic fracture.
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Affiliation(s)
- Pascale Coulombe
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada
| | - Christian Malo
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | | | - Alexandra Nadeau
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Marcel Émond
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- Département de Médecine Préventive, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Pierre-Gilles Blanchard
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Axel Benhamed
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Eric Mercier
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada.
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兰 东, 刘 茁, 李 宇, 王 国, 田 晓, 马 潞, 张 树, 张 洪. [Risk factors for massive hemorrhage after radical nephrectomy and removal of venous tumor thrombus]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2023; 55:825-832. [PMID: 37807735 PMCID: PMC10560906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE To investigate and analyze the risk factors of massive hemorrhage in patients with renal cell carcinoma and venous tumor thrombus undergoing radical nephrectomy and removal of venous tumor thrombus. METHODS From January 2014 to June 2020, 241 patients with renal cancer and tumor thrombus in a single center of urology at Peking University Third Hospital were retrospectively analyzed. All patients underwent radical nephrectomy and removal of venous tumor thrombus. The relevant preoperative indicators, intraoperative conditions, and postoperative data were statistically analyzed by using statistical software of SPSS 18.0. The main end point of the study was intraoperative bleeding volume greater than 2 000 mL. Logistic regression analysis was used to determine the relevant influencing factors. First, single factor Logistic regression was used for preliminary screening of influencing factors, and variables with single factor Logistic regression analysis P < 0.05 were included in multivariate Logistic regression. In all statistical analyses, P < 0.05 is considered statistically significant. RESULTS Among the 241 patients included, there were 60 cases of massive hemorrhage, 48 males and 12 females, with a median age of 62 years. The number of non-massive hemorrhage was 181. There were 136 males and 45 females, with a median age of 59 years. Univariate analysis showed that the clinical symptoms (both systemic and local symptoms, OR 2.794, 95%CI 1.087-7.181, P=0.033), surgical approach (open surgery, OR 9.365, 95%CI 4.447-19.72, P < 0.001), Mayo grade (Mayo 3-4, OR 5.257, 95%CI 2.806-10.886, P < 0.001), American Society of Anesthesiologists (ASA) score (ASA level 3, OR 2.842, 95%CI 1.338-6.036, P=0.007), preoperative hemoglobin (OR 0.978, 95%CI 0.965-0.991, P=0.001), preoperative platelet count (OR 0.996, 95%CI 0.992-1.000, P=0.037), maximum tumor thrombus width (OR 1.061, 95%CI 1.033-1.091, P < 0.001), Complicated with bland thrombus (OR 4.493, 95%CI 2.264-8.915, P < 0.001), adrenalectomy (OR 3.101, 95%CI 1.614-5.958, P=0.001), segmental resection of the inferior vena cava (OR 2.857, 95%CI 1.395-5.852, P=0.004). There was a statistically significant difference in these aspects(P < 0.05). Multivariate Logistic regression analysis showed that there was a statistically significant difference in surgical approach (open surgery, OR 6.730, 95%CI 2.947-15.368;P < 0.001), Mayo grade (Mayo 3-4, OR 2.294, 95%CI 1.064-4.948, P=0.034), Complicated with bland thrombus (OR 3.236, 95%CI 1.492-7.020, P=0.003). CONCLUSION Combining the results of univariate and multivariate Logistic regression analysis, the surgical approach, Mayo grade, and tumor thrombus combined with conventional thrombus were associated risk factors for massive hemorrhage during surgery for renal cell carcinoma with tumor thrombus. Patients who undergo open surgery, high Mayo grade, and tumor thrombus combined with conventional thrombus are at a relatively higher risk of massive hemorrhage.
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Affiliation(s)
- 东 兰
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
- 广安市人民医院泌尿外科, 四川广安 638500Department of Urology, Guang'an People's Hospital, Guang'an 638500, Sichuan, China
| | - 茁 刘
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 宇轩 李
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 国良 王
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 晓军 田
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 潞林 马
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 树栋 张
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 洪宪 张
- 北京大学第三医院泌尿外科, 北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
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Van Ditshuizen JC, Rojer LA, Van Lieshout EM, Bramer WM, Verhofstad MH, Sewalt CA, Den Hartog D. Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis. J Trauma Acute Care Surg 2023; 94:877-892. [PMID: 36726194 PMCID: PMC10208644 DOI: 10.1097/ta.0000000000003890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/20/2022] [Accepted: 01/01/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trauma networks have multiple designated levels of trauma care. This classification parallels concentration of major trauma care, creating innovations and improving outcome measures. OBJECTIVES The objective of this study is to assess associations of level of trauma care with patient outcomes for populations with specific severe injuries. METHODS A systematic literature search was conducted using six electronic databases up to April 19, 2022 (PROSPERO CRD42022327576). Studies comparing fatal, nonfatal clinical, or functional outcomes across different levels of trauma care for trauma populations with specific severe injuries or injured body region (Abbreviated Injury Scale score ≥3) were included. Two independent reviewers included studies, extracted data, and assessed quality. Unadjusted and adjusted pooled effect sizes were calculated with random-effects meta-analysis comparing Level I and Level II trauma centers. RESULTS Thirty-five studies (1,100,888 patients) were included, of which 25 studies (n = 443,095) used for meta-analysis, suggesting a survival benefit for the severely injured admitted to a Level I trauma center compared with a Level II trauma center (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06-1.25). Adjusted subgroup analysis on in-hospital mortality was done for patients with traumatic brain injuries (OR, 1.23; 95% CI, 1.01-1.50) and hemodynamically unstable patients (OR, 1.09; 95% CI, 0.98-1.22). Hospital and intensive care unit length of stay resulted in an unadjusted mean difference of -1.63 (95% CI, -2.89 to -0.36) and -0.21 (95% CI, -1.04 to 0.61), respectively, discharged home resulted in an unadjusted OR of 0.92 (95% CI, 0.78-1.09). CONCLUSION Severely injured patients admitted to a Level I trauma center have a survival benefit. Nonfatal outcomes were indicative for a longer stay, more intensive care, and more frequently posthospital recovery trajectories after being admitted to top levels of trauma care. Trauma networks with designated levels of trauma care are beneficial to the multidisciplinary character of trauma care. LEVEL OF EVIDENCE Systematic review and meta-analysis; Level III.
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Matthews L, Kelly E, Fleming A, Byerly S, Fischer P, Molyneaux I, Kerwin A, Howley I. An Analysis of Injured Patients Treated at Level 1 Trauma Centers Versus Other Centers: A Scoping Review. J Surg Res 2023; 284:70-93. [PMID: 36549038 DOI: 10.1016/j.jss.2022.11.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Trauma systems continue to evolve to create the best outcomes possible for patients who have undergone traumatic injury. OBJECTIVE This review aims to evaluate the existing research on outcomes based on field triage to a Level 1 trauma center (L1TC) compared to other levels of hospitals and nontrauma centers. METHODS A structured literature search was conducted using PubMed, CINAHL, Embase, and the Cochrane Database. Studies analyzing measures of morbidity, mortality, and cost after receiving care at L1TCs compared to lower-level trauma centers and nontrauma centers in the United States and Canada were included. Three independent reviewers reviewed abstracts, and two independent reviewers conducted full-text review and quality assessment of the included articles. RESULTS Twelve thousand five hundred fourteen unique articles were identified using the literature search. 61 relevant studies were included in this scoping review. 95.2% of included studies were national or regional studies, and 96.8% were registry-based studies. 72.6% of included studies adjusted their results to account for injury severity. The findings from receiving trauma care at L1TCs vary depending on severity of injury, type of injury sustained, and patient characteristics. Existing literature suffers from limitations inherent to large de-identified databases, making record linkage between hospitals impossible. CONCLUSIONS This scoping review shows that the survival benefit of L1TC care is largest for patients with the most severe injuries. This scoping review demonstrates that further research using high-quality data is needed to elucidate more about how to structure trauma systems to improve outcomes for patients with different severities of injuries and in different types of facilities.
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Affiliation(s)
- Lynley Matthews
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Emma Kelly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew Fleming
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Peter Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ian Molyneaux
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew Kerwin
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Isaac Howley
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Coulombe P, Tardif PA, Nadeau A, Beaumont-Boileau R, Malo C, Emond M, Blanchard PG, Moore L, Mercier E. Accuracy of Prehospital Trauma Triage to Select Older Adults Requiring Urgent and Specialized Trauma Care. J Surg Res 2022; 275:281-290. [DOI: 10.1016/j.jss.2022.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/12/2022] [Accepted: 02/12/2022] [Indexed: 10/18/2022]
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Elkbuli A, Dowd B, Flores R, Boneva D, McKenney M. Variability in Current Trauma Systems and Outcomes. J Emerg Trauma Shock 2020; 13:201-207. [PMID: 33304070 PMCID: PMC7717469 DOI: 10.4103/jets.jets_49_19] [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: 06/04/2019] [Revised: 04/17/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background: Complication rates may be indicative of trauma center (TC) performance. The complication rates between Level 1 and 2 TCs at the national level are unknown. Our study aimed to determine the relationship between American College of Surgeons (ACS)-verified and state-designated TCs and complications. Study Design and Methods: This was a cohort review of the National Sample Program (NSP) from the National Trauma Data Bank, the world's largest validated trauma database. TCs were categorized by ACS or state Level 1 or 2. TCs not categorized as Level 1 or 2 were excluded. All 22 complications provided by the NSP were analyzed. Chi-squared analysis was used with statistical significance defined as P < 0.05. Results: Of the 94 TCs in the NSP, 67 had ACS and 80 had state designations of Level 1 or 2. There were 38 ACS Level 1 TCs treating 87,340 patients and 29 ACS Level 2 TCs treating 35,763. There were 45 state Level 1 TCs treating 106,640 and 35 state Level 2 TCs treating 43,290. ACS Level 1 TCs had significantly higher complications compared to ACS Level 2 TCs (13.5% [11,776/87,340] vs. 10.1% [3,606/35,763], P < 0.0001). In addition, state Level 1 TCs had significantly more complications compared to state Level 2 TCs (4.4% [4,681/106,640] vs. 1.6% [673/43,290], P < 0.0001). Conclusion: Both ACS and state Level 2 TCs had significantly lower complication rates than ACS and state Level 1 TCs. Further investigations should look for the source and impact of this difference.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
| | - Brianna Dowd
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
| | - Rudy Flores
- Department of Trauma, HCA-South Atlantic Division, Charleston, SC, USA
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
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Patients with gunshot wounds to the torso differ in risk of mortality depending on treating hospital. Updates Surg 2019; 71:561-567. [PMID: 31011998 DOI: 10.1007/s13304-019-00657-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/16/2019] [Indexed: 10/27/2022]
Abstract
Previous studies have had conflicting results when comparing risk of mortality in patients with gunshot wounds (GSWs) treated at Level-I and II trauma centers. However, the populations studied were restricted geographically. We hypothesized that patients presenting after a GSW to the torso at Level-I centers would have a shorter time to surgical intervention (exploratory laparotomy or thoracotomy) and a lower risk of mortality, compared to Level-IIs in a national database. The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to Level-I or II trauma center after a GSW to the torso. A multivariable logistic regression analysis was performed. From 17,965 patients with GSWs, 13,812 (76.8%) were treated at Level-Is and 4153 (23.2%) at Level-IIs. There was no difference in the injury severity score (ISS) (p = 0.55). The Level-I cohort had a higher rate of laparotomy (38.9% vs. 36.5%, p < 0.001) with a shorter median time to laparotomy (49 vs. 55 min, p < 0.001) but no difference in rate (p = 0.14) and time to thoracotomy (p = 0.62). After adjusting for covariates, only patients undergoing thoracotomy (OR = 0.66, CI = 0.47-0.95, p = 0.02) or those undergoing non-operative management (NOM) (OR = 0.85, CI = 0.74-0.98, p = 0.03) at a Level-I center had lower risk for death, compared to Level-II. Patients with torso GSWs managed with thoracotomy or NOM at a Level-I center have a lower risk of mortality, compared to a Level-II. Future prospective studies examining variations in practice, resources available and surgeon experience to account for these differences are warranted.
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Differences in hospital outcomes following traumatic injury for patients experiencing immediate transfer to a level I trauma facility versus resuscitation at a critical access hospital (CAH). Am J Surg 2018; 217:643-647. [PMID: 30473224 DOI: 10.1016/j.amjsurg.2018.10.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/02/2018] [Accepted: 10/16/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Critical access hospitals (CAH) serve a key role in providing medical care to rural patients. The purpose of this study was to assess effectiveness of CAHs in initial care of trauma patients. METHODS A 5-year retrospective review was conducted of all adult trauma patients who were transported directly to a level I trauma facility or were transported to a CAH then transferred to a level I trauma facility after initial resuscitation. RESULTS Of 1478 patients studied, 1084 were transferred from a CAH with 394 transported directly to the level I facility. Patients transported directly to the level I hospital were younger and more severely injured. After controlling for injury severity score, age, GCS, and shock, the odds of mortality did not differ between CAH transfer patients and patients transported directly to a level I facility (OR 0.70, P = 0.20). Transfer from CAH was associated with decreased ICU and hospital days, but not associated with increased ventilator days. CONCLUSION This study demonstrates that use of a CAH for initial trauma care in rural areas is effective.
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Tran A, Matar M, Lampron J, Steyerberg E, Vaillancourt C, Taljaard M. Outcome variation among Canadian trauma centres: toward a clinical prediction rule for standardizing approaches to clinical assessment of hemorrhage. Can J Surg 2017; 60:E3. [PMID: 28930038 DOI: 10.1503/cjs.1760051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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