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Malhotra AK, Patel B, Hoeft CJ, Shakil H, Smith CW, Jaffe R, Kulkarni AV, Wilson JR, Witiw CD, Nathens AB. Association between trauma center type and mortality for injured children with severe traumatic brain injury. J Trauma Acute Care Surg 2024; 96:777-784. [PMID: 37599416 DOI: 10.1097/ta.0000000000004126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND There is conflicting evidence regarding the relationship between trauma center type and mortality for children with traumatic brain injuries. Identification of mortality differences following brain injury across differing trauma center types may result in actionable quality improvement initiatives to standardize care for these children. METHODS We used Trauma Quality Improvement Program data from 2017 to 2020 to identify children with severe traumatic brain injury (TBI) managed at levels I and II state or American College of Surgeon-verified trauma centers. We used a random intercept multilevel logistic regression model to assess the relationship between exposure (trauma center type either adult, pediatric, or mixed) and outcome (in-hospital mortality). Several secondary analyses were performed to assess the influence of trauma center volume, age strata, and TBI heterogeneity. RESULTS There were 10,105 patients identified across 512 trauma centers. Crude mortality was 25.2%, 36.2%, and 28.9% for pediatric, adult, and mixed trauma centers, respectively. After adjustment for confounders, odds of mortality were higher for children managed at adult trauma centers (odds ratio, 1.67; 95% confidence interval, 1.30-2.13) compared with pediatric trauma centers. There were several patient demographic and injury factors associated with greater odds of death; these included male sex, self-pay insurance status, interfacility transfer, non-fall related inury, age-adjusted hypotension, lack of pupil reactivity and midline shift >5 mm. Adjustment for trauma volume and subgroup analysis using a homogenous TBI subgroup did not change the demonstrated associations. CONCLUSION Our results suggest that mortality was higher at adult trauma centers compared with mixed and pediatric trauma centers for children with traumatic brain injuries. Importantly, there exists the potential for unmeasured confounding. We aim for these findings to direct continuing quality improvement initiatives to improve outcomes for brain injured children. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Armaan K Malhotra
- From the Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada (A.K.M., H.S., C.W.S., R.J., J.R.W., C.D.W.); Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada (A.K.M., H.S., C.W.S., R.J., J.R.W., C.D.W.); Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (A.K.M., H.S., R.J., A.V.K., J.R.W., C.D.W., A.B.N.); American College of Surgeons, Chicago, Illinois, United States (B.P., C.J.H., A.B.N.); Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada (A.V.K.); Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (A.B.N.)
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Kirkendoll SD, Hink AB, Kuhls DA, Rivara FP, Sakran JV, Agoubi LL, Winchester AS, Richards J, Hoeft C, Patel B, Michaels H, Nathens AB. Characteristics of Firearm Injury by Injury Intent: The Need for Tailored Interventions. J Trauma Acute Care Surg 2024:01586154-990000000-00704. [PMID: 38654417 DOI: 10.1097/ta.0000000000004344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
INTRODUCTION While the U.S. has high quality data on firearm-related deaths, less information is available on those who arrive at trauma centers alive, especially those discharged from the emergency department. This study sought to describe characteristics of patients arriving to trauma centers alive following a firearm injury, postulating that significant differences in firearm injury intent might provide insights into injury prevention strategies. METHODS This was a multi-center prospective cohort study of patients treated for firearm-related injuries at 128 U.S. trauma centers from 3/2021-2/2022. Data collected included patient-level sociodemographic, injury and clinical characteristics, community characteristics, and context of injury. The outcome of interest was the association between these factors and the intent of firearm injury. Measures of urbanicity, community distress, and strength of state firearm laws were utilized to characterize patient communities. RESULTS 15,232 patients presented with firearm-related injuries across 128 centers in 41 states. Overall, 9.5% of patients died, and deaths were more common among law enforcement and self-inflicted (SI) firearm injuries (80.9% and 50.5%, respectively). These patients were also more likely to have a history of mental illness. SI firearm injuries were more common in older White men from rural and less distressed communities, whereas firearm assaults were more common in younger, Black men from urban and more distressed communities. Unintentional injuries were more common among younger patients and in states with lower firearm safety grades whereas law enforcement-related injuries occurred most often in unemployed patients with a history of mental illness. CONCLUSIONS Injury, clinical, sociodemographic, and community characteristics among patients injured by a firearm significantly differed between intents. With the goal of reducing firearm-related deaths, strategies and interventions need to be tailored to include community improvement and services that address specific patient risk factors for firearm injury intent. LEVEL OF EVIDENCE Level III, Prognostic/Epidemiological.
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Affiliation(s)
| | - Ashley B Hink
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Deborah A Kuhls
- Department of Surgery. Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, NV
| | - Frederick P Rivara
- Departments of Pediatrics and Epidemiology and the Firearm Injury and Policy Research Program, University of Washington, Seattle, WA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Lauren L Agoubi
- Harborview Injury Prevention and Research Center and the Department of Surgery, University of Washington, Seattle, WA
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Badhiwala JH, Witiw CD, Wilson JR, da Costa LB, Nathens AB, Fehlings MG. Treatment of Acute Traumatic Central Cord Syndrome: A Study of North American Trauma Centers. Neurosurgery 2024; 94:700-710. [PMID: 38038474 DOI: 10.1227/neu.0000000000002767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/25/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Central cord syndrome (CCS) is expected to become the most common traumatic spinal cord injury, yet its optimal management remains unclear. This study aimed to evaluate variability in nonoperative vs operative treatment for CCS between trauma centers in the American College of Surgeons Trauma Quality Improvement Program, identify patient- and hospital-level factors associated with treatment, and determine the association of treatment with outcomes. METHODS Adults with CCS were identified from the Trauma Quality Improvement Program database (2014-2016). Mixed-effects modeling with a random intercept for trauma centers was used to examine the adjusted association of patient- and hospital-level variables with nonoperative treatment. The random-effects output of the model assessed the risk-adjusted variability in nonoperative treatment across centers. Outlier hospitals were identified, and the median odds ratio was calculated. The adjusted effect of nonoperative treatment on mortality, morbidity, and hospital length of stay (LOS) was examined at the patient and hospital level by mixed-effects regression. RESULTS Three thousand, nine hundred twenty-eight patients across 255 centers were eligible; of these, 1523 (38.8%) were treated nonoperatively. Older age, noncommercial insurance (odds ratio [OR] 1.26, 95% CI 1.08-1.48, P = .004), absence of fracture (OR 0.58, 95% CI 0.49-0.68, P < .001), severe head injury (OR 1.41, 95% CI 1.09-1.82, P = .008), and comatose presentation (1.82, 95% CI 1.15-2.89, P = .011) were associated with nonoperative treatment. Twenty-eight hospitals were outliers, and the median odds ratio was 2.02. Patients receiving nonoperative treatment had shorter LOS (mean difference -4.65 days). Nonoperative treatment was associated with lesser in-hospital morbidity (OR 0.49, 95% CI 0.37-0.63, P < .001) at the patient level. There was no difference in mortality. CONCLUSION Operative decision-making for CCS is influenced by patient factors. There remains substantial variability between trauma centers not explained by case-mix differences. Nonoperative treatment was associated with shorter hospital LOS and lesser inpatient morbidity.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
| | - Christopher D Witiw
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto , Ontario , Canada
| | - Jefferson R Wilson
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto , Ontario , Canada
| | - Leodante B da Costa
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto , Ontario , Canada
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto , Ontario , Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto , Ontario , Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto , Ontario , Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
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4
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Smith CW, Malhotra AK, Hammill C, Beaton D, Harrington EM, He Y, Shakil H, McFarlan A, Jones B, Lin HM, Mathieu F, Nathens AB, Ackery AD, Mok G, Mamdani M, Mathur S, Wilson JR, Moreland R, Colak E, Witiw CD. Vision Transformer-based Decision Support for Neurosurgical Intervention in Acute Traumatic Brain Injury: Automated Surgical Intervention Support Tool. Radiol Artif Intell 2024; 6:e230088. [PMID: 38197796 PMCID: PMC10982820 DOI: 10.1148/ryai.230088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 11/15/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
Purpose To develop an automated triage tool to predict neurosurgical intervention for patients with traumatic brain injury (TBI). Materials and Methods A provincial trauma registry was reviewed to retrospectively identify patients with TBI from 2005 to 2022 treated at a specialized Canadian trauma center. Model training, validation, and testing were performed using head CT scans with binary reference standard patient-level labels corresponding to whether the patient received neurosurgical intervention. Performance and accuracy of the model, the Automated Surgical Intervention Support Tool for TBI (ASIST-TBI), were also assessed using a held-out consecutive test set of all patients with TBI presenting to the center between March 2021 and September 2022. Results Head CT scans from 2806 patients with TBI (mean age, 57 years ± 22 [SD]; 1955 [70%] men) were acquired between 2005 and 2021 and used for training, validation, and testing. Consecutive scans from an additional 612 patients (mean age, 61 years ± 22; 443 [72%] men) were used to assess the performance of ASIST-TBI. There was accurate prediction of neurosurgical intervention with an area under the receiver operating characteristic curve (AUC) of 0.92 (95% CI: 0.88, 0.94), accuracy of 87% (491 of 562), sensitivity of 87% (196 of 225), and specificity of 88% (295 of 337) on the test dataset. Performance on the held-out test dataset remained robust with an AUC of 0.89 (95% CI: 0.85, 0.91), accuracy of 84% (517 of 612), sensitivity of 85% (199 of 235), and specificity of 84% (318 of 377). Conclusion A novel deep learning model was developed that could accurately predict the requirement for neurosurgical intervention using acute TBI CT scans. Keywords: CT, Brain/Brain Stem, Surgery, Trauma, Prognosis, Classification, Application Domain, Traumatic Brain Injury, Triage, Machine Learning, Decision Support Supplemental material is available for this article. © RSNA, 2024 See also commentary by Haller in this issue.
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Affiliation(s)
| | | | - Christopher Hammill
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Derek Beaton
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Erin M. Harrington
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Yingshi He
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Husain Shakil
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Amanda McFarlan
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Blair Jones
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Hui Ming Lin
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - François Mathieu
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Avery B. Nathens
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Alun D. Ackery
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Garrick Mok
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Muhammad Mamdani
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Shobhit Mathur
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Jefferson R. Wilson
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
| | - Robert Moreland
- From the Division of Neurosurgery (C.W.S., A.K.M., E.M.H., Y.H.,
H.S., J.R.W., C.D.W.), Trauma Program and Quality Assurance (A.M., E.C.),
Department of Emergency Medicine (A.D.A., G.M.), and Department of Medical
Imaging (S.M., R.M., E.C.), St Michael's Hospital, 30 Bond St, Toronto,
ON, Canada M5B 1W8; Li Ka Shing Knowledge Institute (C.W.S., A.K.M., E.M.H.,
Y.H., H.S., H.M.L., M.M., S.M., J.R.W., E.C., C.D.W.) and Data Science and
Advanced Analytics (C.H., D.B., B.J., M.M.), Unity Health Toronto, Toronto,
Ontario, Canada; Institute for Health Policy, Management and Evaluation (A.K.M.,
H.S., M.M., J.R.W., C.D.W.), Interdepartmental Division of Critical Care (F.M.),
Temerty Faculty of Medicine (A.D.A., G.M., M.M., S.M., J.R.W., R.M., C.D.W.),
and Leslie Dan Faculty of Pharmacy (M.M.), University of Toronto, Toronto,
Ontario, Canada; and Division of Trauma Surgery, Sunnybrook Health Sciences
Centre, Toronto, Ontario, Canada (A.B.N.)
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Malhotra AK, Shakil H, Smith CW, Sader N, Ladha K, Wijeysundera DN, Singhal A, Kulkarni AV, Wilson JR, Witiw CD, Nathens AB. Withdrawal of Life-Sustaining Treatment for Pediatric Patients With Severe Traumatic Brain Injury. JAMA Surg 2024; 159:287-296. [PMID: 38117514 PMCID: PMC10733846 DOI: 10.1001/jamasurg.2023.6531] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/13/2023] [Indexed: 12/21/2023]
Abstract
Importance The decision to withdraw life-sustaining treatment for pediatric patients with severe traumatic brain injury (TBI) is challenging for clinicians and families with limited evidence quantifying existing practices. Given the lack of standardized clinical guidelines, variable practice patterns across trauma centers seem likely. Objective To evaluate the factors influencing decisions to withdraw life-sustaining treatment across North American trauma centers for pediatric patients with severe TBI and to quantify any existing between-center variability in withdrawal of life-sustaining treatment practices. Design, Setting, and Participants This retrospective cohort study used data collected from 515 trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. Pediatric patients younger than 19 years with severe TBI and a documented decision for withdrawal of life-sustaining treatment were included. Data were analyzed from January to May 2023. Main Outcomes and Measures A random intercept multilevel logistic regression model was used to quantify patient, injury, and hospital characteristics associated with the decision to withdraw life-sustaining treatment; the median odds ratio was used to characterize residual between-center variability. Centers were ranked by their conditional random intercepts and quartile-specific adjusted mortalities were computed. Results A total of 9803 children (mean [SD] age, 12.6 [5.7]; 2920 [29.8%] female) with severe TBI were identified, 1003 of whom (10.2%) had a documented decision to withdraw life-sustaining treatment. Patient-level factors associated with an increase in likelihood of withdrawal of life-sustaining treatment were young age (younger than 3 years), higher severity intracranial and extracranial injuries, and mechanism of injury related to firearms. Following adjustment for patient and hospital attributes, the median odds ratio was 1.54 (95% CI, 1.46-1.62), suggesting residual variation in withdrawal of life-sustaining treatment between centers. When centers were grouped into quartiles by their propensity for withdrawal of life-sustaining treatment, adjusted mortality was higher for fourth-quartile compared to first-quartile centers (odds ratio, 1.66; 95% CI, 1.45-1.88). Conclusions and Relevance Several patient and injury factors were associated with withdrawal of life-sustaining treatment decision-making for pediatric patients with severe TBI in this study. Variation in withdrawal of life-sustaining treatment practices between trauma centers was observed after adjustment for case mix; this variation was associated with differences in risk-adjusted mortality rates. Taken together, these findings highlight the presence of inconsistent approaches to withdrawal of life-sustaining treatment in children, which speaks to the need for guidelines to address this significant practice pattern variation.
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Affiliation(s)
- Armaan K. Malhotra
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Husain Shakil
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Christopher W. Smith
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
| | - Nicholas Sader
- Division of Neurosurgery, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Karim Ladha
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of Anesthesiology, Unity Health, Toronto, Ontario, Canada
| | - Duminda N. Wijeysundera
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of Anesthesiology, Unity Health, Toronto, Ontario, Canada
| | - Ashutosh Singhal
- Division of Neurosurgery, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Abhaya V. Kulkarni
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jefferson R. Wilson
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Christopher D. Witiw
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Avery B. Nathens
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Kirkendoll SD, Silver CM, Stey AM, Nathens AB, Jackson K, Campbell BT. Surgeon views on firearm safety counseling in clinical practice: A cross-sectional survey. J Trauma Acute Care Surg 2024; 96:455-460. [PMID: 37934626 DOI: 10.1097/ta.0000000000004197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Firearms are commonplace in the United States, and one proposed strategy to decrease risk of firearm injury is to have physicians counsel their patients about safe firearm ownership. Current rates of firearm safety counseling by surgeons who care for injured people are unknown. METHODS This study used an anonymous cross-sectional survey derived from previously published survey instruments and was piloted (n = 13) at the annual meeting of the American Association for the Surgery of Trauma (2022). The finalized survey was distributed using a quick response code during two sessions at the 2022 American College of Surgeons Clinical Congress. Eligible participants included the surgeons and surgical trainees who attended these sessions. RESULTS One hundred fourteen individuals completed the survey (20% response rate), and a majority were male (n = 71 [62.3%]), attending surgeons (n = 108 [94.7%]), and specialized in acute care surgery (n = 72 [63.2%]). Few participants (n = 43 [37.7%]) reported counseling patients on firearm safety as part of their routine clinical practice; however, the majority (n = 102 [89.5%]) believed that surgeons should provide firearm safety counseling. Counseling rates did not vary significantly by age, sex, surgical specialty, or region of practice, but attitudes toward counseling did differ by firearm safety counseling practices ( p = 0.03) and region of practice (0.04). Noted barriers to counseling included lack of time (n = 47 [41.2%]), perceived lack of training (n = 43 [37.7%]), and lack of firearm knowledge/experience (n = 36 [31.6%]). CONCLUSION Most surgeon respondents did not provide firearm safety counseling to their patients despite the fact the majority believed they should. This suggests that counseling interventions that do not solely rely on surgeons for implementation could increase the number of patients who receive firearm safety guidance during clinical encounters. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Shelbie D Kirkendoll
- From the American College of Surgeons (S.D.K.); Department of Surgery (S.D.K., C.M.S., A.M.S.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery (A.B.N.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Department of Medical Social Sciences (K.J.), Northwestern University, Chicago, Illinois; and Department of Pediatric Surgery (B.T.C.), Connecticut Children's Medical Center, Hartford, Connecticut
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7
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Tillmann BW, Nathens AB, Guttman MP, Pequeno P, Scales DC, Pechlivanoglou P, Haas B. The impact of referring hospital resources on interfacility overtriage: A population-based analysis. Injury 2024; 55:111332. [PMID: 38281350 DOI: 10.1016/j.injury.2024.111332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/13/2023] [Accepted: 01/13/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Nearly half of patients transferred from non-trauma to trauma centres have minor injuries. The transfer of patients with minor injuries to trauma centres is not associated with any known patient benefit and represents an opportunity to reduce healthcare costs and improve patient experience. In this study, we evaluated the relationship between hospital resources and overtriage, with the objective of identifying targets for system-level intervention. METHODS We conducted a population-based cohort study of adults, age ≥ 16, presenting with minor injuries to non-trauma centres in Ontario, Canada (2009-2020). The primary outcome was overtriage, defined as transfer to a trauma centre. Hierarchical logistic regression was used to evaluate the association between hospital resources and a patient's likelihood of being overtriaged, adjusting for case-mix. RESULTS amongst 165,302 patients with minor injuries, 15,641 (9.5 %) were transferred to a trauma centre (overtriage). Presence of a CT scanner, surgical support, or intensive care unit had no impact on a patient's likelihood of overtriage. Relative to community hospitals, presentation to a teaching hospital was independently associated with greater odds of overtriage (OR 2.97, 95 % CI: 1.26-7.00). Accounting for case-mix and resources, the median difference in a patient's odds of overtriage varied 3.7-fold across non-trauma centres (MOR 3.76). CONCLUSIONS There is significant variability in overtriage across non-trauma centres, even after adjusting for case-mix and hospital resources. These finding suggests that some centres have developed processes to minimize overtriage independent of available resources. Broad implementation of these processes may represent an opportunity for system-wide quality improvement.
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Affiliation(s)
- Bourke W Tillmann
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Respirology and Critical Care Medicine, University Health Network, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - Avery B Nathens
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Petros Pechlivanoglou
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economic and Technology Assessment Collaborative, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Melhado C, Evans LL, Miskovic A, Subacius H, Nathens AB, Stein DM, Burd RS, Jensen AR. Benchmarking Pediatric Trauma Care in Mixed Trauma Centers: Adult Risk-Adjusted Mortality Is Not a Reliable Indicator of Pediatric Outcomes. J Am Coll Surg 2024; 238:243-251. [PMID: 38059567 DOI: 10.1097/xcs.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND Trauma center benchmarking has become standard practice for assessing quality. The American College of Surgeons adult trauma center verification standards do not specifically require participation in a pediatric-specific benchmarking program. Centers that treat adults and children may therefore rely solely on adult benchmarking metrics as a surrogate for pediatric quality. This study assessed discordance between adult and pediatric mortality within mixed trauma centers to determine the need to independently report pediatric-specific quality metrics. STUDY DESIGN A cohort of trauma centers (n = 493, including 347 adult-only, 44 pediatric-only, and 102 mixed) that participated in the American College of Surgeons TQIP in 2017 to 2018 was analyzed. Center-specific observed-to-expected mortality estimates were calculated using TQIP adult inclusion criteria for 449 centers treating adults (16 to 65 years) and using TQIP pediatric inclusion criteria for 146 centers treating children (0 to 15 years). We then correlated risk-adjusted mortality estimates for pediatric and adult patients within mixed centers and evaluated concordance of their outlier status between adults and children. RESULTS The cohort included 394,075 adults and 97,698 children. Unadjusted mortality was 6.1% in adults and 1.2% in children. Mortality estimates had only moderate correlation ( r = 0.41) between adult and pediatric cohorts within individual mixed centers. Mortality outlier status for adult and pediatric cohorts was discordant in 31% (32 of 102) of mixed centers (weighted Kappa statistic 0.06 [-0.11 to 0.22]), with 78% (23 of 32) of discordant centers having higher odds of mortality for children than for adults (6 centers with average adult mortality and high pediatric mortality and 17 centers with low adult mortality and average pediatric mortality, p < 0.01). CONCLUSIONS Adult mortality is not a reliable surrogate for pediatric mortality in mixed trauma centers. Incorporation of pediatric-specific benchmarks should be required for centers that admit children.
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Affiliation(s)
- Caroline Melhado
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
| | - Lauren L Evans
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
| | - Amy Miskovic
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
| | - Haris Subacius
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
| | - Avery B Nathens
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
- Department of Surgery, University of Toronto, Toronto, ON (Nathens)
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Stein)
| | - Randall S Burd
- Division of Burn and Trauma Surgery, Children's National Medical Center, Washington, DC (Burd)
| | - Aaron R Jensen
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
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9
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Silver CM, Thomas AC, Reddy S, Kirkendoll S, Nathens AB, Issa N, Patel PP, Plevin RE, Kanzaria HK, Stey AM. Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America. JAMA Netw Open 2024; 7:e240795. [PMID: 38416488 PMCID: PMC10902734 DOI: 10.1001/jamanetworkopen.2024.0795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024] Open
Abstract
Importance Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures People experiencing homelessness were identified using the TQP's alternate home residence variable. Main Outcomes and Measures Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.
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Affiliation(s)
- Casey M. Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Arielle C. Thomas
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Avery B. Nathens
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nabil Issa
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Purvi P. Patel
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | | | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
| | - Anne M. Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Tillmann BW, Guttman MP, Thakore J, Evans DC, Nathens AB, McMillan J, Gezer R, Phillips A, Yanchar NL, Pequeno P, Scales DC, Pechlivanoglou P, Haas B. Internal and external validation of an updated ICD-10-CA to AIS-2005 update 2008 algorithm. J Trauma Acute Care Surg 2024; 96:297-304. [PMID: 37405813 DOI: 10.1097/ta.0000000000004052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
BACKGROUND Administrative data are a powerful tool for population-level trauma research but lack the trauma-specific diagnostic and injury severity codes needed for risk-adjusted comparative analyses. The objective of this study was to validate an algorithm to derive Abbreviated Injury Scale (AIS-2005 update 2008) severity scores from Canadian International Classification of Diseases (ICD-10-CA) diagnostic codes in administrative data. METHODS This was a retrospective cohort study using data from the 2009 to 2017 Ontario Trauma Registry for the internal validation of the algorithm. This registry includes all patients treated at a trauma center who sustained a moderate or severe injury or were assessed by a trauma team. It contains both ICD-10-CA codes and injury scores assigned by expert abstractors. We used Cohen's kappa (𝜅) coefficient to compare AIS-2005 Update 2008 scores assigned by expert abstractors to those derived using the algorithm and the intraclass correlation coefficient to compare assigned and derived Injury Severity Scores. Sensitivity and specificity for detection of a severe injury (AIS score, ≥ 3) were then calculated. For the external validation of the algorithm, we used administration data to identify adults who either died in an emergency department or were admitted to hospital in Ontario secondary to a traumatic injury (2009-2017). Logistic regression was used to evaluate the discriminative ability and calibration of the algorithm. RESULTS Of 41,869 patients in the Ontario Trauma Registry, 41,793 (99.8%) had at least one diagnosis matched to the algorithm. Evaluation of AIS scores assigned by expert abstractors and those derived using the algorithm demonstrated a high degree of agreement in identification of patients with at least one severe injury (𝜅 = 0.75; 95% confidence interval [CI], 0.74-0.76). Likewise, algorithm-derived scores had a strong ability to rule in or out injury with AIS ≥ 3 (specificity, 78.5%; 95% CI, 77.7-79.4; sensitivity, 95.1; 95% CI, 94.8-95.3). There was strong correlation between expert abstractor-assigned and crosswalk-derived Injury Severity Score (intraclass correlation coefficient, 0.80; 95% CI, 0.80-0.81). Among the 130,542 patients identified using administrative data, the algorithm retained its discriminative properties. CONCLUSION Our ICD-10-CA to AIS-2005 update 2008 algorithm produces reliable estimates of injury severity and retains its discriminative properties with administrative data. Our findings suggest that this algorithm can be used for risk adjustment of injury outcomes when using population-based administrative data. LEVEL OF EVIDENCE Diagnostic Tests/Criteria; Level II.
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Affiliation(s)
- Bourke W Tillmann
- From the Interdepartmental Division of Critical Care (B.W.T., D.C.S., B.H.), University of Toronto; Department of Critical Care Medicine (B.W.T., D.C.S., B.H.), Sunnybrook Health Sciences Centre; Institute of Health Policy, Management, and Evaluation (B.W.T., M.P.G., A.B.N., D.C.S., P.P., B.H.), Department of Surgery (M.P.G., A.B.N., B.H.), University of Toronto, Toronto, Ontario; Trauma Services (J.T., J.M.M., R.G.), Provincial Health Services Authority; Division of General Surgery, Department of Surgery, (D.C.E.), University of British Columbia, Vancouver, British Columbia; ICES (A.B.N., P.P., D.C.S., P.P., B.H.); Sunnybrook Research Institute (A.B.N., D.C.S., B.H.); Tory Trauma Program (A.P.), Sunnybrook Health Sciences Centre, Toronto, Ontario; Department of Surgery (N.L.Y.), University of Calgary, Calgary, Alberta; Department of Medicine (D.C.S.), University of Toronto; Toronto Health Economic and Technology Assessment Collaborative (P.P.); and The Hospital for Sick Children (P.P.), Toronto, Ontario, Canada
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MacDermott R, Berger FH, Phillips A, Robins JA, O’Keeffe ME, Mughli RA, MacLean DB, Liu G, Heipel H, Nathens AB, Qamar SR. Initial Imaging of Pregnant Patients in the Trauma Bay-Discussion and Review of Presentations at a Level-1 Trauma Centre. Diagnostics (Basel) 2024; 14:276. [PMID: 38337792 PMCID: PMC10855036 DOI: 10.3390/diagnostics14030276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/15/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Trauma is the leading non-obstetric cause of maternal and fetal mortality and affects an estimated 5-7% of all pregnancies. Pregnant women, thankfully, are a small subset of patients presenting in the trauma bay, but they do have distinctive physiologic and anatomic changes. These increase the risk of certain traumatic injuries, and the gravid uterus can both be the primary site of injury and mask other injuries. The primary focus of the initial management of the pregnant trauma patient should be that of maternal stabilization and treatment since it directly affects the fetal outcome. Diagnostic imaging plays a pivotal role in initial traumatic injury assessment and should not deviate from normal routine in the pregnant patient. Radiographs and focused assessment with sonography in the trauma bay will direct the use of contrast-enhanced computed tomography (CT), which remains the cornerstone to evaluate the potential presence of further management-altering injuries. A thorough understanding of its risks and benefits is paramount, especially in the pregnant patient. However, like any other trauma patient, if evaluation for injury with CT is indicated, it should not be denied to a pregnant trauma patient due to fear of radiation exposure.
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Affiliation(s)
- Roisin MacDermott
- Department of Medical Imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.M.); (F.H.B.); (J.A.R.); (M.E.O.); (R.A.M.)
| | - Ferco H. Berger
- Department of Medical Imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.M.); (F.H.B.); (J.A.R.); (M.E.O.); (R.A.M.)
| | - Andrea Phillips
- Tory Trauma Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Jason A. Robins
- Department of Medical Imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.M.); (F.H.B.); (J.A.R.); (M.E.O.); (R.A.M.)
| | - Michael E. O’Keeffe
- Department of Medical Imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.M.); (F.H.B.); (J.A.R.); (M.E.O.); (R.A.M.)
| | - Rawan Abu Mughli
- Department of Medical Imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.M.); (F.H.B.); (J.A.R.); (M.E.O.); (R.A.M.)
| | - David B. MacLean
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Grace Liu
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Heather Heipel
- Department of Medicine (Emergency Medicine), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Avery B. Nathens
- Tory Trauma Program, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada;
| | - Sadia Raheez Qamar
- Department of Medical Imaging, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.M.); (F.H.B.); (J.A.R.); (M.E.O.); (R.A.M.)
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12
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Patel VR, Rozycki G, Jopling J, Subramanian M, Kent A, Manukyan M, Sakran JV, Haut E, Levy M, Nathens AB, Brown C, Byrne JP. Association Between Geospatial Access to Trauma Center Care and Motor Vehicle Crash Mortality in the United States. J Trauma Acute Care Surg 2023:01586154-990000000-00580. [PMID: 38053239 DOI: 10.1097/ta.0000000000004221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Motor vehicle crashes (MVCs) are a leading cause of preventable trauma death in the United States (US). Access to trauma center care is highly variable nationwide. The objective of this study was to measure the association between geospatial access to trauma center care and MVC mortality. METHODS This was a population-based study of MVC-related deaths that occurred in 3,141 US counties (2017-2020). ACS and state-verified level I-III trauma centers were mapped. Geospatial network analysis estimated the ground transport time to the nearest trauma center from the population-weighted centroid for each county. In this way, the exposure was the predicted access time to trauma center care for each county population. Hierarchical negative binomial regression measured the risk-adjusted association between predicted access time and MVC mortality, adjusting for population demographics, rurality, access to trauma resources, and state traffic safety laws. RESULTS We identified 92,398 crash fatalities over the four-year study period. Trauma centers mapped included 217 level I, 343 level II, and 495 level III trauma centers. The median county predicted access time was 47 min (IQR 26-71 min). Median county MVC mortality was 12.5 deaths/100,000 person-years (IQR 7.4-20.3 deaths/100,000 person-years). After risk-adjustment, longer predicted access times were significantly associated with higher rates of MVC mortality (>60 min vs. <15 min; MRR 1.36; 95%CI 1.31-1.40). This relationship was significantly more pronounced in urban/suburban vs. rural/wilderness counties (p for interaction, <0.001). County access to trauma center care explained 16% of observed state-level variation in MVC mortality. CONCLUSIONS Geospatial access to trauma center care is significantly associated with MVC mortality and contributes meaningfully to between-state differences in road traffic deaths. Efforts to improve trauma system organization should prioritize access to trauma center care to minimize crash fatalities. LEVEL OF EVIDENCE Level III, Epidemiological.
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Affiliation(s)
- Vishal R Patel
- Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Grace Rozycki
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey Jopling
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madhu Subramanian
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alistair Kent
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mariuxi Manukyan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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13
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Malhotra AK, Lozano CS, Shakil H, Smith CW, Ibrahim GM, Lebel DE, Kulkarni AV, Wilson JR, Witiw CD, Nathens AB. Risk factors associated with in-hospital adverse events: a multicenter observational cohort study of 1853 pediatric patients with traumatic spinal cord injury. J Neurosurg Pediatr 2023; 32:701-709. [PMID: 37877947 DOI: 10.3171/2023.8.peds23354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/30/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE In this study, the authors aimed to quantify the frequency of in-hospital major adverse events (AEs) in a multicenter cohort of pediatric patients with spinal cord injury (SCI) managed at North American trauma centers. They also sought to identify patient and injury factors associated with the occurrence of major and immobility-related AEs. METHODS Data derived from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) were used to identify a cohort of pediatric patients (age < 19 years) with traumatic SCI. The authors identified individuals with major and immobility-related AEs following injury. They used mixed-effects multivariable logistic regression to identify clinical variables associated with AEs after injury. This analytical approach allowed them to account for similarities in care delivery between patients managed in the same trauma settings during the study period while also adjusting for patient-level confounders. The adjusted impact of AEs on in-hospital mortality and length of stay (LOS) were also assessed through further multivariable regression analysis. Additional subgroup analyses were performed to reduce bias associated with competing risks and explore the age-specific risk factor associations with AEs. RESULTS A total of 1853 pediatric patients who sustained either cervical or thoracic SCI were managed at ACS TQIP trauma centers between 2017 and 2020. The most frequently encountered AE types were pressure ulcer, unplanned intubation, cardiac arrest requiring cardiopulmonary resuscitation, and ventilator-associated pneumonia. The crude rate of major in-hospital and immobility-related AEs significantly differed between subgroups, with higher proportions of AEs in complete injuries compared with incomplete injuries. The adjusted risk for major AE following injury was significantly elevated for cervical complete SCI, patients with severe concomitant abdominal injuries, and for those presenting with depressed Glasgow Coma Scale scores less than 13. These same risk factors were associated with major AEs in children older than 8 years but were not significant for younger children (age ≤ 8 years). Complication occurrence was not associated with difference in risk-adjusted mortality (OR 0.72, 95% CI 0.45-1.14), but did increase LOS by 2.2 days (95% CI 1.4-2.7 days). CONCLUSIONS The authors outlined the prevalence of in-hospital AEs in a large multicenter cohort of North American pediatric SCI patients. Important risk factors predisposing this population to AEs include cervical complete injuries, simultaneous abdominal trauma, and Glasgow Coma Scale scores < 13 at presentation. Postinjury complications impacted health resource utilization by increased LOS but did not affect postinjury mortality. These findings have important implications for pediatric SCI providers and future care quality benchmarking.
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Affiliation(s)
- Armaan K Malhotra
- 1Division of Neurosurgery, St. Michael's Hospital, Toronto
- 2Li Ka Shing Knowledge Institute, Unity Health, Toronto
- 3Institute for Health Policy, Management and Evaluation, University of Toronto
| | - Christopher S Lozano
- 1Division of Neurosurgery, St. Michael's Hospital, Toronto
- 2Li Ka Shing Knowledge Institute, Unity Health, Toronto
| | - Husain Shakil
- 1Division of Neurosurgery, St. Michael's Hospital, Toronto
- 2Li Ka Shing Knowledge Institute, Unity Health, Toronto
- 3Institute for Health Policy, Management and Evaluation, University of Toronto
| | - Christopher W Smith
- 1Division of Neurosurgery, St. Michael's Hospital, Toronto
- 2Li Ka Shing Knowledge Institute, Unity Health, Toronto
| | | | - David E Lebel
- 5Department of Orthopaedic Surgery, Hospital for Sick Children, Toronto; and
| | - Abhaya V Kulkarni
- 3Institute for Health Policy, Management and Evaluation, University of Toronto
- 4Division of Neurosurgery, Hospital for Sick Children, Toronto
| | - Jefferson R Wilson
- 1Division of Neurosurgery, St. Michael's Hospital, Toronto
- 2Li Ka Shing Knowledge Institute, Unity Health, Toronto
- 3Institute for Health Policy, Management and Evaluation, University of Toronto
| | - Christopher D Witiw
- 1Division of Neurosurgery, St. Michael's Hospital, Toronto
- 2Li Ka Shing Knowledge Institute, Unity Health, Toronto
- 3Institute for Health Policy, Management and Evaluation, University of Toronto
| | - Avery B Nathens
- 3Institute for Health Policy, Management and Evaluation, University of Toronto
- 6Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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14
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Shakil H, Malhotra AK, Jaffe RH, Smith CW, Harrington EM, Wang AP, Yuan EY, He Y, Ladha K, Wijeysundera DN, Nathens AB, Wilson JR, Witiw CD. Factors influencing withdrawal of life-supporting treatment in cervical spinal cord injury: a large multicenter observational cohort study. Crit Care 2023; 27:448. [PMID: 37980485 PMCID: PMC10656773 DOI: 10.1186/s13054-023-04725-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/08/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) leads to profound neurologic sequelae, and the provision of life-supporting treatment serves great importance among this patient population. The decision for withdrawal of life-supporting treatment (WLST) in complete traumatic SCI is complex with the lack of guidelines and limited understanding of practice patterns. We aimed to evaluate the individual and contextual factors associated with the decision for WLST and assess between-center differences in practice patterns across North American trauma centers for patients with complete cervical SCI. METHODS This retrospective multicenter observational cohort study utilized data derived from the American College of Surgeons Trauma Quality Improvement Program database between 2017 and 2020. The study included adult patients (> 16 years) with complete cervical SCI. We constructed a multilevel mixed effect logistic regression model to adjust for patient, injury and hospital factors influencing WLST. Factors associated with WLST were estimated through odds ratios with 95% confidence intervals. Hospital variability was characterized using the median odds ratio. Unexplained residual variability was assessed through the proportional change in variation between models. RESULTS We identified 5070 patients with complete cervical SCI treated across 477 hospitals, of which 960 (18.9%) had WLST. Patient-level factors associated with significantly increased likelihood of WLST were advanced age, male sex, white race, prior dementia, low presenting Glasgow Coma Scale score, having a pre-hospital cardiac arrest, SCI level of C3 or above, and concurrent severe injury to the head or thorax. Patient-level factors associated with significantly decreased likelihood of WLST included being racially Black or Asian. There was significant variability across hospitals in the likelihood for WLST while accounting for case-mix, hospital size, and teaching status (MOR 1.51 95% CI 1.22-1.75). CONCLUSIONS A notable proportion of patients with complete cervical SCI undergo WLST during their in-hospital admission. We have highlighted several factors associated with this decision and identified considerable variability between hospitals. Further work to standardize WLST guidelines may improve equity of care provided to this patient population.
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Affiliation(s)
- Husain Shakil
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Armaan K Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Rachael H Jaffe
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christopher W Smith
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Erin M Harrington
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Alick P Wang
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Eva Y Yuan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Yingshi He
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Karim Ladha
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Avery B Nathens
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Trauma Surgery, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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15
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Melhado C, Remick K, Miskovic A, Patel B, Hewes HA, Newgard CD, Nathens AB, Macias C, Gray L, Yorkgitis BK, Dingeldein MW, Jensen AR. The Association between Pediatric Readiness and Mortality for Injured Children Treated at US Trauma Centers. Ann Surg 2023:00000658-990000000-00671. [PMID: 37830240 DOI: 10.1097/sla.0000000000006126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To use updated 2021 weighted Pediatric Readiness Score (wPRS) data to identify a threshold level of trauma center emergency department (ED) pediatric readiness. SUMMARY BACKGROUND DATA Most children in the US receive initial trauma care at non-pediatric centers. The National Pediatric Readiness Project (NPRP) aims to ensure that all EDs are prepared to provide quality care for children. Trauma centers reporting the highest quartile of wPRS on the 2013 national assessment have been shown to have lower mortality. Significant efforts have been invested to improve pediatric readiness in the past decade. STUDY DESIGN A retrospective cohort of trauma centers that completed the NPRP 2021 national assessment and contributed to the National Trauma Data Bank (NTDB) in 2019-21 was analyzed. Center-specific observed-to-expected mortality estimates for children (0-15y) were calculated using Pediatric TQIP models. Deterministic linkage was used for transferred patients to account for wPRS at the initial receiving center. Center-specific mortality odds ratios were then compared across quartiles of wPRS. RESULTS 66,588 children from 630 centers with a median [IQR] wPRS of 79 [66-93] were analyzed. The average observed-to-expected odds of mortality (1.02 [0.97-1.06]) for centers in the highest quartile (wPRS≥93) was lower than any of the lowest three wPRS quartiles (1.19 [1.14-1.23](Q1), 1.29 [1.24-1.33](Q2), and 1.28 [1.19-1.36](Q3), all P <0.05). The presence of a pediatric-specific quality improvement plan was the domain with the strongest independent association with mortality (standardized beta -0.095 [-0.146--0.044]). CONCLUSION Trauma centers should address gaps in pediatric readiness to include a pediatric-specific quality improvement plan and aim to achieve wPRS ≥93.
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Affiliation(s)
- Caroline Melhado
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, and UCSF Benioff Children's Hospitals, San Francisco, CA
| | - Katherine Remick
- Departments of Pediatrics and Surgery and Perioperative Medicine, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Amy Miskovic
- The American College of Surgeons Trauma Quality Programs, Chicago, IL
| | - Bhavin Patel
- The American College of Surgeons Trauma Quality Programs, Chicago, IL
| | - Hilary A Hewes
- Division of Pediatric Emergency Medicine, Department Pediatrics, University of Utah School of Medicine, and Intermountain Primary Children's Hospital, Salt Lake City, UT
| | - Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | | | - Charles Macias
- Division of Pediatric Emergency Medicine, University Hospitals Rainbow Babies & Children's Hospital, and College of Medicine, Case Western Reserve University, Cleveland, OH
| | - Lisa Gray
- Emergency Medical Services for Children Innovation and Improvement Center, University of Texas at Austin, Austin, TX
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Michael W Dingeldein
- Division of Pediatric Surgery, Rainbow Babies & Children's Hospital, and College of Medicine, Case Western Reserve University, Cleveland, OH
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16
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Newgard CD, Babcock SR, Song X, Remick KE, Gausche-Hill M, Lin A, Malveau S, Mann NC, Nathens AB, Cook JNB, Jenkins PC, Burd RS, Hewes HA, Glass NE, Jensen AR, Fallat ME, Ames SG, Salvi A, McConnell KJ, Ford R, Auerbach M, Bailey J, Riddick TA, Xin H, Kuppermann N. Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival. Ann Surg 2023; 278:e580-e588. [PMID: 36538639 PMCID: PMC10149578 DOI: 10.1097/sla.0000000000005741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sean R. Babcock
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Xubo Song
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Katherine E. Remick
- Departments of Pediatrics and Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, California
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, District of Columbia
| | - Hilary A. Hewes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Aaron R. Jensen
- Department of Surgery, University of California, San Francisco, Benioff Children’s Hospitals, San Francisco, California
| | - Mary E. Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - K. John McConnell
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Rachel Ford
- Oregon Emergency Medical Services for Children Program, Oregon Health Authority, Portland, Oregon
| | - Marc Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jessica Bailey
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tyne A. Riddick
- Oregon Health & Science University-Portland State University, School of Public Health, Portland, Oregon
| | - Haichang Xin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California
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17
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Elliott CG, Notario L, Wong B, Javidan AP, Pannell D, Nathens AB, Tien H, Johnston M, Thomas-Boaz W, Freedman C, da Luz L. Implementing the IMIST-AMBO tool for paramedic to trauma team handovers: a video review analysis. CAN J EMERG MED 2023; 25:421-428. [PMID: 37087711 DOI: 10.1007/s43678-023-00503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/28/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Patient handover between paramedics and the trauma team is vulnerable to communication errors that may adversely affect patient care. This study assesses the feasibility of a handover tool, IMIST-AMBO (acronym of categories), implementation in the trauma bay and evaluates the degree to which it improves handover metrics. METHODS This is a prospective observational cohort study conducted at Canada's largest level-one trauma center. Feasibility of the tool implementation and improvement in handover metrics were assessed. Strategies for implementation included distribution of an educational video and posters, and point-of-care reminders in the trauma bay. Two reviewers independently assessed video recordings of handovers to evaluate handover metrics. Findings were compared to data obtained during a knowledge gap analysis conducted prior to the initiation of this study at the same institution. RESULTS Over 13 weeks (August to November 2020), 140 videos were recorded, of which 80 used the IMIST-AMBO tool (compliance of 57%). Paramedic adherence to the handover structure occurred in 70.4% of cases, with greater adherence to the IMIST (82.2%) compared to the AMBO (47.1%) section. The mean (± standard deviation) handover duration was shorter (1 min:58 s ± 0:44 s during implementation vs. 2 min:47 s ± 1:14 s pre-implementation, [p < 0.001]). Frequency of parallel conversations and informal handovers improved (61% to 30% and 65% to 13%, [p < 0.001], respectively). Interruptions during the handover decreased from 3.05 (± 1.95) to 1.5 (± 1.7), p < 0.001. The tool was received favorably among study participants. CONCLUSION The IMIST-AMBO tool reduced the frequency of interruptions, parallel conversations, and informal handovers during paramedic-trauma team handovers at our institution. The quality and amount of information communicated per handover improved, all with a decrease in handover duration. The IMIST-AMBO tool may be applied to other trauma centers across Canada, or more broadly on an international scale.
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Affiliation(s)
- Cara G Elliott
- Department of Obstetrics and Gynaecology, Western University, London, ON, Canada
| | - Lowyl Notario
- Tory Regional Trauma Program and Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Brian Wong
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Arshia P Javidan
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Dylan Pannell
- Tory Regional Trauma Program and Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Avery B Nathens
- Tory Regional Trauma Program and Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Homer Tien
- Tory Regional Trauma Program and Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Will Thomas-Boaz
- Tory Regional Trauma Program and Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Corey Freedman
- Tory Regional Trauma Program and Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Luis da Luz
- Tory Regional Trauma Program and Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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18
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Conn LG, Nathens AB, Scales DC, Vogt K, Wong CL, Haas B. A qualitative study of older adult trauma survivors' experiences in acute care and early recovery. CMAJ Open 2023; 11:E323-E328. [PMID: 37041014 PMCID: PMC10095264 DOI: 10.9778/cmajo.20220013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Older adults (aged ≥ 65 yr) account for a substantial proportion of hospital admissions for severe injury, yet little is known about their care experiences and views regarding outcomes. We sought to characterize the acute care and early recovery experiences of older adults who had been discharged after traumatic injury, with a long-term goal to inform the selection of patient-centred process and outcome measures in geriatric trauma. METHODS From June 2018 to September 2019, we conducted telephone interviews with adults aged 65 years or older who had been discharged after traumatic injury within 6 months from Sunnybrook or London Health Sciences Centres in Ontario, Canada. Using interpretive description and thematic analysis, we drew on social science theories of illness and aging for data interpretation. We analyzed data to the point of theoretical saturation. RESULTS We interviewed 25 trauma survivors aged 65-88 years. Most were injured in a fall. Four themes characterized participants' experiences, as follows: "I don't feel like a senior" (i.e., participants disliked being viewed as a senior or as needing senior-specific care); "don't bother telling him anything" (i.e., participants perceived ageist assumptions and treatment in acute care processes); getting back to normal (i.e., participants emphasized their active lifestyles and functional recovery as goals of care); "I have lost control of my life" (i.e., substantial social and personal losses linked to participants' experiences and adaptations to aging generally). INTERPRETATION Findings suggest that older adults experience social and personal loss after injury, and underscore how implicit age bias may influence care experiences and outcomes. This can inform improvements in injury care and guide providers in the selection of patient-centred outcome measures.
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Affiliation(s)
- Lesley Gotlib Conn
- Sunnybrook Research Institute (Gotlib Conn, Nathens, Scales, Haas), Sunnybrook Health Sciences Centre; Departments of Anthropology (Gotlib Conn) and Surgery (Nathens, Haas), and Interdepartmental Division of Critical Care (Scales, Haas), University of Toronto, Toronto, Ont.; London Health Sciences Centre (Vogt); Department of Surgery (Vogt), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Wong), St Michael's Hospital; Department of Medicine (Wong), University of Toronto, Toronto, Ont.
| | - Avery B Nathens
- Sunnybrook Research Institute (Gotlib Conn, Nathens, Scales, Haas), Sunnybrook Health Sciences Centre; Departments of Anthropology (Gotlib Conn) and Surgery (Nathens, Haas), and Interdepartmental Division of Critical Care (Scales, Haas), University of Toronto, Toronto, Ont.; London Health Sciences Centre (Vogt); Department of Surgery (Vogt), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Wong), St Michael's Hospital; Department of Medicine (Wong), University of Toronto, Toronto, Ont
| | - Damon C Scales
- Sunnybrook Research Institute (Gotlib Conn, Nathens, Scales, Haas), Sunnybrook Health Sciences Centre; Departments of Anthropology (Gotlib Conn) and Surgery (Nathens, Haas), and Interdepartmental Division of Critical Care (Scales, Haas), University of Toronto, Toronto, Ont.; London Health Sciences Centre (Vogt); Department of Surgery (Vogt), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Wong), St Michael's Hospital; Department of Medicine (Wong), University of Toronto, Toronto, Ont
| | - Kelly Vogt
- Sunnybrook Research Institute (Gotlib Conn, Nathens, Scales, Haas), Sunnybrook Health Sciences Centre; Departments of Anthropology (Gotlib Conn) and Surgery (Nathens, Haas), and Interdepartmental Division of Critical Care (Scales, Haas), University of Toronto, Toronto, Ont.; London Health Sciences Centre (Vogt); Department of Surgery (Vogt), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Wong), St Michael's Hospital; Department of Medicine (Wong), University of Toronto, Toronto, Ont
| | - Camilla L Wong
- Sunnybrook Research Institute (Gotlib Conn, Nathens, Scales, Haas), Sunnybrook Health Sciences Centre; Departments of Anthropology (Gotlib Conn) and Surgery (Nathens, Haas), and Interdepartmental Division of Critical Care (Scales, Haas), University of Toronto, Toronto, Ont.; London Health Sciences Centre (Vogt); Department of Surgery (Vogt), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Wong), St Michael's Hospital; Department of Medicine (Wong), University of Toronto, Toronto, Ont
| | - Barbara Haas
- Sunnybrook Research Institute (Gotlib Conn, Nathens, Scales, Haas), Sunnybrook Health Sciences Centre; Departments of Anthropology (Gotlib Conn) and Surgery (Nathens, Haas), and Interdepartmental Division of Critical Care (Scales, Haas), University of Toronto, Toronto, Ont.; London Health Sciences Centre (Vogt); Department of Surgery (Vogt), Western University, London, Ont.; Li Ka Shing Knowledge Institute (Wong), St Michael's Hospital; Department of Medicine (Wong), University of Toronto, Toronto, Ont
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19
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Newgard CD, Lin A, Malveau S, Cook JNB, Smith M, Kuppermann N, Remick KE, Gausche-Hill M, Goldhaber-Fiebert J, Burd RS, Hewes HA, Salvi A, Xin H, Ames SG, Jenkins PC, Marin J, Hansen M, Glass NE, Nathens AB, McConnell KJ, Dai M, Carr B, Ford R, Yanez D, Babcock SR, Lang B, Mann NC. Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care. JAMA Netw Open 2023; 6:e2250941. [PMID: 36637819 PMCID: PMC9857584 DOI: 10.1001/jamanetworkopen.2022.50941] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. OBJECTIVE To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. EXPOSURE ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. RESULTS There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. CONCLUSIONS AND RELEVANCE These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.
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Affiliation(s)
- Craig D. Newgard
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Susan Malveau
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - McKenna Smith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Katherine E. Remick
- Department of Pediatric, Dell Medical School, University of Texas at Austin, Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, California
| | - Jeremy Goldhaber-Fiebert
- Centers for Health Policy, Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children’s National Hospital, Washington, DC
| | - Hilary A. Hewes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Apoorva Salvi
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Haichang Xin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Jennifer Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew Hansen
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K. John McConnell
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Mengtao Dai
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Brendan Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel Ford
- Oregon Emergency Medical Services for Children Program, Oregon Health Authority, Portland
| | - Davis Yanez
- Department of Anesthesia, Yale School of Medicine, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Sean R. Babcock
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Benjamin Lang
- Department of Pediatric, Dell Medical School, University of Texas at Austin, Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
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20
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Thomas AC, Campbell BT, Subacius H, Orlas CP, Bulger E, Stewart RM, Stey AM, Jang A, Hamad D, Bilimoria KY, Nathens AB. National evaluation of the association between stay-at-home orders on mechanism of injury and trauma admission volume. Injury 2022; 53:3655-3662. [PMID: 36167686 PMCID: PMC9467931 DOI: 10.1016/j.injury.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/11/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The COVID-19 pandemic had numerous negative effects on the US healthcare system. Many states implemented stay-at-home (SAH) orders to slow COVID-19 virus transmission. We measured the association between SAH orders on the injury mechanism type and volume of trauma center admissions during the first wave of the COVID-19 pandemic. METHODS All trauma patients aged 16 years and older who were treated at the American College of Surgeons Trauma Quality Improvement Program participating centers from January 2018-September 2020. Weekly trauma patient volume, patient demographics, and injury characteristics were compared across the corresponding SAH time periods from each year. Patient volume was modeled using harmonic regression with a random hospital effect. RESULTS There were 166,773 patients admitted in 2020 after a SAH order and an average of 160,962 patients were treated over the corresponding periods in 2018-2019 in 474 centers. Patients presenting with a pre-existing condition of alcohol misuse increased (13,611 (8.3%) vs. 10,440 (6.6%), p <0.001). Assault injuries increased (19,056 (11.4%) vs. 15,605 (9.8%)) and firearm-related injuries (14,246 (8.5%) vs. 10,316 (6.4%)), p<0.001. Firearm-specific assault injuries increased (10,748 (75.5%) vs. 7,600 (74.0%)) as did firearm-specific unintentional injuries (1,318 (9.3%) vs. 830 (8.1%), p<0.001. In the month preceding the SAH orders, trauma center admissions decreased. Within a week of SAH implementation, hospital admissions increased (p<0.001) until a plateau occurred 10 weeks later above predicted levels. On regional sub-analysis, admission volume remained significantly elevated for the Midwest during weeks 11-25 after SAH order implementation, (p<0.001).
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Affiliation(s)
- Arielle C. Thomas
- Medical College of Wisconsin, Milwaukee, WI, USA,American College of Surgeons, Chicago, IL, USA,Corresponding author at: Medical College of Wisconsin, Milwaukee, WI, USA
| | - Brendan T. Campbell
- American College of Surgeons, Chicago, IL, USA,Department of Pediatric Surgery, Connecticut Children's Medical Center and University of Connecticut School of Medicine, Hartford, CT, USA
| | - Haris Subacius
- American College of Surgeons, Chicago, IL, USA,Society of Thoracic Surgeons, Chicago, IL, USA
| | - Claudia P. Orlas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eileen Bulger
- American College of Surgeons, Chicago, IL, USA,Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ronald M. Stewart
- American College of Surgeons, Chicago, IL, USA,Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Anne M. Stey
- Medical College of Wisconsin, Milwaukee, WI, USA,American College of Surgeons, Chicago, IL, USA
| | - Angie Jang
- Northwestern University, Chicago, IL, USA
| | - Doulia Hamad
- Department of Surgery, Sunnybrook Health Sciences Center and the University of Toronto, Canada
| | - Karl Y. Bilimoria
- Medical College of Wisconsin, Milwaukee, WI, USA,American College of Surgeons, Chicago, IL, USA
| | - Avery B. Nathens
- American College of Surgeons, Chicago, IL, USA,Department of Surgery, Sunnybrook Health Sciences Center and the University of Toronto, Canada
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21
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Zwaiman A, da Luz LT, Perrier L, Hacker Teper M, Strauss R, Harth T, Haas B, Nathens AB, Gotlib Conn L. The involvement of trauma survivors in hospital-based injury prevention, violence intervention and peer support programs: A scoping review. Injury 2022; 53:2704-2716. [PMID: 35773023 DOI: 10.1016/j.injury.2022.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/26/2022] [Accepted: 06/20/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite decades-long involvement of trauma survivors in hospital-based program delivery, their roles and impact on trauma care have not been previously described. We aimed to characterize the literature on trauma survivor involvement in hospital-based injury prevention, violence intervention and peer support programs to map what is currently known and identify future research opportunities. METHODS A scoping review was conducted following the Joanna Briggs Institute (JBI) methodology. Articles were identified through electronic databases and gray literature. Included articles described hospital-based injury prevention programs, violence intervention programs and peer support programs that involved trauma survivors leveraging their injury experiences to counsel others. Studies were screened and data were abstracted in duplicate. Data were synthesized generally and by program type. RESULTS Thirty-six published articles and four program reports were included. Peer support programs were described in 21 articles, mainly involving trauma survivors as mentors or peer supporters. Peer support programs' most commonly reported outcome was participant satisfaction (n = 6), followed by participant self-efficacy (n = 5), depression (n = 4), and community integration (n = 3). Eleven injury prevention studies were included, all involving trauma survivors as speakers in youth targeted programs. Injury prevention studies commonly reported outcomes of participants' risk behaviors and awareness (n = 9). Violence intervention programs were included in four articles involving trauma survivors as intervention counsellors. Recidivism rate was the most commonly reported outcome (n = 3). Variability exists across and within program types when reporting on involved trauma survivors' gender, age, selection and training, duration of involvement and number of survivors involved. Outcomes related to trauma survivors' own experiences and the impacts to them of program involvement were under-studied. CONCLUSIONS Significant opportunity exists to fill current knowledge gaps in trauma survivors' involvement in trauma program delivery. There is a need to describe more fully who involved trauma survivors are to inform the development of effective future interventions.
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Affiliation(s)
- Ashley Zwaiman
- University of Toronto, 27 King's College Cir, Toronto, ON M5S 1A1 Canada
| | - Luis T da Luz
- Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
| | - Laure Perrier
- University Health Network, 190 Elizabeth St, Toronto, ON M5G 2C4, Canada
| | | | - Rachel Strauss
- Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
| | - Tamara Harth
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
| | - Barbara Haas
- Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 5 College St 4th Floor, Toronto, ON M5T 3M6 Canada
| | - Avery B Nathens
- Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 5 College St 4th Floor, Toronto, ON M5T 3M6 Canada
| | - Lesley Gotlib Conn
- Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 5 College St 4th Floor, Toronto, ON M5T 3M6 Canada.
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22
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Ko CY, Shah T, Nelson H, Nathens AB. Developing the American College of Surgeons Quality Improvement Framework to Evaluate Local Surgical Improvement Efforts. JAMA Surg 2022; 157:737-739. [PMID: 35704310 PMCID: PMC9201737 DOI: 10.1001/jamasurg.2022.1826] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, University of California, Los Angeles, Los Angeles
| | - Tejen Shah
- Department of Surgery, The Ohio State University, Columbus
| | - Heidi Nelson
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Avery B Nathens
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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23
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Bhangu A, Notario L, Pinto RL, Pannell D, Thomas-Boaz W, Freedman C, Tien H, Nathens AB, da Luz L. Closed loop communication in the trauma bay: identifying opportunities for team performance improvement through a video review analysis. CAN J EMERG MED 2022; 24:419-425. [PMID: 35412259 PMCID: PMC9002216 DOI: 10.1007/s43678-022-00295-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/09/2022] [Indexed: 01/17/2023]
Abstract
Objectives Communication among trauma team members in the trauma bay is vulnerable to errors, which may impact patient outcomes. We used the previously validated trauma-non-technical skills (T-NOTECHS) tool to identify communication gaps during patient management in the trauma bay and to inform development strategies to improve team performance. Methods Two reviewers independently assessed non-technical skills of team members through video footage at Sunnybrook Health Sciences Centre. Team performance was measured using T-NOTECHS across five domains using a five-point Likert scale (lower score indicating worse performance): (1) leadership; (2) cooperation and resource management; (3) communication and interaction; (4) assessment and decision making; (5) situation awareness/coping with stress. Secondary outcomes assessed the number of callouts, closed loop communications and parallel conversations. Results The study included 55 trauma activations. Injury severity score (ISS) was used as a measure of trauma severity. A case with an ISS score ≥ 16 was considered severe. ISS was ≥ 16 in 37% of cases. Communication and interaction scored significantly lower compared to all other domains (p < 0.0001). There were significantly more callouts and completed closed loop communications in more severe cases compared to less severe cases (p = 0.017 for both). Incomplete closed loop communications and parallel conversations were identified, irrespective of case severity. Conclusion A lower communication score was identified using T-NOTECHS, attributed to incomplete closed loop communications and parallel conversations. Through video review of trauma team activations, opportunities for improvement in communication can be identified by the T-NOTECHS tool, as well as specifically identifying callouts and closed loop communication. This process may be useful for trauma programs as part of a quality improvement program on communication skills and team performance. Supplementary Information The online version contains supplementary material available at 10.1007/s43678-022-00295-z.
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Affiliation(s)
- Avneesh Bhangu
- School of Medicine, Faculty of Health Sciences, Queen's University, Unit 505 - 91 King Street East, Kingston, ON, K7L 2Z8, Canada.
| | - Lowyl Notario
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Tory Regional Trauma Program and the Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ruxandra L Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Dylan Pannell
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Will Thomas-Boaz
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Tory Regional Trauma Program and the Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Corey Freedman
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Tory Regional Trauma Program and the Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Homer Tien
- 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.,, Ornge, Mississauga, ON, Canada
| | - Avery B Nathens
- 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.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Luis da Luz
- 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
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24
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Thomas AC, Campbell BT, Subacius H, Bilimoria KY, Stey AM, Hamad D, Nasca B, Nathens AB. Time to OR for patients with abdominal gunshot wounds: A potential process measure to assess the quality of trauma care? J Trauma Acute Care Surg 2022; 92:708-716. [PMID: 35001021 DOI: 10.1097/ta.0000000000003511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abdominal gunshot wounds (GSWs) require rapid assessment and operative intervention to reduce the risk of death and complications. We sought to determine if time to the operating room (OR) might be a useful process measure for the assessment of trauma care quality. We evaluated the facility benchmark time to OR for patients with serious injury and whether this was associated with lower rates of complications and mortality. METHODS We evaluated time to OR for adult patients with an abdominal GSW presenting in shock to American College of Surgeons Trauma Quality Improvement Program centers from 2015 to 2020. We calculated the 75th percentile time to the OR for each center and characterized centers as average, slow, or fast. We compared patient and facility characteristics across outlier status, as well as risk-adjusted complications and mortality using hierarchical multivariable logistic regression models. RESULTS There were 4,027 patients in 230 centers that met the inclusion criteria. Mortality was 28%. There were 61 (27%) fast and 52 (23%) slow centers. The median time for slow centers was 83 minutes (68-94 minutes) compared with fast centers, 35 minutes (32-38 minutes). Injury Severity Score and emergency department vital signs were similar across centers. Fast hospitals had higher total case volumes, more cases per surgeon, and were more likely to be Level I centers. Patients cared for in these centers had similar risk-adjusted rates of complications and mortality. CONCLUSION Time to OR for patients with abdominal GSWs and shock might be a useful process measure to evaluate rapid decision making and OR access. Surgeon and center experience as measured by annual case volumes, coupled with a rapid surgical response required through Level I trauma center standards might be contributory. There was no association between outlier status and complications or mortality suggesting other factors apart from time to the OR are of greater significance. LEVEL OF EVIDENCE Therapeutic/care management, Level IV.
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Affiliation(s)
- Arielle C Thomas
- From the Department of Surgery, Feinberg School of Medicine (A.T., K.B., A.M.S., B.N.), Northwestern University; Committee on Trauma, American College of Surgeons (A.T., H.S., K.B., A.B.N.), Chicago, Illinois; Department of Surgery (B.C.), University of Connecticut, Mansfield, Connecticut; and Department of Surgery (D.H., A.B.N.), Sunnybrook Health Sciences Center and the University of Toronto, Canada
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25
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Tillmann BW, Guttman MP, Nathens AB, de Mestral C, Kayssi A, Haas B. Author's reply. J Trauma Acute Care Surg 2022; 92:e77-e78. [PMID: 34936594 DOI: 10.1097/ta.0000000000003510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Forner D, Noel CW, Guttman MP, Haas B, Enepekides D, Rigby MH, Taylor SM, Nathens AB, Eskander A. Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:4131-4141. [PMID: 35320370 DOI: 10.1007/s00068-022-01950-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma. METHODS This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized. RESULTS In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile. CONCLUSION Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.
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Affiliation(s)
- David Forner
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christopher W Noel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barbara Haas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Danny Enepekides
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 047, Toronto, ON, M4N 3M5, Canada
| | - Matthew H Rigby
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - S Mark Taylor
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - Avery B Nathens
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Antoine Eskander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Otolaryngology, Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 047, Toronto, ON, M4N 3M5, Canada.
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Hamad DM, Mandell SP, Stewart RM, Patel B, Guttman MP, Williams P, Thomas A, Jerath A, Bulger EM, Nathens AB. Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting system. J Trauma Acute Care Surg 2022; 92:473-480. [PMID: 34840270 DOI: 10.1097/ta.0000000000003485] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Twenty years ago, the landmark report To Err Is Human illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Nevertheless, rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program developed a voluntary Mortality Reporting System to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths. The objective of this work is to describe the factors contributing to potentially preventable deaths after injury and to evaluate the effectiveness of strategies identified by trauma centers to mitigate future harm, as reported in the Mortality Reporting System. METHODS An anonymous structured web-based reporting template based on the Joint Commission on Accreditation of Healthcare Organizations taxonomy was made available to trauma centers participating in the Trauma Quality Improvement Program to allow for reporting of deaths that were potentially preventable. Contributing factors leading to death were evaluated. The effectiveness of mitigating strategies was assessed using a validated framework and mapped to tiers of effectiveness ranging from person-focused to system-oriented interventions. RESULTS Over a 2-year period, 395 deaths were reviewed. Of the mortalities, 33.7% were unanticipated. Errors pertained to management (50.9%), clinical performance (54.7%), and communication (56.2%). Human failures were cited in 61% of cases. Person-focused strategies like education were common (56.0%), while more effective system-based strategies were seldom used. In 7.3% of cases, centers could not identify a specific strategy to prevent future harm. CONCLUSION Most strategies to reduce errors in trauma centers focus on changing the performance of providers rather than system-level interventions such as automation, standardization, and fail-safe approaches. Centers require additional support to develop more effective mitigations that will prevent recurrent errors and patient harm. LEVEL OF EVIDENCE Therapeutic/Care Management, level V.
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Affiliation(s)
- Doulia M Hamad
- From the Department of Surgery (D.M.H., M.P.G., P.W., A.B.N.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Department of Surgery (S.P.M.), UT Southwestern Medical Center, Dallas, Texas; Department of Surgery (R.M.S.), University of Texas Health Science Center, San Antonio, Texas; Trauma Quality Improvement Program (B.P., A.T., A.B.N.), American College of Surgeons, Chicago, Illinois; Feinberg School of Medicine (A.T.), Northwestern University, Chicago, Illinois; Department of Anesthesia (A.J.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; and Division of Trauma, Critical Care and Burn Surgery (E.M.B.), University of Washington, Seattle, Washington
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Guttman MP, Haas B, Kim M, Mador B, Nathens AB, Ahmed N, Wheeler S, Gotlib Conn L. Innovative curriculum is needed to address residents' attitudes toward older adults: the case of geriatric trauma. BMC Med Educ 2022; 22:130. [PMID: 35219294 PMCID: PMC8881881 DOI: 10.1186/s12909-022-03196-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 02/15/2022] [Indexed: 06/08/2023]
Abstract
BACKGROUND Medical trainees' negative perceptions towards older adult care have been widely reported, catalyzing targeted curricula in geriatric medicine. Little is known about surgical residents' attitudes toward and perceptions of the educational value of caring for injured older adults. This information is needed to ensure the surgical workforce is adequately trained to care for this growing patient population. In this study, we assessed surgical trainees' attitudes towards geriatric trauma care to inform a curriculum in geriatric trauma. METHODS We surveyed North American general surgery trainees' beliefs and attitudes toward caring for older trauma patients, and the educational value they ascribed to learning about older trauma patient care. Descriptive statistics were used to report participant characteristics and responses. RESULTS Three hundred general surgery trainees from 94 post-graduate programs responded. Respondents reported too much time co-ordinating care (56%), managing non-operative patients (56%), and discharge planning (65%), all activities important to the care of older trauma patients. They recognized the importance of geriatric trauma care for their future careers (52%) but were least interested in reading about managing geriatric trauma patients (28%). When asked to rank clinical vignettes by educational value, respondents ranked the case of an older adult as least interesting (74%). As respondents progressed through their training, they reported less interest in geriatric trauma care. CONCLUSIONS Our survey results demonstrate the generally negative attitudes and beliefs held by postgraduate surgical trainees towards the care of older adult trauma patients. Future work should focus on identifying specific changes to the postgraduate surgical curriculum which can effectively alter these attitudes and beliefs and improve the care for injured older adults.
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Affiliation(s)
- Matthew P Guttman
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Haas
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Michael Kim
- Department of Surgery, University of Alberta, Alberta, Canada
| | - Brett Mador
- Department of Surgery, University of Alberta, Alberta, Canada
| | - Avery B Nathens
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- American College of Surgeons, Chicago, IL, United States
| | - Najma Ahmed
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Sarah Wheeler
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Ontario Health, Toronto, Ontario, Canada
| | - Lesley Gotlib Conn
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
- Sunnybrook Research Institute, Toronto, Ontario, Canada.
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Jacob-Brassard J, Al-Omran M, Haas B, Nathens AB, Gomez D, Dueck AD, Forbes TL, de Mestral C. A multicenter retrospective cohort study of blunt traumatic injury to the common or internal carotid arteries. Injury 2022; 53:152-159. [PMID: 34376278 DOI: 10.1016/j.injury.2021.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Current EAST guidelines recommend against routine carotid intervention for patients with blunt carotid artery injury (BCI), but offer limited information on its role for BCI patients presenting with neurological deficit. Our goal was to describe the contemporary management and outcomes of patients presenting with BCI and neurological deficit unrelated to head injury. METHODS We identified all adults who sustained a BCI between 2010 and 2017 in the American College of Surgeons Trauma Quality Improvement Program. We extracted patient demographics, injury characteristics (carotid and non-carotid), as well as the frequency, timing and approach of carotid intervention. Presence of neurological deficit unrelated to head injury at presentation was determined using Abbreviated Injury Scale codes. The main outcomes were in-hospital mortality and home discharge. Patients with and without neurological deficit at presentation were compared through multivariable logistic regression modeling. Among those with neurological deficit at presentation, the associations between carotid intervention (open or endovascular) and the outcomes were also assessed through multivariable logistic regression. RESULTS We identified 5,788 patients with BCI of whom 383 (7%) presented with neurological deficit unrelated to head injury. Among the 296 patients (5%) who underwent carotid intervention, 36 (12%) had presented with neurological deficit unrelated to head injury. Interventions were most often endovascular (68% [200/296]) and within a median time of 32 h (IQR 5-203). In-hospital mortality was 16% (918/5,788), and in-hospital stroke prevalence was 6% (336/5,788). When comparing patients with and without neurological deficit at presentation, those with deficits were more frequently managed with an intervention. After adjustment, the likelihood of mortality was higher (OR [95% CI] = 2.16 [1.63-2.85]) and the likelihood of home discharge lower (OR [95% CI] = 0.29 [0.21-0.40]) among patients presenting with neurological deficit. Among those with neurological deficit, carotid intervention was positively associated with home discharge (OR [95% CI] = 2.96 [1.21-7.23]), but not with in-hospital mortality (OR [95% CI] = 0.87 [0.36-2.10]). Results were similar in the subgroup of patients with isolated BCI (2,971/5,788). CONCLUSIONS Intervention in BCI patients presenting with neurological deficit may contribute to a greater likelihood of home discharge but not reduced in-hospital mortality.
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Affiliation(s)
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Avery B Nathens
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - David Gomez
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | - Andrew D Dueck
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Thomas L Forbes
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
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Byrne JP, Witiw CD, Schuster JM, Pascual JL, Cannon JW, Martin ND, Reilly PM, Nathens AB, Seamon MJ. Association of Venous Thromboembolism Prophylaxis After Neurosurgical Intervention for Traumatic Brain Injury With Thromboembolic Complications, Repeated Neurosurgery, and Mortality. JAMA Surg 2021; 157:e215794. [PMID: 34910096 DOI: 10.1001/jamasurg.2021.5794] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance There is a lack of evidence regarding the effectiveness and safety of pharmacologic venous thromboembolism (VTE) prophylaxis among patients who undergo neurosurgical interventions for traumatic brain injury (TBI). Objective To measure the association between timing of VTE prophylaxis after urgent neurosurgical intervention for TBI and thromboembolic and intracranial complications. Design, Setting, and Participants This retrospective cohort study included adult patients (aged ≥16 years) who underwent urgent neurosurgical interventions (craniotomy/craniectomy or intracranial monitor/drain insertion within 24 hours after admission) for TBI at level 1 and 2 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program between January 1, 2012, and December 31, 2016. Data were analyzed from January to August 2020. Exposures Timing of pharmacologic VTE prophylaxis initiation after urgent neurosurgical intervention (prophylaxis delay) measured in days (24-hour periods). Main Outcomes and Measures The primary outcome was VTE (deep vein thrombosis or pulmonary embolism). Secondary outcomes were repeated neurosurgery (neurosurgical reintervention after initiation of VTE prophylaxis) and mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis delay and each outcome at the patient level and were adjusted for patient baseline and injury characteristics. Results The study included 4951 patients (3676 [74%] male; median age, 50 years [IQR, 31-64 years]) who underwent urgent neurosurgical intervention for TBI at 304 trauma centers. The median prophylaxis delay was 3 days (IQR, 1-5 days). After adjustment for patient baseline and injury characteristics, prophylaxis delay was associated with increased odds of VTE (adjusted odds ratio [aOR], 1.08 per day; 95% CI, 1.04-1.12). Earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. During the first 3 days, each additional day of prophylaxis delay was associated with a 28% decrease in odds of repeated neurosurgery (aOR, 0.72 per day; 95% CI, 0.59-0.88). After 3 days, each additional day of prophylaxis delay was associated with an additional 15% decrease in odds of repeated neurosurgery (aOR, 0.85 per day; 95% CI, 0.80-0.90). Earlier prophylaxis was associated with greater mortality among patients who initially underwent intracranial monitor/drain procedures, such that each additional day of prophylaxis delay was associated with decreased odds of death (aOR, 0.94 per day; 95% CI, 0.89-0.99). Conclusions and Relevance In this cohort study of patients who underwent urgent neurosurgical interventions for TBI, early pharmacologic VTE prophylaxis was associated with reduced risk of thromboembolism. However, earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. These findings suggest that although timely initiation of prophylaxis should be prioritized, caution should be used particularly during the first 3 days after the index procedure, when this risk appears to be highest.
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Affiliation(s)
- James P Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher D Witiw
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James M Schuster
- Department of Neurosurgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jose L Pascual
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Rutka JT, Fleshner N, Nathens AB. Re: Jeremy Yuen-Chun Teoh, Daniele Castellani, Claudia Mercader, et al. A Quantitative Analysis Investigating the Prevalence of "Manels" in Major Urology Meetings. Euro Urol 2021;80:442-9. Eur Urol 2021; 81:e51. [PMID: 34872785 DOI: 10.1016/j.eururo.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/12/2021] [Indexed: 11/26/2022]
Affiliation(s)
- James T Rutka
- Division of Neurosurgery, Department of Surgery, Temerty Medicine, University of Toronto, Toronto, Canada.
| | - Neil Fleshner
- Division of Urology, Department of Surgery, Temerty Medicine, University of Toronto, Toronto, Canada
| | - Avery B Nathens
- Division of General Surgery, Department of Surgery, Temerty Medicine, University of Toronto, Toronto, Canada
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Lin S, Nolan B, Dashi G, Nathens AB. The relative importance of clinical factors in initiating interfacility transfer of major trauma patients: A discrete choice experiment. Trauma 2021. [DOI: 10.1177/14604086211031744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction and Objectives Approximately 30% of patients meeting severe injury criteria are never transferred to lead trauma centers (LTCs). The reasons for this gap are not fully understood but involve both system-level factors and individual decision-making. We used a method called discrete choice modeling (DCM) to evaluate which clinical and demographic patient factors might make emergency physicians more likely to initiate transfers to LTCs. Methods An email survey was distributed to physicians working in emergency departments (EDs) in Ontario. The relative importance of clinical and demographic patient attributes as drivers for transfer was evaluated using DCM. Simulated patient cases were created using a random generator to combine attributes. Each respondent was presented with 36 different patients in sets of three and asked if they would transfer each patient to an LTC. The relative importance of each driver was then compared across physician characteristics. Results One hundred and fifty three emergency physicians completed the survey. The drivers for transfer, expressed as utility scores, were derangements in hemodynamics (22), CNS/head injuries (19), pelvic fractures (11), chest injuries (10), comorbidities (9), abdominal injuries (8), extremity injuries (7), mechanism of injury (7), age (5), and gender (2). Drivers for patient transfer did not differ based on physician experience or type of training. Conclusion In this DCM study, the clinical and demographic factors most likely to make emergency physicians consider patient transfers to LTCs were patient hemodynamic derangements and CNS/head injuries. Overall, these drivers did not differ by physician experience or training. An understanding of such patient-level drivers for transfers to LTCs may improve the implementation of evidence-based interfacility transfer criteria.
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Affiliation(s)
- Steve Lin
- Department of Emergency Medicine, Unity Health Toronto, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Brodie Nolan
- Department of Emergency Medicine, Unity Health Toronto, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gerhard Dashi
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Avery B Nathens
- Department Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department Surgery, University of Toronto, Toronto, ON, Canada
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Evans LL, Melhado C, Miskovic A, Subacius H, Stein DM, Burd RS, Nathens AB, Jensen AR. Benchmarking Pediatric Trauma Care in Mixed Trauma Centers: Center-Specific Risk-Adjusted Mortality Is Frequently Discordant Between Pediatric and Adult Cohorts. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hamad DM, Guttman MP, Thomas A, Haas B, Nathens AB. Timely Intubation in Severe Traumatic Brain Injury: An Indicator of Trauma Center Performance. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Guttman MP, Tillmann BW, Nathens AB, Saskin R, Bronskill SE, Huang A, Haas B. Long-term survival in high-risk older adults following emergency general surgery admission. J Trauma Acute Care Surg 2021; 91:634-640. [PMID: 34252059 DOI: 10.1097/ta.0000000000003346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions. METHODS We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups. RESULTS A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation. CONCLUSION Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Matthew P Guttman
- From the Sunnybrook Health Sciences Centre (M.P.G., BWT, ABN, BH); Institute of Health Policy, Management, and Evaluation (M.P.G., B.W.T., A.B.N., R.S., S.E.B., B.H.), Department of Surgery (M.P.G., A.B.N., B.H.), and Interdepartmental Division of Critical Care Medicine, Department of Medicine (B.W.T., B.H.), University of Toronto; Sunnybrook Research Institute (A.B.N., S.E.B., B.H.), Toronto, Ontario, Canada; American College of Surgeons (A.B.N.), Chicago, Illinois; and ICES (A.B.N., R.S., S.E.B., A.H., B.H.), Toronto, Ontario, Canada
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da Luz LT, Callum J, Beckett A, Hucke HP, Carroll J, Grewal D, Schwartz B, Peng H, Engels PT, Parry N, Petrosoniak A, Tien H, Nathens AB, Scales D, Karkouti K. Protocol for a multicentre, randomised, parallel-control, superiority trial comparing administration of clotting factor concentrates with a standard massive haemorrhage protocol in severely bleeding trauma patients: the FiiRST 2 trial (a 2020 EAST multicentre trial). BMJ Open 2021; 11:e051003. [PMID: 34479938 PMCID: PMC8420689 DOI: 10.1136/bmjopen-2021-051003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Acute traumatic coagulopathy (ATC) in bleeding trauma patients increase in-hospital mortality. Fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC) are two purified concentrates of clotting factors that have been used to treat ATC. However, there is a knowledge gap on their use compared with the standard of care, the transfusion of plasma. METHODS AND ANALYSIS The factors in the initial resuscitation of severe trauma 2 trial is a multicentre, randomised, parallel-control, single-blinded, phase IV superiority trial. The study aims to address efficacy and safety of the early use of FC and PCC compared with a plasma-based resuscitation. Adult trauma patients requiring massive haemorrhage protocol activation on hospital arrival will receive FC 4 g and PCC 2000 IU or plasma 4 U, based on random allocation. The primary outcome is a composite of the cumulative number of all units of red cells, plasma and platelets transfused within 24 hours following admission. Secondary outcomes include measures of efficacy and safety of the intervention. Enrolment of 350 patients will provide an initial power >80% to demonstrate superiority for the primary outcome. After enrolment of 120 patients, a preplanned adaptive interim analysis will be conducted to reassess assumptions, check for early superiority demonstration or reassess the sample size for remainder of the study. ETHICS AND DISSEMINATION The study has been approved by local and provincial research ethics boards and will be conducted according to the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. As per the Tri-Council Policy Statement, patient consent will be deferred due to the emergency nature of the interventions. If superiority is established, results will have a major impact on clinical practice by reducing exposure to non-virally inactivated blood products, shortening the time for administration of clotting factors, correct coagulopathy more efficaciously and reduce the reliance on AB plasma. TRIAL REGISTRATION NUMBER NCT04534751, pre results.
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Affiliation(s)
- Luis Teodoro da Luz
- General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Transfusion Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- General Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Hans-Peter Hucke
- Ergomed, Center for Data Management and Statistics, Cologne, North Rhine-Westphalia, Germany
| | - Jo Carroll
- Anesthesia, University Health Network, Toronto, Ontario, Canada
| | - Deep Grewal
- Anesthesia, University Health Network, Toronto, Ontario, Canada
| | - Bruce Schwartz
- Research and Development, Octapharma AG, Lachen, Switzerland
| | | | - Paul T Engels
- General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Neil Parry
- General Surgery, London Health Sciences Centre, London, Ontario, Canada
| | | | - Homer Tien
- General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery B Nathens
- General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Damon Scales
- Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Keyvan Karkouti
- Anesthesia, University Health Network, Sinai Health System, and Women's College Hospital, Toronto, Ontario, Canada
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Newgard CD, Lin A, Olson LM, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Malveau S, Smith M, Dai M, Nathens AB, Glass NE, Jenkins PC, McConnell KJ, Remick KE, Hewes H, Mann NC. Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers. JAMA Pediatr 2021; 175:947-956. [PMID: 34096991 PMCID: PMC8185631 DOI: 10.1001/jamapediatrics.2021.1319] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/25/2021] [Indexed: 01/20/2023]
Abstract
Importance The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers. Objective To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers. Design, Setting, and Participants A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources. Exposures Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment. Main Outcomes and Measures In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100. Results There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers. Conclusions and Relevance In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Lenora M. Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | | | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care, and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - McKenna Smith
- Department of Biostatistics, The University of Utah School of Medicine, Salt Lake City
| | - Mengtao Dai
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - K. John McConnell
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Katherine E. Remick
- Departments of Pediatrics and Surgery, Dell Medical School, The University of Texas at Austin
| | - Hilary Hewes
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - N. Clay Mann
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Tillmann BW, Guttman MP, Nathens AB, de Mestral C, Kayssi A, Haas B. The timing of amputation of mangled lower extremities does not predict post-injury outcomes and mortality: A retrospective analysis from the ACS TQIP database. J Trauma Acute Care Surg 2021; 91:447-456. [PMID: 34039934 DOI: 10.1097/ta.0000000000003302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While limb salvage does not result in improved functional outcomes among patients with a mangled lower extremity, the impact of attempted limb salvage on mortality and complications is poorly understood. The objective of this study was to evaluate the relationship between attempted limb salvage and in-hospital outcomes among patients with a mangled lower extremity. METHODS We performed a retrospective cohort study of adults, 16 years or older, with a mangled lower extremity. Data were derived from the American College of Surgeons' Trauma Quality Improvement Program (2012-2017). We compared mortality, complications (severe sepsis, acute kidney injury [AKI], decubitus ulcers) and length of stay between patients managed with the intention of limb salvage (amputation beyond 24 hours or no amputation) and those who underwent early amputation (within 24 hours of presentation). Instrumental variable analysis was used to evaluate the relationship between management strategy and outcomes. RESULTS We identified 5,527 patients with a mangled lower extremity, of which 901 (16.3%) underwent early amputation. Among those managed with attempted limb salvage, 42.5% underwent amputation prior to discharge. After adjusting for patient and hospital characteristics, there was no association between initial management strategy and mortality (odds ratio, 1.20; 95% confidence interval [CI], 0.83-1.74 early amputation vs. attempted limb salvage). Early amputation was associated with lower odds of AKI (OR, 0.59; 95% CI, 0.39-0.88) and a trend toward shorter length of stay (relative risk, 0.77; 95% CI, 0.52-1.14). CONCLUSION Over half of patients who sustain a mangled lower extremity undergo amputation during their initial hospital course. While a limb salvage strategy is associated with an elevated risk of AKI, there is no association between attempted limb preservation and mortality. These findings suggest that in patients in which there is no clear indication for early amputation, attempts at limb salvage do not come at the cost of increased mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Bourke W Tillmann
- From the Institute of Health Policy, Management, and Evaluation (B.W.T., M.P.G., A.B.N., B.H.), University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine (B.W.T., B.H.), University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine (B.W.T., B.H.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery (M.P.G., A.B.N., C.dM., A.K., B.H.), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute (A.B.N., A.K., B.H.), Toronto, Ontario, Canada; Division of Vascular Surgery (C.dM.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; and Division of Vascular Surgery (A.K.), Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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40
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Balas M, Prömmel P, Nguyen L, Jack A, Lebovic G, Badhiwala JH, Da Costa L, Nathens AB, Fehlings MG, Wilson JR, Witiw CD. The Reality of Accomplishing Surgery Within 24 hours for Complete Cervical Spinal Cord Injury: Clinical Practices and Safety. J Neurotrauma 2021; 38:3011-3019. [PMID: 34382411 DOI: 10.1089/neu.2021.0177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Substantial clinical data supports an association between superior neurological outcomes and early (within 24 hours) surgical decompression for those with traumatic cervical spinal cord injury (SCI). Despite this, much discussion persists around feasibility and safety of this time threshold, particularly for those with a complete cervical SCI. This study aims to assess clinical practices and the safety profile of early surgery across a large sample of North American trauma centers. Data was derived from the Trauma Quality Improvement Program database from 2010-2016. Adult patients with a complete cervical SCI (ASIA A) who underwent surgery were included. Patients were stratified into those receiving surgery at or before 24 hours and those receiving delayed intervention. Risk-adjusted variability in surgical timing across trauma centers was investigated using mixed-effects regression. In-hospital adverse events including mortality, major complications, and immobility-related complications were compared between groups after propensity score matching. 2,862 patients from 353 North American trauma centers were included. 1,760 (61.5%) underwent surgery within 24 hours. Case-mix and hospital-level characteristics explained only 6% of the variability in surgical timing both between-centers and within-centers. No significant differences in adverse events were identified between groups. These findings suggest a relatively large proportion of patients are not receiving surgery within the recommended timeframe, despite apparent safety. Moreover, patient and hospital-level characteristics explain little of the variability in time-to-surgery. Further knowledge translation is needed to increase the proportion of patients in whom surgery is performed before the 24-hour threshold so patients might reach their greatest potential for neurologic recovery.
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Affiliation(s)
- Michael Balas
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, 27 King's College Cirle, Toronto, Ontario, Canada, M5S;
| | - Peter Prömmel
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,Kantonsspital St Gallen, 30883, Department of Neurosurgery, Sankt Gallen, SG, Switzerland;
| | - Laura Nguyen
- University of Ottawa, 6363, School of Medicine, Ottawa, Ontario, Canada;
| | - Andrew Jack
- University of California San Francisco, 8785, Neurological Surgery, 400 Parnassus Ave, San Francisco, California, United States, 94143;
| | - Gerald Lebovic
- St Michael's Hospital Li Ka Shing Knowledge Institute, 518773, Toronto, Ontario, Canada.,University of Toronto Institute of Health Policy Management and Evaluation, 206712, Toronto, Ontario, Canada;
| | - Jetan H Badhiwala
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada;
| | - Leodante Da Costa
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, 71545, Sunnybrook Research Institute, Toronto, Ontario, Canada;
| | - Avery B Nathens
- Sunnybrook Health Sciences Centre, 71545, Sunnybrook Research Institute, Toronto, Ontario, Canada.,University of Toronto, 7938, Division of General Surgery, Department of Surgery, Toronto, Ontario, Canada.,American College of Surgeons, 2417, Medical Director, Trauma Quality Improvement Program, Chicago, Illinois, United States;
| | - Michael G Fehlings
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,Toronto Western Hospital, 26625, Spine Program, Krembil Brain Institute, Toronto, Ontario, Canada;
| | - Jefferson R Wilson
- St Michael's Hospital, 10071, Division of Neurosurgery, Toronto, Ontario, Canada.,St Michael's Hospital, 10071, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.,University of Toronto, 7938, Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada;
| | - Christopher D Witiw
- University of Toronto, 7938, Division of Neurosurgery, Department of Surgery, Toronto, Ontario, Canada.,St Michael's Hospital, 10071, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.,University of Toronto, 7938, Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada;
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41
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Byrne JP, Nance ML, Scantling DR, Holena DN, Kaufman EJ, Nathens AB, Reilly PM, Seamon MJ. Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties. J Trauma Acute Care Surg 2021; 91:84-92. [PMID: 33605706 DOI: 10.1097/ta.0000000000003110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Access to pediatric trauma care is highly variable across the United States. The purpose of this study was to measure the association between pediatric trauma center care and motor vehicle crash (MVC) mortality in children (<15 years) at the US county level for 5 years (2014-2018). METHODS The exposure was defined as the highest level of pediatric trauma care present within each county: (1) pediatric trauma center, (2) adult level 1/2, (3) adult level 3, or (4) no trauma center. Pediatric deaths due to passenger vehicle crashes on public roads were identified from the NHTSA Fatality Analysis Reporting System. Hierarchical negative binomial modeling measured the relationship between highest level of pediatric trauma care and pediatric MVC mortality within counties. Adjusted analyses accounted for population age and sex, emergency medical service response times, helicopter ambulance availability, state traffic safety laws, and measures of rurality. RESULTS During the study period 3,067 children died in fatal crashes. We identified 188 pediatric trauma centers in 141 counties. Significant disparities in access to pediatric trauma care were observed. Specifically, 99% of pediatric trauma centers were situated in population-dense urban counties, while 28% of children lived in counties no trauma center. After risk adjustment, counties with pediatric trauma centers had significantly lower rates of pediatric MVC death than those with no trauma center: 0.7 versus 3.2 deaths/100,000 child-years; mortality rate ratio, 0.58; and 95% confidence interval, 0.39 to 0.86. In counties where pediatric trauma centers were absent, adult level 1/2 trauma centers were associated with comparable risk reduction. CONCLUSION The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement. LEVEL OF EVIDENCE Epidemiological, level III; Care management, level III.
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Affiliation(s)
- James P Byrne
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery (JPB, DRS, DNH, EJK, PMR, MJS), Department of Surgery of the Children's Hospital of Philadelphia (MLN), and the Penn Injury Science Center (JPB, MLN, DNH, EJK, PMR), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada (ABN)
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42
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Badhiwala JH, Lebovic G, Balas M, da Costa L, Nathens AB, Fehlings MG, Wilson JR, Witiw CD. Variability in time to surgery for patients with acute thoracolumbar spinal cord injuries. Sci Rep 2021; 11:13312. [PMID: 34172757 PMCID: PMC8233434 DOI: 10.1038/s41598-021-92310-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
There are limited data pertaining to current practices in timing of surgical decompression for acute thoracolumbar spinal cord injury (SCI). We conducted a retrospective cohort study to evaluate variability in timing between- and within-trauma centers in North America; and to identify patient- and hospital-level factors associated with treatment delay. Adults with acute thoracolumbar SCI who underwent decompressive surgery within five days of injury at participating trauma centers in the American College of Surgeons Trauma Quality Improvement Program were included. Mixed-effects regression with a random intercept for trauma center was used to model the outcome of time to surgical decompression and assess risk-adjusted variability in surgery timeliness across centers. 3,948 patients admitted to 214 TQIP centers were eligible. 28 centers were outliers, with a significantly shorter or longer time to surgery than average. Case-mix and hospital characteristics explained < 1% of between-hospital variability in surgical timing. Moreover, only 7% of surgical timing variability within-centers was explained by case-mix characteristics. The adjusted intraclass correlation coefficient of 12% suggested poor correlation of surgical timing for patients with similar characteristics treated at the same center. These findings support the need for further research into the optimal timing of surgical intervention for thoracolumbar SCI.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Gerald Lebovic
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, TorontoToronto, ON, M5W 1W8, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Michael Balas
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Healthsciences Center, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Avery B Nathens
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Healthsciences Center, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Medical Director, Trauma Quality Improvement Program, American College of Surgeons, Chicago, IL, USA
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spine Program, Krembil Brain Institute, Toronto Western Hospital, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, TorontoToronto, ON, M5W 1W8, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, TorontoToronto, ON, M5W 1W8, Canada. .,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Hashmi ZG, Chehab M, Nathens AB, Joseph B, Bank EA, Jansen JO, Holcomb JB. Whole truths but half the blood: Addressing the gap between the evidence and practice of pre-hospital and in-hospital blood product use for trauma resuscitation. Transfusion 2021; 61 Suppl 1:S348-S353. [PMID: 34086349 DOI: 10.1111/trf.16515] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND In recent years, several studies have demonstrated the efficacy of using pre-hospital blood product and in-hospital whole blood for trauma resuscitation. While some observations suggest an encouraging uptake of this evidence by emergency medical service (EMS) agencies and trauma centers, a nationwide characterization of blood product utilization for bleeding trauma patients remains unknown. The objective of this study is to determine nationwide estimates of pre-hospital blood product and in-hospital whole blood utilization for trauma resuscitation. STUDY DESIGN AND METHODS All adult trauma patients reported to the National Emergency Medical Services Information System (NEMSIS) dataset 2019 were included. Proportions of patients who received any pre-hospital blood product were calculated. The American College of Surgeons (ACS) Trauma Quality Programs (TQP) databases 2015-2017 and first quarter of 2020 were used to calculate the proportion of ACS-verified trauma centers that transfused whole blood. RESULTS Among a total of 3,058,804 pre-hospital trauma patients, only 313 (0.01%) received any blood transfusion; 208 (0.21%) patients with systolic blood pressure (SBP) ≤90 mmHg and 121 (0.67%) patients with SBP ≤90 mmHg and heart rate ≥120 beats per minute received any blood product. The proportion of ACS-verified trauma centers transfusing whole blood increased from 16.7% (45/269) in 2015 to 24.5% (123/502) in first quarter of 2020. DISCUSSION Despite strong evidence and recommendations, pre-hospital utilization of blood products for trauma resuscitation remains low. Additionally, while the overall in-hospital whole blood use also remains low, its use has increased at ACS-verified trauma centers over the past 5 years.
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Affiliation(s)
- Zain G Hashmi
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mohamad Chehab
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Alabama, USA
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Alabama, USA
| | - Eric A Bank
- Harris County Emergency Services District No. 48, Katy, Texas, USA
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Tillmann BW, Nathens AB, Scales DC, Haas B. Association Between Intoxication and Urgent Neurosurgical Procedures in Severe Traumatic Brain Injury: Results From the American College of Surgeons Trauma Quality Improvement Program. J Intensive Care Med 2021; 37:373-384. [PMID: 34013826 PMCID: PMC8772018 DOI: 10.1177/08850666211017497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The probability of undergoing surgery after severe traumatic brain injury (TBI) varies significantly across studies and centers. However, causes of this variability are poorly understood. We hypothesized that intoxication may impact the probability of receiving an urgent neurosurgical procedure among patients with severe TBI. METHODS We performed a retrospective cohort study of adult patients admitted to a Level I or II trauma center in the United States or Canada with an isolated severe TBI (2012-2016). Data were derived from the Trauma Quality Improvement Program dataset. An urgent neurosurgical procedure was defined as a procedure that occurred within 24 hours of admission. Multivariable logistic regression was utilized to examine the independent effect of intoxication on a patient's likelihood of undergoing an urgent procedure, as well as the timing of the procedure. RESULTS Of the 33,646 patients with an isolated severe TBI, 11,313 (33.6%) were intoxicated. An urgent neurosurgical procedure was performed in 8,255 (24.5%) cases. Overall, there was no difference in the probability of undergoing an urgent procedure between patients who were and were not intoxicated (OR 0.99; 95% CI 0.94-1.06). While intoxication status had no impact on the probability of surgery among patients with the most severe TBI (head AIS 5: OR 1.06 [95% CI 0.98-1.15]), intoxicated patients on the lower spectrum of injury had lower odds of undergoing an urgent procedure (AIS 3: OR 0.80 [95% CI 0.66-0.97]). Among patients who underwent an urgent procedure, intoxication had no impact on timing. CONCLUSION Intoxication status was not associated with differences in the probability of undergoing an urgent neurosurgical procedure among all patients with a severe TBI. However, in patients with less severe TBI, intoxication status was associated with decreased likelihood of receiving an urgent intervention. This finding underscores the challenge in the management of intoxicated patients with TBI.
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Affiliation(s)
- Bourke W Tillmann
- Interdepartmental Division of Critical Care, University of Toronto, Ontario, Canada.,Department of Critical Care Medicine, 71545Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, 7938University of Toronto, Ontario, Canada
| | - Avery B Nathens
- Institute of Health Policy, Management, and Evaluation, 7938University of Toronto, Ontario, Canada.,Department of Surgery, 7938University of Toronto, Ontario, Canada.,Sunnybrook Research Institute, 7938Toronto, Ontario, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Ontario, Canada.,Department of Critical Care Medicine, 71545Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, 7938University of Toronto, Ontario, Canada.,Sunnybrook Research Institute, 7938Toronto, Ontario, Canada.,Department of Medicine, 7938University of Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Ontario, Canada.,Department of Critical Care Medicine, 71545Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, 7938University of Toronto, Ontario, Canada.,Department of Surgery, 7938University of Toronto, Ontario, Canada.,Sunnybrook Research Institute, 7938Toronto, Ontario, Canada
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Locke JA, Neu S, Navaratnam R, Phillips A, Nathens AB, Herschorn S, Kodama R. Management of high-grade renal traumas with collecting system injuries. Can Urol Assoc J 2021; 15:E588-E592. [PMID: 33999807 DOI: 10.5489/cuaj.7115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Approximately 50% of all high-grade renal traumas (HGRT, American Association for the Surgery of Trauma [AAST] grade 4/5) have associated collecting system injuries. Although most of these collecting system injuries will heal spontaneously, approximately 20-30% of these injuries are managed with ureteric stents. The objective of the study was to review the management of HGRT with collecting system injuries in a level 1 trauma center. METHODS This was a single-center, retrospective cohort study of trauma patients with HGRT and collecting system injuries from 1998-2019. RESULTS We identified 147 patients with HGRT. Of the 105 patients who had trauma computed tomography (CT) imaging within 24 hours, 46 were found to have collecting system injuries. Seven of these patients underwent intervention based on initial CT findings; the remaining 39 patients with urinary extravasation were conservatively managed. Of the 37 patients who underwent reimaging, 22 (59%) demonstrated a stable or resolving collection and 15 (41%) demonstrated continued urinary extravasation. Resolution of extravasation on subsequent imaging was observed in 10 of those patients, while five patients (14%) required intervention (four stents, one percutaneous drain) for symptoms/signs of urinary extravasation. CONCLUSIONS In this study, most patients with HGRT and collecting system injuries did not require intervention unless the patient became symptomatic. The majority of collecting system injuries resolved with no intervention. This study underscores the need for future prospective trials to investigate the necessity of intervening in HGRT collecting system injuries and, secondarily, the need for routine reimaging in these asymptomatic patients.
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Affiliation(s)
- Jennifer A Locke
- Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Sarah Neu
- Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Roshan Navaratnam
- Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Andrea Phillips
- Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Sender Herschorn
- Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
| | - Ronald Kodama
- Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
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Lam PW, Tarighi P, Elligsen M, Nathens AB, Riegert D, Tarshis J, Leis JA. Impact of the Allergy Clarification for Cefazolin Evidence-based Prescribing Tool on Receipt of Preferred Perioperative Prophylaxis: An Interrupted Time Series Study. Clin Infect Dis 2021; 71:2955-2957. [PMID: 32364587 DOI: 10.1093/cid/ciaa516] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/29/2020] [Indexed: 01/30/2023] Open
Abstract
Implementation of a perioperative allergy and antibiotic assessment tool in patients with reported beta-lactam allergy resulted in a pronounced and sustained increase in perioperative cefazolin use. This intervention could result in improved efficiencies surrounding perioperative antibiotic administration and possible reductions in surgical site infection rates.
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Affiliation(s)
- Philip W Lam
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Payam Tarighi
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Daniel Riegert
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jerome A Leis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
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47
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Balas M, Guttman MP, Badhiwala JH, Lebovic G, Nathens AB, da Costa L, Zador Z, Spears J, Fehlings MG, Wilson JR, Witiw CD. Earlier Surgery Reduces Complications in Acute Traumatic Thoracolumbar Spinal Cord Injury: Analysis of a Multi-Center Cohort of 4108 Patients. J Neurotrauma 2021; 39:277-284. [PMID: 33724051 DOI: 10.1089/neu.2020.7525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Early surgical intervention to decompress the spinal cord and stabilize the spinal column in patients with acute traumatic thoracolumbar spinal cord injury (TLSCI) may lessen the risk of developing complications and improve outcomes. However, there has yet to be agreement on what constitutes "early" surgery; reported thresholds range from 8 to 72 h. To address this knowledge gap, we conducted an observational cohort study using data from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) from 2010 to 2016. The association between time from hospital arrival to surgical intervention and risk of major complications was assessed using restricted cubic splines. Propensity score matching was then used to assess the association between delayed surgery and risk of complications. Across 354 trauma centers 4108 adult TLSCI patients who underwent surgery were included. Median time-to-surgery was 18.8 h (interquartile range [IQR]: 7.4-40.9 h). The spline model suggests the risk of major complication rises consistently after a 12-h surgical wait-time. After propensity score matching, the odds of major complication were significantly lower for those receiving surgery within 12 h (odds ratio [OR] 0.77, 95% confidence interval [CI]: 0.64 to 0.94). This was also true for immobility-related complications (OR 0.79, 95% CI: 0.64 to 0.97). Patients in the early group spent 1.5 fewer days in the critical care unit on average (95% CI: -2.09 to -0.88). Although surgery within 12 h may not always be feasible, these data suggest that whenever possible surgeons should strive to reduce the amount of time between hospital arrival and surgical intervention, and health care systems should support this endeavor.
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Affiliation(s)
- Michael Balas
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Matthew P Guttman
- Division of General Surgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gerald Lebovic
- Institute of Health Policy Management and Evaluation, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Avery B Nathens
- Division of General Surgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Trauma Quality Programs, American College of Surgeons, Chicago, Illinois, USA
| | - Leodante da Costa
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Zsolt Zador
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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48
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Guttman MP, Tillmann BW, Nathens AB, Saskin R, Bronskill SE, Huang A, Haas B. Alive and at home: Five-year outcomes in older adults following emergency general surgery. J Trauma Acute Care Surg 2021; 90:287-295. [PMID: 33502146 DOI: 10.1097/ta.0000000000003018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship. METHODS We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models. RESULTS A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17-5.11). CONCLUSION Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Matthew P Guttman
- From the Institute of Health Policy, Management, and Evaluation (M.P.G., B.W.T., A.B.N., S.E.B., B.H.), Department of Surgery (M.P.G., A.B.N., B.H.), and Interdepartmental Division of Critical Care Medicine, Department of Medicine (B.W.T., B.H.), University of Toronto; Evaluative Clinical Sciences, Sunnybrook Research Institute (A.B.N., S.E.B., B.H.), Toronto, Ontario, Canada; American College of Surgeons, Trauma Quality Improvement Program (A.B.N.), Chicago, Illinois; and ICES Central, ICES (R.S., S.E.B., A.H.), Toronto, Ontario, Canada
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Affiliation(s)
- Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Todd A Schwartz
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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50
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Forner D, Noel CW, Guttman MP, Haas B, Enepekides D, Rigby MH, Nathens AB, Eskander A. Blunt Versus Penetrating Neck Trauma: A Retrospective Cohort Study. Laryngoscope 2020; 131:E1109-E1116. [PMID: 32894596 DOI: 10.1002/lary.29088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/23/2020] [Accepted: 08/19/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVES/HYPOTHESIS Despite being common, neck injuries have received relatively little attention for important quality of care metrics. This study sought to determine the association between blunt and penetrating neck injuries on mortality and length of stay, and to identify additional patient and hospital-level characteristics that impact these outcomes. STUDY DESIGN Retrospective cohort study utilizing the American College of Surgeons Trauma Quality Improvement Program database. METHODS Adult patients (≥18) who sustained traumatic injuries involving the soft tissues of the neck between 2012 and 2016 were eligible. Multiple imputation was used to account for missing data. Logistic regression and negative binomial models were used to analyze 1) in-hospital mortality and 2) length of stay respectively while adjusting for potential confounders and accounting for clustering at the hospital level. RESULTS In a cohort of 20,285 patients, the crude mortality rate was lower in those sustaining blunt neck injuries compared to penetrating injuries (4.9% vs. 6.0%, P < .01), while length of hospital stay was similar (median 9.9 vs. 10.2, P = 0.06). In adjusted analysis, blunt neck injuries were associated with a reduced odds of mortality during hospital admission (odds ratio: 0.66, 95% confidence intervals [0.564, 0.788]), as well as significant reductions in length of stay (rate ratio: 0.92, 95% confidence intervals [0.880, 0.954]). CONCLUSIONS Blunt neck injuries are associated with lower mortality and length of stay compared to penetrating injuries. Areas of future study have been identified, including elucidation of processes of care in specific organs of injury. LEVEL OF EVIDENCE Level 3 Laryngoscope, 131:E1109-E1116, 2021.
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Affiliation(s)
- David Forner
- Division of Otolaryngology - Head & Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Christopher W Noel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Haas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danny Enepekides
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew H Rigby
- Division of Otolaryngology - Head & Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Avery B Nathens
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antoine Eskander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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