An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System

BACKGROUND

We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC.

MATERIALS AND METHODS

The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge.

RESULTS

A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT.

CONCLUSIONS

POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Radiographic Reread Protocols to Identify Clinically Relevant Errors in Initial Trauma Evaluations

INTRODUCTION

Diagnostic radiology interpretive errors in trauma patients can lead to missed diagnoses, compromising patient care. Due to this, our level II trauma center implemented a reread protocol of all radiographic imaging within 24 hours on our highest trauma activation level (Code T). We sought to determine the efficacy of this reread protocol in identifying missed diagnoses in Code T patients. We hypothesized that a few, but clinically relevant errors, would be identified upon reread.

METHODS

All radiographic study findings (initial read and reread) performed for Code T admissions from July 2015 to May 2016 were queried. The reviewed radiological imaging was given one of four designations: agree with interpretation, minor (non-life threatening) nonclinically relevant error(s)-addendum/correction required or clinically relevant error(s) (major [life threatening] and minor)-addendum/correction required, and trauma surgeon notified. The results were compiled, and the number of each type of error was calculated.

RESULTS

Of the 752 radiological imaging studies reviewed on the 121 Code T patients during this period, 3 (0.40%) contained minor clinically relevant errors, 11 (1.46%) contained errors that were not clinically relevant, and 738 (98.1%) agreed with the original interpretation. The three clinically relevant errors included a right mandibular fracture found on X-ray and a temporal bone fracture that crossed the clivus and bilateral rib fractures found on computerized tomography.

DISCUSSION

Clinically relevant errors, although minimal, were discovered during rereads for Code T patients. Although the clinical errors were significant, none affected patient outcomes. We propose that the implementation of reread protocols should be based upon institution-specific practices.

Geriatric Trauma Mortality: Does Trauma Center Level Matter?

BACKGROUND

Given their mostly rural/suburban locations, level II trauma centers (TCs) may offer greater exposure to and experience in managing geriatric trauma patients. We hypothesized that geriatric patients would have improved outcomes at level II TCs compared to level I TCs.

METHODS

The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for geriatric (age ≥65 years) trauma patients admitted to level I and II TCs in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in care between level I and II TCs. A multivariate logistic regression model assessed the adjusted impact of care at level I vs II TCs on mortality, complications, and functional status at discharge (FSD). The National Trauma Data Bank (NTDB) was retrospectively queried for geriatric (age ≥65 years) trauma admissions to state-accredited level I or level II TCs in 2013.

RESULTS

112 648 patients met inclusion criteria. The proportion of geriatric trauma patients across level I and level II TCs were determined to be 29.1% and 36.2% (P <.001), respectively. In adjusted analysis, there was no difference in mortality (adjusted odds ratio [AOR]: 1.13; P = .375), complications (AOR: 1.25; P = .080) or FSD (AOR: 1.09; P = .493) when comparing level I to level II TCs. Adjusted analysis from the NTDB (n = 144 622) also found that mortality was not associated with TC level (AOR: 1.04; P = .182).

DISCUSSION

Level I and level II TCs had similar rates of mortality, complications, and functional outcomes despite a higher proportion (but lower absolute number) of geriatric patients being admitted to level II TCs. Future consideration for location of centers of excellence in geriatric trauma should include both level I and II TCs.

An analysis of pediatric social vulnerability in the Pennsylvania trauma system

BACKGROUND

The social vulnerability index (SVI) is used to assess resilience to external influences that may affect human health. Social vulnerability has been noted to be a barrier to healthcare access for pediatric patients. We hypothesized that Pennsylvania (PA) pediatric trauma patients high on the social vulnerability index would have significantly lower rates of rehab admission following admission to a hospital for traumatic injury.

METHODS

The SVI was determined for each PA zip code area utilizing the census tract based 2014 SVI provided by the CDC along with a weighted crosswalk between census tracts and zip code areas using the Housing and Urban Development zip code crosswalk files. The rate of the uninsured population was extracted from the CDC SVI files in addition to other US Census variables based upon estimates from the 2014 American Community Survey (ACS). We also included the individual primary payer status of each subject. Pediatric (age <15 years) trauma admissions with in-hospital mortality excluded, were extracted from the PA Healthcare Cost Containment Council (PHC4) for all hospital admissions for the period of 2003-2015 (n = 63,545). Complete case analysis was conducted based upon the final model providing a sample of 52,794. Cases were coded as rehab patients based upon discharge status (n = 603; 1.1%). A multi-level logistic model was used to determine if subjects had a higher odds of being discharged to rehab based on SVI, undertriage rates of their zip code area of residence and their own primary payer status; this was adjusted for age, multi-system injury and a head, chest or abdomen injury with abbreviate injury scale (AIS) severity > = 3.

RESULTS

SVI and undertriage rates of the zip code areas of residence were not significantly associated with admission to rehab. The individual primary payer status of the subject was significantly associated with admission to rehab (OR 95%CI vs. self/uninsured; Medicaid 3.65 1.84-7.24; Commercial = 3.09 1.56-6.11; other/unknown = 2.85 1.02-7.93). Admission to rehab was also significantly associated with age, injury severity (ISS), head or chest injury with AIS scores > = 3, year of admission and hospital type.

CONCLUSION

Individual patient level factors (primary payer of patient) may be associated with the odds of rehab admission rather than neighborhood factors.

LEVEL OF EVIDENCE

Epidemiologic: Level III.

Massive Transfusion Protocol and Subsequent Development of Venous Thromboembolism: Statewide Analysis

BACKGROUND

Massive transfusion protocols (MTP) are a routine component of any major trauma center's armamentarium in the management of exsanguinating hemorrhages. Little is known about the potential complications of those that survive a MTP. We sought to determine the incidence of venous thromboembolism (VTE) following MTP. We hypothesized that MTP would be associated with a higher risk of VTE when compared with a risk-adjusted control population without MTP.

METHODS

The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2015 to 2018 for trauma patients who developed VTE and survived until discharge at accredited trauma centers in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in VTE development between MTP and non-MTP patients. A multivariate logistic regression model assessed the adjusted impact of MTP on VTE development.

RESULTS

176 010 patients survived until discharge, meeting inclusion criteria. Of those, 1667 developed a VTE (pulmonary embolism [PE]: 662 [0.4%]; deep vein thrombosis [DVT]: 1142 [0.6%]; PE and DVT: 137 [0.1%]). 1268 patients (0.7%) received MTP and, of this subset of patients, 171 (13.5%) developed a VTE during admission. In adjusted analysis, patients who had a MTP and survived until discharge had a higher odds of developing a VTE (adjusted odds ratio: 2.62; 95% CI: 2.13-3.24; P < .001).

DISCUSSION

MTP is a harbinger for higher risk of VTE in those patients who survive. This may, in part, be related to the overcorrection of coagulation deficits encountered in the hemorrhagic event. A high index of suspicion for the development of VTE as well as aggressive VTE prophylaxis is warranted in those patients who survive MTP.

The Effects of Fasting Status on the Relative Risk of Pulmonary Aspiration in Acute Care Surgery Patients

BACKGROUND

Acute care surgery patients are often unfasted at the time of surgery, presenting a unique opportunity to study the effects of fasting on the risk of pulmonary aspiration. We aimed to determine the relative risk of aspiration in patients who were fasted at the time of surgery according to guidelines versus those in an unfasted state.

METHODS

A retrospective chart review of 100 patients who underwent appendectomy (n = 76) or exploratory laparotomy (n = 24) was conducted at a single institution in 2016-2017. Using the American Society of Anesthesiologists (ASA) Practice Guidelines for Preoperative Fasting, patients were stratified into study and control groups according to whether they were unfasted (nothing by mouth for <8 hours prior to surgery) or fasted (nothing by mouth for >8 hours prior to surgery). Data controlled for patients' age, sex, body mass index (BMI), most recent hemoglobin A1c, presence of gastroesophageal reflux disease (GERD), and presence of hiatal hernia.

RESULTS

Of the 76 patients who underwent appendectomy, 15% were unfasted with a total of 0 aspiration events (P < .001). Of the 24 patients who underwent exploratory laparotomy, 42% were unfasted with a total of 0 aspiration events (P < .001). This yields a relative risk of pulmonary aspiration of 1.0 (absolute risk of 0) in both the study and control groups.

DISCUSSION

In an acute care surgery population including patients who were not fasted according to guidelines, there was no increase in the risk of pulmonary aspiration.

LEVEL OF EVIDENCE

Epidemiological study; Level III.

Predictors of Trauma High Resource Consumers in a Mature Trauma System

Background

Extended hospital length of stay (LOS) is widely associated with significant healthcare costs. Since LOS is a known surrogate for cost, we sought to evaluate outliers. We hypothesized that particular characteristics are likely predictive of trauma high resource consumers (THRC) and can be used to more effectively manage care of this population.

Methods

The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2017 for all adult (age ≥15) trauma patients admitted to accredited trauma centers in Pennsylvania. THRC were defined as patients with hospital LOS two standard deviations above the population mean or ≥22 days (p<0.05). Patient demographics, comorbid conditions and clinical variables were compared between THRC and non-THRC to identify potential predictor variables. A multilevel mixed-effects logistic regression model controlling for age, gender, injury severity, admission Glasgow coma score, systolic blood pressure, and injury year assessed the adjusted impact of clinical factors in predicting THRC status. The National Trauma Data Bank (NTDB) was retrospectively queried from 2014-2016 for all adult (age ≥15) trauma patients admitted to state-accredited trauma centers and likewise were assessed for factors associated with THRC.

Results

A total of 465,601 patients met inclusion criteria [THRC: 16,818 (3.6%); non-THRC 448,783 (96.4%)]. Compared to non-THRC counterparts, THRC patients were significantly more severely injured (median ISS: 9 vs. 22, p<0.001). In adjusted analysis, gunshot wound (GSW) to the abdomen, undergoing major surgery and reintubation along with injury to the spine, upper or lower extremities were significantly associated with THRC. From the NTDB, 2 323 945 patients met inclusion criteria. In adjusted analysis, GSW to the abdomen was significantly associated with THRC. Penetrating injury overall was associated with decreased risk of being a THRC in the NTDB dataset. Those who had either GSW to abdomen, surgery, or reintubation required significantly longer LOS (p<0.001).

Conclusions

Reintubation, major surgery, gunshot wound to abdomen, along with injury to the spine, upper or lower extremities are all strongly predictive of THRC. Understanding the profile of the THRC will allow clinicians and case management to proactively put processes in place to streamline care and potentially reduce costs and LOS.

A Comprehensive Review of the Outcome for Patients Readmitted to the ICU Following Trauma and Strategies to Decrease Readmission Rates

In recent years, there has been an emphasis on evaluating the outcomes of patients who have experienced an intensive care unit (ICU) readmission. This may in part be due to the Patient Protection and Affordable Care Act's Hospital Readmission Reduction Program which imposes financial sanctions on hospitals who have excessive readmission rates, informally known as bounceback rates. The financial cost associated with avoidable bounceback combined with the potentially preventable expenses can result in unnecessary financial strain. Within the hospital readmissions, there is a subset pertaining to unplanned readmission to the ICU. Although there have been studies regarding ICU bounceback, there are limited studies regarding ICU bounceback of trauma patients and even fewer proven strategies. Although many studies have concluded that respiratory complications were the most common factor influencing ICU readmissions, there is inconclusive evidence in terms of a broadly applicable strategy that would facilitate management of these patients. The purpose of this review is to highlight the outcomes of patients readmitted to the ICU and to provide an overview of possible strategies to aid in decreasing ICU readmission rates.

Emergency operations program is an excellent platform to deal with in-hospital operation disaster

Described herein is the utilization of the hospital's Emergency Operations Plan and incident command structure to mitigate damage caused by the sudden loss of the heating, ventilation, and air conditioning system within the entire operating room suite. The ability to ameliorate a devastating situation that occurred during working hours at a busy Level II trauma center can be ascribed to the dedication of the leadership and clinical teams working seamlessly together. Their concerted efforts were augmented by adherence to an established protocol that had been thoroughly substantiated and practiced during numerous training simulations. This resulted in successful and timely resolution of an internal crisis that crippled the surgical capabilities of the sole trauma center in the county. After thorough investigation and identification of the issues that contributed to the malfunction, redundancies were built into the system to ensure that a similar incident did not occur again.

Vena Cava Filter Use in Trauma and Rates of Pulmonary Embolism, 2003-2015

Importance

Vena cava filter (VCF) placement for pulmonary embolism (PE) prophylaxis in trauma is controversial. Limited research exists detailing trends in VCF use and occurrence of PE over time.

Objective

To analyze state and nationwide temporal trends in VCF placement and PE occurrence from 2003 to 2015 using available data sets.

Design, Setting, and Participants

A retrospective trauma cohort study was conducted using data from the Pennsylvania Trauma Outcome Study (PTOS) (461 974 patients from 2003 to 2015), the National Trauma Data Bank (NTDB) (5 755 095 patients from 2003 to 2014), and the National (Nationwide) Inpatient Sample (NIS) (24 449 476 patients from 2003 to 2013) databases.

Main Outcomes and Measures

Temporal trends in VCF placement and PE rates, filter type (prophylactic or therapeutic), and established predictors of PE (obesity, pregnancy, cancer, deep vein thrombosis, major procedure, spinal cord paralysis, venous injury, lower extremity fracture, pelvic fracture, central line, intracranial hemorrhage, and blood transfusion). Prophylactic filters were defined as VCFs placed before or without an existing PE, while therapeutic filters were defined as VCFs placed after a PE.

Results

Of the 461 974 patients in PTOS, the mean (SD) age was 47.2 (26.4) and 61.6% (284 621) were men; of the 5 755 095 patients in NTDB, the mean age (SD) was 42.0 (24.3) and 63.7% (3 666 504) were men; and of the 24 449 476 patients in NIS, the mean (SD) age was 58.0 (25.2) and 49.7% (12 160 231) were men. Of patients receiving a filter (11 405 in the PTOS, 71 029 in the NTDB, and 189 957 in the NIS), most were prophylactic VCFs (93.6% in the PTOS, 93.5% in the NTDB, and 93.3% in the NIS). Unadjusted and adjusted temporal trends for the PTOS and NTDB showed initial increases in filter placement followed by significant declines (unadjusted reductions in VCF placement rates, 76.8% in the PTOS and 53.3% in the NTDB). The NIS demonstrated a similar unadjusted trend, with a slight increase and modest decline (22.2%) in VCF placement rates over time; however, adjusted trends showed a slight but significant increase in filter rates. Adjusted PE rates for the PTOS and NTDB showed significant initial increases followed by slight decreases, with limited variation during the declining filter use periods. The NIS showed an initial increase in PE rates followed by a period of stagnation.

Conclusions and Relevance

Despite a precipitous decline of VCF use in trauma, PE rates remained unchanged during this period. Taking this association into consideration, VCFs may have limited utility in influencing rates of PE. More judicious identification of at-risk patients is warranted to determine individuals who would most benefit from a VCF.

An epidemiologic overview of 13 years of firearm hospitalizations in Pennsylvania

BACKGROUND

Gun violence is a controversial public health issue plagued by a lack of recent research. We sought to provide a 13-y overview of firearm hospitalizations in Pennsylvania, analyzing trends in mode, intent, and outcome. We hypothesized that no adjusted change in mortality or functional status at discharge (FSD) would be observed for gunshot wound (GSW) victims over the study period.

METHODS

All admissions to the Pennsylvania Trauma Outcome Study database from 2003 to 2015 were queried. GSWs were identified by external cause-of-injury codes. Collected variables included patient demographics, firearm type, intent (assault and attempted suicide), FSD, and mortality. Multilevel mixed-effects logistic regression models and ordinal regression analyses using generalized linear mixed models assessed the impact of admission year (continuous) on adjusted mortality and FSD score, respectively. Significance was set at P < 0.05.

RESULTS

Of the 462,081 patients presenting to Pennsylvania trauma centers from 2003 to 2015, 19,342 were GSWs (4.2%). Handguns were the most common weapon of injury (n = 7007; 86.7%) among cases with specified firearm type. Most GSWs were coded as assaults (n = 15,415; 79.7%), with suicide attempts accounting 1866 hospitalizations (9.2%). Suicide attempts were most prevalent among young and middle-aged white males, whereas assaults were more common in young black males. Rates of firearm hospitalizations decreased over time (test of trend P = 0.001); however, admission year was not associated with improved adjusted survival (adjusted odds ratio: 0.99, 95% confidence interval: 0.97-1.01; P = 0.353) or FSD (adjusted odds ratio: 0.99, 95% confidence interval: 0.98-1.00; P = 0.089) while controlling for demographic and injury severity covariates.

CONCLUSIONS

Temporal trends in outcomes suggest rates of firearm hospitalizations are declining in Pennsylvania; however, outcomes remain unchanged. To combat this epidemic, a multidisciplinary, demographic-specific approach to prevention should be the focus of future scientific pursuits.

Alternatives to Indwelling Catheters Cause Unintended Complications

To reduce the risk of catheter-associated urinary tract infection (CAUTI), limiting use of indwelling catheters is encouraged with alternative collection methods and early removal. Adverse effects associated with such practices have not been described. We also determined if CAUTI preventative measures increase the risk of catheter-related complications. We hypothesized that there are complications associated with early removal of indwelling catheters. We described complications associated with indwelling catheterization and intermittent catheterization, and compared complication rates before and after policy updates changed catheterization practices. We performed retrospective cohort analysis of trauma patients admitted between August 1, 2009, and December 31, 2013 who required indwelling catheter. Associations between catheter days and adverse outcomes such as infection, bladder overdistention injury, recatheterization, urinary retention, and patients discharged with indwelling catheter were evaluated. The incidence of CAUTI and the total number of catheter days pre and post policy change were similar. The incidence rate of urinary retention and associated complications has increased since the policy changed. Practices intended to reduce the CAUTI rate are associated with unintended complications, such as urinary retention. Patient safety and quality improvement programs should monitor all complications associated with urinary catheterization practices, not just those that represent financial penalties.

Alternatives to Indwelling Catheters Cause Unintended Complications

To reduce the risk of catheter-associated urinary tract infection (CAUTI), limiting use of indwelling catheters is encouraged with alternative collection methods and early removal. Adverse effects associated with such practices have not been described. We also determined if CAUTI preventative measures increase the risk of catheter-related complications. We hypothesized that there are complications associated with early removal of indwelling catheters. We described complications associated with indwelling catheterization and intermittent catheterization, and compared complication rates before and after policy updates changed catheterization practices. We performed retrospective cohort analysis of trauma patients admitted between August 1, 2009, and December 31, 2013 who required indwelling catheter. Associations between catheter days and adverse outcomes such as infection, bladder overdistention injury, recatheterization, urinary retention, and patients discharged with indwelling catheter were evaluated. The incidence of CAUTI and the total number of catheter days pre and post policy change were similar. The incidence rate of urinary retention and associated complications has increased since the policy changed. Practices intended to reduce the CAUTI rate are associated with unintended complications, such as urinary retention. Patient safety and quality improvement programs should monitor all complications associated with urinary catheterization practices, not just those that represent financial penalties.

Vital Signs Strongly Predict Massive Transfusion Need in Geriatric Trauma Patients

Early recognition of massive transfusion (MT) requirement in geriatric trauma patients presents a challenge, as older patients present with vital signs outside of traditional thresholds for hypotension and tachycardia. Although many systems exist to predict MT need in trauma patients, none have specifically evaluated the geriatric population. We sought to evaluate the predictive value of presenting vital signs in geriatric trauma patients for prediction of MT. We retrospectively reviewed geriatric trauma patients presenting to our Level I trauma center from 2010 to 2013 requiring full trauma team activation. The area under the receiver operating characteristic curve was calculated to assess discrimination of arrival vital signs for MT prediction. Ideal cutoffs with high sensitivity and specificity were identified. A total of 194 patients with complete data were analyzed. Of these, 16 patients received MT. There was no difference between the MT and non-MT groups in sex, age, or mechanism. Systolic blood pressure, pulse pressure, diastolic blood pressure, and shock index all were strongly predictive of MT need. Interestingly, we found that heart rate does not predict MT. MT in geriatric trauma patients can be reliably and simply predicted by arrival vital signs. Heart rate may not reflect serious hemorrhage in this population.

Vital Signs Strongly Predict Massive Transfusion Need in Geriatric Trauma Patients

Early recognition of massive transfusion (MT) requirement in geriatric trauma patients presents a challenge, as older patients present with vital signs outside of traditional thresholds for hypotension and tachycardia. Although many systems exist to predict MT need in trauma patients, none have specifically evaluated the geriatric population. We sought to evaluate the predictive value of presenting vital signs in geriatric trauma patients for prediction of MT. We retrospectively reviewed geriatric trauma patients presenting to our Level I trauma center from 2010 to 2013 requiring full trauma team activation. The area under the receiver operating characteristic curve was calculated to assess discrimination of arrival vital signs for MT prediction. Ideal cutoffs with high sensitivity and specificity were identified. A total of 194 patients with complete data were analyzed. Of these, 16 patients received MT. There was no difference between the MT and non-MT groups in sex, age, or mechanism. Systolic blood pressure, pulse pressure, diastolic blood pressure, and shock index all were strongly predictive of MT need. Interestingly, we found that heart rate does not predict MT. MT in geriatric trauma patients can be reliably and simply predicted by arrival vital signs. Heart rate may not reflect serious hemorrhage in this population.

Admission ionized calcium levels predict the need for multiple transfusions: a prospective study of 591 critically ill trauma patients

BACKGROUND

Deaths from uncontrolled exsanguinating hemorrhage occur rapidly postinjury. Any successful resuscitation strategy must also occur early, underscoring the importance of rapid identification of patients at risk for multiple transfusions. Previous studies have shown low ionized calcium (iCa) levels to be associated with hypotension and function as a predictor of mortality. We hypothesized that admission iCa levels could potentially predict the need for multiple transfusions in critically ill trauma patients.

METHODS

Admission iCa was collected prospectively on all trauma activations during a 9-month period. Youden's index was used to determine the appropriate cutpoint for iCa. Outcomes (mortality, multiple transfusions [≥5 units packed red blood cells in 24 hours] and massive transfusion [≥10 units packed red blood cells in 24 hours]) were compared using Wilcoxon rank-sum and χ tests where appropriate. Multivariable logistic regression was performed to determine whether iCa was an independent predictor of multiple transfusions.

RESULTS

A total of 591 patients were identified: 461 (78%) men and 130 (22%) women. Cutpoint was identified as 1.00. iCa was <1.00 (lo-Cal) in 332 patients and≥1.00 (hi-Cal) in 259 patients. Mortality was significantly increased in the lo-Cal group (15.5% vs. 8.7%, p=0.036). In addition, both multiple transfusions (17.1% vs. 7.1%, p=0.005) and massive transfusion (8.2% vs. 2.2%, p=0.017) were significantly increased in the lo-Cal group. Multivariable logistic regression analysis identified iCa<1 as an independent predictor of the need for multiple transfusions after adjusting for age and injury severity (odds ratio=2.294, 95% confidence interval=1.053-4.996).

CONCLUSIONS

Low iCa levels at admission were associated with increased mortality as well as an increased need for both multiple transfusions and massive transfusion. In fact, multivariable logistic regression analysis identified low iCa levels as an independent predictor of multiple transfusions. Admission iCa levels may facilitate the rapid identification of patients requiring massive transfusion, allowing for earlier preparation and administration of appropriate blood products.