The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system.

PubMed

Ciesla, David J; Pracht, Etienne E; Leitz, Pablo T; Spain, David A; Staudenmayer, Kristan L; Tepas, Joseph J

2017-06-01

Florida serves as a model for the study of trauma system performance. Between 2010 and 2104, 5 new trauma centers were opened alongside 20 existing centers. The purpose of this study was to explore the impact of trauma system expansion on system triage performance and trauma center patients' profiles. A statewide data set was queried for all injury-related discharges from adult acute care hospitals using International Classification of Diseases, Ninth Revision (ICD-9) codes for 2010 and 2014. The data set, inclusion criteria, and definitions of high-risk injury were chosen to match those used by the Florida Department of Health in its trauma registry. Hospitals were classified as existing Level I (E1) or Level II (E2) trauma centers and new E2 (N2) centers. Five N2 centers were established 11.6 to 85.3 miles from existing centers. Field and overall trauma system triage of high-risk patients was less accurate with increased overtriage and no change in undertriage. Annual volume at N2 centers increased but did not change at E1 and E2 centers. In 2014, Patients at E1 and E2 centers were slightly older and less severely injured, while those at N2 centers were substantially younger and more severely injured than in 2010. The injured patient-payer mix changed with a decrease in self-pay and commercial patients and an increase in government-sponsored patients at E1 and E2 centers and an increase in self-pay and commercial patients with a decrease in government-sponsored patients at N2 centers. Designation of new trauma centers in a mature system was associated with a change in established trauma center demographics and economics without an improvement in trauma system triage performance. These findings suggest that the health of an entire trauma system network must be considered in the design and implementation of a regional trauma system. Therapeutic/care management study, level IV; epidemiological, level IV.

Characteristics and Management of Blunt Renal Injury in Children

PubMed Central

Ishida, Yuichi; Tyroch, Alan H.; Emami, Nader; McLean, Susan F.

2017-01-01

Background: Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center. Methods: This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001–June 2014. Results: Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs. Conclusion: Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons. PMID:28855777

Honoring children, mending the circle: cultural adaptation of trauma-focused cognitive-behavioral therapy for American Indian and Alaska native children.

PubMed

BigFoot, Dolores Subia; Schmidt, Susan R

2010-08-01

American Indians and Alaska Natives are vulnerable populations with significant levels of trauma exposure. The Indian Country Child Trauma Center developed an American Indian and Alaska Native (AI/AN) adaptation of the evidence-based child trauma treatment, trauma-focused cognitive-behavioral therapy. Honoring Children, Mending the Circle (HC-MC) guides the therapeutic process through a blending of AI/AN traditional teachings with cognitive-behavioral methods. The authors introduced the HC-MC treatment and illustrated its therapeutic tools by way of a case illustration.

Military-to-civilian translation of battlefield innovations in operative trauma care.

PubMed

Haider, Adil H; Piper, Lydia C; Zogg, Cheryl K; Schneider, Eric B; Orman, Jean A; Butler, Frank K; Gerhardt, Robert T; Haut, Elliott R; Mather, Jacques P; MacKenzie, Ellen J; Schwartz, Diane A; Geyer, David W; DuBose, Joseph J; Rasmussen, Todd E; Blackbourne, Lorne H

2015-12-01

Historic improvements in operative trauma care have been driven by war. It is unknown whether recent battlefield innovations stemming from conflicts in Iraq/Afghanistan will follow a similar trend. The objective of this study was to survey trauma medical directors (TMDs) at level 1-3 trauma centers across the United States and gauge the extent to which battlefield innovations have shaped civilian practice in 4 key domains of trauma care. Domains were determined by the use of a modified Delphi method based on multiple consultations with an expert physician/surgeon panel: (1) damage control resuscitation (DCR), (2) tourniquet use, (3) use of hemostatic agents, and (4) prehospital interventions, including intraosseous catheter access and needle thoracostomy. A corresponding 47-item electronic anonymous survey was developed/pilot tested before dissemination to all identifiable TMD at level 1-3 trauma centers across the US. A total of 245 TMDs, representing nearly 40% of trauma centers in the United States, completed and returned the survey. More than half (n = 127; 51.8%) were verified by the American College of Surgeons. TMDs reported high civilian use of DCR: 95.1% of trauma centers had implemented massive transfusion protocols and the majority (67.7%) tended toward 1:1:1 packed red blood cell/fresh-frozen plasma/platelets ratios. For the other 3, mixed adoption corresponded to expressed concerns regarding the extent of concomitant civilian research to support military research and experience. In centers in which policies reflecting battlefield innovations were in use, previous military experience frequently was acknowledged. This national survey of TMDs suggests that military data supporting DCR has altered civilian practice. Perceived relevance in other domains was less clear. Civilian academic efforts are needed to further research and enhance understandings that foster improved trauma surgeon awareness of military-to-civilian translation. Copyright © 2015 Elsevier Inc. All rights reserved.

Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB).

PubMed

Haider, Adil H; Hashmi, Zain G; Gupta, Sonia; Zafar, Syed Nabeel; David, Jean-Stephane; Efron, David T; Stevens, Kent A; Zafar, Hasnain; Schneider, Eric B; Voiglio, Eric; Coimbra, Raul; Haut, Elliott R

2014-08-01

National trauma registries have helped improve patient outcomes across the world. Recently, the idea of an International Trauma Data Bank (ITDB) has been suggested to establish global comparative assessments of trauma outcomes. The objective of this study was to determine whether global trauma data could be combined to perform international outcomes benchmarking. We used observed/expected (O/E) mortality ratios to compare two trauma centers [European high-income country (HIC) and Asian lower-middle income country (LMIC)] with centers in the North American National Trauma Data Bank (NTDB). Patients (≥16 years) with blunt/penetrating injuries were included. Multivariable logistic regression, adjusting for known predictors of trauma mortality, was performed. Estimates were used to predict the expected deaths at each center and to calculate O/E mortality ratios for benchmarking. A total of 375,433 patients from 301 centers were included from the NTDB (2002-2010). The LMIC trauma center had 806 patients (2002-2010), whereas the HIC reported 1,003 patients (2002-2004). The most important known predictors of trauma mortality were adequately recorded in all datasets. Mortality benchmarking revealed that the HIC center performed similarly to the NTDB centers [O/E = 1.11 (95% confidence interval (CI) 0.92-1.35)], whereas the LMIC center showed significantly worse survival [O/E = 1.52 (1.23-1.88)]. Subset analyses of patients with blunt or penetrating injury showed similar results. Using only a few key covariates, aggregated global trauma data can be used to adequately perform international trauma center benchmarking. The creation of the ITDB is feasible and recommended as it may be a pivotal step towards improving global trauma outcomes.

A Statewide Collaboration: Ohio Level III Trauma Centers' Approach to the Development of a Benchmarking System.

PubMed

Lang, Carrie L; Simon, Diane; Kilgore, Jane

The American College of Surgeons Committee on Trauma revised the Resources for Optimal Care of the Injured Patient to include the criteria for trauma centers to participate in a risk-adjusted benchmarking system. Trauma Quality Improvement Program is currently the risk-adjusted benchmarking program sponsored by the American College of Surgeons, which will be required of all trauma centers to participate in early 2017. Prior to this, there were no risk-adjusted programs for Level III verified trauma centers. The Ohio Society of Trauma Nurse Leaders is a collaborative group made up of trauma program managers, coordinators, and other trauma leaders who meet 6 times a year. Within this group, a Level III Subcommittee was formed initially to provide a place for the Level III centers to discuss issues specific to the Level III centers. When the new requirement regarding risk-adjustment became official, the subcommittee agreed to begin reporting simple data points with the idea to risk adjust in the future.

Exploring the characteristics of high-performing hospitals that influence trauma triage and transfer.

PubMed

Gagliardi, Anna R; Nathens, Avery B

2015-02-01

Many trauma patients might be first cared for at nondesignated centers before transfer to a trauma center. Limited research has investigated determinants of timely triage and transfer to identify those amenable to quality improvement. This study explored factors influencing timely triage and transfer in a regional trauma system. Centers (n = 15) with both long and short transfer times (emergency department length of stay before transfer) in Ontario were identified using a regional trauma registry. Physicians and nurses in these centers were interviewed with a view to determining factors that either impeded or enabled rapid decisions regarding the need for transfer to a trauma center. A grounded theory approach and constant comparative technique were used to collect and analyze data. Nineteen physicians and eight nurses participated. Clinician level (experience, training, personality, fear of judgment, nursing role), institutional level (guidelines, continuing education, trauma infrastructure, human resources) and system-level (bed availability, referral center, air transport, communication with trauma centers) factors influenced timely decision making. Participants offered several recommendations to improve care. These included guidelines for transfer, a "no refusal" policy at trauma centers, improved air transport and referral center services, as well as further regionalization. Additional features of hospitals with shorter transfer times included coaching of new staff, team meetings, leadership engagement, sharing of performance data, and minimum work hours for physicians. Numerous interacting factors that may influence trauma triage and transfer were identified. These findings can be used by policy makers, health care managers, and clinicians in emergency departments or trauma centers to evaluate and improve trauma triage and transfer, or plan new services. The findings can also be used by researchers to examine the relevance of these factors in other settings or to implement and evaluate the impact of interventions informed by recommendations generated here.

The Performance of Trauma Research Centers of Iran during the Past 10 Years; A Science Monitor Survey.

PubMed

Yadollahi, Mahnaz; Shamsedini, Narges; Shayan, Leila; Rezaianzadeh, Abbas; Bolandparvaz, Shahram

2014-01-01

To compare and evaluation of scores of trauma research center of Shiraz University of Medical Sciences in Iran with other trauma research centers in Iran. The assessment scores of each center were gathered from Iran medical research and Ministry of Health and Medical Education website. Each score is recorded in helical year which is defined from the 21th of March of every year until the 20th of March of the next. They are ranked and scored by knowledge production, capacity development, and research projects. The total evaluation scores of the trauma research center of Iran's Universities of Medical Sciences have increased from establishment. The highest increase in assessment scores was related to Tehran Trauma Research Center. An upward trend was observed in the total indicators of knowledge production index of all the trauma research centers from 2001/2002 to 2011/2012. An ascending trend was showed in the published articles score of Shiraz and Kashan Trauma Research Centers through the recent years. The increasing trend in scores of trauma research centers in Iran indicated a significant role in the knowledge production but it is need to find barriers of research and doing interventional projects to promote trauma care and prevention.

The outcome of trauma patients with do-not-resuscitate orders.

PubMed

Matsushima, Kazuhide; Schaefer, Eric W; Won, Eugene J; Armen, Scott B

2016-02-01

Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders. A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models. A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81-2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P = 0.016). Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers. Copyright © 2016 Elsevier Inc. All rights reserved.

[The Academy of Trauma Surgery (AUC). Service provider and management organization of the DGU].

PubMed

Sturm, J A; Hoffmann, R

2016-02-01

At the beginning of this century the German Trauma Society (DGU) became extensively active with an initiative on quality promotion, development of quality assurance and transparency regarding treatment of the severely injured. A white book on "Medical care of the severely injured" was published, focusing on the requirements on structural quality and especially procedural quality. The impact of the white book was immense and a trauma network with approved trauma centers, structured and graded for their individual trauma care performance, was developed. In order to monitor and document the required quality of care, a registry was needed. Furthermore, for cooperation within the trauma networks innovative methods for digital transfer of radiological images and patient documents became necessary. Finally, the auditing criteria for trauma centers had and still have to be completed with advanced medical education and training programs. In order to realize the implementation of such a broad spectrum of economically relevant and increasingly complex activities the Academy of Trauma Surgery (AUC) was established as a subsidiary of the DGU in 2004. The AUC currently has four divisions: 1) networks and health care structures, 2) registries and research management, 3) telemedicine, 4) medical education and training, all of which serve the goal of the initiative. The AUC is a full service provider and management organization in compliance with the statutes of the DGU. According to these statutes the business operations of the AUC also cover projects for numerous groups of patients, projects for the joint society the German Society for Orthopedics and Trauma (DGOU) as well as other medical institutions. This article describes the success stories of the trauma network (TraumaNetzwerk DGU®), the TraumaRegister DGU®, the telecooperation platform TKmed®, the new and fast-growing orthogeriatric center initiative (AltersTraumaZentrum DGU®) and the division of medical education and training, e.g. advanced trauma life support (ATLS®) and other training programs including the innovative interpersonal competence (IC) course.

The Pennsylvania Trauma Outcomes Study Risk-Adjusted Mortality Model: Results of a Statewide Benchmarking Program

PubMed Central

WIEBE, DOUGLAS J.; HOLENA, DANIEL N.; DELGADO, M. KIT; McWILLIAMS, NATHAN; ALTENBURG, JULIET; CARR, BRENDAN G.

2018-01-01

Trauma centers need objective feedback on performance to inform quality improvement efforts. The Trauma Quality Improvement Program recently published recommended methodology for case mix adjustment and benchmarking performance. We tested the feasibility of applying this methodology to develop risk-adjusted mortality models for a statewide trauma system. We performed a retrospective cohort study of patients ≥16 years old at Pennsylvania trauma centers from 2011 to 2013 (n = 100,278). Our main outcome measure was observed-to-expected mortality ratios (overall and within blunt, penetrating, multisystem, isolated head, and geriatric subgroups). Patient demographic variables, physiology, mechanism of injury, transfer status, injury severity, and pre-existing conditions were included as predictor variables. The statistical model had excellent discrimination (area under the curve = 0.94). Funnel plots of observed-to-expected identified five centers with lower than expected mortality and two centers with higher than expected mortality. No centers were outliers for management of penetrating trauma, but five centers had lower and three had higher than expected mortality for blunt trauma. It is feasible to use Trauma Quality Improvement Program methodology to develop risk-adjusted models for statewide trauma systems. Even with smaller numbers of trauma centers that are available in national datasets, it is possible to identify high and low outliers in performance. PMID:28541852

The Pennsylvania Trauma Outcomes Study Risk-Adjusted Mortality Model: Results of a Statewide Benchmarking Program.

PubMed

Wiebe, Douglas J; Holena, Daniel N; Delgado, M Kit; McWilliams, Nathan; Altenburg, Juliet; Carr, Brendan G

2017-05-01

Trauma centers need objective feedback on performance to inform quality improvement efforts. The Trauma Quality Improvement Program recently published recommended methodology for case mix adjustment and benchmarking performance. We tested the feasibility of applying this methodology to develop risk-adjusted mortality models for a statewide trauma system. We performed a retrospective cohort study of patients ≥16 years old at Pennsylvania trauma centers from 2011 to 2013 (n = 100,278). Our main outcome measure was observed-to-expected mortality ratios (overall and within blunt, penetrating, multisystem, isolated head, and geriatric subgroups). Patient demographic variables, physiology, mechanism of injury, transfer status, injury severity, and pre-existing conditions were included as predictor variables. The statistical model had excellent discrimination (area under the curve = 0.94). Funnel plots of observed-to-expected identified five centers with lower than expected mortality and two centers with higher than expected mortality. No centers were outliers for management of penetrating trauma, but five centers had lower and three had higher than expected mortality for blunt trauma. It is feasible to use Trauma Quality Improvement Program methodology to develop risk-adjusted models for statewide trauma systems. Even with smaller numbers of trauma centers that are available in national datasets, it is possible to identify high and low outliers in performance.

The Trauma Center Organizational Culture Survey: development and conduction.

PubMed

Davis, Matthew L; Wehbe-Janek, Hania; Subacius, Haris; Pinto, Ruxandra; Nathens, Avery B

2015-01-01

The Trauma Center Organizational Culture Survey (TRACCS) instrument was developed to assess organizational culture of trauma centers enrolled in the American College of Surgeons Trauma Quality Program (ACS TQIP). The objective is to provide evidence on the psychometric properties of the factors of TRACCS and describe the current organizational culture of TQIP-enrolled trauma centers. A cross-sectional study was conducted by surveying a sampling of employees at 174 TQIP-enrolled trauma centers. Data collection was preceded by multistep survey development. Psychometric properties were assessed by an exploratory factor analysis (construct validity) and the item-total correlations and Cronbach alpha were calculated (internal reliability). Statistical outcomes of the survey responses were measured by descriptive statistics and mixed effect models. The response rate for trauma center participation in the study was 78.7% (n = 137). The factor analysis resulted in 16 items clustered into three factors as described: opportunity, pride, and diversity, trauma center leadership, and employee respect and recognition. TRACCS was found to be highly reliable with a Cronbach alpha of 0.90 in addition to the three factors (0.91, 0.90, and 0.85). Considerable variability of TRACCS overall and factor score among hospitals was measured, with the largest interhospital deviations among trauma center leadership. More than 80% of the variability in the responses occurred within rather than between hospitals. TRACCS was developed as a reliable tool for measuring trauma center organizational culture. Relationships between TQIP outcomes and measured organizational culture are under investigation. Trauma centers could apply TRACCS to better understand current organizational culture and how change tools can impact culture and subsequent patient and process outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Coordination and management of multicenter clinical studies in trauma: Experience from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study

PubMed Central

Rahbar, Mohammad H.; Fox, Erin E.; del Junco, Deborah J.; Cotton, Bryan A.; Podbielski, Jeanette M.; Matijevic, Nena; Cohen, Mitchell J.; Schreiber, Martin A.; Zhang, Jiajie; Mirhaji, Parsa; Duran, Sarah; Reynolds, Robert J.; Benjamin-Garner, Ruby; Holcomb, John B.

2011-01-01

Aim Early death due to hemorrhage is a major consequence of traumatic injury. Transfusion practices differ among hospitals and it is unknown which transfusion practices improve survival. This report describes the experience of the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study Data Coordination Center in designing and coordinating a study to examine transfusion practices at ten Level 1 trauma centers in the U.S. Methods PROMMTT was a multisite prospective observational study of severely injured transfused trauma patients. The clinical sites collected real-time information on the timing and amounts of blood product infusions as well as colloids and crystalloids, vital signs, initial diagnostic and clinical laboratory tests, life saving interventions and other clinical care data. Results Between July 2009 and October 2010, PROMMTT screened 12,561 trauma admissions and enrolled 1,245 patients who received one or more blood transfusions within 6 hours of ED admission. A total of 297 massive transfusions were observed over the course of the study at a combined rate of 5.0 massive transfusion patients/week. Conclusion PROMMTT is the first multisite study to collect real-time prospective data on trauma patients requiring transfusion. Support from the Department of Defense and collaborative expertise from the ten participating centers helped to demonstrate the feasibility of prospective trauma transfusion studies. The observational data collected from this study will be an invaluable resource for research in trauma surgery and it will guide the design and conduct of future randomized trials. PMID:22001613

Injury and violence in Los Angeles. Impact on access to health care and surgical education.

PubMed

Fleming, A W; Sterling-Scott, R P; Carabello, G; Imari-Williams, I; Allmond, B; Foster, R S; Kennedy, F; Shoemaker, W C

1992-06-01

The Los Angeles County (California) Trauma Hospital System was designed to ensure that all patients requiring specialized trauma care would be transported directly to a trauma center using established trauma triage criteria. The designation and implementation of all level 1, 2, and 3 (rural) trauma centers were completed between October 1983 and July 1985. However, by February 1, 1985, one level 2 trauma center withdrew, and nine other level 2 and 3 trauma centers followed suit over the next few months and years. The reasons for closure of these 10 trauma centers were almost exclusively related to economic factors. The major impact of trauma center closure on surgical educational programs at the Drew University of Medicine and Science and the Martin Luther King, Jr/Charles R. Drew Medical Center have been additive and cumulative. The high volume of patients with trauma has been cited, sometimes correctly and sometimes incorrectly, as the primary reason for a lack of access to health care for patients without trauma. We have developed a blueprint for survival that, when fully implemented, will improve access to health care for all residents in our catchment area and optimize surgical education. While the Los Angeles County Trauma Hospital System has had many difficulties during the last 9 years, the population it serves is greater than that in 42 states in the United States. The experiences gained in Los Angeles County may be beneficial to statewide systems in the United States and in countries of comparable size.

911 Emergency Medical Services and Re-Triage to Level I Trauma Centers.

PubMed

Kuncir, Eric; Spencer, Dean; Feldman, Kelly; Barrios, Cristobal; Miller, Kenneth; Lush, Stephanie; Dolich, Matthew; Lekawa, Michael

2018-01-01

Interfacility transfer of undertriaged patients to higher-level trauma centers has been found to result in a delay of appropriate care and an increase in mortality. To address this, for the last 10 years our region has used 911 emergency medical services (EMS) paramedics for rapid re-triage of undertriaged patients to our institution's Level I trauma center. We sought to determine whether using 911 EMS for re-triage to our institution was associated with worse outcomes-with mortality as the primary end point-compared with direct EMS transport from point of injury. We retrospectively reviewed all trauma activations to our institution during a 16-month period; 3,394 active traumas were analyzed. Two hundred and seventy patients (8%) arrived via 911 EMS re-triage and 3,124 (92%) arrived via direct EMS transport. Total EMS transport time was significantly longer (122.5 minutes vs 33.7 minutes; p < 0.001) between the 2 groups, but there was no significant difference in mortality rates (4.1% vs 3.6%; p = 0.67). These data show that although using 911 EMS for re-triage is associated with an increase in total transport time, it does not result in an increase in mortality compared with direct EMS transport. We conclude that the use of 911 EMS can be considered a safe method to re-triage patients to higher-level trauma centers. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

The American College of Surgeons Needs-Based Assessment of Trauma Systems: Estimates for the State of California.

PubMed

Uribe-Leitz, Tarsicio; Esquivel, Micaela M; Knowlton, Lisa M; Ciesla, David; Lin, Feng; Hsia, Renee Y; Spain, David A; Winchell, Robert J; Staudenmayer, Kristan L

2017-05-01

In 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California. Trauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers. A total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results. Estimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool. Economic, level V.

A trauma network with centralized and local health care structures: Evaluating the effectiveness of the first certified Trauma Network of the German Society of Trauma Surgery

PubMed Central

Koller, Michael; Zeman, Florian; Kerschbaum, Maximilian; Hilber, Franz; Diepold, Eva; Loss, Julika; Herbst, Tanja; Nerlich, Michael

2018-01-01

Background Trauma is a global burden of disease and one of the main causes of death worldwide. Therefore, many countries around the world have implemented a wide range of different initiatives to minimize mortality rates after trauma. One of these initiatives is the bundling of treatment expertise in trauma centers and the establishment of trauma networks. Germany has a decentralized system of trauma care medical centers. Severely injured patients ought to receive adequate treatment in both level I and level II centers. This study investigated the effectiveness of a decentralized network and the question whether level I and level II centers have comparable patient outcome. Materials and methods In 2009, the first trauma network DGU® in Germany was certified in the rural area of Eastern Bavaria. All patients admitted to the 25 participating hospitals were prospectively included in this network in the framework of a study sponsored by the German Federal Ministry of Education and Research between March 2012 and February 2014. 2 hospitals were level I centers (maximal care centers), 8 hospitals were level II centers, and 15 hospitals were level III centers. The criterion for study inclusion was an injury severity score (ISS) ≥ 16 for patients´ primarily admitted to a level I or a level II center. Exclusion criteria were transferal to another hospital within 48 h, an unknown revised injury severity classification II score (RISC II), or primary admittance to a level III center (n = 52). 875 patients were included in the study. Univariate analyses were used regarding the preclinical and clinical parameters, the primary endpoint mortality rate, and the secondary endpoints length of stay, organ failure, and neurological outcome (GOS). The primary endpoint was additionally evaluated by means of multivariable analysis. Results Indices for injury severity (GCS, AISHead, ISS, and NISS) as well as the predicted probability of death (RISC II) were higher in level I centers than in level II centers. No significant differences were found between the mortality rate of the unadjusted analysis [level I: 21.6% (CI: 16.5, 27.9), level II: 18.1% (CI: 14.4, 22.5), p = 0.28] and that of the adjusted analysis [level I SMR: 0.94 (CI: 0.72, 1.21), level II SMR: 1.18 (CI 0.95, 1.48) SMR: expected vs. calculated mortality rate according to RISC II]. Multivariable analysis showed a survival advantage of patients admitted to a level I center with a probability of death of 13% (RISC II). The number need to treat was 10 patients. Discussion This study showed that a rural trauma network with centralized and local structures may achieve equivalent results with regard to mortality rates to those obtained in level I and level II centers. These results were furthered by a certain preclinical centralization (24/7 air rescue) of patients. The study also showed a survival advantage of patients admitted to a level I center with a probability of death of 13%. Preclinical and initial clinical evaluation with regard to probable mortality rates should be further improved to identify patients who would benefit from admittance to a level I center. PMID:29538456

Influence of socioeconomic status on trauma center performance evaluations in a Canadian trauma system.

PubMed

Moore, Lynne; Turgeon, Alexis F; Sirois, Marie-Josée; Murat, Valérie; Lavoie, André

2011-09-01

Trauma center performance evaluations generally include adjustment for injury severity, age, and comorbidity. However, disparities across trauma centers may be due to other differences in source populations that are not accounted for, such as socioeconomic status (SES). We aimed to evaluate whether SES influences trauma center performance evaluations in an inclusive trauma system with universal access to health care. The study was based on data collected between 1999 and 2006 in a Canadian trauma system. Patient SES was quantified using an ecologic index of social and material deprivation. Performance evaluations were based on mortality adjusted using the Trauma Risk Adjustment Model. Agreement between performance results with and without additional adjustment for SES was evaluated with correlation coefficients. The study sample comprised a total of 71,784 patients from 48 trauma centers, including 3,828 deaths within 30 days (4.5%) and 5,549 deaths within 6 months (7.7%). The proportion of patients in the highest quintile of social and material deprivation varied from 3% to 43% and from 11% to 90% across hospitals, respectively. The correlation between performance results with or without adjustment for SES was almost perfect (r = 0.997; 95% CI 0.995-0.998) and the same hospital outliers were identified. We observed an important variation in SES across trauma centers but no change in risk-adjusted mortality estimates when SES was added to adjustment models. Results suggest that after adjustment for injury severity, age, comorbidity, and transfer status, disparities in SES across trauma center source populations do not influence trauma center performance evaluations in a system offering universal health coverage. Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

The relationship between processes and outcomes for injured older adults: a study of a statewide trauma system.

PubMed

Saillant, N N; Earl-Royal, E; Pascual, J L; Allen, S R; Kim, P K; Delgado, M K; Carr, B G; Wiebe, D; Holena, D N

2017-02-01

Age is a risk factor for death, adverse outcomes, and health care use following trauma. The American College of Surgeons' Trauma Quality Improvement Program (TQIP) has published "best practices" of geriatric trauma care; adoption of these guidelines is unknown. We sought to determine which evidence-based geriatric protocols, including TQIP guidelines, were correlated with decreased mortality in Pennsylvania's trauma centers. PA's level I and II trauma centers self-reported adoption of geriatric protocols. Survey data were merged with risk-adjusted mortality data for patients ≥65 from a statewide database, the Pennsylvania Trauma Systems Foundation (PTSF), to compare mortality outlier status and processes of care. Exposures of interest were center-specific processes of care; outcome of interest was PTSF mortality outlier status. 26 of 27 eligible trauma centers participated. There was wide variation in care processes. Four trauma centers were low outliers; three centers were high outliers for risk-adjusted mortality rates in adults ≥65. Results remained consistent when accounting for center volume. The only process associated with mortality outlier status was age-specific solid organ injury protocols (p = 0.04). There was no cumulative effect of multiple evidence-based processes on mortality rate (p = 0.50). We did not see a link between adoption of geriatric best-practices trauma guidelines and reduced mortality at PA trauma centers. The increased susceptibility of elderly to adverse consequences of injury, combined with the rapid growth rate of this demographic, emphasizes the importance of identifying interventions tailored to this population. III. Descriptive.

Implementation and Evaluation of a Wiki Involving Multiple Stakeholders Including Patients in the Promotion of Best Practices in Trauma Care: The WikiTrauma Interrupted Time Series Protocol

PubMed Central

Turgeon, Alexis F; Witteman, Holly O; Lauzier, François; Moore, Lynne; Lamontagne, François; Horsley, Tanya; Gagnon, Marie-Pierre; Droit, Arnaud; Weiss, Matthew; Tremblay, Sébastien; Lachaine, Jean; Le Sage, Natalie; Émond, Marcel; Berthelot, Simon; Plaisance, Ariane; Lapointe, Jean; Razek, Tarek; van de Belt, Tom H; Brand, Kevin; Bérubé, Mélanie; Clément, Julien; Grajales III, Francisco Jose; Eysenbach, Gunther; Kuziemsky, Craig; Friedman, Debbie; Lang, Eddy; Muscedere, John; Rizoli, Sandro; Roberts, Derek J; Scales, Damon C; Sinuff, Tasnim; Stelfox, Henry T; Gagnon, Isabelle; Chabot, Christian; Grenier, Richard; Légaré, France

2015-01-01

Background Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting. Objective Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec. Methods First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to complete the Wiki101 training and then use, and contribute to, WikiTrauma for 12 months. The primary outcome will be the change over time of a validated, composite, performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry. Results This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months. Conclusions We expect that this study will add important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge implementation tools across jurisdictions. PMID:25699546

Does EMS Perceived Anatomic Injury Predict Trauma Center Need?

PubMed Central

Lerner, E. Brooke; Roberts, Jennifer; Guse, Clare E.; Shah, Manish N.; Swor, Robert; Cushman, Jeremy T.; Blatt, Alan; Jurkovich, Gregory J.; Brasel, Karen

2013-01-01

Objective Our objective was to determine the predictive value of the anatomic step of the 2011 Field Triage Decision Scheme for identifying trauma center need. Methods EMS providers caring for injured adults transported to regional trauma centers in 3 midsized communities were interviewed over two years. Patients were included, regardless of injury severity, if they were at least 18 years old and were transported by EMS with a mechanism of injury that was an assault, motor vehicle or motorcycle crash, fall, or pedestrian or bicyclist struck. The interview was conducted upon ED arrival and collected physiologic condition and anatomic injury data. Patients who met the physiologic criteria were excluded. Trauma center need was defined as non-orthopedic surgery within 24 hours, intensive care unit admission, or death prior to hospital discharge. Data were analyzed by calculating descriptive statistics including positive likelihood ratios (+LR) with 95% confidence intervals. Results 11,892 interviews were conducted. One was excluded because of missing outcome data and 1,274 were excluded because they met the physiologic step. EMS providers identified 1,167 cases that met the anatomic criteria, of which 307 (26%) needed the resources of a trauma center (38% sensitivity, 91% specificity, +LR 4.4; CI: 3.9 - 4.9). Criteria with a +LR ≥5 were flail chest (9.0; CI: 4.1 - 19.4), paralysis (6.8; CI: 4.2 - 11.2), two or more long bone fractures (6.3; CI: 4.5 - 8.9), and amputation (6.1; CI: 1.5 - 24.4). Criteria with a +LR >2 and <5 were penetrating injury (4.8; CI: 4.2 - 5.6), and skull fracture (4.8; CI: 3.0 - 7.7). Only pelvic fracture (1.9; CI: 1.3 - 2.9) had a +LR less than 2. Conclusions The anatomic step of the Field Triage Guidelines as determined by EMS providers is a reasonable tool for determining trauma center need. Use of EMS perceived pelvic fracture as an indicator for trauma center need should be re-evaluated. PMID:23627418

New Orleans Charity Hospital--your trauma center at work.

PubMed

Stockinger, Zsolt T; Holloway, Vicki L; McSwain, Norman E; Thomas, Dwayne; Fontenot, Cathi; Hunt, John P; Mederos, Eileen; Hewitt, Robert L

2004-01-01

The Medical Center of Louisiana at New Orleans-Charity Hospital stands with pride as one of only two level I trauma centers in the state and one of the largest trauma centers in the United States, seeing over 4,000 trauma patients per year. Despite perennial funding issues, Charity Hospital's Emergency Department treated almost 200,000 patients in 2003. This brief report gives an overview of the emergency- and trauma-related services provided by Charity Hospital and underscores its value as a critical asset to healthcare in the Louisiana.

Treatment of liver injuries at level I and level II centers in a multi-institutional metropolitan trauma system. The Midwest Trauma Society Liver Trauma Study Group.

PubMed

Helling, T S; Morse, G; McNabney, W K; Beggs, C W; Behrends, S H; Hutton-Rotert, K; Johnson, D J; Reardon, T M; Roling, J; Scheve, J; Shinkle, J; Webb, J M; Watkins, M

1997-06-01

The development of trauma systems and trauma centers has had a major impact on the fate of the critically injured patient. However, some have suggested that care may be compromised if too many trauma centers are designated for a given area. As of 1987, the state of Missouri had designated six adult trauma centers, two Level I and four Level II, for the metropolitan Kansas City, Mo, area, serving a population of approximately 1 million people. To determine whether care was comparable between the Level I and II centers, we conducted a concurrent evaluation of the fate of patients with a sentinel injury, hepatic trauma, over a 6-year period (1987-1992) who were treated at these six trauma centers. All patients during the 6-year study period who suffered liver trauma and who survived long enough to be evaluated by computerized tomography or celiotomy were entered into the study. Patients with central nervous system trauma were excluded from analysis. Information concerning mechanism of injury, RTS, Injury Severity Score (ISS), presence of shock, liver injury scoring, mode of treatment, mortality, and length of stay were recorded on abstract forms for analysis. Care was evaluated by mortality, time to the operating room (OR), and intensive care unit (ICU) and hospital length of stay. Over the 6-year period 300 patients with non-central nervous system liver trauma were seen. Level I centers cared for 195 patients and Level II centers cared for 105. There was no difference in mean ISS or ISS > 25 between Level I and II centers. Fifty-five (28%) patients arrived in shock at Level I centers and 24 (23%) at Level II centers. Forty-eight patients (16%) died. Thirty-two (16%) died at Level I centers, and 16 (15%) died at Level II centers. Twenty of 55 patients (36%) in shock died at Level I centers, and 11 of 24 (46%) died at Level II centers (p = 0.428). Forty-three patients (22%) had liver scaling scores of IV-VI at Level I centers, and 10 (10%) had similar scores at Level II centers (p < 0.01). With liver scores IV-VI, 22 of 43 (51%) died at Level I centers and 10 of 14 (71%) died at Level II centers (p = 0.184). There was no difference in mean time or in delays beyond 1 hour to the OR for those patients in shock between Level I and II centers. There was a longer ICU stay at Level II centers (5.0 +/- 8.3 vs. 2.8 +/- 8.4 days, p = 0.04). This difference was confined to penetrating injuries. There was no difference in hospital length of stay. In a metropolitan trauma system, when Level I and II centers were compared for their ability to care for victims of hepatic trauma, there was no discernible difference in care rendered with respect to severity of injury, mortality, delays to the OR, or hospital length of stay. It was observed that more severe liver injuries were seen at Level I centers, but this did not seem to significantly affect care at Level II centers. There was a longer ICU stay observed at Level II centers owing to penetrating injuries, possibly because there were fewer penetrating injuries treated at these facilities. Although the bulk of patients were seen at Level I centers, care throughout the system was equivalent.

Geographic distribution of trauma centers and injury-related mortality in the United States.

PubMed

Brown, Joshua B; Rosengart, Matthew R; Billiar, Timothy R; Peitzman, Andrew B; Sperry, Jason L

2016-01-01

Regionalized trauma care improves outcomes; however, access to care is not uniform across the United States. The objective was to evaluate whether geographic distribution of trauma centers correlates with injury mortality across state trauma systems. Level I or II trauma centers in the contiguous United States were mapped. State-level age-adjusted injury fatality rates per 100,000 people were obtained and evaluated for spatial autocorrelation. Nearest neighbor ratios (NNRs) were generated for each state. A NNR less than 1 indicates clustering, while a NNR greater than 1 indicates dispersion. NNRs were tested for difference from random geographic distribution. Fatality rates and NNRs were examined for correlation. Fatality rates were compared between states with trauma center clustering versus dispersion. Trauma center distribution and population density were evaluated. Spatial-lag regression determined the association between fatality rate and NNR, controlling for state-level demographics, population density, injury severity, trauma system resources, and socioeconomic factors. Fatality rates were spatially autocorrelated (Moran's I = 0.35, p < 0.01). Nine states had a clustered pattern (median NNR, 0.55; interquartile range [IQR], 0.48-0.60), 22 had a dispersed pattern (median NNR, 2.00; IQR, 1.68-3.99), and 10 had a random pattern (median NNR, 0.90; IQR, 0.85-1.00) of trauma center distribution. Fatality rate and NNR were correlated (ρ = 0.34, p = 0.03). Clustered states had a lower median injury fatality rate compared with dispersed states (56.9 [IQR, 46.5-58.9] vs. 64.9 [IQR, 52.5-77.1]; p = 0.04). Dispersed compared with clustered states had more counties without a trauma center that had higher population density than counties with a trauma center (5.7% vs. 1.2%, p < 0.01). Spatial-lag regression demonstrated that fatality rates increased by 0.02 per 100,000 persons for each unit increase in NNR (p < 0.01). Geographic distribution of trauma centers correlates with injury mortality, with more clustered state trauma centers associated with lower fatality rates. This may be a result of access relative to population density. These results may have implications for trauma system planning and require further study to investigate underlying mechanisms. Therapeutic/care management study, level IV.

Vasopressor use following traumatic injury – A single center retrospective study

PubMed Central

Hylands, Mathieu; Godbout, Marie-Pier; Mayer, Sandeep K.; Fraser, William D.; Vanasse, Alain; Leclair, Marc-André; Turgeon, Alexis F.; Lauzier, François; Charbonney, Emmanuel; Trottier, Vincent; Razek, Tarek S.; Roy, André; D’Aragon, Frédérick; Belley-Côté, Emilie; Day, Andrew G.; Le Guillan, Soazig; Sabbagh, Robert

2017-01-01

Objectives Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers. Methods We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management. Results Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7–38.5). Conclusions In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards. PMID:28448605

Then we all fall down: fall mortality by trauma center level.

PubMed

Roubik, Daniel; Cook, Alan D; Ward, Jeanette G; Chapple, Kristina M; Teperman, Sheldon; Stone, Melvin E; Gross, Brian; Moore, Forrest O

2017-09-01

Ground-level falls (GLFs) are the predominant mechanism of injury in US trauma centers and accompany a spectrum of comorbidities, injury severity, and physiologic derangement. Trauma center levels define tiers of capability to treat injured patients. We hypothesized that risk-adjusted observed-to-expected mortality (O:E) by trauma center level would evaluate the degree to which need for care was met by provision of care. This retrospective cohort study used National Trauma Data Bank files for 2007-2014. Trauma center level was defined as American College of Surgeons (ACS) level I/II, ACS III/IV, State I/II, and State III/IV for within-group homogeneity. Risk-adjusted expected mortality was estimated using hierarchical, multivariable regression techniques. Analysis of 812,053 patients' data revealed the proportion of GLF in the National Trauma Data Bank increased 8.7% (14.1%-22.8%) over the 8 y studied. Mortality was 4.21% overall with a three-fold increase for those aged 60 y and older versus younger than 60 y (4.93% versus 1.46%, P < 0.001). O:E was lowest for ACS III/IV, (0.973, 95% CI: 0.971-0.975) and highest for State III/IV (1.043, 95% CI: 1.041-1.044). Risk-adjusted outcomes can be measured and meaningfully compared among groups of trauma centers. Differential O:E for ACS III/IV and State III/IV centers suggests that factors beyond case mix alone influence outcomes for GLF patients. More work is needed to optimize trauma care for GLF patients across the spectrum of trauma center capability. Copyright © 2017 Elsevier Inc. All rights reserved.

Measuring trauma center injury prevention activity: an assessment and reporting tool.

PubMed

Sise, Michael J; Sise, Carol Beth

2006-02-01

To develop an assessment and reporting tool for a trauma center's community partnership strategy to deliver injury prevention programs in a large metropolitan area. The tool was designed to track prevention activity and serve as a reporting format for the parent health system, county designating agency, and the American College of Surgeons' Trauma Center Verification Process. The tool collected data including trauma center paid and volunteer personnel time, equipment, resource, and financial costs, community group and public agency contributions, number of community members receiving prevention material or presentations, impact on public policy, and print and broadcast media coverage. These measurements were incorporated in a reporting grid format. Six youth injury prevention programs were evaluated over a recent 2-year interval to demonstrate the tool's usefulness. Of six programs, three focused on motor vehicle injuries, one on teen suicide, one on firearm injuries, and one on drug and alcohol abuse. Trauma Center personnel asset allocation included 3% full-time equivalent by the Trauma Medical Director, 30% by the Injury Prevention and Community Outreach Coordinator, and 473 person hours (both work and volunteer) by physicians, nurses, and other personnel. Trauma Center equipment and fixed asset expenses totaled $3,950 and monetary contribution totaled $4,430. Community groups and public agencies contributed 20,400 person hours with estimated in-kind costs exceeding $750,000. Five of the six programs continued during the 2-year period. A gun-lock giveaway program was suspended because of a product recall. A total of over 29,000 youth received prevention material and presentations. Four public policy initiatives and 18 Trauma Center media stories with over 50 mentions and 37 new community partnerships resulted. The reports generated were easily incorporated in the trauma center's reports to local and national organizations and agencies. This assessment tool provided a detailed but concise accounting of trauma center injury prevention activity. The reports generated were effective in displaying the center's work.

Lead-Time Bias and Interhospital Transfer after Injury: Trauma Center Admission Vital Signs Underpredict Mortality in Transferred Trauma Patients.

PubMed

Holena, Daniel N; Wiebe, Douglas J; Carr, Brendan G; Hsu, Jesse Y; Sperry, Jason L; Peitzman, Andrew B; Reilly, Patrick M

2017-03-01

Admission physiology predicts mortality after injury, but may be improved by resuscitation before transfer. This phenomenon, which has been termed lead-time bias, may lead to underprediction of mortality in transferred patients and inaccurate benchmarking in centers receiving large numbers of transfer patients. We sought to determine the impact of using vital signs on arrival at the referring center vs on arrival at the trauma center in mortality prediction models for transferred trauma patients. We performed a retrospective cohort study using a state-wide trauma registry including all patients age 16 years or older, with Abbreviated Injury Scale scores ≥ 3, admitted to level I and II trauma centers in Pennsylvania, from 2011 to 2014. The primary outcomes measure was the risk-adjusted association between mortality and interhospital transfer (IHT) when adjusting for physiology (as measured by Revised Trauma Score [RTS]) using the referring hospital arrival vital signs (model 1) compared with trauma center arrival vital signs (model 2). After adjusting for patient and injury factors, IHT was associated with reduced mortality (odds ratio [OR] 0.85; 95% CI 0.77 to 0.93) using the RTS from trauma center admission, but with increased mortality (OR 1.15; 95% CI 1.05 to 1.27) using RTS from the referring hospital. The greater the number of transfer patients seen by a center, the greater the difference in center-level mortality predicted by the 2 models (β -0.044; 95% CI -0.044 to -0.0043; p ≤ 0.001). Trauma center vital signs underestimate mortality in transfer patients and may lead to incorrect estimates of expected mortality. Where possible, benchmarking efforts should use referring hospital vital signs to risk-adjust IHT patients. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Effect of a curfew law on juvenile trauma.

PubMed

Shatz, D V; Zhang, C; McGrath, M

1999-12-01

As a method of crime reduction among teenagers, several cities, counties, and states across the country have enacted, or attempted to enact, curfew laws. A curfew law was successfully implemented in Dade County, Florida, in January of 1996. Although its efficacy for crime reduction has been questioned, its benefit for trauma prevention may be real. Trauma registry data was collected retrospectively and prospectively from Dade County's Level I trauma center for all trauma victims 5 to 16 years of age. The time period spanned the 2 years before the institution of the curfew law (January 1, 1996) and the 2 years after. Total adult and pediatric trauma volumes during the 4-year period were used as comparisons, as well as juvenile traumas occurring during noncurfew hours. Total trauma volume did not change significantly across the 4-year period, nor did the volume among the curfew age group during noncurfew hours. The predominant mechanisms of injury during curfew hours were motor vehicle crashes and gunshots. Neither the patterns of mechanisms nor ages changed significantly during the precurfew and postcurfew eras. However, the volume of cases seen at the trauma center among the curfew age group was significantly lower with the curfew law in effect (mean, 7.0/month) than before it was in effect (mean, 9.5/month, p = 0.043). Although the overall trauma admissions and juvenile trauma admissions during the noncurfew hours remained relatively stable, juvenile trauma admissions during curfew hours dropped significantly in the 2 years after enforcement of the curfew law compared with the 2 years before the curfew law. This finding suggests that attempts to prevent late-night nonproductive street presence among teens can decrease the incidence of trauma occurrences.

Comparison of Helicopter Emergency Medical Services Transport Types and Delays on Patient Outcomes at Two Level I Trauma Centers.

PubMed

Nolan, Brodie; Tien, Homer; Sawadsky, Bruce; Rizoli, Sandro; McFarlan, Amanda; Phillips, Andrea; Ackery, Alun

2017-01-01

Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems. In Ontario, transportation for trauma patients is through one of three ways: scene call, modified scene call, or interfacility transfer. We hypothesize that differences exist between these types of transports in both patient demographics and patient outcomes. This study compares the characteristics of patients transported by each of these methods to two level 1 trauma centers and assesses for any impact on morbidity or mortality. As a secondary outcome reasons for delay were identified. A local trauma registry was used to identify and abstract data for all patients transported to two trauma centers by HEMS over a 36-month period. Further chart abstraction using the HEMS patient care reports was done to identify causes of delay during HEMS transport. During the study period HEMS transferred a total of 911 patients of which 139 were scene calls, 333 were modified scene calls and 439 were interfacility transfers. Scene calls had more patients with an ISS of less than 15 and had more patients discharged home from the ED. Modified scene calls had more patients with an ISS greater than 25. The most common delays that were considered modifiable included the sending physician doing a procedure, waiting to meet a land EMS crew, delays for diagnostic imaging and confirming disposition or destination. Differences exist between the types of transports done by HEMS for trauma patients. Many identified reasons for delay to HEMS transport are modifiable and have practical solutions. Future research should focus on solutions to identified delays to HEMS transport. Key words: helicopter emergency medical services; trauma; prehospital care; delays.

Function of "nontrauma" surgeons in level I trauma centers in the United States.

PubMed

Pate, J W

1997-06-01

Although the general "trauma" surgeon is usually the team leader in level I trauma centers, the use of surgical subspecialists and nonsurgeons is frequently ill-defined. This study was done to gain data in regard to actual use of subspecialists in busy centers. First, a survey of the patterns of staffing in 140 trauma centers was elicited by mail questionnaire, supplemented by telephone cells. Second, records of 400 consecutive patients at the Elvis Presley Trauma Center were reviewed to determine the use of subspecialists during the first 24 hours of care of individual patients. There were differences in the use of surgical subspecialists and nonsurgeons at different centers: in receiving, admitting, operating, and critical care areas and in privileges for admission and attending of inpatients. Consultation "guidelines" are used for many specific injuries. At our center, a mean of 1.92 subspecialists, in addition to general surgeons, were involved in the early care of each patient. Problems exist in many centers regarding the use of subspecialists, especially for management of facial and chest injuries. In some centers nonsurgeons function in the intensive care unit, and as admitting and attending physicians of trauma patients.

Traumatic Injury in the United States: In-Patient Epidemiology 2000–2011

PubMed Central

DiMaggio, Charles; Ayoung-Chee, Patricia; Shinseki, Matthew; Wilson, Chad; Marshall, Gary; Lee, David C.; Wall, Stephen; Maulana, Shale; Pachter, H. Leon; Frangos, Spiros

2017-01-01

Background Trauma is a leading cause of death and disability in the United States (US). This analysis describes trends and annual changes in in-hospital trauma morbidity and mortality; evaluates changes in age and gender specific outcomes, diagnoses, causes of injury, injury severity and surgical procedures performed; examines the role of teaching hospitals and Level 1 trauma centers in the care of severely injured patients. Methods We conducted a retrospective descriptive and analytic epidemiologic study of an inpatient database representing 20,659,684 traumatic injury discharges from US hospitals between 2000 and 2011. The main outcomes and measures were survey-adjusted counts, proportions, means, standard errors, and 95% confidence intervals. We plotted time series of yearly data with overlying loess smoothing, created tables of proportions of common injuries and surgical procedures, and conducted survey-adjusted logistic regression analysis for the effect of year on the odds of in-hospital death with control variables for age, gender, weekday vs. weekend admission, trauma-center status, teaching-hospital status, injury severity and Charlson index score. Results The mean age of a person discharged from a US hospital with a trauma diagnosis increased from 54.08 (s.e.= 0.71) in 2000 to 59.58 (s.e. = 0.79) in 2011. Persons age 45 to 64 were the only age group to experience increasing rates of hospital discharges for trauma. The proportion of trauma discharges with a Charlson Comorbidity Index score greater than or equal to 3 nearly tripled from 0.048 (s.e. = 0.0015) of all traumatic injury discharges in 2000 to 0.139 (s.e. = 0.005) in 2011. The proportion of patients with traumatic injury classified as severe increased from 22% of all trauma discharges in 2000 (95% CI 21, 24) to 28% in 2011 (95% CI 26, 30). Level 1 trauma centers accounted for approximately 3.3% of hospitals. The proportion of severely injured trauma discharges from Level 1 trauma centers was 39.4% (95% CI 36.8, 42.1). Falls, followed by motor-vehicle crashes, were the most common causes of all injuries. The total cost of trauma-related inpatient care between 2001 and 2011 in the US was $240.7 billion (95% CI 231.0, 250.5). Annual total US inpatient trauma-related hospital costs increased each year between 2001 and 2011, more than doubling from $12.0 billion (95% CI 10.5, 13.4) in 2001 to 29.1 billion (95% CI 25.2, 32.9) in 2011. Conclusions Trauma, which has traditionally been viewed as a predicament of the young, is increasingly a disease of the old. The strain of managing the progressively complex and costly care associated with this shift rests with a small number of trauma centers. Optimal care of injured patients requires a reappraisal of the resources required to effectively provide it given a mounting burden. PMID:27157986

Understanding the risk factors of trauma center closures: do financial pressure and community characteristics matter?

PubMed

Shen, Yu-Chu; Hsia, Renee Y; Kuzma, Kristen

2009-09-01

We analyze whether hazard rates of shutting down trauma centers are higher due to financial pressures or in areas with vulnerable populations (such as minorities or the poor). This is a retrospective study of all hospitals with trauma center services in urban areas in the continental US between 1990 and 2005, identified from the American Hospital Association Annual Surveys. These data were linked with Medicare cost reports, and supplemented with other sources, including the Area Resource File. We analyze the hazard rates of trauma center closures among several dimensions of risk factors using discrete-time proportional hazard models. The number of trauma center closures increased from 1990 to 2005, with a total of 339 during this period. The hazard rate of closing trauma centers in hospitals with a negative profit margin is 1.38 times higher than those hospitals without the negative profit margin (P < 0.01). Hospitals receiving more generous Medicare reimbursements face a lower hazard of shutting down trauma centers (ratio: 0.58, P < 0.01) than those receiving below average reimbursement. Hospitals in areas with higher health maintenance organizations penetration face a higher hazard of trauma center closure (ratio: 2.06, P < 0.01). Finally, hospitals in areas with higher shares of minorities face a higher risk of trauma center closure (ratio: 1.69, P < 0.01). Medicaid load and uninsured populations, however, are not risk factors for higher rates of closure after we control for other financial and community characteristics. Our findings give an indication on how the current proposals to cut public spending could exacerbate the trauma closure particularly among areas with high shares of minorities. In addition, given the negative effect of health maintenance organizations on trauma center survival, the growth of Medicaid managed care population should be monitored. Finally, high shares of Medicaid or uninsurance by themselves are not independent risk factors for higher closure as long as financial pressures are mitigated. Targeted policy interventions and further research on the causes, are needed to address these systems-level disparities.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Vlies, C. H. van der, E-mail: c.h.vandervlies@amc.uva.nl; Hoekstra, J.; Ponsen, K. J.

Introduction: Nonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center. Methods: An analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment. Results: A total ofmore » 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%. Conclusions: SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States.« less

The association of insurance status on the probability of transfer for pediatric trauma patients.

PubMed

Hamilton, Emma C; Miller, Charles C; Cotton, Bryan A; Cox, Charles; Kao, Lillian S; Austin, Mary T

2016-12-01

The purpose of this study was to evaluate the association of insurance status on the probability of transfer of pediatric trauma patients to level I/II centers after initial evaluation at lower level centers. A retrospective review of all pediatric trauma patients (age<16years) registered in the 2007-2012 National Trauma Data Bank was performed. Multiple regression techniques controlling for clustering at the hospital level were used to determine the impact of insurance status on the probability of transfer to level I/II trauma centers. Of 38,205 patients, 33% of patients (12,432) were transferred from lower level centers to level I/II trauma centers. Adjusting for demographics and injury characteristics, children with no insurance had a higher likelihood of transfer than children with private insurance. Children with public or unknown insurance status were no more likely to be transferred than privately insured children. There were no variable interactions with insurance status. Among pediatric trauma patients, lack of insurance is an independent predictor for transfer to a major trauma center. While burns, severely injured, and younger patients remain the most likely to be transferred, these findings suggest a triage bias influenced by insurance status. Additional policies may be needed to avoid unnecessary transfer of uninsured pediatric trauma patients. Case-control study, level III. Copyright © 2016 Elsevier Inc. All rights reserved.

Canceled to Be Called Back: A Retrospective Cohort Study of Canceled Helicopter Emergency Medical Service Scene Calls That Are Later Transferred to a Trauma Center.

PubMed

Nolan, Brodie; Ackery, Alun; Nathens, Avery; Sawadsky, Bruce; Tien, Homer

In our trauma system, helicopter emergency medical services (HEMS) can be requested to attend a scene call for an injured patient before arrival by land paramedics. Land paramedics can cancel this response if they deem it unnecessary. The purpose of this study is to describe the frequency of canceled HEMS scene calls that were subsequently transferred to 2 trauma centers and to assess for any impact on morbidity and mortality. Probabilistic matching was used to identify canceled HEMS scene call patients who were later transported to 2 trauma centers over a 48-month period. Registry data were used to compare canceled scene call patients with direct from scene patients. There were 290 requests for HEMS scene calls, of which 35.2% were canceled. Of those canceled, 24.5% were later transported to our trauma centers. Canceled scene call patients were more likely to be older and to be discharged home from the trauma center without being admitted. There is a significant amount of undertriage of patients for whom an HEMS response was canceled and later transported to a trauma center. These patients face similar morbidity and mortality as patients who are brought directly from scene to a trauma center. Copyright © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

Pediatric trauma at an adult trauma center.

PubMed

Siram, Suryanarayana; Oyetunji, Tolulope A; Khoury, Amal L; Walker, Sonya R; Bolorunduro, Oluwaseyi B; Chang, David C; Greene, Wendy R; Cornwell, Edward E; Frederick, Wayne A I

2010-08-01

Accidental traumatic injury is the number 1 cause of morbidity and mortality in the pediatric population. In this study, we aim to prove that certain pediatric patients can be treated with good outcomes at an adult level 1 trauma center. Retrospective analysis using the Howard University Hospital trauma registry identified 71 patients treated at Howard University Hospital between the ages of 1 and 17 years old. Specific variables were identified and collected for each patient. The majority of pediatric traumas treated at Howard University Hospital between June 2004 and May 2005 had high survival rates (93%). The patients who did not survive (7%) included 3 patients who were dead on arrival and 2 who died shortly after arrival to the hospital. Certain pediatric populations who present with minor and/or isolated injuries can be treated in an adult level 1 trauma center with similar outcomes to treatment in a pediatric level 1 trauma center.

Outcome differences in adolescent blunt severe polytrauma patients managed at pediatric versus adult trauma centers.

PubMed

Rogers, Amelia T; Gross, Brian W; Cook, Alan D; Rinehart, Cole D; Lynch, Caitlin A; Bradburn, Eric H; Heinle, Colin C; Jammula, Shreya; Rogers, Frederick B

2017-12-01

Previous research suggests adolescent trauma patients can be managed equally effectively at pediatric and adult trauma centers. We sought to determine whether this association would be upheld for adolescent severe polytrauma patients. We hypothesized that no difference in adjusted outcomes would be observed between pediatric trauma centers (PTCs) and adult trauma centers (ATCs) for this population. All severely injured adolescent (aged 12-17 years) polytrauma patients were extracted from the Pennsylvania Trauma Outcomes Study database from 2003 to 2015. Polytrauma was defined as an Abbreviated Injury Scale (AIS) score ≥3 for two or more AIS-defined body regions. Dead on arrival, transfer, and penetrating trauma patients were excluded from analysis. ATC were defined as adult-only centers, whereas standalone pediatric hospitals and adult centers with pediatric affiliation were considered PTC. Multilevel mixed-effects logistic regression models assessed the adjusted impact of center type on mortality and total complications while controlling for age, shock index, Injury Severity Score, Glasgow Coma Scale motor score, trauma center level, case volume, and injury year. A generalized linear mixed model characterized functional status at discharge (FSD) while controlling for the same variables. A total of 1,606 patients met inclusion criteria (PTC: 868 [54.1%]; ATC: 738 [45.9%]), 139 (8.66%) of which died in-hospital. No significant difference in mortality (adjusted odds ratio [AOR]: 1.10, 95% CI 0.54-2.24; p = 0.794; area under the receiver operating characteristic: 0.89) was observed between designations in adjusted analysis; however, FSD (AOR: 0.38, 95% CI 0.15-0.97; p = 0.043) was found to be lower and total complication trends higher (AOR: 1.78, 95% CI 0.98-3.32; p = 0.058) at PTC for adolescent polytrauma patients. Contrary to existing literature on adolescent trauma patients, our results suggest patients aged 12-17 presenting with polytrauma may experience improved overall outcomes when managed at adult compared to pediatric trauma centers. Epidemiologic study, level III.

Mortality factors in geriatric blunt trauma patients.

PubMed

Knudson, M M; Lieberman, J; Morris, J A; Cushing, B M; Stubbs, H A

1994-04-01

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma. In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score. Three urban trauma centers. Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989). The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3. Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

Evacuation Priorities in Mass Casualty Terror-Related Events

PubMed Central

Einav, Sharon; Feigenberg, Zvi; Weissman, Charles; Zaichik, Daniel; Caspi, Guy; Kotler, Doron; Freund, Herbert R.

2004-01-01

Objective: To assess evacuation priorities during terror-related mass casualty incidents (MCIs) and their implications for hospital organization/contingency planning. Summary Background Data: Trauma guidelines recommend evacuation of critically injured patients to Level I trauma centers. The recent MCIs in Israel offered an opportunity to study the impositions placed on a prehospital emergency medical service (EMS) regarding evacuation priorities in these circumstances. Methods: A retrospective analysis of medical evacuations from MCIs (29.9.2000–31.9.2002) performed by the Israeli National EMS rescue teams. Results: Thirty-three MCIs yielded data on 1156 casualties. Only 57% (506) of the 1123 available and mobilized ambulances were needed to provide 612 evacuations. Rescue teams arrived on scene within <5 minutes and evacuated the last urgent casualty within 15–20 minutes. The majority of non-urgent and urgent patients were transported to medical centers close to the event. Less than half of the urgent casualties were evacuated to more distant trauma centers. Independent variables predicting evacuation to a trauma center were its being the hospital closest to the event (OR 249.2, P < 0.001), evacuation within <10 minutes of the event (OR 9.3, P = 0.003), and having an urgent patient on the ambulance (OR 5.6, P < 0.001). Conclusions: Hospitals nearby terror-induced MCIs play a major role in trauma patient care. Thus, all hospitals should be included in contingency plans for MCIs. Further research into the implications of evacuation of the most severely injured casualties to the nearest hospital while evacuating all other casualties to various hospitals in the area is needed. The challenges posed by terror-induced MCIs require consideration of a paradigm shift in trauma care. PMID:15075645

Protocol for rapid sequence intubation in pediatric patients -- a four-year study.

PubMed

Marvez-Valls, Eduardo; Houry, Debra; Ernst, Amy A; Weiss, Steven J; Killeen, James

2002-04-01

To evaluate a protocol for rapid sequence intubation (RSI) for pediatric patients in a Level 1 trauma center. Retrospective review of prospectively gathered Continuing Quality Improvement (CQI) data at an inner city Level 1 trauma center with an emergency medicine residency program. Protocols for RSI were established prior to initiating the study. All pediatric intubations at the center from February 1996 to February 2000 were included. Statistical analysis included descriptive statistics for categorical data and Chi-square for comparisons between groups. Over the 4-year study period there were 83 pediatric intubations ranging in age from 18 months to 17 years; mean age 8.6. All had data collected at the time of intubation. There were 20 (24%) females and 62 (76%) males (p<0.001). Reasons for intubation were related to trauma in 71 (86%) and medical reasons in 12 (14%) (p<0.001). Of the trauma intubations 7 (10%) were for gunshot wounds, 39 (55%) were secondary to MVCs, and the remainder (25; 35%) were from assaults, falls, and closed head injuries. The non-trauma intubations were for smoke inhalation, overdose, seizure, HIV related complications, eclampsia, and near drowning. Intubations were successful with one attempt in 65 (78%) cases. No surgical airways were necessary. Rocuronium was used in 4 cases. Protocol deviations did not lead to complications. This protocol based pediatric rapid sequence intubation method worked well in an EM residency program. More intubations were in males and more were necessary due to trauma in this group.

Screening and Intervention for Comorbid Substance Disorders, PTSD, Depression, and Suicide: A Trauma Center Survey.

PubMed

Love, Jeff; Zatzick, Douglas

2014-07-01

Few investigations have examined screening and intervention procedures for comorbid substance use and mental disorders at trauma centers in the United States, although these disorders are endemic among survivors of traumatic injury. In 2006, the American College of Surgeons (ACS) mandated that level I and level II trauma centers screen for alcohol use problems and that level I centers provide brief intervention for those who screen positive. The ACS is expected to recommend best practice policy guidelines for screening for drug use problems and posttraumatic stress disorder (PTSD). This study examined screening and intervention procedures for the full spectrum of comorbid mental and substance use disorders at U.S. trauma centers. Respondents at all level I and level II trauma centers (N=518) in the United States were asked to complete a survey describing screening and intervention procedures for alcohol and drug use problems, suicidality, depression, and PTSD. There were 391 (75%) respondents. Over 80% of trauma centers routinely screened for alcohol and drug use problems. Routine screening and intervention for suicidality, depression, and PTSD were markedly less common; in fact, only 7% of centers reported routine screening for PTSD. Consistent with ACS policy, level I centers were significantly more likely than level II centers to provide alcohol intervention. Alcohol screening and intervention occurred frequently at U.S. trauma centers and appeared to be responsive to ACS mandates. In the future, efforts to orchestrate clinical investigation and policy could enhance screening and intervention procedures for highly prevalent, comorbid mental disorders.

Enhancing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma

PubMed Central

Zatzick, Douglas; Rivara, Frederick; Jurkovich, Gregory; Russo, Joan; Trusz, Sarah Geiss; Wang, Jin; Wagner, Amy; Stephens, Kari; Dunn, Chris; Uehara, Edwina; Petrie, Megan; Engel, Charles; Davydow, Dimitri; Katon, Wayne

2011-01-01

Objective To develop and implement a stepped collaborative care intervention targeting PTSD and related co-morbidities to enhance the population impact of early trauma-focused interventions. Method We describe the design and implementation of the Trauma Survivors Outcomes & Support Study (TSOS II). An interdisciplinary treatment development team was comprised of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between front-line trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures. Results Two-hundred and seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing, and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by front-line acute care MSW and ARNP providers. Conclusions Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other non-specialty posttraumatic contexts. PMID:21596205

Health care reform at trauma centers--mortality, complications, and length of stay.

PubMed

Shafi, Shahid; Barnes, Sunni; Nicewander, David; Ballard, David; Nathens, Avery B; Ingraham, Angela M; Hemmila, Mark; Goble, Sandra; Neal, Melanie; Pasquale, Michael; Fildes, John J; Gentilello, Larry M

2010-12-01

The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications. The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity. Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS. Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

Unregulated proliferation of trauma centers undermines cost efficiency of population-based injury control.

PubMed

Tepas, Joseph J; Kerwin, Andrew J; Ra, Jin Hee

2014-03-01

We evaluated the impact on coverage and regional cost of trauma care produced by the activation of a Level II center with no preceding needs analysis in an established trauma region with a Level I center. Patient deidentified trauma registry data for years 2010, 2011, and 2012 were analyzed to assess the effect on trauma service volume during a period at the midpoint of which the Level II center was activated. Trends for each year were evaluated by patient volume, mechanism, resource use as reflected in a transfer to the intensive care unit (ICU) and ICU stay, patient severity as defined by Injury Severity Score (ISS), and patient injury profile determined by mean body region Abbreviated Injury Scale (AIS) score. Between 2010 and 2011, during which the Level II opened, overall volume at the Level I center dropped by 3.7%, and blunt volume remained unchanged. From 2011 to 2012, overall Level I volume dropped by 9.4%, and blunt injury fell by 14%. Proportions requiring immediate operating room or ICU care did not change. ISS distribution at the Level I center across the years was similar. Head, chest, and abdominal injuries, as assessed by AIS body region, increased slightly in severity and decreased in volume by 25%, 17%, and 18%, respectively. For 2012, the new center publically reported treating 1,100 patients, which, in concert with the Level I decrease, translates to increasing regional trauma center access by 25% while increasing expense of necessary core personnel by 217%. Addition of a second trauma center in a stable region, in which injury incidence was actually decreasing, doubled the cost of personnel, one of the most expensive components of the trauma system and decreased the volume of injuries necessary for training and education. Trauma system expansion must be based on needs assessment, which assures system survival and controls societal cost. Economic & value-based evaluation, level III.

Transforming trauma healthcare delivery in rural areas by use of an integrated call center

PubMed Central

Agrawal, Deepak

2012-01-01

Introduction: There is poor penetration of trauma healthcare delivery in rural areas. On the other hand, mobile penetration in India is now averaging 80% with most families having access to mobile phone. Aims and Objectives: The aim of this study was to assess the implementation and socioeconomic impact of a call center in providing healthcare delivery for patients with head and spinal injuries. Materials and Methods: This was a prospective observational study carried out over a 6-month period at a level I trauma Center in New Delhi, India. A nine-seater call center was outsourced to a private company and the hospital's electronic medical records were integrated with the call-center operations. The call center was given responsibility of maintaining appointments and scheduling clinics for the whole hospital as well as ensuring follow-up visits. Trained call-center staff handled simple patient queries and referred the rest via email to concerned doctors. A telephonic survey was done prior to the start of call-center operations and after 3 months to assess for user satisfaction. Results: The initial cost of outsourcing the call center was Rs 1.6 lakhs (US$ 4000), with a recurring cost of Rs 80,000 (US$ 2000) per month. A total of 484 patients were admitted in the department of Neurosurgery during the study period. Of these, 63% (n=305) were from rural areas. Patients’ overall experience for clinic visits improved markedly following implementation of call center. Patient satisfaction for follow-up visits increased from a mean of 32-96%. Ninety-five percent patients reported a significant decrease in waiting time in clinics 80.4% reporting improved doctor-patient interaction. A total of 52 visits could be postponed/cancelled for patients living in far flung areas resulting in major socioeconomic benefits to these families. Conclusions: As shown by our case study, call centers have the potential to revolutionize delivery of trauma healthcare to rural areas in an extremely cost-effective manner. PMID:22416147

Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?

PubMed

Benedict, Leo Andrew; Paulus, Jessica K; Rideout, Leslie; Chwals, Walter J

2014-01-01

To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging. A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry. A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score <14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%). The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging. © 2014.

Feasibility of and Rationale for the Collection of Orthopaedic Trauma Surgery Quality of Care Metrics.

PubMed

Miller, Anna N; Kozar, Rosemary; Wolinsky, Philip

2017-06-01

Reproducible metrics are needed to evaluate the delivery of orthopaedic trauma care, national care, norms, and outliers. The American College of Surgeons (ACS) is uniquely positioned to collect and evaluate the data needed to evaluate orthopaedic trauma care via the Committee on Trauma and the Trauma Quality Improvement Project. We evaluated the first quality metrics the ACS has collected for orthopaedic trauma surgery to determine whether these metrics can be appropriately collected with accuracy and completeness. The metrics include the time to administration of the first dose of antibiotics for open fractures, the time to surgical irrigation and débridement of open tibial fractures, and the percentage of patients who undergo stabilization of femoral fractures at trauma centers nationwide. These metrics were analyzed to evaluate for variances in the delivery of orthopaedic care across the country. The data showed wide variances for all metrics, and many centers had incomplete ability to collect the orthopaedic trauma care metrics. There was a large variability in the results of the metrics collected among different trauma center levels, as well as among centers of a particular level. The ACS has successfully begun tracking orthopaedic trauma care performance measures, which will help inform reevaluation of the goals and continued work on data collection and improvement of patient care. Future areas of research may link these performance measures with patient outcomes, such as long-term tracking, to assess nonunion and function. This information can provide insight into center performance and its effect on patient outcomes. The ACS was able to successfully collect and evaluate the data for three metrics used to assess the quality of orthopaedic trauma care. However, additional research is needed to determine whether these metrics are suitable for evaluating orthopaedic trauma care and cutoff values for each metric.

Moving from "optimal resources" to "optimal care" at trauma centers.

PubMed

Shafi, Shahid; Rayan, Nadine; Barnes, Sunni; Fleming, Neil; Gentilello, Larry M; Ballard, David

2012-04-01

The Trauma Quality Improvement Program has shown that risk-adjusted mortality rates at some centers are nearly 50% higher than at others. This "quality gap" may be due to different clinical practices or processes of care. We have previously shown that adoption of processes called core measures by the Joint Commission and Centers for Medicare and Medicaid Services does not improve outcomes of trauma patients. We hypothesized that improved compliance with trauma-specific clinical processes of care (POC) is associated with reduced in-hospital mortality. Records of a random sample of 1,000 patients admitted to a Level I trauma center who met Trauma Quality Improvement Program criteria (age ≥ 16 years and Abbreviated Injury Scale score 3) were retrospectively reviewed for compliance with 25 trauma-specific POC (T-POC) that were evidence-based or expert consensus panel recommendations. Multivariate regression was used to determine the relationship between T-POC compliance and in-hospital mortality, adjusted for age, gender, injury type, and severity. Median age was 41 years, 65% were men, 88% sustained a blunt injury, and mortality was 12%. Of these, 77% were eligible for at least one T-POC and 58% were eligible for two or more. There was wide variation in T-POC compliance. Every 10% increase in compliance was associated with a 14% reduction in risk-adjusted in-hospital mortality. Unlike adoption of core measures, compliance with T-POC is associated with reduced mortality in trauma patients. Trauma centers with excess in-hospital mortality may improve patient outcomes by consistently applying T-POC. These processes should be explored for potential use as Core Trauma Center Performance Measures.

Variation in ICU Utilization and Mortality After Blunt Splenic Injury

PubMed Central

Kaufman, Elinore J.; Wiebe, Douglas J.; Martin, Niels D.; Pascual, Jose L.; Reilly, Patrick M.; Holena, Daniel N.

2016-01-01

Background While trauma patients are frequently cared for in the ICU, admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission. Materials and Methods We conducted a retrospective cohort study of patients treated for blunt splenic injuries at 30 level I and II Pennsylvania trauma centers, 2011–2014. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman’s rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement, between high- and low-ICU-utilization centers. Results Of 2,587 patients with blunt splenic injuries, 63.9% (1,654) were admitted to the ICU. Median injury severity score (ISS) was 17 overall, 13 for non-ICU patients and 17 for ICU patients (p < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9% to 87.3%. Risk-adjusted mortality rates ranged from 1.2% to 9.6%. There was no correlation between O:E ratios for ICU utilization and mortality (rs = −0.2595, p=0.2103). Proportionately fewer ICU patients at high-utilization centers received critical care procedures than at low-utilization centers. Conclusions Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality. PMID:27363642

Determining the hospital trauma financial impact in a statewide trauma system.

PubMed

Mabry, Charles D; Kalkwarf, Kyle J; Betzold, Richard D; Spencer, Horace J; Robertson, Ronald D; Sutherland, Michael J; Maxson, Robert T

2015-04-01

There have been no comprehensive studies across an organized statewide trauma system using a standardized method to determine cost. Trauma financial impact includes the following costs: verification, response, and patient care cost (PCC). We conducted a survey of participating trauma centers (TCs) for federal fiscal year 2012, including separate accounting for verification and response costs. Patient care cost was merged with their trauma registry data. Seventy-five percent of the 2012 state trauma registry had data submitted. Each TC's reasonable cost from the Medicare Cost Report was adjusted to remove embedded costs for response and verification. Cost-to-charge ratios were used to give uniform PCC across the state. Median (mean ± SD) costs per patient for TC response and verification for Level I and II centers were $1,689 ($1,492 ± $647) and $450 ($636 ± $431) for Level III and IV centers. Patient care cost-median (mean ± SD) costs for patients with a length of stay >2 days rose with increasing Injury Severity Score (ISS): ISS <9: $6,787 ($8,827 ± $8,165), ISS 9 to 15: $10,390 ($14,340 ± $18,395); ISS 16 to 25: $15,698 ($23,615 ± $21,883); and ISS 25+: $29,792 ($41,407 ± $41,621), and with higher level of TC: Level I: $13,712 ($23,241 ± $29,164); Level II: $8,555 ($13,515 ± $15,296); and Levels III and IV: $8,115 ($10,719 ± $11,827). Patient care cost rose with increasing ISS, length of stay, ICU days, and ventilator days for patients with length of stay >2 days and ISS 9+. Level I centers had the highest mean ISS, length of stay, ICU days, and ventilator days, along with the highest PCC. Lesser trauma accounted for lower charges, payments, and PCC for Level II, III, and IV TCs, and the margin was variable. Verification and response costs per patient were highest for Level I and II TCs. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Hospital-based ocular emergencies: epidemiology, treatment, and visual outcomes.

PubMed

Cheung, Cindy A; Rogers-Martel, Melanie; Golas, Liliya; Chepurny, Anna; Martel, James B; Martel, Joseph R

2014-03-01

Ocular trauma is recognized as the leading cause of unilateral blindness. However, few studies to date have focused on the clinical features of hospital-based ocular emergencies. Effectiveness of trauma centers in treating ocular emergencies was compared with treatment in traditional community hospital emergency departments. Demographics, causes, and nature of ocular emergencies, as well as visual outcome in community hospitals emergency departments and trauma centers, were also examined. Records of 1027 patients with ocular emergencies seen between July 2007 and November 2010 at 3 community hospitals emergency departments and 2 hospitals with level II trauma centers were retrospectively examined. Unpaired t test and Pearson χ(2) test were used to determine statistical significance. The incidence of patients requiring ophthalmic intervention was 77.2 per 100 000 in the community hospitals and 208.9 per 100 000 in the trauma centers. Rates of ocular emergencies were higher in middle-aged, white men. Orbital fractures were found in 86% of all orbital contusion cases in trauma centers, whereas 66.7% of patients with fall injuries and open globe diagnoses resulted in legal blindness. The middle-aged, white men are more vulnerable to ocular injuries caused mainly by motor vehicle accidents. The ability of trauma centers to provide comparable increases in vision outcomes, despite treating more severe ocular emergencies, demonstrates the effectiveness of trauma centers. Patients diagnosed as having orbital contusions or who have fall injuries deserve careful evaluation because they are more likely to have more severe sight-threatening injuries. Copyright © 2014 Elsevier Inc. All rights reserved.

Attempting to validate the overtriage/undertriage matrix at a Level I trauma center

PubMed Central

Davis, James W.; Dirks, Rachel C.; Sue, Lawrence P.; Kaups, Krista L.

2017-01-01

BACKGROUND The Optimal Resources Document mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the overtriage/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different, and Matrix does not discriminate the needs or outcomes of these different groups of patients. METHODS Trauma registry data, from January 2013 to December 2015, at a Level I trauma center, were reviewed. Overtriage and undertriage rates were calculated by Matrix. Patients with Injury Severity Score (ISS) of 16 or greater were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared with patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, intensive care unit admission, length of stay, and mortality. RESULTS Seven thousand thirty-one patients met activation criteria. Compliance with American College of Surgeons tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2,282 patients with an ISS of 16 or greater, 1,026 were appropriately triaged (full activation), and 1,256 were undertriaged. Undertriaged patients had better Glasgow Coma Scale score, blood pressure, and base deficit than patients with full activation. Intensive care unit admission, hospital stays, and mortality were lower in the undertriaged group. The undertriaged group required fewer operative interventions with fewer delays to procedure. CONCLUSION Despite having an ISS of 16 or greater, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The American College of Surgeons Committee on Trauma full and tiered activation criteria are a robust means to have the appropriate personnel present based on the available prehospital information. Evaluation of the process of care, regardless of level of activation, should be used to evaluate trauma center performance. LEVEL OF EVIDENCE Therapeutic and care management, level III. PMID:29189678

Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems

PubMed Central

Newgard, Craig D.; Mann, N. Clay; Hsia, Renee Y.; Bulger, Eileen M.; Ma, O. John; Staudenmayer, Kristan; Haukoos, Jason S.; Sahni, Ritu; Kuppermann, Nathan

2013-01-01

Objectives Reasons for under-triage (transporting seriously injured patients to non-trauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis. Methods This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and non-trauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department (ED) data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included: closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. “Serious injury” was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings. Results A total of 176,981 injured patients were evaluated and transported by EMS over the three-year period, of whom 5,752 (3.3%) had ISS ≥ 16, and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21 to 30 year olds to 75.8% among those older than 90 years. This trend paralleled under-triage rates, and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols. Conclusions Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age, and involves inherent differences in patient prognosis. PMID:24050797

Performance of advanced air bags based on data William Lehman Injury Research Center and new NASS PSUs.

PubMed

Augenstein, Jeffrey; Digges, Kennerly

2003-01-01

The Ryder Trauma Center is a Level I trauma center that treats only the most severely injured occupants of vehicle crashes as well as other severe cases of trauma. The center investigates these crashes through funding provided by the Alliance of Automobile Manufacturers and the U.S. Department of Transportation-sponsored Crash Injury Research and Engineering Network (CIREN) program. MAIS 3+ nonfatal and fatal injuries comprise approximately 2 percent of the total NASS/CDS cases. Among the Ryder trauma center cases, 50 percent are MAIS 3+ and 25 percent are fatal. If the MAIS 3+ fatal and nonfatal injuries were considered as "failures" and the remaining 98 percent with MAIS 2 or less as successes, this could be equated to the 75 percent failure rate (MAIS 3+ and fatal) in the trauma center cases for analysis purposes. The total database of frontal cases with no rollover consists of 147 drivers with first-generation airbags and 58 cases with second-generation airbags.

Correlating weather and trauma admissions at a level I trauma center.

PubMed

Rising, William R; O'Daniel, Joseph A; Roberts, Craig S

2006-05-01

Popular emergency room wisdom touts higher temperatures, snowfall, weekends, and evenings as variables that increase trauma admissions. This study analyzed the possible correlation between trauma admissions and specific weather variables, and between trauma admissions and time of day or season. Trauma admission data from a Level I trauma center database from July 1, 1996 to January 31, 2002 was downloaded and linked with local weather data from the Archives of the National Oceanic and Atmospheric Administration website, and then analyzed. There were 8,269 trauma admissions over a total of 48,984 hours for an average of one admission every 6 hours. Daily high temperature and precipitation were valid predictors of trauma admission volume, with a 5.25% increase in hourly incidents for each 10-degree difference in temperature, and a 60% to 78% increase in the incident rate for each inch of precipitation in the previous 3 hours. Weather and seasonal variations affect admissions at a Level I trauma center. Data from this study could be useful for determining staffing requirements and resource allocation.

Insuring the uninsured: potential impact of Health Care Reform Act of 2010 on trauma centers.

PubMed

Shafi, Shahid; Ogola, Gerald; Fleming, Neil; Rayan, Nadine; Kudyakov, Rustam; Barnes, Sunni A; Ballard, David J

2012-11-01

Viability of trauma centers is threatened by cost of care provided to patients without health insurance. The health care reform of 2010 is likely to benefit trauma centers by mandating universal health insurance by 2014. However, the financial benefit of this mandate will depend on the reimbursement provided. The study hypothesis was that compensation for the care of uninsured trauma patients at Medicare or Medicaid rates will lead to continuing losses for trauma centers. Financial data for first hospitalization were obtained from an urban Level I trauma center for 3 years (n = 6,630; 2006-2008) and linked with clinical information. Patients were grouped into five payments categories: commercial (29%), Medicaid (8%), Medicare (20%), workers' compensation (6%), and uninsured (37%). Prediction models for costs and payments were developed for each category using multiple regression models, adjusting for patient demographics, injury characteristics, complications, and survival. These models were used to predict payments that could be expected if uninsured patients were covered by different insurance types. Results are reported as net margin per patient (payments minus total costs) for each insurance type, with 95% confidence intervals, discounted to 2008 dollar values. Patients were typical for an urban trauma center (median age of 43 years, 66% men, 82% blunt, 5% mortality, and median length of stay 4 days). Overall, the trauma center lost $5,655 per patient, totaling $37.5 million over 3 years. These losses were encountered for patients without insurance ($14,343), Medicare ($4,838), and Medicaid ($15,740). Patients with commercial insurance were profitable ($5,295) as were those with workers' compensation ($6,860). Payments for the care of the uninsured at Medicare/Medicaid levels would lead to continued losses at $2,267 to $4,143 per patient. The health care reforms of 2010 would lead to continued losses for trauma centers if uninsured are covered with Medicare/Medicaid-type programs. Economic analysis, level II.

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

PubMed

Joubert, Kyla D; Mabry, Charles D; Kalkwarf, Kyle J; Betzold, Richard D; Spencer, Horace J; Spinks, Kara M; Porter, Austin; Karim, Saleema; Robertson, Ronald D; Sutherland, Michael J; Maxson, Robert T

2016-09-01

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

Illinois Trauma Centers and Intimate Partner Violence: Are We Doing Our Share?

ERIC Educational Resources Information Center

Crandall, Marie; Schwab, Jennifer; Sheehan, Karen; Esposito, Thomas

2009-01-01

Intimate partner violence (IPV) is a major source of morbidity and mortality nationally. Trauma Centers can be very helpful for victims of IPV but there may be variability in IPV resource provision. A survey was mailed to each of the 65 Trauma Centers in Illinois. Stata and EZ-Text statistical software were used for analysis. Eighty-three percent…

Factors Associated with the Use of Helicopter Inter-facility Transport of Trauma Patients to Tertiary Trauma Centers within an Organized Rural Trauma System

PubMed Central

Stewart, Kenneth; Garwe, Tabitha; Bhandari, Naresh; Danford, Brandon; Albrecht, Roxie

2016-01-01

Objective A review of the literature yielded little information regarding factors associated with the decision to use ground (GEMS) or helicopter (HEMS) emergency medical services for trauma patients transferred inter-facility. Furthermore, studies evaluating the impact of inter-facility transport mode on mortality have reported mixed findings. Since HEMS transport is generally reserved for more severely injured patients, this introduces indication bias, which may explain the mixed findings. Our objective was to identify factors at referring non-tertiary trauma centers (NTC) influencing transport mode decision. Methods This was a case-control study of trauma patients transferred from a Level III or IV NTC to a tertiary trauma center (TTC) within 24-hours reported to the Oklahoma State Trauma Registry between 2005 and 2012. Multivariable logistic regression was used to determine clinical and non-clinical factors associated with the decision to use HEMS. Results A total of 7380 patients met the study eligibility. Of these, 2803(38%) were transported inter-facility by HEMS. Penetrating injury, prehospital EMS transport, severe torso injury, hypovolemic shock, and TBI were significant predictors (p<0.05) of HEMS use regardless of distance to a TTC. Association between HEMS use and male gender, Level IV NTC, and local ground EMS resources varied by distance from the TTC. Many HEMS transported patients had minor injuries and normal vital signs. Conclusions Our results suggest that while distance remains the most influential factor associated with HEMS use, significant differences exist in clinical and non-clinical factors between patients transported by HEMS versus GEMS. To ensure comparability of study groups, studies evaluating outcome differences between HEMS and GEMS should take factors determining transport mode into account. The findings will be used to develop propensity scores to balance baseline risk between GEMS and HEMS patients for use in subsequent studies of outcomes. PMID:26986053

Associations of Distance to Trauma Care, Community Income, and Neighborhood Median Age With Rates of Injury Mortality.

PubMed

Jarman, Molly P; Curriero, Frank C; Haut, Elliott R; Pollack Porter, Keshia; Castillo, Renan C

2018-02-07

Rural, low-income, and historically underrepresented minority communities face substantial barriers to trauma care and experience high injury incidence and mortality rates. Characteristics of injury incident locations may contribute to poor injury outcomes. To examine the association of injury scene characteristics with injury mortality. In this cross-sectional study, data from trauma center and emergency medical services provided by emergency medical services companies and designated trauma centers in the state of Maryland from January 1, 2015, to December 31, 2015, were geocoded by injury incident locations and linked with injury scene characteristics. Participants included adults who experienced traumatic injury in Maryland and were transported to a designated trauma center or died while in emergency medical services care at the incident scene or in transit. The primary exposures of interest were geographic characteristics of injury incident locations, including distance to the nearest trauma center, designation level and ownership status of the nearest trauma center, and land use, as well as community-level characteristics such as median age and per capita income. Odds of death were estimated with multilevel logistic regression, controlling for individual demographic measures and measures of injury and health. Of the 16 082 patients included in this study, 8716 (52.4%) were white, and 5838 (36.3%) were African American. Most patients were male (10 582; 65.8%) and younger than 65 years (12 383; 77.0%). Odds of death increased by 8.0% for every 5-mile increase in distance to the nearest trauma center (OR, 1.08; 95% CI, 1.01-1.15; P = .03). Compared with privately owned level 1 or 2 centers, odds of death increased by 49.9% when the nearest trauma center was level 3 (OR, 1.50; 95% CI, 1.06-2.11; P = .02), and by 80.7% when the nearest trauma center was publicly owned (OR, 1.81; 95% CI, 1.39-2.34; P < .001). At the zip code tabulation area level, odds of death increased by 16.0% for every 5-year increase in median age (OR, 1.16; 95% CI, 1.03-1.30; P = .02), and decreased by 26.6% when the per capita income was greater than $25 000 (OR, 0.73; 95% CI, 0.54-0.99; P = .05). Injury scene characteristics are associated with injury mortality. Odds of death are highest for patients injured in communities with higher median age or lower per capita income and at locations farthest from level 1 or 2 trauma centers.

New and emerging patient-centered CT imaging and image-guided treatment paradigms for maxillofacial trauma.

PubMed

Dreizin, David; Nam, Arthur J; Hirsch, Jeffrey; Bernstein, Mark P

2018-06-20

This article reviews the conceptual framework, available evidence, and practical considerations pertaining to nascent and emerging advances in patient-centered CT-imaging and CT-guided surgery for maxillofacial trauma. These include cinematic rendering-a novel method for advanced 3D visualization, incorporation of quantitative CT imaging into the assessment of orbital fractures, low-dose CT imaging protocols made possible with contemporary scanners and reconstruction techniques, the rapidly growing use of cone-beam CT, virtual fracture reduction with design software for surgical pre-planning, the use of 3D printing for fabricating models and implants, and new avenues in CT-guided computer-aided surgery.

What helps or hinders the transformation from a major tertiary center to a major trauma center? Identifying barriers and enablers using the Theoretical Domains Framework.

PubMed

Roberts, Neil; Lorencatto, Fabiana; Manson, Joanna; Brundage, Susan I; Jansen, Jan O

2016-03-12

Major Trauma Centers (MTCs), as part of a trauma system, improve survival and functional outcomes from injury. Developing such centers from current teaching hospitals is likely to generate diverse beliefs amongst staff. These may act as barriers or enablers. Prior identification of these may make the service development process more efficient. The importance of applying theory to systematically identify barriers and enablers to changing clinical practice in emergency medicine has been emphasized. This study systematically explored theory-based barriers and enablers towards implementing the transformation of a tertiary hospital into a MTC. Our goal was to demonstrate the use of a replicable method to identify targets that could be addressed to achieve a successful transformation from an organization evolved to provide a particular type of clinical care into a clinical system with different demands, requirements and expectations. The Theoretical Domains Framework (TDF) is a tool designed to elicit and analyze beliefs affecting behavior. Semi-structured interviews based around the TDF were conducted in a major tertiary hospital in Scotland due to become a MTC with a purposive sample of major stakeholders including clinicians and nurses from specialties involved in trauma care, clinical managers and administration. Belief statements were identified through qualitative analysis, and assessed for importance according to prevalence, discordance and evidence base. 1728 utterances were recorded and coded into 91 belief statements. 58 were classified as important barriers/enablers. There were major concerns about resource demands, with optimism conditional on these being met. Distracting priorities abound within the Emergency Department. Better communication is needed. Staff motivation is high and they should be engaged in skills development and developing performance improvement processes. This study presents a systematic and replicable method of identifying theory-based barriers and enablers towards complex service development. It identifies multiple barriers/enablers that may serve as a basis for developing an implementation intervention to enhance the development of MTCs. This method can be used to address similar challenges in developing specialist centers or implementing clinical practice change in emergency care across both developing and developed countries.

Out-of-Hospital Decision-Making and Factors Influencing the Regional Distribution of Injured Patients in a Trauma System

PubMed Central

Newgard, Craig D.; Nelson, Maria J.; Kampp, Michael; Saha, Somnath; Zive, Dana; Schmidt, Terri; Daya, Mohamud; Jui, Jonathan; Wittwer, Lynn; Warden, Craig; Sahni, Ritu; Stevens, Mark; Gorman, Kyle; Koenig, Karl; Gubler, Dean; Rosteck, Pontine; Lee, Jan; Hedges, Jerris R.

2011-01-01

Background The decision-making processes used for out-of-hospital trauma triage and hospital selection in regionalized trauma systems remain poorly understood. The objective of this study was to understand the process of field triage decision-making in an established trauma system. Methods We used a mixed methods approach, including EMS records to quantify triage decisions and reasons for hospital selection in a population-based, injury cohort (2006 - 2008), plus a focused ethnography to understand EMS cognitive reasoning in making triage decisions. The study included 10 EMS agencies providing service to a 4-county regional trauma system with 3 trauma centers and 13 non-trauma hospitals. For qualitative analyses, we conducted field observation and interviews with 35 EMS field providers and a round-table discussion with 40 EMS management personnel to generate an empirical model of out-of-hospital decision making in trauma triage. Results 64,190 injured patients were evaluated by EMS, of whom 56,444 (88.0%) were transported to acute care hospitals and 9,637 (17.1% of transports) were field trauma activations. For non-trauma activations, patient/family preference and proximity accounted for 78% of destination decisions. EMS provider judgment was cited in 36% of field trauma activations and was the sole criterion in 23% of trauma patients. The empirical model demonstrated that trauma triage is driven primarily by EMS provider “gut feeling” (judgment) and relies heavily on provider experience, mechanism of injury, and early visual cues at the scene. Conclusions Provider cognitive reasoning for field trauma triage is more heuristic than algorithmic and driven primarily by provider judgment, rather than specific triage criteria. PMID:21817971

Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center.

PubMed

Givergis, Roshan; Munnangi, Swapna; Fayaz M Fomani, Katayoun; Boutin, Anthony; Zapata, Luis Carlos; Angus, Ld George

2018-04-18

To evaluate massive transfusion protocol practices by trauma type at a level I trauma center. A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained. Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01). Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients. Copyright © 2018 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Trauma system evaluation in developing countries: applicability of American College of Surgeons/Committee on Trauma (ACS/COT) basic criteria.

PubMed

Latifi, Rifat; Ziemba, Michelle; Leppäniemi, Ari; Dasho, Erion; Dogjani, Agron; Shatri, Zhaneta; Kociraj, Agim; Oldashi, Fatos; Shosha, Lida

2014-08-01

Trauma continues to be a major health problem worldwide, particularly in the developing world, with high mortality and morbidity. Yet most developing countries lack an organized trauma system. Furthermore, developing countries do not have in place any accreditation process for trauma centers; thus, no accepted standard assessment tools exist to evaluate their trauma services. The aims of this study were to evaluate the trauma system in Albania, using the basic trauma criteria of the American College of Surgeons/Committee on Trauma (ACS/COT) as assessment tools, and to provide the Government with a situational analysis relative to these criteria. We used the ACS/COT basic criteria as assessment tools to evaluate the trauma system in Albania. We conducted a series of semi-structured interviews, unstructured interviews, and focus groups with all stakeholders at the Ministry of Health, at the University Trauma Hospital (UTH) based in Tirana (the capital city), and at ten regional hospitals across the country. Albania has a dedicated national trauma center that serves as the only tertiary center, plus ten regional hospitals that provide some trauma care. However, overall, its trauma system is in need of major reforms involving all essential elements in order to meet the basic requirements of a structured trauma system. The ACS/COT basic criteria can be used as assessment tools to evaluate trauma care in developing countries. Further studies are needed in other developing countries to validate the applicability of these criteria.

A Civilian/Military Trauma Institute: National Trauma Research Coordinating Center

DTIC Science & Technology

2011-10-01

Rebuttals, Q&A Salon A Craniofacial Trauma LtCol Cecila Schmalbach 1540-1550 Speaker: Dr. Manuel Lopez Title: OIF: Perspective of H&N Surgeon in...Intubation Endoscope. Station 10 Video Laryngoscope Dr. (Maj) Elvin Cruz , Staff Anesthesiologist, Wilford Hall Medical Center Practice video

The Compassion Fatigue Scale: Its Use With Social Workers Following Urban Disaster

PubMed Central

Adams, Richard E.; Figley, Charles R.; Boscarino, Joseph A.

2008-01-01

Objective The present study has two goals: to assess the difference between secondary trauma and job burnout and to examine the utility of secondary trauma in predicting psychological distress. Method The data come from a survey of social workers (N = 236) living in New York City 20 months following the September 11 terrorist attacks on the World Trade Center (WTC). Results Social workers’ involvement in WTC recovery efforts is related to secondary trauma but not burnout. Analyses also reveal that both secondary trauma and burnout are related to psychological distress after controlling for other risk factors. Conclusion This study supports the importance of compassion fatigue as a risk factor for social workers counseling traumatized clients and its association with psychological problems. PMID:18458750

The Role of Stent-Grafts in the Management of Aortic Trauma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rousseau, Herve, E-mail: rousseau.h@chu-toulouse.fr; Elaassar, Omar; Marcheix, Bertrand

Stent graft has resulted in major advances in the treatment of trauma patients with blunt traumatic aortic injury (TAI) and has become the preferred method of treatment at many trauma centers. In this review, we provide an overview of the place of stent grafts for the management of this disease. As a whole, TEVAR repair of TAIs offers a survival advantage and reduction in major morbidity, including paraplegia, compared with open surgery. However, endovascular procedures in trauma require a sophisticated multidisciplinary and experienced team approach. More research and development of TAI-specific endograft devices is needed and large, multicenter studies willmore » help to clarify the role of TEVAR compared with open repair of TAI.« less

Trauma Registry of the Pan-American Trauma Society: One year of experience in two hospitals in southwest Colombia

PubMed Central

Ordoñez, Carlos A; Rojas-Mirquez, Johanna Carolina; Bonilla-Escobar, Francisco Javier; Badiel, Marisol; Miñán Arana, Fernando; González, Adolfo; Pino, Luis Fernando; Uribe-Gómez, Amadeus; Herrera, Mario Alain; Gutiérrez-Martínez, Maria Isabel; Puyana, Juan Carlos; Abutanos, Michael; Ivatury, Rao R

2016-01-01

Background: Trauma information systems are needed to improve decision making and to identify potential areas of intervention. Objective: To describe the first year of experience with a trauma registry in two referral centers in southwest Colombia. Methods: The study was performed in two referral centers in Cali. Patients with traumatic injuries seen between January 1 and December 31, 2012, were included. The collected information included demographics, mechanism of trauma, injury severity score (ISS), and mortality. A descriptive analysis was carried out. Results: A total of 17,431 patients were registered, of which 67.8% were male with an average age of 30 (±20) years. Workplace injuries were the cause of emergency consultations in 28.2% of cases, and falls were the most common mechanism of trauma (37.3%). Patients with an ISS ≥15 were mostly found in the 18-35-year age range (6.4%). Most patients who suffered a gunshot wound presented an ISS ≥15. A total of 2.5% of all patients died, whereas the mortality rate was 54% among patients with an ISS ≥15 and a gunshot wound. Conclusion: Once the trauma registry was successfully implemented in two institutions in Cali, the primary causes of admission were identified as falls and workplace injuries. The most severely compromised patients were in the population range between 18 and 35 years of age. The highest mortality was caused by gunshot wounds. PMID:27821894

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2)

PubMed Central

2012-01-01

Background Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. Methods/design The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. Discussion The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. Trial Registration ClinicalTrials.gov: (NCT01523626). PMID:22458247

Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma

PubMed Central

Galvagno, Samuel M.; Haut, Elliott R.; Zafar, S. Nabeel; Millin, Michael G.; Efron, David T.; Koenig, George J.; Baker, Susan P.; Bowman, Stephen M.; Pronovost, Peter J.; Haider, Adil H.

2012-01-01

Context Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted. Objective To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries. Design, Setting, and Participants Retrospective cohort study involving 223 475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007–2009 versions of the American College of Surgeons National Trauma Data Bank. Interventions Transport by helicopter or ground emergency services to level I or level II trauma centers. Main Outcome Measures Survival to hospital discharge and discharge disposition. Results A total of 61 909 patients were transported by helicopter and 161 566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17 775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score–matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14–1.17; P<.001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13–1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P < .001). Conclusion Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders. PMID:22511688

Changes in Negative Cognitions Mediate PTSD Symptom Reductions During Client-Centered Therapy and Prolonged Exposure for Adolescents

PubMed Central

McLean, Carmen P.; Yeh, Rebecca; Rosenfield, David; Foa, Edna B.

2015-01-01

Objective To assess whether changes in negative trauma-related cognitions play an important role in reducing symptoms of posttraumatic stress disorder (PTSD) and depression during prolonged exposure therapy for adolescents (PE-A). Method Secondary analysis of data from a randomized controlled trial comparing PE-A with client-centered therapy (CCT) for PTSD. Participants were 61 adolescent female sexual assault survivors ages 13–18 who received 8–14 weekly sessions of PE-A or CCT at a community rape crisis center. PTSD severity was assessed at baseline, mid-treatment, post-treatment, and 3-months post-treatment. Participants also completed self-report measures of negative posttraumatic cognitions and depressive symptoms at the same assessment points. Results Cross lag panel mediation analyses showed that change in negative trauma-related cognitions mediated change in PTSD symptoms and depressive symptoms whereas change in PTSD and depressive symptoms did not mediate change in negative cognitions. Conclusion Our findings support EPT and suggest that change in negative trauma-related cognitions is a mechanism of both PE-A and CCT. PMID:25812826

Comparison of pediatric motor vehicle collision injury outcomes at Level I trauma centers.

PubMed

Dreyfus, Jill; Flood, Andrew; Cutler, Gretchen; Ortega, Henry; Kreykes, Nathan; Kharbanda, Anupam

2016-10-01

Examine the association of American College of Surgeons Level I pediatric trauma center designation with outcomes of pediatric motor vehicle collision-related injuries. Observational study of the 2009-2012 National Trauma Data Bank, including n=28,145 patients <18years directly transported to a Level I trauma center. Generalized estimating equations estimated odds ratios (ORs) for injury outcomes, comparing freestanding pediatric trauma centers (PTCs) with adult centers having added Level I pediatric qualifications (ATC+PTC) and general adult trauma centers (ATC). Models were stratified by age following PTC designation guidelines, and adjusted for demographic and clinical risk factors. Analyses included n=16,643 children <15 and n=11,502 adolescents 15-17years. Among children, odds of laparotomy (OR=1.88, 95% CI 1.28-2.74) and pneumonia (OR=2.13, 95% CI 1.32-3.46) were greater at ATCs vs. freestanding PTCs. Adolescents treated at ATC+PTCs or ATCs experienced greater odds of death (OR=2.18, 95% CI 1.30-3.67; OR=1.98, 95% CI 1.37-2.85, respectively) and laparotomy (OR=4.33, 95% CI 1.56-12.02; OR=5.11, 95% CI 1.92-13.61, respectively). Compared with freestanding PTCs, children treated at general ATCs experienced more complications; adolescents treated at ATC+PTCs or general ATCs had greater odds of death. Identification and sharing of best practices among Level I trauma centers may reduce variation in care and improve outcomes for children. Copyright © 2016 Elsevier Inc. All rights reserved.

Effective trauma center partnerships to address firearm injury: a new paradigm.

PubMed

Richmond, Therese S; Schwab, C William; Riely, Jeaneen; Branas, Charles C; Cheney, Rose; Dunfey, Maura

2004-06-01

Firearm violence is the second leading cause of injury-related death. This study examined the use of local trauma centers as lead organizations in their communities to address firearm injury. Three trauma centers in cities with populations less than 100,000 were linked with a university-based firearm injury research center. A trauma surgeon director and coordinator partnered with communities, recruited and directed advisory boards, established a local firearm injury surveillance system, and informed communities using community-specific profiles. Primary process and outcome measures included completeness of data, development of community-specific profiles, number of data-driven consumer media pieces, number of meetings to inform policy makers, and an analysis of problems encountered. Local trauma centers in smaller communities implemented a firearm injury surveillance system, produced community-specific injury profiles, and engaged community leaders and policy makers to address firearm injury. Community-specific profiles demonstrated consistent firearm suicide rates (6.58-6.82 per 100,000) but variation in firearm homicide rates (1.08-12.5 per 100,000) across sites. There were 63 data-driven media pieces and 18 forums to inform community leaders and policy makers. Completeness of data elements ranged from 57.1% to 100%. Problems experienced were disconnected data sources, multiple data owners, potential for political fallout, limited trauma center data, skills sets of medical professionals, and sustainability. Trauma centers, when provided resources and support, with the model described, can function as lead organizations in partnering with the community to acquire and use community-specific data for local firearm injury prevention.

A patient education tool for nonoperative management of blunt abdominal trauma.

PubMed

Budinger, Julie Marie

2007-01-01

Blunt trauma is the primary mechanism of injury seen at Charleston Area Medical Center, a rural level I trauma center. Blunt abdominal trauma occurs as a result of various mechanisms. It can be safely managed nonoperatively and is considered to be the standard of care in hemodynamically stable patients. Appropriate patient education before discharge will enable patients to identify complications early and seek appropriate medical care.

Trauma patients: I can't get no (patient) satisfaction?

PubMed

Bentley-Kumar, Karalyn; Jackson, Theresa; Holland, Danny; LeBlanc, Brian; Agrawal, Vaidehi; Truitt, Michael S

2016-12-01

The Centers for Medicare and Medicaid Services (CMS) provides financial incentives to hospitals based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey. This data is made publicly available on their website to be utilized by patients and insurers. Hospitals are profoundly interested in identifying patient populations that negatively contribute to overall patient satisfaction scores. Hospitals consider trauma patients "high risk" from a HCAHPS perspective, but there is no data to inform this opinion. The purpose of this study is to evaluate trauma patient satisfaction scores and their impact on overall patient satisfaction. Three different analyses were performed. Group 1 was composed of ALL patients admitted to our hospital over a 7-month period who were administered a validated patient satisfaction survey by a 3rd party and compared patient satisfaction of trauma vs. non-trauma patients (ALL). Group 2 compared admitted patients with a specific ICD-9 procedure code to non-trauma patients who underwent a procedure with the same ICD-9 code (ICD). Group 3 examines patient satisfaction between three Level I Trauma Centers within our geographic area (TC). Patient satisfaction data of trauma vs non-trauma patients (ALL), those with a specific ICD-9 procedure code (ICD), and the 3 Level I Trauma Centers in our area (TC) were analyzed with the appropriate statistical test. In the ALL group, no difference in satisfaction was noted in 18/21 questions for trauma patients when compared to non-trauma patients at our hospital. In the ICD group, 57 ICD-9 procedure codes were analyzed. Of these, only patients who required spinal fusion secondary to trauma reported lower overall patient satisfaction. No meaningful difference was found in HCAHPS associated satisfaction between the Level I Trauma Centers in our area (TC). In contrast to commonly held opinion, trauma patients do not negatively contribute to overall patient satisfaction in our facility. Certain injuries may offer opportunities for improvement and efforts around improved physician-patient communication may be warranted. In the era of public reporting and financial penalties, surgeons should embrace patient satisfaction as it may be vital to the survival of the trauma center. Copyright © 2016. Published by Elsevier Inc.

The Intensive Care Unit Perspective of Becoming a Level I Trauma Center: Challenges of Strategy, Leadership, and Operations Management.

PubMed

Savel, Richard H; Cohen, Wess; Borgia, Dena; Simon, Ronald J

2018-01-01

The primary purpose of this narrative is to elucidate the numerous significant changes that occur at the intensive care unit (ICU) level as a medical center pursues becoming a Level I trauma center. Specifically, we will focus on the following important areas: (1) leadership and strategy issues behind the decision to move forward with becoming a trauma center; (2) preparation needed to take a highly functioning surgical ICU and align it for the inevitable changes that happen as trauma go-live occurs; (3) intensivist staffing changes; (4) roles for and training of advanced practice practitioners; (5) graduate medical education issues; (6) optimizing interactions with closely related services; (7) nursing, staffing, and training issues; (8) bed allocation issues; and (9) reconciling the advantages of a "unified adult critical care service" with the realities of the central relationship between trauma and surgical critical care.

The Intensive Care Unit Perspective of Becoming a Level I Trauma Center: Challenges of Strategy, Leadership, and Operations Management

PubMed Central

Savel, Richard H.; Cohen, Wess; Borgia, Dena; Simon, Ronald J.

2018-01-01

The primary purpose of this narrative is to elucidate the numerous significant changes that occur at the intensive care unit (ICU) level as a medical center pursues becoming a Level I trauma center. Specifically, we will focus on the following important areas: (1) leadership and strategy issues behind the decision to move forward with becoming a trauma center; (2) preparation needed to take a highly functioning surgical ICU and align it for the inevitable changes that happen as trauma go-live occurs; (3) intensivist staffing changes; (4) roles for and training of advanced practice practitioners; (5) graduate medical education issues; (6) optimizing interactions with closely related services; (7) nursing, staffing, and training issues; (8) bed allocation issues; and (9) reconciling the advantages of a “unified adult critical care service” with the realities of the central relationship between trauma and surgical critical care. PMID:29628674

Assessing the academic and professional needs of trauma nurse practitioners and physician assistants.

PubMed

Wilson, Laurie N; Wainwright, Gail A; Stehly, Christy D; Stoltzfus, Jill; Hoff, William S

2013-01-01

Because of multiple changes in the health care environment, the use of services of physician assistants (PAs) and nurse practitioners (NPs) in trauma and critical care has expanded. Appropriate training and ongoing professional development for these providers are essential to optimize clinical outcomes. This study offers a baseline assessment of the academic and professional needs of the contemporary trauma PAs/NPs in the United States. A 14-question electronic survey, using SurveyMonkey, was distributed to PAs/NPs at trauma centers identified through the American College of Surgeons Web site and other online resources. Demographic questions included trauma center level, provider type, level of education, and professional affiliations. Likert scale questions were incorporated to assess level of mentorship, comfort level with training, and individual perceived needs for academic and professional development. There were 120 survey respondents: 60 NPs and 60 PAs. Sixty-two respondents (52%) worked at level I trauma centers and 95 (79%) were hospital-employed. Nearly half (49%) reported working in trauma centers for 3 years or less. One hundred nineteen respondents (99%) acknowledged the importance of trauma-specific education; 98 (82%) were required by their institution to obtain such training. Thirty-five respondents (32%) reported receiving $1000 per year or less as a continuing medical education benefit. Insufficient mentorship, professional development, and academic development were identified by 22 (18%), 16 (13%), and 30 (25%) respondents, respectively. Opportunities to network with trauma PAs/NPs outside their home institution were identified as insufficient by 79 (66%). While PAs/NPs in trauma centers recognize the importance of continued contemporary trauma care and evidence-based practices, attending trauma-related education is not universally required by their employers. Financial restrictions may pose an additional impediment to academic development. Therefore, resource-efficient opportunities should be a prime consideration for advanced practitioners education, especially since half of the reported workforce has 3 years or less experience. The Eastern Association of Trauma and other organizations can provide an ideal venue for mentorship, academic development, and networking that is vital to PA/NP professional development and, ultimately, quality patient care.

Comparison of ISS, NISS, and RTS score as predictor of mortality in pediatric fall.

PubMed

Soni, Kapil Dev; Mahindrakar, Santosh; Gupta, Amit; Kumar, Subodh; Sagar, Sushma; Jhakal, Ashish

2017-01-01

Studies to identify an ideal trauma score tool representing prediction of outcomes of the pediatric fall patient remains elusive. Our study was undertaken to identify better predictor of mortality in the pediatric fall patients. Data was retrieved from prospectively maintained trauma registry project at level 1 trauma center developed as part of Multicentric Project-Towards Improving Trauma Care Outcomes (TITCO) in India. Single center data retrieved from a prospectively maintained trauma registry at a level 1 trauma center, New Delhi, for a period ranging from 1 October 2013 to 17 February 2015 was evaluated. Standard anatomic scores Injury Severity Score (ISS) and New Injury Severity Score (NISS) were compared with physiologic score Revised Trauma Score (RTS) using receiver operating curve (ROC). Heart rate and RTS had a statistical difference among the survivors to nonsurvivors. ISS, NISS, and RTS were having 50, 50, and 86% of area under the curve on ROCs, and RTS was statistically significant among them. Physiologically based trauma score systems (RTS) are much better predictors of inhospital mortality in comparison to anatomical based scoring systems (ISS and NISS) for unintentional pediatric falls.

Variability in interhospital trauma data coding and scoring: A challenge to the accuracy of aggregated trauma registries.

PubMed

Arabian, Sandra S; Marcus, Michael; Captain, Kevin; Pomphrey, Michelle; Breeze, Janis; Wolfe, Jennefer; Bugaev, Nikolay; Rabinovici, Reuven

2015-09-01

Analyses of data aggregated in state and national trauma registries provide the platform for clinical, research, development, and quality improvement efforts in trauma systems. However, the interhospital variability and accuracy in data abstraction and coding have not yet been directly evaluated. This multi-institutional, Web-based, anonymous study examines interhospital variability and accuracy in data coding and scoring by registrars. Eighty-two American College of Surgeons (ACS)/state-verified Level I and II trauma centers were invited to determine different data elements including diagnostic, procedure, and Abbreviated Injury Scale (AIS) coding as well as selected National Trauma Data Bank definitions for the same fictitious case. Variability and accuracy in data entries were assessed by the maximal percent agreement among the registrars for the tested data elements, and 95% confidence intervals were computed to compare this level of agreement to the ideal value of 100%. Variability and accuracy in all elements were compared (χ testing) based on Trauma Quality Improvement Program (TQIP) membership, level of trauma center, ACS verification, and registrar's certifications. Fifty registrars (61%) completed the survey. The overall accuracy for all tested elements was 64%. Variability was noted in all examined parameters except for the place of occurrence code in all groups and the lower extremity AIS code in Level II trauma centers and in the Certified Specialist in Trauma Registry- and Certified Abbreviated Injury Scale Specialist-certified registrar groups. No differences in variability were noted when groups were compared based on TQIP membership, level of center, ACS verification, and registrar's certifications, except for prehospital Glasgow Coma Scale (GCS), where TQIP respondents agreed more than non-TQIP centers (p = 0.004). There is variability and inaccuracy in interhospital data coding and scoring of injury information. This finding casts doubt on the validity of registry data used in all aspects of trauma care and injury surveillance.

Epidemiology of trauma deaths in an urban level-1 trauma center predominantly among African Americans--implications for prevention.

PubMed Central

Lyn-Sue, Jerome; Siram, Suryanarayana; Williams, Daniel; Mezghebe, Haile

2006-01-01

This is a retrospective review to determine demographics, presentation and injury characteristics of trauma deaths at Howard University Hospital over an 1-year period (1994-2005) and to make recommendations for education and prevention in the community based on our findings. Data was obtained from the Howard University Hospital trauma registry. From the study period 1994-2005, there was a total of 365 trauma deaths. The injuries sustained were mainly intentional, which accounted for almost 75% of cases--the majority of deaths being due to penetrating injuries. There was an almost two-fold increase in trauma deaths on Saturdays compared to the rest of the week. The demographics of our study population were similar to those reported in the trauma literature. These were younger patients and predominantly male. Unique to our population was the overwhelming predominance of African-American patients (90%). With these unique features, injury prevention would be better served focusing on social and community prevention and education rather than the usual methods of blunt-trauma prevention--e.g., pedestrian- and motor-vehicle-oriented policies, which may be more beneficial in other trauma systems. PMID:17225838

Trauma center accessibility for road traffic injuries in Hanoi, Vietnam.

PubMed

Nagata, Takashi; Takamori, Ayako; Kimura, Yoshinari; Kimura, Akio; Hashizume, Makoto; Nakahara, Shinji

2011-09-30

Rapid economic growth in Vietnam over the last decade has led to an increased frequency of road traffic injury (RTI), which now represents one of the leading causes of death in the nation. Various efforts toward injury prevention have not produced a significant decline in the incidence of RTIs. Our study sought to describe the geographic distribution of RTIs in Hanoi, Vietnam and to evaluate the accessibility of trauma centers to those injured in the city. We performed a cross-sectional study using Hanoi city police reports from 2006 to describe the epidemiology of RTIs occurring in Hanoi city. Additionally, we identified geographic patterns and determined the direct distance from injury sites to trauma centers by applying geographical information system (GIS) software. Factors associated with the accessibility of trauma centers were evaluated by multivariate regression analysis. We mapped 1,271 RTIs in Hanoi city. About 40% of RTIs occurred among people 20-29 years of age. Additionally, 63% of RTIs were motorcycle-associated incidents. Two peak times of injury occurrence were observed: 12 am-4 pm and 8 pm-0 am. "Hot spots" of road traffic injuries/fatalities were identified in the city area and on main highways using Kernel density estimation. Interestingly, RTIs occurring along the two north-south main roads were not within easy access of trauma centers. Further, fatal cases, gender and injury mechanism were significantly associated with the distance between injury location and trauma centers. Geographical patterns of RTIs in Hanoi city differed by gender, time, and injury mechanism; such information may be useful for injury prevention. Specifically, RTIs occurring along the two north-south main roads have lower accessibility to trauma centers, thus an emergency medical service system should be established.

Compliance with recommended care at trauma centers: association with patient outcomes.

PubMed

Shafi, Shahid; Barnes, Sunni A; Rayan, Nadine; Kudyakov, Rustam; Foreman, Michael; Cryer, H Gil; Alam, Hasan B; Hoff, William; Holcomb, John

2014-08-01

State health departments and the American College of Surgeons focus on the availability of optimal resources to designate hospitals as trauma centers, with little emphasis on actual delivery of care. There is no systematic information on clinical practices at designated trauma centers. The objective of this study was to measure compliance with 22 commonly recommended clinical practices at trauma centers and its association with in-hospital mortality. This retrospective observational study was conducted at 5 Level I trauma centers across the country. Participants were adult patients with moderate to severe injuries (n = 3,867). The association between compliance with 22 commonly recommended clinical practices and in-hospital mortality was measured after adjusting for patient demographics and injuries and their severity. Compliance with individual clinical practices ranged from as low as 12% to as high as 94%. After adjusting for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in the risk of death. Patients who received all recommended care were 58% less likely to die (odds ratio = 0.42; 95% CI, 0.28-0.62) compared with those who did not. Compliance with commonly recommended clinical practices remains suboptimal at designated trauma centers. Improved adoption of these practices can reduce mortality. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

A trauma outreach program provided by a level I trauma center is an effective way to initiate peer review at referring hospitals and foster process improvements.

PubMed

Byrnes, Matthew C; Irwin, Eric; Becker, Leslie; Thorson, Melissa; Beilman, Greg; Horst, Patrick; Croston, Kevin

2010-04-01

The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.

Using Trauma and Injury Severity Score (TRISS)-based analysis in the development of regional risk adjustment tools to trend quality in a voluntary trauma system: the experience of the Trauma Foundation of Northeast Ohio.

PubMed

Mancuso, C; Barnoski, A; Tinnell, C; Fallon, W

2000-04-01

Presently, no trauma system exists in Ohio. Since 1993, all hospitals in Cuyahoga County (CUY), northeast Ohio (n = 22) provide data to a trauma registry. In return, each received hospital-specific data, comparison data by trauma care level and a county-wide aggregate summary. This report describes the results of this approach in our region. All cases were entered by paper abstract or electronic download. Interrater reliability audits and z score analysis was performed by using the Major Trauma Outcome Study and the CUY 1994 baseline groups. Risk adjustment of mortality data was performed using statistical modeling and logistic regression (Trauma and Injury Severity Score, Major Trauma Outcome Study, CUY). Trauma severity measures were defined. In 1995, 3,375 patients were entered. Two hundred ninety-one died (8.6%). Severity measures differed by level of trauma care, indicating differences in case mix. Probability of survival was lowest in the Level I centers, highest in the acute care hospitals. Outcomes z scores demonstrated survival differences for all levels. In a functioning trauma system, the most severely injured patients should be cared for at the trauma centers. A low volume at acute care hospitals is desirable. By using Trauma and Injury Severity Score with community-specific constants, NE Ohio is accomplishing these goals. The Level I performance data are an interesting finding compared with the data from the Level II centers in the region

Sphenoid Sinus and Sphenoid Bone Fractures in Patients with Craniomaxillofacial Trauma

PubMed Central

Cantini Ardila, Jorge Ernesto; Mendoza, Miguel Ángel Rivera; Ortega, Viviana Gómez

2013-01-01

Background and Purpose Sphenoid bone fractures and sphenoid sinus fractures have a high morbidity due to its association with high-energy trauma. The purpose of this study is to describe individuals with traumatic injuries from different mechanisms and attempt to determine if there is any relationship between various isolated or combined fractures of facial skeleton and sphenoid bone and sphenoid sinus fractures. Methods We retrospectively studied hospital charts of all patients who reported to the trauma center at Hospital de San José with facial fractures from December 2009 to August 2011. All patients were evaluated by computed tomography scan and classified into low-, medium-, and high-energy trauma fractures, according to the classification described by Manson. Design This is a retrospective descriptive study. Results The study data were collected as part of retrospective analysis. A total of 250 patients reported to the trauma center of the study hospital with facial trauma. Thirty-eight patients were excluded. A total of 212 patients had facial fractures; 33 had a combination of sphenoid sinus and sphenoid bone fractures, and facial fractures were identified within this group (15.5%). Gender predilection was seen to favor males (77.3%) more than females (22.7%). The mean age of the patients was 37 years. Orbital fractures (78.8%) and maxillary fractures (57.5%) were found more commonly associated with sphenoid sinus and sphenoid bone fractures. Conclusions High-energy trauma is more frequently associated with sphenoid fractures when compared with medium- and low-energy trauma. There is a correlation between facial fractures and sphenoid sinus and sphenoid bone fractures. A more exhaustive multicentric case-control study with a larger sample and additional parameters will be essential to reach definite conclusions regarding the spectrum of fractures of the sphenoid bone associated with facial fractures. PMID:24436756

Blunt traumatic injury during pregnancy: a descriptive analysis from a level 1 trauma center.

PubMed

Al-Thani, Hassan; El-Menyar, Ayman; Sathian, Brijesh; Mekkodathil, Ahammed; Thomas, Sam; Mollazehi, Monira; Al-Sulaiti, Maryam; Abdelrahman, Husham

2018-03-27

The precise incidence of trauma in pregnancy is not well-known, but trauma is estimated to complicate nearly 1 in 12 pregnancies and it is the leading non-obstetrical cause of maternal death. A retrospective study of all pregnant women presented to national level 1 trauma center from July 2013 to June 2015 was conducted. Descriptive and inferential statistics applied for data analysis. Across the study period, a total of 95 pregnant women were presented to the trauma center. The average incidence rate of traumatic injuries was 250 per 1000 women of childbearing age presented to the Hamad Trauma Center. The mean age of patients was 30.4 ± SD 5.6 years, with age ranging from 20 to 42 years. The mean gestational age at the time of injury was 24.7 ± 8.7 weeks which ranged from 5 to 37 weeks. The majority (47.7%) was in the third trimester of the pregnancy. In addition, the large majority of injuries was due to MVCs (74.7%) followed by falls (15.8%). Trauma during pregnancy is not an uncommon event particularly in the traffic-related crashes. As it is a complex condition for trauma surgeons and obstetrician, an appropriate management protocol and multidisciplinary team are needed to improve the outcome and save lives of both the mother and fetus.

Trauma center finances and length of stay: identifying a profitability inflection point.

PubMed

Fakhry, Samir M; Couillard, Debbie; Liddy, Casey T; Adams, David; Norcross, E Douglass

2010-05-01

Trauma centers frequently report unfavorable financial results for the care of injured patients. Many variables contribute to these results. The objective of this study was to determine the relationship of adult trauma patient hospital length of stay (LOS) to trauma center profitability. The trauma registry of a Level I trauma center was queried for patients older than 18 years for the period July 1, 2003 to June 30, 2008. Hospital financial records were matched to patient trauma registry data. There were 7,990 patients who met selection criteria: 71% were men, mean age was 40 years, mean Injury Severity Score was 12 +/-10, 84.2% of injuries were blunt, and mean LOS was 6.23 days. In the 5 years of the study, total charges were $329,315,191, total costs were $137,680,039, and overall profit was $7,644,894. Total costs rose each year and percent collections fell. The bulk of the profit was realized from patients with LOS < 11 days, with progressively escalating cost per case, lower collections, and resultant lower profitability as LOS increased. A notable "inflection point" at 11 days defined the cohort of profitable patients. Trauma patient LOS correlates closely with profitability. In this center, the vast majority of profit was realized from patients with LOS < 11 days and was eroded by most patient cohorts with longer LOS. Identification of an institution's "inflection point" may help direct efforts at increasing profitability and reflects the current reimbursement environment, which rewards shorter LOS over severity and quality. Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Development of a prehospital vital signs chart sharing system.

PubMed

Nakada, Taka-aki; Masunaga, Naohisa; Nakao, Shota; Narita, Maiko; Fuse, Takashi; Watanabe, Hiroaki; Mizushima, Yasuaki; Matsuoka, Tetsuya

2016-01-01

Physiological parameters are crucial for the caring of trauma patients. There is a significant loss of prehospital vital signs data of patients during handover between prehospital and in-hospital teams. Effective strategies for reducing the loss remain a challenging research area. We tested whether the newly developed electronic automated prehospital vital signs chart sharing system would increase the amount of prehospital vital signs data shared with a remote trauma center prior to hospital arrival. Fifty trauma patients, transferred to a level I trauma center in Japan, were studied. The primary outcome variable was the number of prehospital vital signs shared with the trauma center prior to hospital arrival. The prehospital vital signs chart sharing system significantly increased the number of prehospital vital signs, including blood pressure, heart rate, and oxygen saturation, shared with the in-hospital team at a remote trauma center prior to patient arrival at the hospital (P < .0001). There were significant differences in prehospital vital signs during ambulance transfer between patients who had severe bleeding and non-severe bleeding within 24 hours after injury onset. Vital signs data collected during ambulance transfer via patient monitors could be automatically converted to easily visible patient charts and effectively shared with the remote trauma center prior to hospital arrival. The prehospital vital signs chart sharing system increased the number of precise vital signs shared prior to patient arrival at the hospital, which can potentially contribute to better trauma care without increasing labor and reduce information loss during clinical handover. Copyright © 2015 Elsevier Inc. All rights reserved.

Clinical characteristics of dental emergencies and prevalence of dental trauma at a university hospital emergency center in Korea.

PubMed

Bae, Ji-Hyun; Kim, Young-Kyun; Choi, Yong-Hoon

2011-10-01

The aim of this study was to examine the clinical characteristics of dental emergency patients who visited a university hospital emergency center and to evaluate the incidence of dental trauma. A retrospective chart review of patients with dental complaints and who visited the Seoul National University Bundang Hospital (SNUBH) emergency center in Gyeonggi-do, Korea, from January 2009 to December 2009 was conducted. Information regarding age, gender, the time, day, and month of presentation, diagnosis, treatment, and follow up was collected and analyzed. One thousand four hundred twenty-five patients with dental problems visited the SNUBH emergency center. Dental patients accounted for 1.47% of the total 96,708 patients at the emergency center. The male-to-female ratio was 1.68:1, with a considerably larger number of male patients (62.7%). The age distribution peak was at 0-9 years (27.5%), followed by patients in their forties (14.1%). The number of patients visiting the dental emergency center peaked in May (14.2%), on Sundays (22.4%), and between 2100 and 2400 h (20.8%). The patients' chief complaints were as follows: dental trauma, dental infection, oral bleeding, and temporomandibular joint disorder (TMD). The prevalence of dental trauma was 66%. The reasons for dental emergency visits included the following: dental trauma, dental infection, oral bleeding, and TMD, with 66% of the patients requiring management of dental trauma. It is important that dentists make a prompt, accurate diagnosis and initiate effective treatment in case of dental emergencies, especially dental trauma. © 2011 John Wiley & Sons A/S.

Patient volume per surgeon does not predict survival in adult level I trauma centers.

PubMed

Margulies, D R; Cryer, H G; McArthur, D L; Lee, S S; Bongard, F S; Fleming, A W

2001-04-01

The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome. Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival. From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44). The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.

A Population-Based Survival Assessment of Categorizing Level III and IV Rural Hospitals as Trauma Centers

ERIC Educational Resources Information Center

Arthur, Melanie; Newgard, Craig D.; Mullins, Richard J.; Diggs, Brian S.; Stone, Judith V.; Adams, Annette L.; Hedges, Jerris R.

2009-01-01

Context: Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse. Purpose: To determine if there is improved survival among injured patients hospitalized in states that categorize rural…

A Geographic Simulation Model for the Treatment of Trauma Patients in Disasters.

PubMed

Carr, Brendan G; Walsh, Lauren; Williams, Justin C; Pryor, John P; Branas, Charles C

2016-08-01

Though the US civilian trauma care system plays a critical role in disaster response, there is currently no systems-based strategy that enables hospital emergency management and local and regional emergency planners to quantify, and potentially prepare for, surges in trauma care demand that accompany mass-casualty disasters. A proof-of-concept model that estimates the geographic distributions of patients, trauma center resource usage, and mortality rates for varying disaster sizes, in and around the 25 largest US cities, is presented. The model was designed to be scalable, and its inputs can be modified depending on the planning assumptions of different locales and for different types of mass-casualty events. To demonstrate the model's potential application to real-life planning scenarios, sample disaster responses for 25 major US cities were investigated using a hybrid of geographic information systems and dynamic simulation-optimization. In each city, a simulated, fast-onset disaster epicenter, such as might occur with a bombing, was located randomly within one mile of its population center. Patients then were assigned and transported, in simulation, via the new model to Level 1, 2, and 3 trauma centers, in and around each city, over a 48-hour period for disaster scenario sizes of 100, 500, 5000, and 10,000 casualties. Across all 25 cities, total mean mortality rates ranged from 26.3% in the smallest disaster scenario to 41.9% in the largest. Out-of-hospital mortality rates increased (from 21.3% to 38.5%) while in-hospital mortality rates decreased (from 5.0% to 3.4%) as disaster scenario sizes increased. The mean number of trauma centers involved ranged from 3.0 in the smallest disaster scenario to 63.4 in the largest. Cities that were less geographically isolated with more concentrated trauma centers in their surrounding regions had lower total and out-of-hospital mortality rates. The nine US cities listed as being the most likely targets of terrorist attacks involved, on average, more trauma centers and had lower mortality rates compared with the remaining 16 cities. The disaster response simulation model discussed here may offer insights to emergency planners and health systems in more realistically planning for mass-casualty events. Longer wait and transport times needed to distribute high numbers of patients to distant trauma centers in fast-onset disasters may create predictable increases in mortality and trauma center resource consumption. The results of the modeled scenarios indicate the need for a systems-based approach to trauma care management during disasters, since the local trauma center network was often too small to provide adequate care for the projected patient surge. Simulation of out-of-hospital resources that might be called upon during disasters, as well as guidance in the appropriate execution of mutual aid agreements and prevention of over-response, could be of value to preparedness planners and emergency response leaders. Study assumptions and limitations are discussed. Carr BG , Walsh L , Williams JC , Pryor JP , Branas CC . A geographic simulation model for the treatment of trauma patients in disasters. Prehosp Disaster Med. 2016;31(4):413-421.

Benchmarking statewide trauma mortality using Agency for Healthcare Research and Quality's patient safety indicators.

PubMed

Ang, Darwin; McKenney, Mark; Norwood, Scott; Kurek, Stanley; Kimbrell, Brian; Liu, Huazhi; Ziglar, Michele; Hurst, James

2015-09-01

Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the state's registry are not publicly available. Promotion of optimal care throughout the state is not possible unless clinical benchmarks are available for comparison. Using publicly available administrative data from the State Department of Health and the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), we sought to create a statewide method for benchmarking trauma mortality and at the same time also identifying a pattern of unique complications that have an independent influence on mortality. Data for this study were obtained from State of Florida Agency for Health Care Administration. Adult trauma patients were identified as having International Classification of Disease ninth edition codes defined by the state. Multivariate logistic regression was used to create a predictive inpatient expected mortality model. The expected value of PSIs was created using the multivariate model and their beta coefficients provided by the AHRQ. Case-mix adjusted mortality results were reported as observed to expected (O/E) ratios to examine mortality, PSIs, failure to prevent complications, and failure to rescue from death. There were 50,596 trauma patients evaluated during the study period. The overall fit of the expected mortality model was very strong at a c-statistic of 0.93. Twelve of 25 trauma centers had O/E ratios <1 or better than expected. Nine statewide PSIs had failure to prevent O/E ratios higher than expected. Five statewide PSIs had failure to rescue O/E ratios higher than expected. The PSI that had the strongest influence on trauma mortality for the state was PSI no. 9 or perioperative hemorrhage or hematoma. Mortality could be further substratified by PSI complications at the hospital level. AHRQ PSIs can have an integral role in an adjusted benchmarking method that screens at risk trauma centers in the state for higher than expected mortality. Stratifying mortality based on failure to prevent PSIs may identify areas of needed improvement at a statewide level. Copyright © 2015 Elsevier Inc. All rights reserved.

Infectious Complications of Noncombat Trauma Patients Provided Care at a Military Trauma Center

DTIC Science & Technology

2010-05-01

complication~ and risk factors of noncombat trauma patients cared for in a military le,·ell trauma center with an a\\sociated burn unit u~ing the... risk factors for infection, and since the combat tnjured population is generally without serious comorbidities, MTLITARY MEDICINE, Vol. 175, M ay 20...wound infection’> were most common in the JTTR. Risk factors for in fection seen 1n the BAMC TR more closely reflected those reported in other studies

A trauma network with centralized and local health care structures: Evaluating the effectiveness of the first certified Trauma Network of the German Society of Trauma Surgery.

PubMed

Ernstberger, Antonio; Koller, Michael; Zeman, Florian; Kerschbaum, Maximilian; Hilber, Franz; Diepold, Eva; Loss, Julika; Herbst, Tanja; Nerlich, Michael

2018-01-01

Trauma is a global burden of disease and one of the main causes of death worldwide. Therefore, many countries around the world have implemented a wide range of different initiatives to minimize mortality rates after trauma. One of these initiatives is the bundling of treatment expertise in trauma centers and the establishment of trauma networks. Germany has a decentralized system of trauma care medical centers. Severely injured patients ought to receive adequate treatment in both level I and level II centers. This study investigated the effectiveness of a decentralized network and the question whether level I and level II centers have comparable patient outcome. In 2009, the first trauma network DGU® in Germany was certified in the rural area of Eastern Bavaria. All patients admitted to the 25 participating hospitals were prospectively included in this network in the framework of a study sponsored by the German Federal Ministry of Education and Research between March 2012 and February 2014. 2 hospitals were level I centers (maximal care centers), 8 hospitals were level II centers, and 15 hospitals were level III centers. The criterion for study inclusion was an injury severity score (ISS) ≥ 16 for patients´ primarily admitted to a level I or a level II center. Exclusion criteria were transferal to another hospital within 48 h, an unknown revised injury severity classification II score (RISC II), or primary admittance to a level III center (n = 52). 875 patients were included in the study. Univariate analyses were used regarding the preclinical and clinical parameters, the primary endpoint mortality rate, and the secondary endpoints length of stay, organ failure, and neurological outcome (GOS). The primary endpoint was additionally evaluated by means of multivariable analysis. Indices for injury severity (GCS, AISHead, ISS, and NISS) as well as the predicted probability of death (RISC II) were higher in level I centers than in level II centers. No significant differences were found between the mortality rate of the unadjusted analysis [level I: 21.6% (CI: 16.5, 27.9), level II: 18.1% (CI: 14.4, 22.5), p = 0.28] and that of the adjusted analysis [level I SMR: 0.94 (CI: 0.72, 1.21), level II SMR: 1.18 (CI 0.95, 1.48) SMR: expected vs. calculated mortality rate according to RISC II]. Multivariable analysis showed a survival advantage of patients admitted to a level I center with a probability of death of 13% (RISC II). The number need to treat was 10 patients. This study showed that a rural trauma network with centralized and local structures may achieve equivalent results with regard to mortality rates to those obtained in level I and level II centers. These results were furthered by a certain preclinical centralization (24/7 air rescue) of patients. The study also showed a survival advantage of patients admitted to a level I center with a probability of death of 13%. Preclinical and initial clinical evaluation with regard to probable mortality rates should be further improved to identify patients who would benefit from admittance to a level I center.

Abdominal injuries in a major Scandinavian trauma center – performance assessment over an 8 year period

PubMed Central

2014-01-01

Introduction Damage control surgery and damage control resuscitation have reduced mortality in patients with severe abdominal injuries. The shift towards non-operative management in haemodynamically stable patients suffering blunt abdominal trauma has further contributed to the improved results. However, in many countries, low volume of trauma cases and limited exposure to trauma laparotomies constitute a threat to trauma competence. The aim of this study was to evaluate the institutional patient volume and performance for patients with abdominal injuries over an eight-year period. Methods Data from 955 consecutive trauma patients admitted in Oslo University Hospital Ulleval with abdominal injuries during the eight-year period 2002-2009 were retrospectively explored. A separate analysis was performed on all trauma patients undergoing laparotomy during the same period, whether abdominal injuries were identified or not. Variable life-adjusted display (VLAD) was used in order to describe risk-adjusted survival trends throughout the period and the patients admitted before (Period 1) and after (Period 2) the institution of a formal Trauma Service (2005) were compared. Results There was a steady increase in admitted patients with abdominal injuries, while the number of patients undergoing laparotomy was constant exposing the surgical trauma team leaders to an average of 8 trauma laparotomies per year. No increase in missed injuries or failures of non-operative management was detected. Unadjusted mortality rates decreased from period 1 to period 2 for all patients with abdominal injuries as well as for the patients undergoing laparotomy. However, this apparent decrease was not confirmed as significant in TRISS-based analysis of risk-adjusted mortality. VLAD demonstrated a steady performance throughout the study period. Conclusion Even in a high volume trauma center the exposure to abdominal injuries and trauma laparotomies is limited. Due to increasing NOM, an increasing number of patients with abdominal injuries was not accompanied by an increase in number of laparotomies. However, we have demonstrated a stable performance throughout the study period as visualized by VLAD without an increase in missed injuries or failures of NOM. PMID:25097664

Level-I Trauma Center Effects on Return-to-Work Outcomes

ERIC Educational Resources Information Center

Prada, Sergio I.; Salkever, David; MacKenzie, Ellen J.

2012-01-01

Background: Injury is the leading cause of death for persons aged 1-44 years in the United States. Injuries have a substantial economic cost. For that reason, regional systems of trauma care in which the more acutely injured patients are transported to Level-I (L-I) trauma centers (TCs) has been widely advocated. However, the cost of TC care is…

Trauma Collaborative Care Intervention: Effect on Surgeon Confidence in Managing Psychosocial Complications After Orthopaedic Trauma.

PubMed

Wegener, Stephen T; Carroll, Eben A; Gary, Joshua L; McKinley, Todd O; OʼToole, Robert V; Sietsema, Debra L; Castillo, Renan C; Frey, Katherine P; Scharfstein, Daniel O; Huang, Yanjie; Collins, Susan C J; MacKenzie, Ellen J

2017-08-01

The impact of the Trauma Collaborative Care (TCC) program on surgeon confidence in managing the psychosocial sequelae of orthopaedic trauma was evaluated as part of a larger prospective, multisite, cluster clinical trial. We compared confidence and perceived resource availability among surgeons practicing in trauma centers that implemented the TCC program with orthopaedic trauma surgeons in similar trauma centers that did not implement the TCC. Prospective cohort design. Level-I trauma centers. Attending surgeons and fellows (N = 95 Pre and N = 82 Post). Self-report 10-item measure of surgeon confidence in managing psychosocial issues associated with trauma and perceived availability of support resources. Analyses, performed on the entire sample and repeated on the subset of 52 surgeons who responded to the survey at both times points, found surgeons at intervention sites experienced a significantly greater positive improvement (P < 0.05) in their (1) belief that they have strategies to help orthopaedic trauma patients change their psychosocial situation; (2) confidence in making appropriate referrals for orthopaedic trauma patients with psychosocial problems; and (3) belief that they have access to information to guide the management of psychosocial issues related to recovery. Initial data suggest that the establishment of the TCC program can improve surgeons' perceived availability of resources and their confidence in managing the psychosocial sequelae after injury. Further studies will be required to determine if this translates into beneficial patient effects. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Trauma Center Based Youth Violence Prevention Programs: An Integrative Review.

PubMed

Mikhail, Judy Nanette; Nemeth, Lynne Sheri

2016-12-01

Youth violence recidivism remains a significant public health crisis in the United States. Violence prevention is a requirement of all trauma centers, yet little is known about the effectiveness of these programs. Therefore, this systematic review summarizes the effectiveness of trauma center-based youth violence prevention programs. A systematic review of articles from MEDLINE, CINAHL, and PsychINFO databases was performed to identify eligible control trials or observational studies. Included studies were from 1970 to 2013, describing and evaluating an intervention, were trauma center based, and targeted youth injured by violence (tertiary prevention). The social ecological model provided the guiding framework, and findings are summarized qualitatively. Ten studies met eligibility requirements. Case management and brief intervention were the primary strategies, and 90% of the studies showed some improvement in one or more outcome measures. These results held across both social ecological level and setting: both emergency department and inpatient unit settings. Brief intervention and case management are frequent and potentially effective trauma center-based violence prevention interventions. Case management initiated as an inpatient and continued beyond discharge was the most frequently used intervention and was associated with reduced rearrest or reinjury rates. Further research is needed, specifically longitudinal studies using experimental designs with high program fidelity incorporating uniform direct outcome measures. However, this review provides initial evidence that trauma centers can intervene with the highest of risk patients and break the youth violence recidivism cycle. © The Author(s) 2015.

Embolization of Isolated Lumbar Artery Injuries in Trauma Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sofocleous, Constantinos T., E-mail: constant@pol.net; Hinrichs, Clay R.; Hubbi, Basil

Purpose. The purpose of the study was to evaluate the angiographic findings and results of embolotherapy in the management of lumbar artery trauma. Methods. All patients with lumbar artery injury who underwent angiography and percutaneous embolization in a state trauma center within a 10-year period were retrospectively reviewed. Radiological information and procedural reports were reviewed to assess immediate angiographic findings and embolization results. Long-term clinical outcome was obtained by communication with the trauma physicians as well as with chart review. Results. In a 10-year period, 255 trauma patients underwent abdominal aortography. Eleven of these patients (three women and eight men)more » suffered a lumbar artery injury. Angiography demonstrated active extravasation (in nine) and/or pseudoaneurysm (in four). Successful selective embolization of abnormal vessel(s) was performed in all patients. Coils were used in six patients, particles in one and gelfoam in five patients. Complications included one retroperitoneal abscess, which was treated successfully. One patient returned for embolization of an adjacent lumbar artery due to late pseudoaneurysm formation. Conclusions. In hemodynamically stable patients, selective embolization is a safe and effective method for immediate control of active extravasation, as well as to prevent future hemorrhage from an injured lumbar artery.« less

Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults.

PubMed

Ichwan, Brian; Darbha, Subrahmanyam; Shah, Manish N; Thompson, Laura; Evans, David C; Boulger, Creagh T; Caterino, Jeffrey M

2015-01-01

We evaluate the sensitivity of Ohio's 2009 emergency medical services (EMS) geriatric trauma triage criteria compared with the previous adult triage criteria in identifying need for trauma center care among older adults. We studied a retrospective cohort of injured patients aged 16 years or older in the 2006 to 2011 Ohio Trauma Registry. Patients aged 70 years or older were considered geriatric. We identified whether each patient met the geriatric and the adult triage criteria. The outcome measure was need for trauma center care, defined by surrogate markers: Injury Severity Score greater than 15, operating room in fewer than 48 hours, any ICU stay, and inhospital mortality. We calculated sensitivity and specificity of both triage criteria for both age groups. We included 101,577 patients; 33,379 (33%) were geriatric. Overall, 57% of patients met adult criteria and 68% met geriatric criteria. Using Injury Severity Score, for older adults geriatric criteria were more sensitive for need for trauma center care (93%; 95% confidence interval [CI] 92% to 93%) than adult criteria (61%; 95% CI 60% to 62%). Geriatric criteria decreased specificity in older adults from 61% (95% CI 61% to 62%) to 49% (95% CI 48% to 49%). Geriatric criteria in older adults (93% sensitivity, 49% specificity) performed similarly to the adult criteria in younger adults (sensitivity 87% and specificity 44%). Similar patterns were observed for other outcomes. Standard adult EMS triage guidelines provide poor sensitivity in older adults. Ohio's geriatric trauma triage guidelines significantly improve sensitivity in identifying Injury Severity Score and other surrogate markers of the need for trauma center care, with modest decreases in specificity for older adults. Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Heterogeneity in Trauma Registry Data Quality: Implications for Regional and National Performance Improvement in Trauma.

PubMed

Dente, Christopher J; Ashley, Dennis W; Dunne, James R; Henderson, Vernon; Ferdinand, Colville; Renz, Barry; Massoud, Romeo; Adamski, John; Hawke, Thomas; Gravlee, Mark; Cascone, John; Paynter, Steven; Medeiros, Regina; Atkins, Elizabeth; Nicholas, Jeffrey M

2016-03-01

Led by the American College of Surgeons Trauma Quality Improvement Program, performance improvement efforts have expanded to regional and national levels. The American College of Surgeons Trauma Quality Improvement Program recommends 5 audit filters to identify records with erroneous data, and the Georgia Committee on Trauma instituted standardized audit filter analysis in all Level I and II trauma centers in the state. Audit filter reports were performed from July 2013 to September 2014. Records were reviewed to determine whether there was erroneous data abstraction. Percent yield was defined as number of errors divided by number of charts captured. Twelve centers submitted complete datasets. During 15 months, 21,115 patient records were subjected to analysis. Audit filter captured 2,901 (14%) records and review yielded 549 (2.5%) records with erroneous data. Audit filter 1 had the highest number of records identified and audit filter 3 had the highest percent yield. Individual center error rates ranged from 0.4% to 5.2%. When comparing quarters 1 and 2 with quarters 4 and 5, there were 7 of 12 centers with substantial decreases in error rates. The most common missed complications were pneumonia, urinary tract infection, and acute renal failure. The most common missed comorbidities were hypertension, diabetes, and substance abuse. In Georgia, the prevalence of erroneous data in trauma registries varies among centers, leading to heterogeneity in data quality, and suggests that targeted educational opportunities exist at the institutional level. Standardized audit filter assessment improved data quality in the majority of participating centers. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

PubMed

van Rein, Eveline A J; van der Sluijs, Rogier; Houwert, R Marijn; Gunning, Amy C; Lichtveld, Rob A; Leenen, Luke P H; van Heijl, Mark

2018-01-27

In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using "trauma", "trauma center," or "trauma system", combined with "triage", "undertriage," or "overtriage", as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher-level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients. Copyright © 2018. Published by Elsevier Inc.

Prevalence of Domestic Violence Among Trauma Patients.

PubMed

Joseph, Bellal; Khalil, Mazhar; Zangbar, Bardiya; Kulvatunyou, Narong; Orouji, Tahereh; Pandit, Viraj; O'Keeffe, Terence; Tang, Andrew; Gries, Lynn; Friese, Randall S; Rhee, Peter; Davis, James W

2015-12-01

Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown. To assess the reported prevalence of domestic violence among trauma patients. A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years. Trauma patients presenting to trauma centers participating in the National Trauma Data Bank. To assess the reported prevalence of domestic violence among trauma patients. A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per 1000 discharges in 2012; P = .001) over the 6-year period and remained unchanged for elderly patients (0.8 cases per 1000 discharges in 2007 to 0.96 cases per 1000 discharges in 2012; P = .09). On subanalysis of adults and elderly patients, the prevalence of domestic violence increased among both female (4.6 cases per 1000 discharges in 2007 to 5.3 cases per 1000 discharges in 2012; P = .001) and male patients (1.5 cases per 1000 discharges in 2007 to 2.8 cases per 1000 discharges in 2012; P = .001). Domestic violence is prevalent among trauma patients. Over the years, the reported prevalence of domestic violence has been increasing among children and adults, and continues to remain high among female trauma patients. A robust mandatory screening for evaluating domestic violence among trauma patients, along with a focused national intervention, is warranted.

Variation in seizure prophylaxis in severe pediatric traumatic brain injury.

PubMed

Ostahowski, Paige J; Kannan, Nithya; Wainwright, Mark S; Qiu, Qian; Mink, Richard B; Groner, Jonathan I; Bell, Michael J; Giza, Christopher C; Zatzick, Douglas F; Ellenbogen, Richard G; Boyle, Linda Ng; Mitchell, Pamela H; Vavilala, Monica S

2016-10-01

OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.

Trends in 1029 Trauma Deaths at a Level 1 Trauma Center

PubMed Central

Oyeniyi, Blessing T.; Fox, Erin E.; Scerbo, Michelle; Tomasek, Jeffrey S.; Wade, Charles E.; Holcomb, John B.

2016-01-01

Background Over the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center. Methods Records at a urban Level 1 trauma center were reviewed. Two time periods (2005–2006 and 2012–2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05. Results 7080 patients (498 deaths) were examined in 2005–2006, while 8767 patients (531 deaths) were reviewed in 2012–2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for > 91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p<0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24 hours. Unadjusted mortality dropped from 7.0% to 6.1% (p=0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p<0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9–8.2) to 5.8% (95% CI: 5.3–6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0–7.2) to 4.7 (95% CI: 4.2–5.1). Conclusions Over the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, likely attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts. PMID:27847192

Prehospital Helicopter Transport and Survival of Patients With Traumatic Brain Injury

PubMed Central

Mackenzie, Todd A.

2015-01-01

Objective To investigate the association of helicopter transport with survival of patients with traumatic brain injury (TBI), in comparison with ground emergency medical services (EMS). Background Helicopter utilization and its effect on the outcomes of TBI remain controversial. Methods We performed a retrospective cohort study involving patients with TBI who were registered in the National Trauma Data Bank between 2009 and 2011. Regression techniques with propensity score matching were used to investigate the association of helicopter transport with survival of patients with TBI, in comparison with ground EMS. Results During the study period, there were 209,529 patients with TBI who were registered in the National Trauma Data Bank and met the inclusion criteria. Of these patients, 35,334 were transported via helicopters and 174,195 via ground EMS. For patients transported to level I trauma centers, 2797 deaths (12%) were recorded after helicopter transport and 8161 (7.8%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival [OR (odds ratio), 1.95; 95% confidence interval (CI), 1.81–2.10; absolute risk reduction (ARR), 6.37%]. This persisted after propensity score matching (OR, 1.88; 95% CI, 1.74–2.03; ARR, 5.93%). For patients transported to level II trauma centers, 1282 deaths (10.6%) were recorded after helicopter transport and 5097 (7.3%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (OR, 1.81; 95% CI, 1.64–2.00; ARR 5.17%). This again persisted after propensity score matching (OR, 1.73; 95% CI, 1.55–1.94; ARR, 4.69). Conclusions Helicopter transport of patients with TBI to level I and II trauma centers was associated with improved survival, in comparison with ground EMS. PMID:24743624

Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission

PubMed Central

Hall, Erin C; Tyrrell, Rebecca; Scalea, Thomas M; Stein, Deborah M

2018-01-01

Background Unplanned hospital readmissions increase healthcare costs and patient morbidity. We hypothesized that a program designed to reduce trauma readmissions would be effective. Methods A Trauma Transitional Care Coordination (TTCC) program was created to support patients at high risk for readmission. TTCC interventions included call to patient (or caregiver) within 72 hours of discharge to identify barriers to care, complete medication reconciliation, coordination of appointments, and individualized problem solving. Information on all 30-day readmissions was collected. 30-day readmission rates were compared with center-specific readmission rates and population-based, risk-adjusted rates of readmission using published benchmarks. Results 260 patients were enrolled in the TTCC program from January 2014 to September 2015. 30.8% (n=80) of enrollees were uninsured, 41.9% (n=109) reported current substance abuse, and 26.9% (n=70) had a current psychiatric diagnosis. 74.2% (n=193) attended outpatient trauma appointments within 14 days of discharge. 96.3% were successfully followed. Only 6.6% (n=16) of patients were readmitted in the first 30 days after discharge. This was significantly lower than both center-specific readmission rates before start of the program (6.6% vs. 11.3%, P=0.02) and recently published population-based trauma readmission rates (6.6% vs. 27%, P<0.001). Discussion A nursing-led TTCC program successfully followed patients and was associated with a significant decrease in 30-day readmission rates for patients with high-risk trauma. Targeted outpatient support for these most vulnerable patients can lead to better utilization of outpatient resources, increased patient satisfaction, and more consistent attainment of preinjury level of functioning or better. Level of evidence Level IV. PMID:29766133

Analysis of Pediatric Maxillofacial Fractures Requiring Operative Treatment: Characteristics, Management, and Outcomes.

PubMed

Allred, Lindsay J; Crantford, John C; Reynolds, Michael F; David, Lisa R

2015-11-01

Maxillofacial fractures in pediatric trauma patients require significant force and frequently are associated with concomitant injuries. The anatomic and developmental differences between the adult and child that impact patterns of injury also affect management and outcomes. The aim of this study was to analyze fracture location, mechanism, concomitant injuries as well as methods of surgical treatment and outcomes, to improve management of this patient population. A retrospective review was conducted of pediatric patients with maxillofacial fractures presenting to a level-1 trauma center during an 8-year span. Only patients requiring surgical intervention, 204, were included in this study. Data pertaining to the location of injury, mechanism, associated injuries, surgical treatment, outcomes, and complications were analyzed. The most common fracture location was the mandible (36.3%), then the nasal bone (35.3%), followed by the tripod fracture (10.8%). A total of 30.7% of patients were involved in motor vehicle accidents, with the next most common mechanisms being sports (24.4%), and assault (13.7%). A total of 46% of the patients sustained concomitant injuries, with the majority involving cerebral trauma (14.7%) or the extremities (9.3%). Total 75.4% of all fractures, excluding the nose, were treated with open reduction and internal fixation (ORIF). Our complication rate was 11.2%. Pediatric craniofacial trauma remains a frequent presentation to the emergency department of trauma centers. Facial fracture patterns and mechanism of trauma observed in the pediatric population presenting to this facility are consistent with incidences reported in the literature. Knowledge of treatment options and potential complications is an important tool in the management of the pediatric trauma patient.

Minimal acceptable care as a vital component to Missouri's trauma system.

PubMed

Helling, Thomas S

2002-07-01

Immediate attention to life-threatening injuries and expeditious transfer of major and complex wounds to tertiary care trauma centers are the cornerstones of any trauma system. Rapid assessment and "minimalization" of care should be the buzz-word of rural (Level III) and suburban (Level II) trauma centers in order to provide quickest treatment of injuries by timely referral of patients for definitive attention. This concept is called minimal acceptable care and may serve to improve patient outcome by reducing the interval to ultimate treatment and avoidance of duplication of services.

SWOT analysis in Sina Trauma and Surgery Research Center.

PubMed

Salamati, Payman; ashraf Eghbali, Ali; Zarghampour, Manijeh

2014-01-01

The present study was conducted with the aim of identifying and evaluating the internal and external factors, affecting the Sina Trauma and Surgery Research Center, affiliated to Tehran University of Medical Sciences and propose some of related strategies to senior managers. We used a combined quantitative and qualitative methodology. Our study population consisted of personnel (18 individuals) at Sina Trauma and Surgery Research Center. Data-collection tools were the group discussions and the questionnaires. Data were analyzed with descriptive statistics and SWOT (Strength, Weakness, Opportunities and Threats) analysis. 18 individuals participated in sessions, consisting of 8 women (44.4%) and 10 men (55.6%). The final scores were 2.45 for internal factors (strength-weakness) and 2.17 for external factors (opportunities-threats). In this study, we proposed 36 strategies (10 weakness-threat strategies, 10 weakness-opportunity strategies, 7 strength-threat strategies, and 9 strength-opportunity strategies). The current status of Sina Trauma and Surgery Research Center is threatened weak. We recommend the center to implement the proposed strategies.

Paying a Premium: How Patient Complexity Affects Costs and Profit Margins

PubMed Central

Taheri, Paul A.; Butz, David A.; Greenfield, Lazar J.

1999-01-01

Objective and Background Tertiary medical centers continue to be under extreme pressure to deliver high-complexity care, but paradoxically there is considerable pressure within these institutions to reduce their emphasis on tertiary care and refocus their efforts to develop a more community-like practice. The genesis of this pressure is the perceived profitability of routine surgical activity when compared with more complex care. The purpose of this study is to assess how the total cost and profit (loss) margin can vary for an entire trauma service. The authors also evaluate payments for specific trauma-related diagnostic-related groups (DRGs) and analyze how hospital margins were affected based on mortality outcome. Materials and Methods The authors analyzed the actual cost of all trauma discharges (n = 692) at their level I trauma center for fiscal year 1997. Data were obtained from the trauma registry and the hospital cost accounting system. Total cost was defined as the sum of the variable, fixed, and indirect costs associated with each patient. Margin was defined as expected payments minus total cost. The entire population and all DRGs with 10 or more patients were stratified based on survival outcome, Injury Severity Score, insurance status, and length of stay. The mean total costs for survivors and nonsurvivors within these various categories and their margins were evaluated. Results The profit margin on nonsurvivors was $5898 greater than for survivors, even though the mean total cost for nonsurvivors was $28,821 greater. Within the fixed fee arrangement, approximately 44% of transfers had a negative margin. Both survivors and nonsurvivors become increasingly profitable out to 20 days and subsequently become unprofitable beyond 21 days, but nonsurvivors were more profitable than survivors. Conclusions There is a wide variance in both the costs and margins within trauma-related DRGs. The DRG payment system disproportionately reimburses providers for nonsurvivors, even though on average they are more costly. Because payers are likely to engage in portfolio management, patients can be transferred between hospitals based on the contractual relationship between the payer and the provider. This payment system potentially allows payers to act strategically, sending relatively low-cost patients to hospitals where they use fee-for-service reimbursement and high-cost patients to hospitals where their reimbursement is contractually capped. Although specific to the authors’ trauma center and its payer mix, these data demonstrate the profitability of maintaining a level I trauma center and preserving the mission of delivering care to the severely injured. PMID:10363894

Patterns of Injury Among Drivers Hospitalized in Level-I Trauma Centers: Have Frontal Airbags Made a Difference?

PubMed Central

Segui-Gomez, Maria; Graham, John D.

2000-01-01

This study describes the injuries of drivers discharged from Level-I Trauma Centers between 1995–1997. Differences in the drivers’ injuries and outcomes by airbag deployment status and gender were evaluated using Chi2 and T-tests. Data on 1,065 drivers (66 with airbags, 423 females) were obtained from the Massachusetts Registry of Motor Vehicle and Trauma Registries. Once admitted to trauma centers, drivers with airbags did not differ from drivers without airbags regarding the number, type, clustering, severity or outcome of their injuries. The only exception was that female drivers sustained more fractures to the upper extremities and less injuries to blood vessels and certain traumatic complications (p<0.05). PMID:11558082

Developing a Mass Casualty Surge Capacity Protocol for Emergency Medical Services to Use for Patient Distribution.

PubMed

Shartar, Samuel E; Moore, Brooks L; Wood, Lori M

2017-12-01

Metropolitan areas must be prepared to manage large numbers of casualties related to a major incident. Most US cities do not have adequate trauma center capacity to manage large-scale mass casualty incidents (MCIs). Creating surge capacity requires the distribution of casualties to hospitals that are not designated as trauma centers. Our objectives were to extrapolate MCI response research into operational objectives for MCI distribution plan development; formulate a patient distribution model based on research, hospital capacities, and resource availability; and design and disseminate a casualty distribution tool for use by emergency medical services (EMS) personnel to distribute patients to the appropriate level of care. Working with hospitals within the region, we refined emergency department surge capacity for MCIs and developed a prepopulated tool for EMS providers to use to distribute higher-acuity casualties to trauma centers and lower-acuity casualties to nontrauma hospitals. A mechanism to remove a hospital from the list of available resources, if it is overwhelmed with patients who self-transport to the location, also was put into place. The number of critically injured survivors from an MCI has proven to be consistent, averaging 7% to 10%. Moving critically injured patients to level 1 trauma centers can result in a 25% reduction in mortality, when compared with care at nontrauma hospitals. US cities face major gaps in the surge capacity needed to manage an MCI. Sixty percent of "walking wounded" casualties self-transport to the closest hospital(s) to the incident. Directing critically ill patients to designated trauma centers has the potential to reduce mortality associated with the event. When applied to MCI responses, damage-control principles reduce resource utilization and optimize surge capacity. A universal system for mass casualty triage was identified and incorporated into the region's EMS. Flagship regional coordinating hospitals were designated to coordinate the logistics of the disaster response of both trauma-designated and undesignated hospitals. Finally, a distribution tool was created to direct the flow of critically injured patients to trauma centers and redirect patients with lesser injuries to centers without trauma designation. The tool was distributed to local EMS personnel and validated in a series of tabletop and functional drills. These efforts demonstrate that a regional response to MCIs can be implemented in metropolitan areas under-resourced for trauma care.

Does Mechanism of Injury Predict Trauma Center Need?

PubMed Central

Lerner, E. Brooke; Shah, Manish N.; Cushman, Jeremy T.; Swor, Robert; Guse, Clare E.; Brasel, Karen; Blatt, Alan; Jurkovich, Gregory J.

2011-01-01

Objective To determine the predictive value of the Mechanism of Injury step of the American College of Surgeon’s Field Triage Decision Scheme for determining trauma center need. Methods EMS providers caring for injured adult patients transported to the regional trauma center in 3 midsized communities over two years were interviewed upon ED arrival. Included was any injured patient, regardless of injury severity. The interview collected patient physiologic condition, apparent anatomic injury, and mechanism of injury. Using the 1999 Scheme, patients who met the physiologic or anatomic steps were excluded. Patients were considered to need a trauma center if they had non-orthopedic surgery within 24 hours, intensive care unit admission, or died prior to hospital discharge. Data were analyzed by calculating positive likelihood ratios (+LR) and 95% confidence intervals (CI) for each mechanism of injury criteria. Results 11,892 provider interviews were conducted. Of those, 1was excluded because outcome data were not available and 2,408 were excluded because they met the other steps of the Field Triage Decision Scheme. Of the remaining 9,483 cases, 2,363 met one of the mechanism of injury criteria, 204 (9%) of which needed the resources of a trauma center. Criteria with a +LR ≥5 were death of another occupant in the same vehicle (6.8; CI:2.7–16.7), fall >20 ft.(5.2; CI:2.4–11.3), and motor vehicle crash (MVC) extrication >20 minutes (5.0; CI:3.2–8.0). Criteria with a +LR between 2 and <5 were intrusion >12 inches (3.7; CI:2.6–5.3), ejection (3.2; CI:1.3–8.2), and deformity >20 inches (2.3; CI:1.7–3.0). The criteria with a +LR <2 were MVC speed >40 mph (1.9; CI:1.5–2.2), pedestrian/bicyclist struck >5mph (1.2; CI:1.0–1.5), bicyclist/pedestrian thrown or run over (1.2; CI:0.9–1.6), motorcycle crash >20mph (1.1; CI:0.96–1.3), rider separated from motorcycle (1.0; CI:0.9–1.2), and MVC rollover (1.0; CI:0.7–1.5). Conclusion Death of another occupant, fall distance, and extrication time were good predictors of trauma center need when a patient did not meet the anatomic or physiologic conditions. Intrusion, ejection, and vehicle deformity were moderate predictors. PMID:21870946

Geriatric resources in acute care hospitals and trauma centers: a scarce commodity.

PubMed

Maxwell, Cathy A; Mion, Lorraine C; Minnick, Ann

2013-12-01

The number of older adults admitted to acute care hospitals with traumatic injury is rising. The purpose of this study was to examine the location of five prominent geriatric resource programs in U.S. acute care hospitals and trauma centers (N = 4,865). As of 2010, 5.8% of all U.S. hospitals had at least one of these programs. Only 8.8% of trauma centers were served by at least one program; the majorities were in level I trauma centers. Slow adoption of geriatric resource programs in hospitals may be due to lack of champions who will advocate for these programs, lack of evidence of their impact on outcomes, or lack of a business plan to support adoption. Future studies should focus on the benefits of geriatric resource programs from patients' perspectives, as well as from business case and outcomes perspectives. Copyright 2013, SLACK Incorporated.

Whole body computed tomography for trauma patients in the Nordic countries 2014: survey shows significant differences and a need for common guidelines.

PubMed

Wiklund, E; Koskinen, S K; Linder, F; Åslund, P-E; Eklöf, H

2016-06-01

Whole body computed tomography in trauma (WBCTT) is a standardized CT examination of trauma patients. It has a relatively high radiation dose. Therefore, well-defined clinical indications and imaging protocols are needed. This information regarding Nordic countries is limited. To identify Nordic countries' WBCTT imaging protocols, radiation dose, and integration in trauma care, and to inquire about the need for common Nordic guidelines. A survey with 23 multiple choice questions or free text responses was sent to 95 hospitals and 10 trauma centers in and outside the Nordic region, respectively. The questions were defined and the hospitals selected in collaboration with board members of "Nordic Forum for Trauma and Emergency Radiology" (www.nordictraumarad.com). Two Nordic hospitals declined to take part in the survey. Out of the remaining 93 Nordic hospitals, 56 completed the questionnaire. Arterial visualization is routine in major trauma centers but only in 50% of the Nordic hospitals. The CT scanner is located within 50 m of the emergency department in all non-Nordic trauma centers but only in 60% of Nordic hospitals. Radiation dose for WBCTT is in the range of 900-3600 mGy × cm. Of the 56 responding Nordic hospitals, 84% have official guidelines for WBCTT. Eighty-nine percent of the responders state there is a need for common guidelines. Scanning protocols, radiation doses, and routines differ significantly between hospitals and trauma centers. Guideline for WBCTT is presently defined locally in most Nordic hospitals. There is an interest in most Nordic hospitals to endorse new and common guidelines for WBCTT. © The Foundation Acta Radiologica 2015.

The implications of alcohol intoxication and the Uniform Policy Provision Law on trauma centers; a national trauma data bank analysis of minimally injured patients.

PubMed

O'Keeffe, Terence; Shafi, Shahid; Sperry, Jason L; Gentilello, Larry M

2009-02-01

Alcohol intoxication may confound the initial assessment of trauma patients, resulting in increased use of diagnostic and therapeutic procedures, thereby increasing hospital costs. The Uniform Policy Provision Law (UPPL) exists in many states and allows insurance companies to deny payment for medical treatment for alcohol-related injuries. If intoxication increases resource utilization, these denials compound the financial burden of alcohol use on trauma centers. We hypothesized that patients injured while under the influence of alcohol require more diagnostic tests, procedures, and hospital admissions, leading to higher hospital charges. The National Trauma Databank (2000-2004) was analyzed to identify adult trauma patients (age > or = 16 years) who were discharged alive, had a length of stay < or = 1 day and minor injuries (Injury Severity Score < 9), and were tested for blood alcohol. The study was confined to minimally injured patients to facilitate identification of unexpected resource use most likely attributable to alcohol use. Resource utilization was compared among patients who tested positive or negative for alcohol use. Results are presented as odds ratio (OR) with 95% confidence intervals (CI). Sixty-eight thousand eight patients met study criteria, of which 31,020 were positive for alcohol. Despite similar baseline characteristics, alcohol-positive patients required significantly more invasive procedures, including intubation (OR 4.16, 95% CI = 3.56-4.85) and Foley catheter insertion (OR 1.52, 95% CI = 1.39-1.67) as well as diagnostic tests (CT scan OR 1.16, 95% CI = 1.12-1.20). They were also less likely to be discharged from the emergency department (OR 0.61, 95% CI = 0.58-0.64), and more frequently required hospital (OR 1.64, 95% CI = 1.57-1.73) or intensive care unit admission (OR 1.82, 95% CI = 1.71-1.94). Mean hospital charges were $1,833 greater ($10,405 +/- 225 vs. 8,572 +/- 68). A significant amount of trauma center costs are primarily attributable to alcohol use rather than injury severity or outcome. The financial costs associated with alcohol use and UPPL-related cost-shifting to trauma centers is a significant burden to trauma centers. UPPL laws that penalize trauma centers for identifying intoxicated patients should be repealed in states where they exist.

Effect of the Uniform Accident and Sickness Policy Provision Law on alcohol screening and intervention in trauma centers.

PubMed

Gentilello, Larry M; Donato, Anthony; Nolan, Susan; Mackin, Robert E; Liebich, Franesa; Hoyt, David B; LaBrie, Richard A

2005-09-01

Alcohol screening and intervention in trauma centers are widely recommended. The Uniform Accident and Sickness Policy Provision Law (UPPL) exists in most states, and allows insurers to refuse payment for treatment of injuries in patients with a positive alcohol or drug test. This article analyzed the UPPL's impact on screening and reimbursement, measured the knowledge of legislators about substance use problems in trauma centers, and determined their opinions about substance use-related exclusions in insurance contracts for trauma care. A nationwide survey of members of the American Association for the Surgery of Trauma was conducted. A separate survey of legislators who are members of the Senate, House, or Assembly and serve in some leadership role on committees responsible for insurance in their state was also performed. Ninety-eight trauma surgeon and 56 legislator questionnaires were analyzed. Surgeons' familiarity with the UPPL was limited; only 13% believed they practiced in a UPPL state, but 70% actually did. Despite lack of knowledge of the statute, 24% reported an alcohol- or drug-related insurance denial in the past 6 months. This appeared to affect screening practices; the majority of surgeons (51.5%) do not routinely measure blood alcohol concentration, even though over 91% believe blood alcohol concentration testing is important. Most (82%) indicated that if there were no insurance barriers, they would be willing to establish a brief alcohol intervention program in their center. Legislators were aware of the impact of substance use on trauma centers. They overwhelmingly agreed (89%) that alcohol problems are treatable, and 80% believed it is a good idea to offer counseling in trauma centers. As with surgeons, the majority (53%) were not sure whether the UPPL existed in their state, but they favored prohibiting alcohol-related exclusions by a 2:1 ratio, with strong bipartisan support. The study documents strong support for screening and intervention programs by both trauma surgeons and legislators. Surgeons experience alcohol-related insurance denials but are not familiar with the state law that sanctions this practice. A majority of legislators are also not familiar with the UPPL but support elimination of insurance statutes that allow exclusion of coverage for trauma care on the basis of intoxication.

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

PubMed

Joseph, Bellal; Haider, Ansab A; Azim, Asad; Kulvatunyou, Narong; Tang, Andrew; OʼKeeffe, Terence; Latifi, Rifat; Green, Donald J; Friese, Randall S; Rhee, Peter

2016-09-01

The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. Economic and value-based evaluation, level III.

Does a single specialty intensive care unit make better business sense than a multi-specialty intensive care unit? A costing study in a trauma center in India

PubMed Central

Kumar, Parmeshwar; Jithesh, Vishwanathan; Gupta, Shakti Kumar

2015-01-01

Context: Though intensive care units (ICUs) only account for 10% of hospital beds, they consume nearly 22% of hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. Aim: To evaluate and compare the cost of intensive care delivery between multi-specialty and neurosurgery ICU in an apex trauma care facility in India. Materials and Methods: The study was conducted in a polytrauma and neurosurgery ICU at a 203 bedded level IV trauma care facility in New Delhi, India from May, 2012 to June 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Statistical Analysis: Fisher's two-tailed t-test. Results: Total cost/bed/day for the multi-specialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU was Rs. 14,306.7/-, manpower constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Conclusions: Quantification of expenditure in running an ICU in a trauma center would assist healthcare decision makers in better allocation of resources. Although multi-specialty ICUs are more expensive, other factors will also play a role in defining the kind of ICU that need to be designed. PMID:25829909

The first 5 years since trauma center designation in the Hong Kong Special Administrative Region, People's Republic of China.

PubMed

Leung, Gilberto Ka Kit; Chang, Annice; Cheung, F C; Ho, H F; Ho, Wendy; Hui, S M; Kam, C W; Lai, Albert; Lam, K W; Leung, M; Liu, S H; Lo, C B; Mok, Francis; Rainer, Timothy H; Shen, W Y; So, F L; Wong, Gordon; Wu, Amy; Yeung, Janice; Yuen, W K

2011-05-01

In 1994, the Hong Kong Special Administrative Region (HKSAR) introduced plans to implement a trauma system based on the recommendations outlined by Professor Donald Trunkey in his report to the local Hospital Authority. Five government-subsidized public hospitals were subsequently designated as trauma centers in 2003. This article reviews the initial experience in these five centers. Prospective trauma registries from January 2004 to December 2008 were reviewed. Primary clinical outcome measures were hospital mortality. The Trauma and Injury Severity Score methodology was used for benchmarking with the Major Trauma Outcome Study (MTOS) database. The majority (83.3%) of the 10,462 patients suffered from blunt trauma. Severe injury, defined as Injury Severity Score>15, occurred in 29.7% of patients. The leading causes of trauma were motor vehicle collisions and falls, with crude hospital mortality rates of 6.9% and 10.7%, respectively. The M-statistic was 0.95, indicating comparable case-mix with the MTOS. The worst outcome occurred in the first year. Significant improvement was seen in patients with penetrating injuries. By 2008, these patients had significantly higher survival rates than expected (Z-statistic=0.85). Although the overall mortality rates for blunt trauma were higher than expected, the difference was no longer statistically significant from the second year onward. The case-mix of trauma patients in the HKSAR is comparable with that of the MTOS. A young trauma system relatively unburdened by dissimilar reimbursement and patient access issues may achieve significant improvement and satisfactory patient outcomes. Our findings may serve as a useful benchmark for HK and other Southeast Asian cities and trauma systems to establish local coefficients for future evaluations.

Length of stay and medical stability for spinal cord-injured patients on admission to an inpatient rehabilitation hospital: a comparison between a model SCI trauma center and non-SCI trauma center.

PubMed

Ploumis, A; Kolli, S; Patrick, M; Owens, M; Beris, A; Marino, R J

2011-03-01

Retrospective database review. To compare lengths of stay (LOS), pressure ulcers and readmissions to the acute care hospital of patients admitted to the inpatient rehabilitation facility (IRF) from a model spinal cord injury (SCI) trauma center or from a non-SCI acute hospital. Only sparse data exist comparing the status of patients admitted to IRF from a model SCI trauma center or from a non-SCI acute hospital. Acute care, IRF and total LOS were compared between patients transferred to IRF from the SCI center (n=78) and from non-SCI centers (n=131). The percentages of pressure ulcers on admission to IRF and transfer back to acute care were also compared. Patients admitted to IRF from the SCI trauma center (SCI TC) had significantly shorter (P=0.01) acute care LOS and total LOS compared with patients admitted from non-SCI TCs. By neurological category, acute-care LOS was less for all groups admitted from the SCI center, but statistically significant only for tetraplegia. There was no significant difference in the incidence of readmissions to acute care from IRF. More patients from non-SCI centers (34%) than SCI centers (12%) had pressure ulcers (P<0.001). Acute care in organized SCI TCs before transfer to IRF can significantly lower acute-care LOS or total LOS and incidence of pressure ulcers compared with non-SCI TCs. Patients admitted to IRF from SCI TCs are no more likely to be sent back to an acute hospital than those from non-SCI TCs.

CRISIS UNDER THE RADAR: ILLICIT AMPHETAMINE USE IS REACHING EPIDEMIC PROPORTIONS AND CONTRIBUTING TO RESOURCE OVER-UTILIZATION AT A LEVEL 1 TRAUMA CENTER.

PubMed

Gemma, Vincent A; Chapple, Kristina A; Goslar, Pamela W; Israr, Sharjeel; Petersen, Scott R; Weinberg, Jordan A

2018-05-21

Trauma centers reported illicit amphetamine use in approximately 10% of trauma admissions in the previous decade. From experience at a trauma center located in a southwestern metropolis, our perception is that illicit amphetamine use is on the rise, and that these patients utilize in-hospital resources beyond what would be expected for their injuries. The purpose of this study was to document the incidence of illicit amphetamine use among our trauma patients and to evaluate its impact on resource utilization. We conducted a retrospective cohort study using 7 consecutive years of data (starting July 2010) from our institution's trauma registry. Toxicology screenings were used to categorize patients into one of three groups: illicit amphetamine, other drugs, or drug free. Adjusted linear and logistic regression models were used to predict hospital cost, length of stay, ICU admission and ventilation between drug groups. Models were conducted with combined injury severity (ISS) and then repeated for ISS <9, ISS 9-15 and ISS 16 and above. 8,589 patients were categorized into the following three toxicology groups: 1255 (14.6%) illicit amphetamine, 2214 (25.8%) other drugs, and 5120 (59.6%) drug free. Illicit amphetamine use increased threefold over the course of the study (from 7.85% to 25.0% of annual trauma admissions). Adjusted linear models demonstrated that illicit amphetamine among patients with ISS<9 was associated with 4.6% increase in hospital cost (P=.019) and 7.4% increase in LOS (P=.043). Logistic models revealed significantly increased odds of ventilation across all ISS groups and increased odds of ICU admission when all ISS groups were combined (P=.001) and within the ISS<9 group (P=.002). Hospital resource utilization of amphetamine patients with minor injuries is significant. Trauma centers with similar epidemic growth in proportion of amphetamine patients face a potentially significant resource strain relative to other centers. Prognostic and Epidemiological LEVEL OF EVIDENCE: III.

Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals.

PubMed

Knowlton, Lisa M; Morris, Arden M; Tennakoon, Lakshika; Spain, David A; Staudenmayer, Kristan L

2018-04-20

Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability. We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin. California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n = 4) and nonprofit-owned SNHs (64%, n = 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p < 0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively. The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system. Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Impact of a TeamSTEPPS Trauma Nurse Academy at a Level 1 Trauma Center.

PubMed

Peters, V Kristen; Harvey, Ellen M; Wright, Andi; Bath, Jennifer; Freeman, Dan; Collier, Bryan

2018-01-01

Nurses are crucial members of the team caring for the acutely injured trauma patient. Until recently, nurses and physicians gained an understanding of leadership and supportive roles separately. With the advent of a multidisciplinary team approach to trauma care, formal team training and simulation has transpired. Since 2007, our Level I trauma system has integrated TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety; Agency for Healthcare Research and Quality, Rockville, MD) into our clinical care, joint training of nurses and physicians, using simulations with participation of all health care providers. With the increased expectations of a well-orchestrated team and larger number of emergency nurses, our program created the Trauma Nurse Academy. This academy provides a core of experienced nurses with an advanced level of training while decreasing the variability of personnel in the trauma bay. Components of the academy include multidisciplinary didactic education, the Essentials of TeamSTEPPS, and interactive trauma bay learning, to include both equipment and drug use. Once completed, academy graduates participate in the orientation and training of General Surgery and Emergency Medicine residents' trauma bay experience and injury prevention activities. Internal and published data have demonstrated growing evidence linking trauma teamwork training to knowledge and self-confidence in clinical judgment to team performance, patient outcomes, and quality of care. Although trauma resuscitations are stressful, high risk, dynamic, and a prime environment for error, new methods of teamwork training and collaboration among trauma team members have become essential. Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Disaster preparedness of Canadian trauma centres: the perspective of medical directors of trauma

PubMed Central

Gomez, David; Haas, Barbara; Ahmed, Najma; Tien, Homer; Nathens, Avery

2011-01-01

Background Owing to their constant readiness to treat injured patients, trauma centres are essential to regional responses to mass casualty incidents (MCIs). Reviews of recent MCIs suggest that trauma centre preparedness has frequently been limited. We set out to evaluate Canadian trauma centre preparedness and the extent of their integration into a regional response to MCIs. Methods We conducted a survey of Canadian level-1 trauma centres (n = 29) to characterize their existing disaster-response plans and to identify areas where pre-paredness could be improved. The survey was directed to the medical director of trauma at each centre. Descriptive statistics were used to analyze responses. Results Twenty-three (79%) trauma centres in 5 provinces responded. Whereas most (83%) reported the presence of a committee dedicated to disaster preparedness, only half of the medical directors of trauma were members of these committees. Almost half (43%) the institutions had not run any disaster drill in the previous 2 years. Only 70% of trauma centres used communications assets designed to function during MCIs. Additionally, more than half of the trauma directors (59%) did not know if their institutions had the ability to sustain operations for at least 72 hours during MCIs. Conclusion The results of this study suggest important opportunities to better prepare Canadian trauma centers to respond to an MCI. The main areas identified for potential improvement include the need for the standardization of MCI planning and response at a regional level and the implementation of strategies such as stockpiling of resources and novel communication strategies to avoid functional collapse during an MCI. PMID:21251427

Evaluating trauma care capabilities in Mexico with the World Health Organization's Guidelines for Essential Trauma Care publication.

PubMed

Arreola-Risa, Carlos; Mock, Charles; Vega Rivera, Felipe; Romero Hicks, Eduardo; Guzmán Solana, Felipe; Porras Ramírez, Giovanni; Montiel Amoroso, Gilberto; de Boer, Melanie

2006-02-01

To identify affordable, sustainable methods to strengthen trauma care capabilities in Mexico, using the standards in the Guidelines for Essential Trauma Care, a publication that was developed by the World Health Organization and the International Society of Surgery to provide recommendations on elements of trauma care that should be in place in the various levels of health facilities in all countries. The Guidelines publication was used as a basis for needs assessments conducted in 2003 and 2004 in three Mexican states. The states were selected to represent the range of geographic and economic conditions in the country: Oaxaca (south, lower economic status), Puebla (center, middle economic status), and Nuevo León (north, higher economic status). The sixteen facilities that were assessed included rural clinics, small hospitals, and large hospitals. Site visits incorporated direct inspection of physical resources as well as interviews with key administrative and clinical staff. Human and physical resources for trauma care were adequate in the hospitals, especially the larger ones. The survey did identify some deficiencies, such as shortages of stiff suction tips, pulse oximetry equipment, and some trauma-related medications. All of the clinics had difficulties with basic supplies for resuscitation, even though some received substantial numbers of trauma patients. In all levels of facilities there was room for improvement in administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and uniform in-service training. This study identified several low-cost ways to strengthen trauma care in Mexico. The study also highlighted the usefulness of the recommended norms in the Guidelines for Essential Trauma Care publication in providing a standardized template by which to assess trauma care capabilities in nations worldwide.

Epidemiology of Pelvic Ring Fractures in a Level 1 Trauma Center in the Netherlands

PubMed Central

Biert, Jan; Edwards, Michael John Richard

2017-01-01

Purpose This study was conducted to study the epidemiology, classification, treatment and outcome of a large patient group with pelvic ring injury in a level 1 trauma center in the Netherlands. Materials and Methods In the period of 2004 to 2014, we encountered 537 patients with a pelvic fracture. Many of them are due to a high energy trauma and therefore many concomitant injuries are observed. Tile A fractures were seen in 137 patients (25.5%), Tile B fractures in 211 (39.3%) and Tile C fractures in 189 patients (35.2%). Results Patients with unstable fracture types (Tile B1 and B3, Tile C) had significantly higher injury severity score, transfusion rates, need for laparotomy and definitive operative stabilization and complication rate. However, mortality did not differ significantly among Tile A, B or C fractures. Conclusion Overall outcome was good with a mortality rate of 13.6%, which is comparable with other rAelpmorotsst. half of the patients treated could directly be dismissed to their own homes. PMID:29250500

Effect of a Dedicated Orthopaedic Advanced Practice Provider in a Level I Trauma Center: Analysis of Length of Stay and Cost.

PubMed

Hiza, Elise A; Gottschalk, Michael B; Umpierrez, Erica; Bush, Patricia; Reisman, William M

2015-07-01

The objective of this study is to analyze the effect of an orthopaedic trauma advanced practice provider on length of stay (LOS) and cost in a level I trauma center. The hypothesis of this study is that the addition of a single full-time nurse practitioner (NP) to the orthopaedic trauma team at a level I Trauma center would decrease overall LOS and hospital cost. A retrospective chart review of all patients discharged from the orthopaedic surgery service 1 year before the addition of a NP (pre-NP) and 1 year after the hiring of a NP (post-NP) were reviewed. Chart review included age, gender, LOS, discharge destination, intravenous antibiotic use, wound VAC therapy, admission location, and length of time to surgery. Statistical analysis was performed using the Wilcoxon/Kruskal-Wallis test. The hiring of a NP yielded a statistically significant decrease in the LOS across the following patient subgroups: patients transferred from the trauma service (13.56 compared with 7.02 days, P < 0.001), patients aged 60 years and older (7.34 compared with 5.04 days, P = 0.037), patients discharged to a rehabilitation facility (10.84 compared with 8.31 days, P = 0.002), and patients discharged on antibiotics/wound VAC therapy (15.16 compared with 11.24 days, P = 0.017). Length of time to surgery was also decreased (1.48 compared with 1.31 days, P = 0.37). The addition of a dedicated orthopaedic trauma advanced practice provider at a county level I trauma center resulted in a statistically significant decrease in LOS and thus reduced indirect costs to the hospital. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The French initiated FESUM - historical development, experience and perspectives.

PubMed

Dubert, T; Merle, M

2013-12-01

FESUM is an association dedicated to management, research and education of hand trauma. Created by surgeons in 1979, it is now accepted by the national and regional health administrations. The first goal of FESUM is to apply strict guidelines for specialized hand trauma centers. These guidelines are verified on site by 2 FESUM surgeons, and re-checked every 3 years. Patients are selected to be directed to the FESUM cen-ters following very simple recommendations: every severe trauma must be addressed to and accepted by FESUM centers, 24/7. Seemingly less severe lesions such as deep palmar lacerations must also be systematically explored in FESUM centers to ensure patients have the best opportunity for treatment. Prevention is also a very important part of FESUM activities. The FESUM prevention campaigns are currently focused more specifically on daily life trauma, that represents 2/3 of the total injuries and is very poorly managed by authorities. © Georg Thieme Verlag KG Stuttgart · New York.

Training forward surgical teams for deployment: the US Army Trauma Training Center.

PubMed

Valdiri, Linda A; Andrews-Arce, Virginia E; Seery, Jason M

2015-04-01

Since the late 1980s, the US Army has been deploying forward surgical teams to the most intense areas of conflict to care for personnel injured in combat. The forward surgical team is a 20-person medical team that is highly mobile, extremely agile, and has relatively little need of outside support to perform its surgical mission. In order to perform this mission, however, team training and trauma training are required. The large majority of these teams do not routinely train together to provide patient care, and that training currently takes place at the US Army Trauma Training Center (ATTC). The training staff of the ATTC is a specially selected 10-person team made up of active duty personnel from the Army Medical Department assigned to the University of Miami/Jackson Memorial Hospital Ryder Trauma Center in Miami, Florida. The ATTC team of instructors trains as many as 11 forward surgical teams in 2-week rotations per year so that the teams are ready to perform their mission in a deployed setting. Since the first forward surgical team was trained at the ATTC in January 2002, more than 112 forward surgical teams and other similar-sized Department of Defense forward resuscitative and surgical units have rotated through trauma training at the Ryder Trauma Center in preparation for deployment overseas. ©2015 American Association of Critical-Care Nurses.

The role of the trauma nurse leader in a pediatric trauma center.

PubMed

Wurster, Lee Ann; Coffey, Carla; Haley, Kathy; Covert, Julia

2009-01-01

The trauma nurse leader role was developed by a group of trauma surgeons, hospital administrators, and emergency department and trauma leaders at Nationwide Children's Hospital who recognized the need for the development of a core group of nurses who provided expert trauma care. The intent was to provide an experienced group of nurses who could identify and resolve issues in the trauma room. Through increased education, exposure, mentoring, and professional development, the trauma nurse leader role has become an essential part of the specialized pediatric trauma care provided at Nationwide Children's Hospital.

Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital.

PubMed

Vernon, Donald D; Bolte, Robert G; Scaife, Eric; Hansen, Kristine W

2005-01-01

Freestanding children's hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. At a tertiary care children's hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score > or =15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.

The Lack of Common Goals and Communication Within a Level I Trauma System: Assessing the Silo Effect Among Trauma Center Employees.

PubMed

Mace-Vadjunec, Daneen; Hileman, Barbara M; Melnykovich, M Ben; Hanes, Marina C; Chance, Elisha A; Emerick, Eric S

2015-01-01

We assessed our level I trauma center's employees' perception of inter- and intradepartmental relationships to determine whether employees who work less often with patients feel less involved-the silo effect. We prospectively evaluated employees who provide direct patient care using the Trauma System Survey tool. Of 1155 employees, 699 responded. Combined interdepartmental relationships showed that 93% believed their unit communicated well with other units, and 86% thought other units communicated well with their unit. However, 69% experienced miscommunication between units. To reduce silos, communication is key. Training and multiunit events may help reduce these silos further.

Including fall prevention for older adults in your trauma injury prevention program--introducing Farewell to Falls.

PubMed

Corman, Ellen

2009-01-01

With data showing that more than 50% of visits to our trauma center for older adults 65 years and older are due to falls, injury prevention programs in trauma centers should be paying more attention to the area of fall prevention for older adults. Farewell to Falls, a free, home-based program of Stanford Hospital and Clinic's trauma service, utilizes a multifaceted approach to help reduce falls. In addition to improving the lives of seniors, the program fulfills a community benefit goal and provides strong hospital marketing opportunities. This program is a benefit to hospitals and the older adults they serve.

Use of laparoscopy in trauma at a level II trauma center.

PubMed

Barzana, Daniel C; Kotwall, Cyrus A; Clancy, Thomas V; Hope, William W

2011-01-01

Enthusiasm for the use of laparoscopy in trauma has not rivaled that for general surgery. The purpose of this study was to evaluate our experience with laparoscopy at a level II trauma center. A retrospective review of all trauma patients undergoing diagnostic or therapeutic laparoscopy was performed from January 2004 to July 2010. Laparoscopy was performed in 16 patients during the study period. The average age was 35 years. Injuries included left diaphragm in 4 patients, mesenteric injury in 2, and vaginal laceration, liver laceration, small bowel injury, renal laceration, urethral/pelvic, and colon injury in 1 patient each. Diagnostic laparoscopy was performed in 11 patients (69%) with 3 patients requiring conversion to an open procedure. Successful therapeutic laparoscopy was performed in 5 patients for repair of isolated diaphragm injuries (2), a small bowel injury, a colon injury, and placement of a suprapubic bladder catheter. Average length of stay was 5.6 days (range, 0 to 23), and 75% of patients were discharged home. Morbidity rate was 13% with no mortalities or missed injuries. Laparoscopy is a seldom-used modality at our trauma center; however, it may play a role in a select subset of patients.

Pattern of maxillofacial fractures in severe multiple trauma patients: a 7-year prospective study.

PubMed

Alves, La-Salete; Aragão, Irene; Sousa, Maria-José Carneiro; Gomes, Ernestina

2014-01-01

The incidence of facial trauma is high. This study has the primary objective of documenting and cataloging maxillofacial fractures in polytrauma patients. From a total of 1229 multiple trauma cases treated at the Emergency Room of the Santo Antonio Hospital - Oporto Hospital Center, Portugal, between August 2001 and December 2007, 251 patients had facial wounds and 209 had maxillofacial fractures. Aged ranged form 13 to 86 years. The applied selective method was based on the presence of facial wound with Abbreviated Injury Scale ≥1. Men had a higher incidence of maxillofacial fractures among multiple trauma patients (86.6%) and road traffic accidents were the primary cause of injuries (69.38%). Nasoorbitoethmoid complex was the most affected region (67.46%) followed by the maxilla (57.42%). The pattern and presentation of maxillofacial fractures had been studied in many parts of the world with varying results. Severe multiple trauma patients had different patterns of maxillofacial injuries. The number of maxillofacial trauma is on the rise worldwide as well as the incidence of associated sequelae. Maxillofacial fractures on multiple trauma patients were more frequent among males and in road traffic crashes. Knowing such data is elementary. The society should have a key role in the awareness of individuals and in prevention of road traffic accidents.

Issues of War Trauma and Working with Refugees. A Compilation of Resources.

ERIC Educational Resources Information Center

Somach, Susan D., Comp.

The Center for Applied Linguistics has compiled these resources on the subjects of war trauma and working with refugees to guide refugee service providers and classroom teachers. The materials include background information about trauma and posttraumatic stress disorder and specific information about problems of refugees and victims of war trauma.…

Evaluation of the influence of the definition of an isolated hip fracture as an exclusion criterion for trauma system benchmarking: a multicenter cohort study.

PubMed

Tiao, J; Moore, L; Porgo, T V; Belcaid, A

2016-06-01

To assess whether the definition of an IHF used as an exclusion criterion influences the results of trauma center benchmarking. We conducted a multicenter retrospective cohort study with data from an integrated Canadian trauma system. The study population included all patients admitted between 1999 and 2010 to any of the 57 adult trauma centers. Seven definitions of IHF based on diagnostic codes, age, mechanism of injury, and secondary injuries, identified in a systematic review, were used. Trauma centers were benchmarked using risk-adjusted mortality estimates generated using the Trauma Risk Adjustment Model. The agreement between benchmarking results generated under different IHF definitions was evaluated with correlation coefficients on adjusted mortality estimates. Correlation coefficients >0.95 were considered to convey acceptable agreement. The study population consisted of 172,872 patients before exclusion of IHF and between 128,094 and 139,588 patients after exclusion. Correlation coefficients between risk-adjusted mortality estimates generated in populations including and excluding IHF varied between 0.86 and 0.90. Correlation coefficients of estimates generated under different definitions of IHF varied between 0.97 and 0.99, even when analyses were restricted to patients aged ≥65 years. Although the exclusion of patients with IHF has an influence on the results of trauma center benchmarking based on mortality, the definition of IHF in terms of diagnostic codes, age, mechanism of injury and secondary injury has no significant impact on benchmarking results. Results suggest that there is no need to obtain formal consensus on the definition of IHF for benchmarking activities.

Coordination and management of multicenter clinical studies in trauma: Experience from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study.

PubMed

Rahbar, Mohammad H; Fox, Erin E; del Junco, Deborah J; Cotton, Bryan A; Podbielski, Jeanette M; Matijevic, Nena; Cohen, Mitchell J; Schreiber, Martin A; Zhang, Jiajie; Mirhaji, Parsa; Duran, Sarah J; Reynolds, Robert J; Benjamin-Garner, Ruby; Holcomb, John B

2012-04-01

Early death due to hemorrhage is a major consequence of traumatic injury. Transfusion practices differ among hospitals and it is unknown which transfusion practices improve survival. This report describes the experience of the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study Data Coordination Center in designing and coordinating a study to examine transfusion practices at ten Level 1 trauma centers in the US. PROMMTT was a multisite prospective observational study of severely injured transfused trauma patients. The clinical sites collected real-time information on the timing and amounts of blood product infusions as well as colloids and crystalloids, vital signs, initial diagnostic and clinical laboratory tests, life saving interventions and other clinical care data. Between July 2009 and October 2010, PROMMTT screened 12,561 trauma admissions and enrolled 1245 patients who received one or more blood transfusions within 6h of Emergency Department (ED) admission. A total of 297 massive transfusions were observed over the course of the study at a combined rate of 5.0 massive transfusion patients/week. PROMMTT is the first multisite study to collect real-time prospective data on trauma patients requiring transfusion. Support from the Department of Defense and collaborative expertise from the ten participating centers helped to demonstrate the feasibility of prospective trauma transfusion studies. The observational data collected from this study will be an invaluable resource for research in trauma surgery and it will guide the design and conduct of future randomized trials. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Measuring the Quality of Care for Psychological Health Conditions in the Military Health System: Candidate Quality Measures for Posttraumatic Stress Disorder and Major Depressive Disorder

DTIC Science & Technology

2015-01-01

therapy CDC Centers for Disease Control and Prevention CESD Center for Epidemiologic Studies Depression Scale CGI-BP Clinical Global Impressions Scale for...dimensions GDS Geriatric Depression Scale HEDIS Healthcare Effectiveness Data and Information Set HOS Health Outcomes Survey HRQOL health-related quality of...TBI traumatic brain injury TF-CBT Trauma-Focused Cognitive–Behavioral Therapy TSC-40 Trauma Symptom Checklist—40 TSI Trauma Symptom Inventory VA U.S

Effect of American College of Surgeons Trauma Center Designation on Outcomes: Measurable Benefit at the Extremes of Age and Injury.

PubMed

Grossman, Michael D; Yelon, Jay A; Szydiak, Lisa

2017-08-01

American College of Surgeons (ACS) verification is believed to provide benefits for trauma patients, but is associated with direct costs. We performed a 1-year retrospective review of the National Trauma Data Bank (NTDB) for 2012. Patients were separated into 3 age groups; Pediatric (PEDS), 0 to 14 years; adult, 15 to 65 years; and elderly (ELD), older than 65 years. We analyzed 2 injury severity cohorts, Injury Severity Score (ISS) 9 to 74 (ALL) and ISS 25 to 74 (MAJ). Multiple logistic regression to determine significance of ACS verification on mortality and major complications, controlling for age, ISS, shock, Glasgow Coma Scale, sex, age, comorbidities, and mechanism. Patients were excluded with an ISS <8 or equal to 75, dead on arrival, emergency department transfers, and burns. There were 392,997 patients: 262,644 in ACS centers and 130,353 in non-ACS centers. Distribution was: PEDS 3.8%, adults 64.5%, ELD 31.7%. For ALL adults, no differences were observed for primary outcome in ACS vs non-ACS centers (p = 0.128 and 0.061, for mortality and complications, respectively). For ALL PEDS and ELD, complications were more likely in non-ACS centers: (p = 0.003, odds ratio [OR] 2.61 [95% CI 1.36 to 5.0], and p < 0.0001, OR 3.17 [95% CI 2.21 to 4.56]). For MAJ trauma, death was more likely in adults in ACS vs non-ACS centers (p = 0.013, OR 0.82 [95% CI 0.71 to 0.96]). Complications for MAJ trauma were more likely in all age groups in non-ACS centers (adult: p = 0.028, OR 1.48 [95% CI 1.04 to 2.1]; ELD: p < 0.0001, OR 2.49 [95% CI 1.7 to 3.7]; PEDS: p < 0.0001, OR 4.29 [95% CI 2.13 to 8.69]). Length of stay was increased for all patients with complications (p < 0.0001). Measurable benefits in complications were observed in all age groups with MAJ trauma and in PEDS and ELD for ALL injury severity in ACS vs non-ACS trauma centers. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Positive and negative volume-outcome relationships in the geriatric trauma population.

PubMed

Matsushima, Kazuhide; Schaefer, Eric W; Won, Eugene J; Armen, Scott B; Indeck, Matthew C; Soybel, David I

2014-04-01

In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. In-hospital mortality, major complications, and mortality after major complications (failure to rescue). Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

Assessment of traumatic deaths in a level one trauma center in Ankara, Turkey.

PubMed

Arslan, E D; Kaya, E; Sonmez, M; Kavalci, C; Solakoglu, A; Yilmaz, F; Durdu, T; Karakilic, E

2015-06-01

Trauma management shows significant progress in last decades. Determining the time and place of deaths indicate where to focus to improve our knowledge about trauma. We conducted this retrospective study from data of trauma victims who were brought to a major tertiary hospital which is a level one trauma center in Ankara, Turkey, and died even if during transport or in the hospital between 1 March 2010 and 1 March 2013. The patients' demographic characteristics, trauma mechanisms, time frames and causes of deaths determined by physicians were recorded. Traumas were grouped as "high energy trauma" (HET) and "low energy trauma" (LET). Falls from ground level were defined as LET. 209 traumatic deaths due to trauma or trauma-related conditions were found in the study period. 161 of 209 (78 %) patients suffered from HET. Motor vehicle collisions (MVC) (56 %) were the most common mechanism of trauma followed by burns (16 %), falls (11 %), gunshots (9 %) and stabs (6 %) in this group and traumatic brain injuries (TBI) (41 %) were the most common cause of death followed by circulatory collapse (22 %) and multi-organ failure (20 %). 36 % of deaths occurred before arrival at hospital, 25 % in the first 24 h of admission, 18 % between 2nd and 7th day and 21 % after first week. Trimodal distribution of traumatic deaths was not valid for all types of injuries and the most important factor to decrease traumatic deaths is still prevention. Also we have to keep on searching to improve our knowledge about trauma management.

Influence of podiatry on orthopedic surgery at a level I trauma center.

PubMed

Jakoi, Andre M; Old, Andrew B; O'Neill, Craig A; Stein, Benjamin E; Stander, Eric P; Rosenblatt, Joseph; Herman, Martin J

2014-06-01

Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patient's emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery department's consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent. Copyright 2014, SLACK Incorporated.

Empirically derived lifespan polytraumatization typologies: A systematic review.

PubMed

Contractor, Ateka A; Caldas, Stephanie; Fletcher, Shelley; Shea, M Tracie; Armour, Cherie

2018-07-01

Polytraumatization classes based on trauma endorsement patterns relate to distinct clinical outcomes. Person-centered approaches robustly evaluate the nature, and construct validity of polytraumatization classes. Our review examined evidence for the nature and construct validity of lifespan polytraumatization typologies. In September 2016, we searched Pubmed, PSYCINFO, PSYC ARTICLES, Academic Search Complete, PILPTS, Web of Science, CINAHL, Medline, PsycEXTRA, and PBSC. Search terms included "latent profile," "latent class," "latent analysis," "person-centered," "polytrauma," "polyvictimization," "traumatization," "lifetime," "cooccurring," "complex," "typology," "multidimensional," "sequential," "multiple," "subtype," "(re)victimization," "cumulative," "maltreatment," "abuse," and "stressor." Inclusionary criteria included: peer-reviewed; latent class/latent profile analyses (LCA/LPA) of lifespan polytrauma classes; adult samples of size greater than 200; only trauma types as LCA/LPA indicators; mental health correlates of typologies; and individual-level trauma assessment. Of 1,397 articles, nine met inclusion criteria. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, research assistants completed a secondary reference search, and independently extracted data with standardized coding forms. Three-class (n = 5) or four-class (n = 4) solutions were found. Seven studies found a class characterized by higher trauma endorsement (high-trauma). All studies found a class characterized by lower trauma endorsement (low-trauma), and predominance of specific traumas (specific-trauma; e.g., childhood maltreatment). High-trauma versus low-trauma classes and specific-trauma versus low-trauma classes differed on mental health correlates. Evidence supports the prevalence of a high-trauma class experiencing poorer mental health, and the detrimental impact of aggregated interpersonal and other traumas. We highlight the clinical importance of addressing polytraumatization classes, and comprehensively assessing the impact of all traumas. © 2018 Wiley Periodicals, Inc.

American College of Surgeons Level I trauma centers outcomes do not correlate with patients' perception of hospital experience.

PubMed

Joseph, Bellal; Azim, Asad; O'Keeffe, Terence; Ibraheem, Kareem; Kulvatunyou, Narong; Tang, Andrew; Vercruysse, Gary; Friese, Randall; Latifi, Rifat; Rhee, Peter

2017-04-01

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a data collection methodology for measuring a patient's perception of his/her hospital experience, and it has been selected by the Centers of Medicare and Medicaid Services as the validated and transparent national survey tool with publicly available results. Since 2012, hospital reimbursements rates have been linked to HCAHPS data based on patient satisfaction scores. The aim of this study was, therefore, to assess whether HCAHPS scores of Level I trauma centers correlate with actual hospital performance. Retrospective analysis of the latest publicly available HCAHPS data (2014-2015) was performed. American College of Surgeons (ACS) verified Level I trauma centers for each state were identified from the ACS registry and then the following data points were collected for each hospital: HCAHPS linear mean scores regarding cleanliness of the hospital, doctor and nurse communication with the patient, staff responsiveness, pain management, overall hospital rating, and patient willingness to recommend the hospital. Our outcome measure were serious complication scores, failure-to-rescue (FTR) scores and readmission-after-discharge scores. Spearman correlation analysis was performed. A total of 119 ACS verified Level I trauma centers across 46 states were included. The median [IQR] overall hospital rating score for Level I trauma centers was 89 (87-90). The mean ± SD score for serious complication was 0.96 ± 0.266, FTR was 123.06 ± 22.5, and readmission after discharge was 15.71 ± 1.07. The Spearman correlation analysis showed that overall HCAHP-based hospital rating scores did not correlate with serious complications (correlation coefficient = 0.14 p = 0.125), FTR (correlation coefficient = -0.15 p = 0.073), or readmission after discharge (correlation coefficient = -0.18 p = 0.053). The findings of our study suggest that no correlation exists between HCAHPS patient satisfaction scores and hospital performance for Level I trauma centers. Consequently, the Centers of Medicare and Medicaid Services should reconsider hospital reimbursement decisions based on HCAHP patient satisfaction scores. Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Better trauma care. How Maryland does it.

PubMed

Wish, John R; Long, William B; Edlich, Richard F

2005-01-01

In March, 1970, the Maryland State Police, in cooperation with the University of Maryland, started the first statewide airborne transportation system. It was modeled after the army's success in Korea and Vietnam, where battlefield injuries were flown to front-line MASH units. The world's premier statewide medical aviation division was made possible through a cooperative effort between the Maryland State Police Aviation Division and Dr. R Adams Cowley at the University of Maryland Hospital as a public service to the citizens of the state. The Maryland Institute for Emergency Medical Services Systems (MIEMSS) has five components: (1) aircraft, (2) state troopers, (3) system communications (SYSCOM) center, (4) ambulance and fire emergency rescue, and (5) Level I adult and pediatric trauma centers and a regional burn center. The Maryland State Police Aviation Division now has 12 Aerospace Dauphin AS365N helicopters that operate out of eight fixed points throughout the state. Each helicopter has a two-person crew that consists of a pilot and a paramedic. Since 1993, the overall coordination of emergency medical services (EMS) has been under the purview of MIEMSS, an independent executive-level state agency that is governed by an appointed board and advisory council. To ensure stable funding for Maryland's world renowned emergency medical services (EMS) system, including med-evac helicopters, ambulances, fire equipment, rescue squads, and trauma units, a "surcharge" of $13.50 per year is collected with the automobile registration fee where applicable. The SYSCOM center in Baltimore coordinates the helicopter transport to the scene of the accident as well as referral to the specialty care facility: Adult Level I Trauma Center, Pediatric Level I Trauma Center, and Regional Burn Center. An on-the-scene evaluation of this exemplary emergency medical system in Maryland provides further convincing evidence of the performance of the Maryland State Police Aviation Division as they transported an injured child to the Johns Hopkins Pediatric Level I Trauma Center. It is our belief that the model emergency medical system in Maryland, if replicated throughout our nation, would save the lives of the critically injured.

Trauma triage in the emergency departments of nontrauma centers: an analysis of individual physician caseload on triage patterns.

PubMed

Mohan, Deepika; Barnato, Amber E; Rosengart, Matthew R; Farris, Coreen; Yealy, Donald M; Switzer, Galen E; Fischhoff, Baruch; Saul, Melissa; Angus, Derek C

2013-06-01

Treatment at Level I/II trauma centers improves outcomes for patients with severe injuries. Little is known about the role of physicians' clinical judgment in triage at outlying hospitals. We assessed the association between physician caseload, case mix, and the triage of trauma patients presenting to nontrauma centers. A retrospective cohort analysis of patients evaluated between January 1, 2007, and December 31, 2010, by emergency physicians working in eight community hospitals in western Pennsylvania. We linked billing records to hospital charts, summarized physicians' caseloads, and calculated rates of undertriage (proportion of patients with moderate-to-severe injuries not transferred to a trauma center), and overtriage (proportion of patients transferred with a minor injury). We measured the correlation between physician characteristics, caseload, and rates of triage. Of 50 eligible physicians, 29 (58%) participated in the study. Physicians had a mean (SD) of 16.8 (10.1) years of postresidency clinical experience; 21 (72%) were board certified in emergency medicine. They evaluated a median of 2,423 patients per year, of whom 148 (6%) were trauma patients and 3 (0.1%) had moderate-to-severe injuries. The median undertriage rate was 80%; the median overtriage rate was 91%. Physicians' caseload of patients with moderate-to-severe injuries was inversely associated with rates of undertriage (correlation coefficient, -0.42; p = 0.03). Compared with physicians in the lowest quartile, those in the highest quartile undertriaged 31% fewer patients. Emergency physicians working in nontrauma centers rarely encounter patients with moderate-to-severe injuries. Caseload was strongly associated with compliance with American College of Surgeons' Committee on Trauma guidelines. Therapeutic/care management, level IV.

Importance of designated thoracic trauma surgeons in the management of traumatic aortic transection.

PubMed

Albrink, M H; Rodriguez, E; England, G J; McKeown, P P; Hurst, J M; Rosemurgy, A S

1994-04-01

The medical literature is replete with reports on traumatic aortic transection. These reports have delineated many factors regarding the morbidity and high mortality of this ominous injury. Most reports are reviews of the collective experience of a single institution over a period of years. It is likely that many authors writing on the subject of traumatic aortic transection have no experience with operative repair of the lesion. There has been debate about the various techniques of primary repair versus graft insertion, as well as the question of whether cardiopulmonary bypass is superior to the "clamp and sew" methods. No studies have directly examined the skills of individual surgeons with respect to outcome. We present the results of a study from a university-affiliated level I trauma center in which the outcomes from various groups of surgeons were compared over a 5-year period. The information in this study strongly suggests that designated thoracic trauma surgeons who are promptly available and have dedicated interests in trauma patients achieve better results.

Perioperative and acute care outcomes in morbidly obese patients with acetabular fractures at a Level 1 trauma center

PubMed Central

Vincent, Heather K.; Haupt, Edward; Tang, Sonya; Egwuatu, Adaeze; Vlasak, Richard; Horodyski, MaryBeth; Carden, Donna; Sadisivan, Kalia K.

2014-01-01

Background Controversy exists regarding obesity-related injury severity and clinical outcomes after orthopedic trauma. Purpose The purposes of this study were to expand our understanding of the effect of morbid obesity on perioperative and acute care outcomes after acetabular fracture. Methods This was a retrospective review of patients with acetabular fracture after trauma. Non-morbidly obese (BMI < 35 kg/m2) and morbidly obese (BMI ≥ 35 kg/m2; N = 81). Injury severity scores and Glasgow Coma Scale scores (GCS) were collected. Perioperative and acute care outcomes were positioning and operative time, extra fractures, estimated blood loss, complications, hospital charges, ventilator days, transfusions, length of stay (LOS) and discharge destination. Positioning and operative times were longer in morbidly obese patients (p < 0.05). No other differences existed between groups. Conclusions Orthopedic trauma surgeons and care teams can expect similar acute care outcomes in morbidly obese and non-morbidly obese patients with acetabular fracture. PMID:25104886

Primary repair for pediatric colonic injury: Are there differences among adult and pediatric trauma centers?

PubMed

Khan, Muhammad; Jehan, Faisal; O'Keeffe, Terence; Pandit, Viraj; Kulvatunyou, Narong; Tang, Andrew; Gries, Lynn; Joseph, Bellal

2017-12-01

Management of colonic injuries (colostomy [CO] versus primary anastomosis [PA]) among pediatric patients remains controversial. The aim of this study was to assess outcomes in pediatric trauma patient with colonic injury undergoing operative intervention. The National Trauma Data Bank (2011-2012) was queried including patients with isolated colonic injury undergoing exploratory laparotomy with PA or CO with age ≤18 y. Missing value analysis was performed. Patients were stratified into two groups: PA and CO. Outcome measures were mortality, in-hospital complications, and hospital length of stay. Multivariate regression analysis was performed. A total of 1151 patients included. Mean ± standard deviation age was 11.61 ± 2.8 y, and median [IQR] Injury Severity Score was 12 [8-16]; 39% (n = 449) of the patients had CO, and 35.6% (n = 410) were managed in pediatric trauma centers (PC). Patients with CO had a higher Injury Severity Score (P < 0.001), a trend toward lower blood pressure (P = 0.40), and an older age (P < 0.001). There was no difference in mortality between the PA and CO groups. However, patients who underwent PA had a shorter length of stay (P < 0.001) and lower in-hospital complications (P < 0.001). A subanalysis shows that, after controlling for all confounding factors, patients managed in PC were 1.2 times (1.2 [1.1-2.1], P = 0.04) more likely to receive a CO than those patients managed in adult trauma centers (AC). Moreover, there was no difference in mortality between the AC and the PC (P = 0.79). Our data demonstrate no difference in mortality in pediatric trauma patients with colonic injury who undergo primary repair or CO. However, adult trauma centers had lower rates of CO performed as compared to a similar cohort of patients managed in pediatric trauma centers. Further assessment of the reasons underlying such differences will help improve patient outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Teen trauma without the drama: outcomes of adolescents treated at Ohio adult versus pediatric trauma centers.

PubMed

Walther, Ashley E; Pritts, Timothy A; Falcone, Richard A; Hanseman, Dennis J; Robinson, Bryce R H

2014-07-01

The optimal treatment facility for adolescent trauma patients is controversial. We sought to investigate risk-adjusted outcomes of adolescents treated at adult-only trauma centers (ATCs) versus pediatric-only trauma centers (PTCs) in a state system with legislated American College of Surgeons-verified institutions to determine ideal prehospital referral patterns. The Ohio Trauma Registry was queried for patients 15 years to 19 years with a length of stay (LOS) greater than 1 day at ATC (Level 1) or PTC (Levels 1 and 2) from 2008 to 2012. Race, sex, emergency department vital signs, Injury Severity Score (ISS), computed tomography, and ultrasound imaging were reviewed. Outcomes by mechanism of injury included ventilator days, intensive care unit LOS, hospital LOS, and mortality. Statistical analysis was performed using χ test, t test, and Wilcoxon rank-sum test. Propensity score-based risk adjustment matching was used to compare groups (propensity score within 0.01, ISS within 5). Of 5,793 adolescents examined, (84% blunt, 16% penetrating) 66% were treated at an ATC. In unmatched comparisons, age, ISS, vital signs, and mortality differed significantly between centers (p < 0.01). For adolescents with blunt injury, more males (71.6% vs. 66.3%, p < 0.01) and nonwhites (19.2% vs. 15.8%, p < 0.01) were seen at PTCs. For penetrating trauma, more males (88.6% vs. 50.8%, p < 0.01) and nonwhites (66.4% vs. 34.3%, p < 0.01) were admitted to ATCs. In 873 propensity-matched pairs for blunt trauma and 95 propensity-matched pairs of penetrating injuries, no differences were seen in a priori outcomes. Imaging (blunt, head computed tomography and abdominal ultrasound, p < 0.01; penetrating, abdominal ultrasound, p = 0.02) was more common at ATCs. Major outcome differences for injured adolescents do not exist between ATCs and PTCs, regardless of injury pattern. Imaging remains more prevalent at ATCs. In a state system with mandatory American College of Surgeons-verified centers, injury patterns need not dictate triage decisions for adolescents. Epidemiologic study, level III.

A Two-Center Validation of "Patient Does Not Follow Commands" and Three Other Simplified Measures to Replace the Glasgow Coma Scale for Field Trauma Triage.

PubMed

Hopkins, Emily; Green, Steven M; Kiemeney, Michael; Haukoos, Jason S

2018-05-02

Out-of-hospital personnel worldwide calculate the 13-point Glasgow Coma Scale (GCS) score as a routine part of field trauma triage. We wish to independently validate a simpler binary assessment to replace the GCS for this task. We analyzed trauma center registries from Loma Linda University Health (2003 to 2015) and Denver Health Medical Center (2009 to 2015) to compare the binary assessment "patient does not follow commands" (ie, GCS motor score <6) with GCS score less than or equal to 13 for the prediction of 5 trauma outcomes: emergency intubation, clinically significant brain injury, need for neurosurgical intervention, Injury Severity Score greater than 15, and mortality. As a secondary analysis, we similarly evaluated 3 other measures simpler than the GCS: GCS motor score less than 5, Simplified Motor Score, and the "alert, voice, pain, unresponsive" scale. In this analysis of 47,973 trauma patients, we found that the binary assessment "patient does not follow commands" was essentially identical to GCS score less than or equal to 13 for the prediction of all 5 trauma outcomes, with slightly superior positive likelihood ratios (eg, those for mortality 2.37 versus 2.13) offsetting slightly inferior negative ones (eg, those for mortality 0.25 versus 0.24) and its graphic depiction of sensitivity versus specificity superimposing the GCS prediction curve. We found similar results for the 3 other simplified measures. In this 2-center external validation, we confirmed that a simple binary assessment-"patient does not follow commands"-could effectively replace the more complicated GCS for field trauma triage. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Opinions of Practicing Surgeons on the Appropriateness of Published Indications for Use of Damage Control Surgery in Trauma Patients: An International Cross-Sectional Survey.

PubMed

Roberts, Derek J; Zygun, David A; Faris, Peter D; Ball, Chad G; Kirkpatrick, Andrew W; Stelfox, Henry T

2016-09-01

Variation in use of damage control (DC) surgery across trauma centers may be partially driven by surgeon uncertainty as to when it is appropriately indicated. We sought to determine opinions of practicing surgeons on the appropriateness of published indications for trauma DC surgery. We asked 384 trauma centers in the United States, Canada, and Australasia to nominate 1 to 3 surgeons at their center to participate in a survey about DC surgery. We then asked nominated surgeons their opinions on the appropriateness (benefit-to-harm ratio) of 43 literature-derived indications for use of DC surgery in adult civilian trauma patients. In total, 232 (64.8%) trauma centers nominated 366 surgeons, of whom 201 (56.0%) responded. Respondents rated 15 (78.9%) preoperative and 23 (95.8%) intraoperative indications to be appropriate. Indications respondents agreed had the greatest expected benefit included a temperature <34°C, arterial pH <7.2, and laboratory-confirmed (international normalized ratio/prothrombin time and/or partial thromboplastin time >1.5 times normal) or clinically observed coagulopathy in the pre- or intraoperative setting; administration of >10 units of packed red blood cells; requirement for a resuscitative thoracotomy in the emergency department; and identification of a juxtahepatic venous injury or devascularized or destroyed pancreas, duodenum, or pancreaticoduodenal complex during operation. Ratings were consistent across subgroups of surgeons with different training, experience, and practice settings. We identified 38 indications that practicing surgeons agreed appropriately justified the use of DC surgery. Until further studies become available, these indications constitute a consensus opinion that can be used to guide practice in the current era of changing trauma resuscitation practices. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Evaluation of SOCOM Wireless Monitor in Trauma Patients

DTIC Science & Technology

2015-02-01

DOD Award W81XWH-11-2-0098 page 7 Do all trauma patients benefit from tranexamic acid ? J Trauma Acute Care Surg 2014...2015 11) Valle EJ, Allen CJ, Van Haren RM, Jouria JM, Li H, Livingstone AS, Proctor KG: Tranexamic acid may have undesirable actions in some trauma...Livingstone AS, Proctor KG: Do all patients benefit from tranexamic acid ? The experience of an urban level 1 trauma center. Presented at 72nd Annual

Operating room efficiency: benefits of an orthopaedic traumatologist at a level II trauma center.

PubMed

Althausen, Peter L; Kauk, Justin R; Shannon, Steven; Lu, Minggen; O'Mara, Timothy J; Bray, Timothy J

2014-05-01

Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center. Retrospective review. Level II community-based trauma hospital. Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011. Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons. Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods. A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P < 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001). This study demonstrates that in our community-based trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operating Room Efficiency: Benefits of an Orthopaedic Traumatologist at a Level II Trauma Center.

PubMed

Althausen, Peter L; Kauk, Justin R; Shannon, Steven; Lu, Minggen; O'Mara, Timothy J; Bray, Timothy J

2016-12-01

Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center. Retrospective review. Level II community-based trauma hospital. Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011. Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons. Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods. A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P , 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001). This study demonstrates that in our communitybased trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Burnout, Perceived Stress, and Job Satisfaction Among Trauma Nurses at a Level I Safety-Net Trauma Center.

PubMed

Munnangi, Swapna; Dupiton, Lynore; Boutin, Anthony; Angus, L D George

Nurses are at the forefront of our health care delivery system and have been reported to exhibit a high level of burnout. Burnout and stress in trauma nurses at a safety-net hospital can negatively impact patient care. Safety-net hospitals are confronted with unique social, financial, as well as resource problems that can potentially make the work environment frustrating. The purpose of this study was to explore the levels of burnout, stress, and job satisfaction in nurses providing care to trauma patients at a Level I safety-net trauma center. A cross-sectional survey design was used to investigate principal factors including personal and professional demographics, burnout, perceived stress, and job satisfaction. Trauma nurses working at a Level I safety-net trauma center are stressed and exhibited moderate degree of burnout. The extent of emotional exhaustion experienced by the nurses varied with work location and was highest in surgical intensive care unit nurses. The level of job satisfaction in terms of opportunities for promotion differed significantly by race and the health status of the nurses. Satisfaction with coworkers was lowest in those nurses between the ages of 60-69 years. Female nurses were more satisfied with their coworkers than male nurses. In addition, the study revealed that significant relationships exist among perceived stress, burnout, and job satisfaction. Work environment significantly impacts burnout, job satisfaction, and perceived stress experienced by trauma nurses in a safety-net hospital. Nursing administration can make an effort to understand the levels of burnout and strategically improve work environment for trauma nurses in order to minimize stressors leading to attrition and enhance job satisfaction.

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa.

PubMed

Chowdhury, Sharfuddin; Nicol, Andrew John; Moydien, Mahammed Riyaad; Navsaria, Pradeep Harkison; Montoya-Pelaez, Luis Felipe

2018-01-01

The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death. Prospective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications. One-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35-60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications ( p  = 0.074). Surgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.

Helicopter overtriage in pediatric trauma.

PubMed

Michailidou, Maria; Goldstein, Seth D; Salazar, Jose; Aboagye, Jonathan; Stewart, Dylan; Efron, David; Abdullah, Fizan; Haut, Elliot R

2014-11-01

Helicopter Emergency Medical Services (HEMS) have been designed to provide faster access to trauma center care in cases of life-threatening injury. However, the ideal recipient population is not fully characterized, and indications for helicopter transport in pediatric trauma vary dramatically by county, state, and region. Overtriage, or unnecessary utilization, can lead to additional patient risk and expense. In this study we perform a nationwide descriptive analysis of HEMS for pediatric trauma and assess the incidence of overtriage in this group. We reviewed records from the American College of Surgeons National Trauma Data Bank (2008-11) and included patients less than 16 years of age who were transferred from the scene of injury to a trauma center via HEMS. Overtriage was defined as patients meeting all of the following criteria: Glasgow Coma Scale (GCS) equal to 15, absence of hypotension, an Injury Severity Score (ISS) less than 9, no need for procedure or critical care, and a hospital length of stay of less than 24 hours. A total of 19,725 patients were identified with a mean age of 10.5 years. The majority of injuries were blunt (95.6%) and resulted from motor vehicle crashes (48%) and falls (15%). HEMS transported patients were predominately normotensive (96%), had a GCS of 15 (67%), and presented with minor injuries (ISS<9, 41%). Overall, 28 % of patients stayed in the hospital for less than 24 hours, and the incidence of overtriage was 17%. Helicopter overtriage is prevalent among pediatric trauma patients nationwide. The ideal model to predict need for HEMS must consider clinical outcomes in the context of judicious resource utilization. The development of guidelines for HEMS use in pediatric trauma could potentially limit unnecessary transfers while still identifying children who require trauma center care in a timely fashion. Copyright © 2014. Published by Elsevier Inc.

Same Abbreviated Injury Scale Values May Be Associated with Different Risks to Mortality in Trauma Patients: A Cross-Sectional Retrospective Study Based on the Trauma Registry System in a Level I Trauma Center.

PubMed

Rau, Cheng-Shyuan; Wu, Shao-Chun; Kuo, Pao-Jen; Chen, Yi-Chun; Chien, Peng-Chen; Hsieh, Hsiao-Yun; Hsieh, Ching-Hua

2017-12-11

The Abbreviated Injury Scale (AIS) measures injury severity of a trauma patient with a numeric method for ranking anatomy-based specific injuries. The summation of the squares of the three most severe injuries in the AIS of six predefined body regions comprises the Injury Severity Score (ISS). It assumes that the mortality of a given AIS value is similar across all body regions. However, such an assumption is less explored in the literature. In this study, we aimed to compare the mortality rates of the patients with the same AIS value in different injured body regions in a level I trauma center. Hospitalized adult trauma patients with isolated serious to critical injury (AIS of 3 to 5) between 1 January 2009, and 31 December 2016, from the Trauma Registry System in a level I trauma center were grouped according to the injured body regions (including, the head/neck, thorax, abdomen, or extremities) and were exclusively compared according to their AIS stratum. Categorical data were compared using the two-sided Fisher exact or Pearson chi-square tests. ANOVA with Games-Howell post hoc test was performed to assess the differences in continuous data of the patients with injury in different body regions. The primary outcome of the study was in-hospital mortality. The adjusted odds ratios (AORs) were estimated using a stepwise selection of a multivariable regression model adjusted by controlling the confounding variables such as sex, age, comorbidities, and ISS. Survival curves were estimated with the Kaplan-Meier approach with a corresponding log-rank test. The patients with AIS of 5 for abdomen injury and those with AIS of 3 for extremity injury had a significantly lower odds of adjusted mortality (adjusted odds ratio (AOR) 0.1, 95% confidence interval (CI) 0.01-0.39, p = 0.004 and AOR 0.3, 95% CI 0.15-0.51, p < 0.001, respectively) than that of the patients with head/neck injury. However, the patients with AIS of 4 for extremity injury demonstrated significantly higher odds of adjusted mortality (AOR 8.4, 95% CI 2.84-25.07, p < 0.001) than the patients with head/neck injury. This study found that the risks to mortality in the patients with a given AIS value of serious to critical injury in different injured body regions were not the same, even after controlling for confounding variables such as sex, age, comorbidities, and ISS.

Same Abbreviated Injury Scale Values May Be Associated with Different Risks to Mortality in Trauma Patients: A Cross-Sectional Retrospective Study Based on the Trauma Registry System in a Level I Trauma Center

PubMed Central

Rau, Cheng-Shyuan; Wu, Shao-Chun; Kuo, Pao-Jen; Chen, Yi-Chun; Chien, Peng-Chen; Hsieh, Hsiao-Yun

2017-01-01

The Abbreviated Injury Scale (AIS) measures injury severity of a trauma patient with a numeric method for ranking anatomy-based specific injuries. The summation of the squares of the three most severe injuries in the AIS of six predefined body regions comprises the Injury Severity Score (ISS). It assumes that the mortality of a given AIS value is similar across all body regions. However, such an assumption is less explored in the literature. In this study, we aimed to compare the mortality rates of the patients with the same AIS value in different injured body regions in a level I trauma center. Hospitalized adult trauma patients with isolated serious to critical injury (AIS of 3 to 5) between 1 January 2009, and 31 December 2016, from the Trauma Registry System in a level I trauma center were grouped according to the injured body regions (including, the head/neck, thorax, abdomen, or extremities) and were exclusively compared according to their AIS stratum. Categorical data were compared using the two-sided Fisher exact or Pearson chi-square tests. ANOVA with Games-Howell post hoc test was performed to assess the differences in continuous data of the patients with injury in different body regions. The primary outcome of the study was in-hospital mortality. The adjusted odds ratios (AORs) were estimated using a stepwise selection of a multivariable regression model adjusted by controlling the confounding variables such as sex, age, comorbidities, and ISS. Survival curves were estimated with the Kaplan–Meier approach with a corresponding log-rank test. The patients with AIS of 5 for abdomen injury and those with AIS of 3 for extremity injury had a significantly lower odds of adjusted mortality (adjusted odds ratio (AOR) 0.1, 95% confidence interval (CI) 0.01–0.39, p = 0.004 and AOR 0.3, 95% CI 0.15–0.51, p < 0.001, respectively) than that of the patients with head/neck injury. However, the patients with AIS of 4 for extremity injury demonstrated significantly higher odds of adjusted mortality (AOR 8.4, 95% CI 2.84–25.07, p < 0.001) than the patients with head/neck injury. This study found that the risks to mortality in the patients with a given AIS value of serious to critical injury in different injured body regions were not the same, even after controlling for confounding variables such as sex, age, comorbidities, and ISS. PMID:29232883

[Benchmarking of university trauma centers in Germany. Research and teaching].

PubMed

Gebhard, F; Raschke, M; Ruchholtz, S; Meffert, R; Marzi, I; Pohlemann, T; Südkamp, N; Josten, C; Zwipp, H

2011-07-01

Benchmarking is a very popular business process and meanwhile is used in research as well. The aim of the present study is to elucidate key numbers of German university trauma departments regarding research and teaching. The data set is based upon the monthly reports given by the administration in each university. As a result the study shows that only well-known parameters such as fund-raising and impact factors can be used to benchmark university-based trauma centers. The German federal system does not allow a nationwide benchmarking.

Saint Louis Center for Sustainment of Trauma and Readiness Skills: A Collaborative Air Force-Civilian Trauma Skills Training Program

DTIC Science & Technology

2016-05-19

NUMBER 6. AUTHOR(S) Jason W. Grimm , Karen Johnson 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION...ABSTRACT SAR 18. NUMBER OF PAGES 5 19a. NAME OF RESPONSIBLE PERSON Jason Grimm a. REPORT U b. ABSTRACT U c. THIS PAGE U 19b... Grimm Karen Johns For correspo Vista at Gra J Emerg Nu 0099-1767 Published b http://dx.do ■ ■ • ■SAINT LOUIS CENTER FOR SUSTAINMENT OF TRAUMA AND

Artificial Intelligence Can Predict Daily Trauma Volume and Average Acuity.

PubMed

Stonko, David P; Dennis, Bradley M; Betzold, Richard D; Peetz, Allan B; Gunter, Oliver L; Guillamondegui, Oscar D

2018-04-19

The goal of this study was to integrate temporal and weather data in order to create an artificial neural network (ANN) to predict trauma volume, the number of emergent operative cases, and average daily acuity at a level 1 trauma center. Trauma admission data from TRACS and weather data from the National Oceanic and Atmospheric Administration (NOAA) was collected for all adult trauma patients from July 2013-June 2016. The ANN was constructed using temporal (time, day of week), and weather factors (daily high, active precipitation) to predict four points of daily trauma activity: number of traumas, number of penetrating traumas, average ISS, and number of immediate OR cases per day. We trained a two-layer feed-forward network with 10 sigmoid hidden neurons via the Levenberg-Marquardt backpropagation algorithm, and performed k-fold cross validation and accuracy calculations on 100 randomly generated partitions. 10,612 patients over 1,096 days were identified. The ANN accurately predicted the daily trauma distribution in terms of number of traumas, number of penetrating traumas, number of OR cases, and average daily ISS (combined training correlation coefficient r = 0.9018+/-0.002; validation r = 0.8899+/- 0.005; testing r = 0.8940+/-0.006). We were able to successfully predict trauma and emergent operative volume, and acuity using an ANN by integrating local weather and trauma admission data from a level 1 center. As an example, for June 30, 2016, it predicted 9.93 traumas (actual: 10), and a mean ISS score of 15.99 (actual: 13.12); see figure 3. This may prove useful for predicting trauma needs across the system and hospital administration when allocating limited resources. Level III STUDY TYPE: Prognostic/Epidemiological.

A comparative cost analysis of polytrauma and neurosurgery Intensive Care Units at an apex trauma care facility in India

PubMed Central

Kumar, Parmeshwar; Jithesh, V.; Gupta, Shakti Kumar

2016-01-01

Context: Although Intensive Care Units (ICUs) only account for 10% of the hospital beds, they consume nearly 22% of the hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. Aim: The aim of this study was to evaluate and compare the cost of intensive care delivery between multispecialty and neurosurgery ICUs at an apex trauma care facility in India. Materials and Methods: The study was conducted in a polytrauma and neurosurgery ICU at a 203-bedded Level IV trauma care facility in New Delhi, India, from May 1, 2012 to June 30, 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in the study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Statistical Analysis: Statistical analysis was performed by Fisher's two tailed t-test. Results: Total cost/bed/day for the multispecialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU, it was Rs. 14,306.7/-, workforce constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Conclusions: Quantification of expenditure in running an ICU in a trauma center would assist health-care decision makers in better allocation of resources. Although multispecialty ICUs are more cost-effective, other factors will also play a role in defining the kind of ICU that needs to be designed. PMID:27555693

Ocular injuries from fireworks: the 11-year experience of a US level I trauma center.

PubMed

Chang, I T; Prendes, M A; Tarbet, K J; Amadi, A J; Chang, S-H; Shaftel, S S

2016-10-01

PurposeCharacterize ocular trauma and visual outcomes from firework injuries at a level I trauma center.MethodsRetrospective review of all firework injuries at Harborview Medical Center between 2003 and 2013.ResultsThree hundred and twenty-seven patients sustained firework injuries, of which 100 (31%) sustained ocular injuries. The average age of all patients who sustained fireworks injuries was 24.2 years, 89% were male and 54% of injuries occurred within 48 h of 4 July. Ocular injuries were most commonly caused by mortars (24%) and rockets (22%). Rockets were associated with four times the frequency of ocular injuries as compared with non-ocular injuries (P<0.001). Spectators were more likely to sustain ocular injuries than non-ocular injuries (P=0.001). The most common injuries sustained were corneal abrasions (67%), hyphemas (42%), eyelid injuries (39%), and ruptured globes (17%). Twenty-eight percent of patients with ocular injuries required surgical intervention. Ruptured globes occurred in 17% of patients, with the majority being complex corneoscleral lacerations. Fifty-eight percent of patients who sustained ruptured globes were left with no light perception in the affected eye. Average follow-up was 188 days. Average visual acuity significantly improved from logMAR 1.8±1.6 at presentation to logMAR 1.3±1.8 at last follow-up.ConclusionsFirework-related ocular trauma frequently results in vision-threatening pathology. Prompt referral to and treatment by ophthalmologists is critical. This study documents the dangers inherent in the personal use of fireworks and provides data that may help guide public policy to decrease the frequency of these devastating injuries.

Ocular injuries from fireworks: the 11-year experience of a US level I trauma center

PubMed Central

Chang, I T; Prendes, M A; Tarbet, K J; Amadi, A J; Chang, S-H; Shaftel, S S

2016-01-01

Purpose Characterize ocular trauma and visual outcomes from firework injuries at a level I trauma center. Methods Retrospective review of all firework injuries at Harborview Medical Center between 2003 and 2013. Results Three hundred and twenty-seven patients sustained firework injuries, of which 100 (31%) sustained ocular injuries. The average age of all patients who sustained fireworks injuries was 24.2 years, 89% were male and 54% of injuries occurred within 48 h of 4 July. Ocular injuries were most commonly caused by mortars (24%) and rockets (22%). Rockets were associated with four times the frequency of ocular injuries as compared with non-ocular injuries (P<0.001). Spectators were more likely to sustain ocular injuries than non-ocular injuries (P=0.001). The most common injuries sustained were corneal abrasions (67%), hyphemas (42%), eyelid injuries (39%), and ruptured globes (17%). Twenty-eight percent of patients with ocular injuries required surgical intervention. Ruptured globes occurred in 17% of patients, with the majority being complex corneoscleral lacerations. Fifty-eight percent of patients who sustained ruptured globes were left with no light perception in the affected eye. Average follow-up was 188 days. Average visual acuity significantly improved from logMAR 1.8±1.6 at presentation to logMAR 1.3±1.8 at last follow-up. Conclusions Firework-related ocular trauma frequently results in vision-threatening pathology. Prompt referral to and treatment by ophthalmologists is critical. This study documents the dangers inherent in the personal use of fireworks and provides data that may help guide public policy to decrease the frequency of these devastating injuries. PMID:27285323

A New Normal: Young Men of Color, Trauma, and Engagement in Learning

ERIC Educational Resources Information Center

Van Thompson, Carlyle; Schwartz, Paul J.

2014-01-01

This chapter will center on the continuing impact of systemic and persistent educational trauma experienced by Black and Latino males and how trauma affects their current learning. The young men's counterstories from a phenomenological study and documentary are included.

How the changes in the system affect trauma care provision: The assessment of and implications for Lithuanian trauma service performance in 2007-2012.

PubMed

Dambrauskas, Žilvinas; Aukštakalnis, Vytautas; Karbonskienė, Aurika; Kačiurinas, Dmitrijus; Vokietienė, Jolanta; Lapka, Robertas; Pamerneckas, Algimantas; Porvaneckas, Narūnas; Stašaitis, Kęstutis; Jasinskas, Nedas; Dobožinskas, Paulius; Vaitkaitis, Dinas; Lunevičius, Raimundas

2017-01-01

The aim of this study was to identify and assess the effects of changes in the Lithuanian trauma service from 2007 to 2012. We postulate that the implications derived from this study will be of importance to trauma policy planners and makers in Lithuania and throughout other countries of Eastern and Central Europe. Out of 10,390 trauma admissions to four trauma centers in 2007, 294 patients (2.8%) were randomly selected for the first arm of a representative study sample. Similarly, of 9918 trauma admissions in 2012, 250 (2.5%) were randomly chosen for comparison in the study arm. Only cases with a diagnosis falling into the ICD-10 "S" and "T" codes were included. A survey of whom regarding changes in quality of trauma care from 2007 to 2012 was carried out by emergency medical service (EMS) providers. The Revised Trauma Score (RTS) mean value was 7.45±1.04 for the 2007 year arm; it was 7.53±0.93 for the 2012 year arm (P=0.33). Mean time from the moment of a call from the site of the traumatic event to the patient's arrival at the trauma center did not differ between the arms of the sample: 49.95min in 2007 vs. 51.6min in 2012 (P=0.81). An application of the operational procedures such as a cervical spine protection using a hard collar, oxygen therapy, infusion of intravenous fluids, and pain relief on the trauma scene was more frequent in 2012 than in 2007. Management of trauma patients in the emergency department improved regarding the availability of 24/7 computed tomography scanner facilities and an on-site radiographer. Time to CT-scanning was reduced by 38.8%, and time to decision-making was reduced by 16.5% in 2012. Changes in operational procedures in the Lithuanian pre-hospital care provision and management of trauma patients in emergency departments of trauma centers improved the efficiency of trauma care delivery over the 2007-2012 period. Copyright © 2017 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Sp. z o.o. All rights reserved.

Current status and future options for trauma and emergency surgery in Turkey.

PubMed

Taviloğlu, Korhan; Ertekin, Cemalettin

2008-01-01

The number of trauma victims in Turkey is expected to increase as a consequence of the increasing vehicular traffic, potential for earthquakes, and risk of terrorist attacks. The Turkish Association for Trauma and Emergency Surgery monitors trauma cases, publishes a quarterly journal, organizes trauma courses and seminars for various health personnel nationwide. It is also extending efforts to improve in-hospital care by establishing trauma and emergency surgery fellowships and trauma and emergency surgery centers nationwide, which is run by General Surgeons currently. Turkey faces the same dilemma as the rest of the developed world regarding the future of trauma surgeons in the current era of nonoperative trauma management. We suggest that the field of trauma and emergency surgery be redefined to include emergency general surgery and cavitary trauma.

Comparison of Facial Nerve Paralysis in Adults and Children

PubMed Central

Cha, Chang Il; Hong, Chang Kee; Park, Moon Suh

2008-01-01

Purpose Facial nerve injury can occur in the regions ranging from the cerebral cortex to the motor end plate in the face, and from many causes including trauma, viral infection, and idiopathic factors. Facial nerve paralysis in children, however, may differ from that in adults. We, therefore, evaluated its etiology and recovery rate in children and adults. Materials and Methods We retrospectively evaluated the records of 975 patients, ranging in age from 0 to 88 years, who displayed facial palsy at Kyung Hee Medical Center between January 1986 and July 2005. Results The most frequent causes of facial palsy in adults were Bell's palsy (54.9%), infection (26.8%), trauma (5.9%), iatrogenic (2.0%), and tumors (1.8%), whereas the most frequent causes of facial palsy in children were Bell's palsy (66.2%), infection (14.6%), trauma (13.4%), birth trauma (3.2%), and leukemia (1.3%). Recovery rates in adults were 91.4% for Bell's palsy, 89.0% for infection, and 64.3% for trauma, whereas recovery rates in children were 93.1% for Bell's palsy, 90.9% for infection, and 42.9% for trauma. Conclusion These results show that causes of facial palsy are similar in adults and children, and recovery rates in adults and children are not significantly different. PMID:18972592

Trauma Quality Improvement: Reducing Triage Errors by Automating the Level Assignment Process.

PubMed

Stonko, David P; O Neill, Dillon C; Dennis, Bradley M; Smith, Melissa; Gray, Jeffrey; Guillamondegui, Oscar D

2018-04-12

Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate. The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals. Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Challenges in the Evaluation for Possible Abuse: Presentations of Congenital Bleeding Disorders in Childhood

ERIC Educational Resources Information Center

Jackson, Jami; Carpenter, Shannon; Anderst, Jim

2012-01-01

Objectives: To describe children with congenital bleeding disorders that present in a manner that may be concerning for non-accidental trauma (NAT), and to evaluate associations with disease and demographic characteristics. Methods: Ten year retrospective charts of subjects were reviewed at a Hemophilia Treatment Center. Demographic, historical,…

Financial implications of nonoperative fracture care at an academic trauma center.

PubMed

Appleton, Paul; Chacko, Aron; Rodriguez, Edward K

2012-11-01

To determine if nonoperative fracture Current Procedural Technology codes generate a significant portion of annual revenues in an academic practice. Retrospective review of an orthopaedic trauma practice billings during fiscal year 2008. An urban level-1 trauma center. Outpatient clinic, and all consults, to the orthopaedic trauma service in the emergency room and hospital wards staffed by an attending traumatologist. An analysis was made of relative value units (RVUs) generated by operative and nonoperative care, separating the later into clinic, consults, and closed (nonoperative) fracture treatment. A total of 19,815 RVUs were generated by the trauma service during the 2008 fiscal year. Emergency department and ward consults generated 2176 (11%) of RVUs, whereas outpatient clinic generated an additional 1313 (7%) of RVUs. Nonoperative (closed) fracture care generated 2725 (14%) RVUs, whereas surgical procedures were responsible for the remaining 13,490 (68%) of RVUs. In terms of overall financial reimbursement, nonoperative management, consults, and office visits generated 31% of income for the trauma service. Although the largest financial contribution to a busy surgical practice is operative procedures, 1 must not overlook the important impact of nonoperative fracture care and consults. In our academic center, nearly one-third of all income was generated from nonsurgical procedures. In the current medical/financial climate, 1 must be diligent in optimizing the finances of trauma care to sustain an economically viable practice. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Liver transplantation after severe hepatic trauma: a sustainable practice. A single-center experience and review of the literature.

PubMed

Patrono, Damiano; Brunati, Andrea; Romagnoli, Renato; Salizzoni, Mauro

2013-01-01

Severe hepatic trauma is a rare indication for liver transplantation (LT). We report our single-center experience of LT for hepatic trauma. Four new cases are discussed in light of a literature review in order to depict the pathways leading from hepatic trauma to LT and to assess the outcomes of this practice. LT is generally indicated in case of uncontrollable hemorrhage, acute liver failure, or post-traumatic late sequelae. Hepatic vessels thrombosis, sepsis, major hepatic resections, and a late referral are factors associated with the progression toward irreversible liver failure. Considering all reported cases, early patient and graft survival reached 68% and 62%, respectively, but in the last decade both have improved to 84%. LT after severe hepatic trauma is a sustainable practice considering the current good outcomes and the ineluctable death of these patients without LT. © 2013 John Wiley & Sons A/S.

[Pediatric multiple trauma].

PubMed

Auner, B; Marzi, I

2014-05-01

Multiple trauma in children is rare so that even large trauma centers will only treat a small number of cases. Nevertheless, accidents are the most common cause of death in childhood whereby the causes are mostly traffic accidents and falls. Head trauma is the most common form of injury and the degree of severity is mostly decisive for the prognosis. Knowledge on possible causes of injury and injury patterns as well as consideration of anatomical and physiological characteristics are of great importance for treatment. The differences compared to adults are greater the younger the child is. Decompression and stopping bleeding are the main priorities before surgical fracture stabilization. The treatment of a severely injured child should be carried out by an interdisciplinary team in an approved trauma center with expertise in pediatrics. An inadequate primary assessment involves a high risk of early mortality. On the other hand children have a better prognosis than adults with comparable injuries.

Lower Urinary Tract Injuries Following Blunt Trauma: A Review of Contemporary Management

PubMed Central

Kong, Jennifer P. L; Bultitude, Matthew F; Royce, Peter; Gruen, Russell L; Cato, Alex; Corcoran, Niall M

2011-01-01

Lower urinary tract trauma, although relatively uncommon in blunt trauma, can lead to significant morbidity when diagnosed late or left untreated; urologists may only encounter a handful of these injuries in their career. This article reviews the literature and reports on the management of these injuries, highlighting the issues facing clinicians in this subspecialty. Also presented is a structured review detailing the mechanisms, classification, diagnosis, management, and complications of blunt trauma to the bladder and urethra. The prognosis for bladder rupture is excellent when treated. Significant intraperitoneal rupture or involvement of the bladder neck mandates surgical repair, whereas smaller extraperitoneal lacerations may be managed with catheterization alone. With the push for management of trauma patients in larger centers, urologists in these hospitals are seeing increasing numbers of lower urinary tract injuries. Prospective analysis may be achieved in these centers to address the current lack of Level 1 evidence. PMID:22114545

Design, development, and evaluation of an online virtual emergency department for training trauma teams.

PubMed

Youngblood, Patricia; Harter, Phillip M; Srivastava, Sakti; Moffett, Shannon; Heinrichs, Wm LeRoy; Dev, Parvati

2008-01-01

Training interdisciplinary trauma teams to work effectively together using simulation technology has led to a reduction in medical errors in emergency department, operating room, and delivery room contexts. High-fidelity patient simulators (PSs)-the predominant method for training healthcare teams-are expensive to develop and implement and require that trainees be present in the same place at the same time. In contrast, online computer-based simulators are more cost effective and allow simultaneous participation by students in different locations and time zones. In this pilot study, the researchers created an online virtual emergency department (Virtual ED) for team training in crisis management, and compared the effectiveness of the Virtual ED with the PS. We hypothesized that there would be no difference in learning outcomes for graduating medical students trained with each method. In this pilot study, we used a pretest-posttest control group, experimental design in which 30 subjects were randomly assigned to either the Virtual ED or the PS system. In the Virtual ED each subject logged into the online environment and took the role of a team member. Four-person teams worked together in the Virtual ED, communicating in real time with live voice over Internet protocol, to manage computer-controlled patients who exhibited signs and symptoms of physical trauma. Each subject had the opportunity to be the team leader. The subjects' leadership behavior as demonstrated in both a pretest case and a posttest case was assessed by 3 raters, using a behaviorally anchored scale. In the PS environment, 4-person teams followed the same research protocol, using the same clinical scenarios in a Simulation Center. Guided by the Emergency Medicine Crisis Resource Management curriculum, both the Virtual ED and the PS groups applied the basic principles of team leadership and trauma management (Advanced Trauma Life Support) to manage 6 trauma cases-a pretest case, 4 training cases, and a posttest case. The subjects in each group were assessed individually with the same simulation method that they used for the training cases. Subjects who used either the Virtual ED or the PS showed significant improvement in performance between pretest and posttest cases (P < 0.05). In addition, there was no significant difference in subjects' performance between the 2 types of simulation, suggesting that the online Virtual ED may be as effective for learning team skills as the PS, the method widely used in Simulation Centers. Data on usability and attitudes toward both simulation methods as learning tools were equally positive. This study shows the potential value of using virtual learning environments for developing medical students' and resident physicians' team leadership and crisis management skills.

Decision-Making in Management of the Complex Trauma Patient: Changing the Mindset of the non-trauma Surgeon.

PubMed

Sonesson, Linda; Boffard, Kenneth; Lundberg, Lars; Rydmark, Martin; Karlgren, Klas

2018-01-16

European surgeons are frequently subspecialized and trained primarily in elective surgical techniques. As trauma leaders, they may occasionally have to deal with complex polytrauma, advanced management techniques, differing priorities, and the need for multidisciplinary care. There is a lack of expertise, experience, and a low trauma volume, as well as a lack of research, with limited support as to the decision-making and teaching challenges present. We studied what experienced trauma experts describe as the challenges that are specific to the advanced surgical decision-making required, whether civilian, humanitarian, or military. Design-based research using combined methods including interviews, reviews of authentic trauma cases, and video-recorded resuscitations performed at a high-volume civilian academic trauma center. Several educational dilemmas were identified: (1) thinking physiologically, (2) the application of damage control resuscitation and surgery, (3) differing priorities and time management, (4) impact of environment, (5) managing limited resources, (6) lack of general surgical skills, (7) different cultural behavior, and (8) ethical issues. The challenges presented, and the educational domains identified, constitute a basis for improved development of education and training in complex surgical decision-making. This study contributes new knowledge about the mindset required for decision-making in patients with complex multisystem trauma and competing priorities of care. This is, especially important in countries having a low intensity of trauma in both military and civilian environments, and consequential limited skills, and lack of expertise. Guidelines focused on the same decision-making process, using virtual patients and blended learning, can be developed.

Vasopressor use following traumatic injury - A single center retrospective study.

PubMed

Hylands, Mathieu; Godbout, Marie-Pier; Mayer, Sandeep K; Fraser, William D; Vanasse, Alain; Leclair, Marc-André; Turgeon, Alexis F; Lauzier, François; Charbonney, Emmanuel; Trottier, Vincent; Razek, Tarek S; Roy, André; D'Aragon, Frédérick; Belley-Côté, Emilie; Day, Andrew G; Le Guillan, Soazig; Sabbagh, Robert; Lamontagne, François

2017-01-01

Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers. We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management. Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7-38.5). In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards.

Mobile in Situ Simulation as a Tool for Evaluation and Improvement of Trauma Treatment in the Emergency Department.

PubMed

Amiel, Imri; Simon, Daniel; Merin, Ofer; Ziv, Amitai

2016-01-01

Medical simulation is an increasingly recognized tool for teaching, coaching, training, and examining practitioners in the medical field. For many years, simulation has been used to improve trauma care and teamwork. Despite technological advances in trauma simulators, including better means of mobilization and control, most reported simulation-based trauma training has been conducted inside simulation centers, and the practice of mobile simulation in hospitals' trauma rooms has not been investigated fully. The emergency department personnel from a second-level trauma center in Israel were evaluated. Divided into randomly formed trauma teams, they were reviewed twice using in situ mobile simulation training at the hospital's trauma bay. In all, 4 simulations were held before and 4 simulations were held after a structured learning intervention. The intervention included a 1-day simulation-based training conducted at the Israel Center for Medical Simulation (MSR), which included video-based debriefing facilitated by the hospital's 4 trauma team leaders who completed a 2-day simulation-based instructors' course before the start of the study. The instructors were also trained on performance rating and thus were responsible for the assessment of their respective teams in real time as well as through reviewing of the recorded videos; thus enabling a comparison of the performances in the mobile simulation exercise before and after the educational intervention. The internal reliability of the experts' evaluation calculated in the Cronbach α model was found to be 0.786. Statistically significant improvement was observed in 4 of 10 parameters, among which were teamwork (29.64%) and communication (24.48%) (p = 0.00005). The mobile in situ simulation-based training demonstrated efficacy both as an assessment tool for trauma teams' function and an educational intervention when coupled with in vitro simulation-based training, resulting in a significant improvement of the teams' function in various aspects of treatment. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Evaluating the traditional day and night shift in an acute care surgery fellowship: Is the swing shift a better choice?

PubMed

Chestovich, Paul J; McNicoll, Christopher F; Ingalls, Nichole K; Kuhls, Deborah A; Fraser, Douglas R; Morrissey, Shawna L; Fildes, John J

2018-01-01

Fellowship trainees in acute care surgery require experience in the management of complex and operative trauma cases. Trauma center staffing usually follows standard 12-hour or 24-hour shifts, with resident and fellow trainees following a similar schedule. Although trauma admissions can be generally unpredictable, we analyzed temporal trends of trauma patient arrival times to determine the best time frame to maximize trainee experience during each day. We reviewed 10 years (2007-2016) of trauma registry data for blunt and penetrating trauma activations. Hourly volumetric trends were observed, and three specific events were chosen for detailed analysis: (1) trauma activation with Injury Severity Score (ISS) greater than 15, (2) laparotomy for trauma, and (3) thoracotomy for trauma. A retrospective shift log was created, which included day (7:00 AM to 7:00 PM), night (7:00 PM to 7:00 AM), and swing (noon to midnight) shifts. A swing shift was chosen because it captures the peak volume for all three events. Means and 95% confidence intervals were calculated, and comparisons were made between shifts using the Wilcoxon matched-pairs signed rank test with Bonferroni correction, and p less than 0.05 considered significant. During the 10-year study period, 28,287 patients were treated at our trauma center. This included the evaluation and management of 7,874 patients with ISS greater than 15, performance of 1,766 laparotomies, and 392 thoracotomies for trauma. Swing shift was superior to both day and night shifts for ISS greater than 15 (p < 0.001). Both swing and night shifts were superior to day shift for laparotomies (p < 0.001). Swing shift was superior to both day shift (p < 0.001) and night shift (p = 0.031). Shifts with the highest yield of ISS greater than 15, laparotomies, and thoracotomies include night and swing shifts on Fridays and Saturdays. Projected experience of acute care surgery fellows in managing complex trauma patients increases with the integration of swing shifts into the schedule. Daily trauma volume follows a temporal pattern which, when used correctly, can increase trainee exposure to complex and operative trauma cases. We encourage other centers to analyze their volume and adjust trainee schedules accordingly to maximize their educational experience. Therapeutic study, level IV.

The state of US trauma systems: public perceptions versus reality--implications for US response to terrorism and mass casualty events.

PubMed

Champion, Howard R; Mabee, Marcia S; Meredith, J Wayne

2006-12-01

Injury has long been identified as the number one killer of Americans under the age of 34, and establishment of regional trauma systems and centers incorporating primary, secondary, and tertiary care and injury-prevention strategies has proved to be a vital element in reducing injury-related sequelae, deaths, and even costs. Despite these facts, trauma system development has not been given priority for funding in many local and state governments and only intermittently at the federal level. Consequently, many of the nation's trauma centers are strapped for funds to provide emergency care to their patients. In response to a 2002 Health Resources and Services Administration (HRSA) report, which identified public support as a key element in the success of trauma system development in states and communities across the United States, a Harris Interactive study was undertaken in the fall of 2004 to determine the public's attitudes, awareness, and knowledge concerning the nature and availability of trauma care and systems of trauma care. Results of the poll were contrasted with current data on the state of US trauma systems to determine the degree of correspondence. Results of the poll indicated that fully 61% of the American public does not know that injury is the leading cause of death for those aged 1 to 34, and most believe that a trauma system is in place in every state. Almost two-thirds of the American public is confident of receiving the best medical care in the event of serious injury and would be seriously concerned if no trauma center were nearby. But only eight states have fully developed trauma systems, and most states have no federal funding or infrastructure in place for managing the aftermath of a natural disaster or terrorist event. These and other objective data reveal the mismatch between public perceptions and reality. Although almost 90% of Americans believe that state trauma systems and hospitals should have a coordinated trauma response, this has not been made a national priority. Trauma systems must be adequately developed and supported to fulfill the public's expectation to receive the best possible care if seriously injured, and to ensure readiness for mass casualty and terrorist incidents.

Novel Anterior Plating Technique for Patella Fracture Fixation.

PubMed

Siljander, Matthew P; Vara, Alexander D; Koueiter, Denise M; Wiater, Brett P; Wiater, Patrick J

2017-07-01

Patella fracture fixation remains a significant challenge for orthopedic surgeons. Although tension band fixation allows for reliable osseous union, especially in simple fracture patterns, it still presents several problems. Plate fixation of patella fractures is a method that allows for more rigid stabilization and earlier mobilization. At the authors' level 1 trauma center, one fellowship-trained trauma surgeon has transitioned to using a novel anterior, low-profile mesh plate construct for all types of patella fractures. This construct allows for stable fixation, osseous union, and neutralization of the inferior pole for even the most comminuted of patella fractures. [Orthopedics. 2017; 40(4):e739-e743.]. Copyright 2017, SLACK Incorporated.

Annual trauma load of the world's largest indoor skiing center.

PubMed

Van Laarhoven, S N; Latten, G; de Loos, E; van Hemert, W; Vles, G F

2017-04-01

There is limited data on the trauma load caused by indoor skiing centers. Therefore, all patients treated at the accident and emergency department of our level I trauma center who sustained injuries at the world's largest indoor skiing center were analyzed during a 3-year period. Business intelligence was used to identify all patients who sustained injury at SnowWorld, Landgraaf, The Netherlands, and were seen at the accident and emergency department of the Zuyderland Medical Center from January 1, 2012 till December 31, 2014. Data were collected on patient characteristics, trauma mechanism, transportation, admission, diagnostics, injury and its severity, and treatment. Of the 732 patients seen, 305 had a fracture and 80 a dislocation. Most patients were male snowboarders and most injuries were sustained during winter. More than 2000 X-rays and 100 CT scans were required. Seventy-two patients were admitted and immediate surgery was performed in 21 patients. Ten patients had Injury Severity Scores of 10 or higher. Snowboarders differed significantly from skiers on several parameters, e.g., 1 in 4 snowboarders seen had sustained a distal radius fracture compared to 1 in 100 skiers. Acquiring more insight into the characteristics of this specific patient population could benefit clinical care and help clinicians identify and target preventive strategies. IV.

Community Disasters, Psychological Trauma, and Crisis Intervention.

PubMed

Boscarino, Joseph A

The current issue of International Journal of Emergency Mental Health and Human Resilience is focused on community disasters, the impact of trauma exposure, and crisis intervention. The articles incorporated include studies ranging from the World Trade Center disaster to Hurricane Sandy. These studies are related to public attitudes and beliefs about disease outbreaks, the impact of volunteerism following the World Trade Center attacks, alcohol misuse among police officers after Hurricane Katrina, posttraumatic stress disorder after Hurricane Sandy among those exposed to the Trade Center disaster, compassion fatigue and burnout among trauma workers, crisis interventions in Eastern Europe, and police officers' use of stress intervention services. While this scope is broad, it reflects the knowledge that has emerged since the Buffalo Creek and Chernobyl catastrophes, to the more recent Hurricane Katrina and Sandy disasters. Given the current threat environment, psychologists, social workers, and other providers need to be aware of these developments and be prepared to mitigate the impact of psychological trauma following community disasters, whether natural or man-made.

Trauma indices for prediction of acute respiratory distress syndrome.

PubMed

Afshar, Majid; Smith, Gordon S; Cooper, Richard S; Murthi, Sarah; Netzer, Giora

2016-04-01

A myriad of trauma indices has been validated to predict probability of trauma survival. We aimed to compare the performance of commonly used indices for the development of the acute respiratory distress syndrome (ARDS). Historic, observational cohort study of 27,385 consecutive patients admitted to a statewide referral trauma center between July 11, 2003 and October 31, 2011. A validated algorithm was adapted to identify patients with ARDS. Each trauma index was evaluated in logistic regression using the area under the receiver operating characteristic curve. The case rate for ARDS development was 5.8% (1594). The receiver operating characteristics for injury severity score (ISS) had the best discrimination and had an area under the curve of 0.88 (95% confidence interval [CI] = 0.87-0.89). Glasgow coma score (0.71, 95% CI = 0.70-0.73), A Severity Characterization of Trauma (0.86, 95% CI = 0.85-0.87), Revised Trauma Score (0.71, 95% CI = 0.70-0.72) and thorax Abbreviated Injury Score (0.73, 95% CI = 0.72-0.74) performed worse (P < 0.001) and Trauma and Injury Severity Score (0.88, 95% CI = 0.87-0.88) performed equivocally (P = 0.51) in comparison to ISS. Using a cutoff point ISS ≥16, sensitivity and specificity were 84.9% (95% CI = 83.0%-86.6%) and 75.6% (95% CI = 75.1%-76.2%), respectively. Among commonly used trauma indices, ISS has superior or equivocal discriminative ability for development of ARDS. A cutoff point of ISS ≥16 provided good sensitivity and specificity. The use of ISS ≥16 is a simple method to evaluate ARDS in trauma epidemiology and outcomes research. Copyright © 2016 Elsevier Inc. All rights reserved.

Ten years of major equestrian injury: are we addressing functional outcomes?

PubMed Central

Ball, Jill E; Ball, Chad G; Mulloy, Robert H; Datta, Indraneel; Kirkpatrick, Andrew W

2009-01-01

Background Horseback riding is considered more dangerous than motorcycle riding, skiing, automobile racing, football and rugby. The integral role of rehabilitation therapy in the recovery of patients who have sustained a major horse-related injury is previously not described. The goals of this paper were to (1) define the incidence and pattern of severe equestrian trauma, (2) identify the current level of in-patient rehabilitation services, (3) describe functional outcomes for patients, and (4) discuss methods for increasing rehabilitation therapy in this unique population. Methods and results A retrospective review of the trauma registry at a level 1 center (1995–2005) was completed in conjunction with a patient survey outlining formal in-hospital therapy. Forty-nine percent of patients underwent in-patient rehabilitation therapy. Injuries predictive of receiving therapy included musculoskeletal and spinal cord trauma. Previous injury while horseback riding was predictive of not receiving therapy. The majority (55%) of respondents had chronic physical difficulties following their accident. Conclusion Rehabilitation therapy is significantly underutilized following severe equestrian trauma. Increased therapy services should target patients with brain, neck and skull injuries. Improvements in the initial provision, and follow-up of rehabilitation therapy could enhance functional outcomes in the treatment resistant Western equestrian population. PMID:19228424

Communication with Orthopedic Trauma Patients via an Automated Mobile Phone Messaging Robot.

PubMed

Anthony, Chris A; Volkmar, Alexander; Shah, Apurva S; Willey, Mike; Karam, Matt; Marsh, J Lawrence

2017-12-20

Communication with orthopedic trauma patients is traditionally problematic with low response rates (RRs). The purpose of this investigation was to (1) evaluate the feasibility of communicating with orthopedic trauma patients postoperatively, utilizing an automated mobile phone messaging platform; and (2) assess the first 2 weeks of postoperative patient-reported pain and opioid use after lower extremity orthopedic trauma procedures. This was a prospective investigation at a Level 1 trauma center in the United States. Adult patients who were capable of mobile phone messaging and were undergoing common, lower extremity orthopedic trauma procedures were enrolled in the study. Patients received a daily mobile phone message protocol inquiring about their current pain level and amount of opioid medication they had taken in the past 24 h starting on postoperative day (POD) 3 and continuing through POD 17. Our analysis considered (1) Patient completion rate of mobile phone questions, (2) Patient-reported pain level (0-10 scale), and (3) Number and percentage of daily prescribed opioid medication patients reported taking. Twenty-five patients were enrolled in this investigation. Patients responded to 87.5% of the pain and opioid medication inquiries they received over the 2-week study period. There were no differences in RRs by patient age, sex, or educational attainment. Patient-reported pain decreased over the initial 2-week study period from an average of 4.9 ± 1.7 on POD 3 to 3 ± 2.2 on POD 16-17. Patients took an average of 68% of their maximum daily narcotic prescription on POD 3 compared with 35% of their prescribed pain medication on POD 16-17. We found that in orthopedic trauma patients, an automated mobile phone messaging platform elicited a high patient RR that improved upon prior methods in the literature. This method may be used to reliably obtain pain and medication utilization data after trauma procedures.

A 2-year retrospective study of pediatric dental emergency visits at a hospital emergency center in Taiwan.

PubMed

Jung, Chia-Pei; Tsai, Aileen I; Chen, Ching-Ming

2016-06-01

There is a paucity of information regarding pediatric dental emergencies in Taiwan. This study investigates the prevalence and characteristics of the pediatric dental emergency services provided at a medical center. This study included a retrospective chart review of patients under 18 years of age with dental complaints who visited the Emergency Department (ED) of Linkou Medical Center of Chang Gung Memorial Hospital from January 2012 to December 2013. Information regarding age, gender, time/day/month of presentation, diagnosis, treatment, and follow-up was collected and analyzed. Statistical analysis included descriptive statistics and Pearson's Chi-square test with the significance level set as p < 0.05. This study revealed that dental emergencies in the medical center ED were predominantly related to orodental trauma (47.1%) and pulpal pain (29.9%). Most patients were male (p < 0.001) and <5 years of age (p < 0.001). The most frequent orodental trauma was luxation, both in primary and permanent dentition. The major management for dental emergencies was prescribing medication for pulp-related problems and orodental trauma. The follow-up rate of orodental trauma was the highest (p < 0.001). For children, trauma and toothache constituted the most common reasons for dental emergency visits at a hospital emergency center in Taiwan. While dental emergencies are sometimes unforeseeable or unavoidable, developing community awareness about proper at-home care as well as regular dental preventive measures can potentially reduce the number of emergency visits. Copyright © 2016 Chang Gung University. Published by Elsevier B.V. All rights reserved.

Academic time at a level 1 trauma center: no resident, no problem?

PubMed

Matsushima, Kazuhide; Dickinson, Rebecca M; Schaefer, Eric W; Armen, Scott B; Frankel, Heidi L

2012-01-01

Globally, the compliance of resident work-hour restrictions has no impact on trauma outcome. However, the effect of protected education time (PET), during which residents are unavailable to respond to trauma patients, has not been studied. We hypothesized that PET has no impact on the outcome of trauma patients. We conducted a retrospective review of relevant patients at an academic level I trauma center. During PET, a trauma attending and advanced practice providers (APPs) responded to trauma activations. PGY1, 3, and 4 residents were also available at all other times. The outcome of new trauma patient activations during Thursday morning 3-hours resident PET was compared with same time period on other weekdays (non-PET) using a univariate and multivariate analysis. From January 2005 to April 2010, a total of 5968 trauma patients were entered in the registry. Of these, 178 patients (2.98%) were included for study (37 PET and 141 non-PET). The mean injury severity score (ISS) was 16.2. Although no significant difference were identified in mortality, complications, or length of stay (LOS), we do see that length of emergency department stay (ED-LOS) tends to be longer during PET, although not significantly (314 vs 381 minutes, p = 0.74). On the multiple logistic regression model, PET was not a significant factor of complications, LOS, or ED-LOS. Few trauma activations occur during PET. New trauma activations can be staffed safely by trauma activations and APPs. However, there could be some delays in transferring patients to appropriate disposition. Additional study is required to determine the effect of PET on existing trauma inpatients. Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Improvement in cost recovery at an urban level I trauma center.

PubMed

Helling, T S; Watkins, M; Robb, C V

1995-11-01

With escalating health care costs and health reimbursement reorganization, the greatest danger to trauma centers will remain expensive uncompensated care. This is caused primarily by costs incurred in treating complex, life-threatening injuries and to the large population of trauma patients with no, or inadequate, means of compensation. In 1986 and 1987, this urban level I trauma center experienced an operating loss totaling $2,335,200. To attempt to reverse this expense, annual tracking of the trauma service's financial performance was begun in 1989. In addition, changes were made. Early multidisciplinary baseline assessment of each admission was instituted for financial profiling and discharge planning. Attempts were made on admission to identify health and vehicular insurance information. Processing for Medicaid and Medicare reimbursement was begun as soon as possible, and coding for diagnoses was checked by medical records personnel and the trauma nurse coordinator. If appropriate, Missouri Crime Victims Compensation was sought. Base on costs incurred in providing trauma services, as required by the state of Missouri and the American College of Surgeons, a trauma response charge was developed and instituted. Over a 5-year period, 1989 to 1993, financial audits were conducted. The cost recovery ratio (CRR) (collections/cost) was utilized as the measure of financial success. The CRR improved from 0.74 in 1989 to 0.93 in 1993, and in 2 years, 1991 and 1992, was 1.03 and 0.99. Over this period, the acuity of injury, as measured by the Injury Severity Score, remained essentially the same, but length of hospital stay decreased from 10.0 to 8.7 days. The CRR was greatest for private insurance.(ABSTRACT TRUNCATED AT 250 WORDS)

Update on prehospital emergency care of severe trauma patients.

PubMed

Tazarourte, K; Cesaréo, E; Sapir, D; Atchabahian, A; Tourtier, J-P; Briole, N; Vigué, B

2013-01-01

The prognosis of severe trauma patients is determined by the ability of a healthcare system to provide high intensity therapeutic treatment on the field and to transport patients as quickly as possible to the structure best suited to their condition. Direct admission to a specialized center ("trauma center") reduces the mortality of the most severe trauma at 30 days and one year. Triage in a non-specialized hospital is a major risk of loss of chance and should be avoided whenever possible. Medical dispatching plays a major role in determining patient care. The establishment of a hospital care network is an important issue that is not formalized enough in France. The initial triage of severe trauma patients must be improved to avoid taking patients to hospitals that are not equipped to take care of them. For this purpose, the MGAP score can predict severity and help decide where to transport the patient. However, it does not help predict the need for urgent resuscitation procedures. Hemodynamic management is central to the care of hemorrhagic shock and severe head trauma. Transport helicopter with a physician on board has an important role to allow direct admission to a specialized center in geographical areas that are difficult to access. Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Undertriage of Firearm-Related Injuries in a Major Metropolitan Area

PubMed Central

Lale, Allison; Krajewski, Allison

2017-01-01

Importance National anatomic triage criteria prescribe specific transport rules for injured patients. However, there is limited information about patients with firearm-related injuries undertriaged to nondesignated facilities (ie, hospitals without specialized trauma teams or units), including what clinical outcomes are achieved and how many are transferred to a higher level of care. Without these data, it is difficult to make informed regional or national policy decisions about triage practices. Undertriage of firearm-related injuries is a good model for evaluating the undertriage of patients with trauma because the anatomic triage criteria for patients with firearm-related injuries are simple. Objective To evaluate the prevalence, spatial distribution, and clinical outcomes of undertriage of firearm-related injuries. Design, Setting, and Participants This study is a retrospective analysis of firearm-related injuries in residents of Cook County, Illinois, from January 1, 2009, to December 31, 2013. Outpatient and inpatient hospital databases were used. Participants included patients with International Classification of Diseases, Ninth Revision, Clinical Modification firearm-related cause-of-injury codes. Data were collected all at once in August 2014. Data analysis took place from March 12, 2015, to February 1, 2016. Main Outcomes and Measures Undertriaged cases were defined as patients who met the national anatomic triage criteria for transfer to higher-level trauma center care. Spatial distribution, injury severity, and clinical outcomes, including death, were analyzed. Results Of the 9886 patients included in this analysis, 8955 (90.6%) were male, 7474 (75.6%) were African American, and 5376 (54.4%) were aged 15 to 24 years.In Cook County, Illinois, where there are 19 trauma centers, 2842 of 9886 (28.7%) firearm-related injuries were initially treated in nondesignated facilities. Among the 4934 cases with firearm-related injury who met the anatomic triage criteria, 884 (17.9%) received initial treatment at a nondesignated facility and only 92 (10.4%) were transferred to a designated trauma center. Significant spatial clustering was identified on the west side of Chicago and in the southern parts of Chicago and Cook County. In the multivariable models, patients treated in nondesignated facilities were less likely to die than were patients treated in designated trauma centers. Conclusions and Relevance Undertriage of firearm-related injuries was much more prevalent than expected. Although the likelihood of dying during hospitalization was greater among patients treated in designated trauma centers, these patients were substantially in worse condition across all measures of injury severity. A smaller proportion of patients treated in designated trauma centers died during the first 24 hours of hospitalization. This study highlights the need for better regional coordination, especially with interhospital transfers, as well as the importance of assessing the distribution of emergency medical services resources to make the trauma care system more effective and equitable. PMID:28114435

Trauma Resuscitation Evaluation Times and Correlating Human Patient Simulation Training Differences-What is the Standard?

PubMed

Bonjour, Timothy J; Charny, Grigory; Thaxton, Robert E

2016-11-01

Rapid effective trauma resuscitations (TRs) decrease patient morbidity and mortality. Few studies have evaluated TR care times. Effective time goals and superior human patient simulator (HPS) training can improve patient survivability. The purpose of this study was to compare live TR to HPS resuscitation times to determine mean incremental resuscitation times and ascertain if simulation was educationally equivalent. The study was conducted at San Antonio Military Medical Center, Department of Defense Level I trauma center. This was a prospective observational study measuring incremental step times by trauma teams during trauma and simulation patient resuscitations. Trauma and simulation patient arms had 60 patients for statistical significance. Participants included Emergency Medicine residents and Physician Assistant residents as the trauma team leader. The trauma patient arm revealed a mean evaluation time of 10:33 and simulation arm 10:23. Comparable time characteristics in the airway, intravenous access, blood sample collection, and blood pressure data subsets were seen. TR mean times were similar to the HPS arm subsets demonstrating simulation as an effective educational tool. Effective stepwise approaches, incremental time goals, and superior HPS training can improve patient survivability and improved departmental productivity using TR teams. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center

PubMed Central

Lockwood, Megan M.; Smith, Gabriel A.; Tanenbaum, Joseph; Lubelski, Daniel; Seicean, Andreea; Pace, Jonathan; Benzel, Edward C.; Mroz, Thomas E.; Steinmetz, Michael P.

2017-01-01

OBJECT Screening for vertebral artery injury (VAI) following cervical spine fractures is routinely performed across trauma centers in North America. From 2002 to 2007, the total number of neck CT angiography (CTA) studies performed in the Medicare population after trauma increased from 9796 to 115,021. In the era of cost-effective medical care, the authors aimed to evaluate the utility of CTA screening in detecting VAI and reduce chances of posterior circulation strokes after traumatic cervical spine fractures. METHODS A retrospective review of all patients presenting with cervical spine fractures to Northeast Ohio’s Level I trauma institution from 2002 to 2012 was performed. RESULTS There was a total of 1717 cervical spine fractures in patients presenting to Northeast Ohio’s Level I trauma institution between 2002 and 2012. CTA screening was performed in 732 patients, and 51 patients (0.7%) were found to have a VAI. Fracture patterns with increased odds of VAI were C-1 and C-2 combined fractures, transverse foramen fractures, and subluxation of adjacent vertebral levels. Ten posterior circulation strokes were identified in this patient population (0.6%) and found in only 4 of 51 cases of VAI (7.8%). High-risk fractures defined by Denver Criteria, VAI, and antiplatelet treatment of VAI were not independent predictors of stroke. CONCLUSIONS Cost-effective screening must be reevaluated in the setting of blunt cervical spine fractures on a case-by-case basis. Further prospective studies must be performed to elucidate the utility of screening for VAI and posterior circulation stroke prevention, if identified. PMID:26613284

Rehabilitation needs of persons discharged from an African trauma center

PubMed Central

Christian, Asare; González-Fernández, Marlís; Mayer, Robert Samuel; Haig, Andrew J

2011-01-01

Background The study prospectively assessed the functional impairments and rehabilitation needs of Africans admitted to a regional trauma center. It also acts as a pilot study to demonstrate the practical use of the Language Independent Functional Evaluation (L.I.F.E.) software in an acute hospital setting. Methods A 5 page questionnaire was used to gather demographic data (age, sex, medical diagnosis, education, housing type, place of residency, occupation), cause of disability/injury, severity of disability or functional impairment, and rehabilitation treatment received (types of rehab, frequency of treatment, duration of therapy, follow up therapy, equipment). Functional status on discharge was evaluated with the L.I.F.E. scale. Results 84 consecutive consenting subjects were recorded. The predominant disability/injury of respondents involved the lower extremities (70%), followed by upper extremities (23%). The mechanisms of injury were largely related to auto accidents (69%). Falls made up 17% of these injuries and 14% were related to violence. Eleven subjects had disability measured using L.I.F.E and all were classified as having major disabilities. Only 14 patients (17%) received any rehabilitation therapy which consisted of only physical therapy provided at a frequency of once a day for less than one week duration. Conclusion This study found that most persons admitted to a sophisticated trauma unit in Ghana are discharged without adequate rehabilitation services, and that the level of disability experienced by these people can be measured, even while they are still sick and in the hospital, using L.I.F.E. The implications are clear: African trauma systems must measure the long term outcomes from their treatments and provide the inpatient medical rehabilitation services that are a standard of care for trauma victims elsewhere in the world. PMID:22187614

Cumulative trauma and posttraumatic stress disorder among children exposed to the 9/11 World Trade Center attack.

PubMed

Mullett-Hume, Elizabeth; Anshel, Daphne; Guevara, Vivianne; Cloitre, Marylene

2008-01-01

Two and one-half years after the September 11, 2001 World Trade Center attack, 204 middle school students in an immigrant community located near Ground Zero were assessed for posttraumatic stress disorder (PTSD) symptoms as influenced by "dose" of exposure to the attack and accumulated lifetime traumas. Ninety percent of students reported at least one traumatic event other than 9/11 (e.g., community violence) with an average of 4 lifetime events reported. An interaction was obtained such that the dose-response effect depended on presence of other traumas. Among students with the lowest number of additional traumas, the usual dose-response pattern of increasing PTSD symptoms with increasing 9/11 exposure was observed; among those with medium to high cumulative life trauma, PTSD symptoms were substantially higher and uniformly so regardless of 9/11 exposure dose. Results suggest that traumas that precede or follow mass violence often have as much as if not greater impact on long-term symptom severity than high-dose exposure to the event. Implications regarding the presence of continuing or previous trauma exposure for postdisaster and early intervention policies are discussed. (c) 2008 APA, all rights reserved

A novel prospective approach to evaluate trauma recidivism: the concept of the past trauma history.

PubMed

McCoy, Andrew M; Como, John J; Greene, Gregory; Laskey, Sara L; Claridge, Jeffrey A

2013-07-01

The purpose of this study was to determine the incidence and burden of trauma recidivism at a regional Level 1 trauma center by incorporating the concept of the past trauma history (PTHx) into the general trauma history. All trauma patients who met prehospital trauma criteria and activated the trauma team during a 13-month period were asked about their PTHx, that is, their history of injury in the previous 5 years. A recidivist presented more than once for separate severe injuries. Recurrent recidivists presented multiple times during the study period. Of the 4,971 trauma activations during the study period, 1,246 (25.2%) were identified as recidivists. Recidivists were 75% male, 62% white, 36% unemployed, 26% uninsured, and 90% unmarried. The recidivism rate among admitted patients was 23.4% compared with 29.3% in those discharged from the emergency department. The highest recidivism rates were noted in patients who reported alcohol or illegal drug use on the day of injury and in victims of interpersonal violence (IPV), defined as those who sustained gunshot wounds, stab wounds, or assaults, Those involved in IPV were more likely to have been involved in IPV at the previous trauma than those with other trauma mechanisms. Key risk factors for recidivism among all patients were male sex and single marital status. Seventy-three patients (1.5%) were recurrent recidivists, representing 157 unique encounters. This is the highest trauma recidivism rate reported on a large population of all consecutive trauma activations at a regional Level 1 trauma center. These data illustrate the tremendous burden of recidivism in the modern era, more than previously recognized. Efforts specifically targeting those involved in IPV may reduce recidivism rates. Incorporating the concept of the PTHx into the general history of the trauma patient is feasible and provides valuable information to the provider. Prognostic study, level II.

Open Repair Versus Thoracic Endovascular Aortic Repair in Multiple-Injured Patients: Observations From a Level-1 Trauma Center

PubMed Central

Brand, Stephan; Breitenbach, Ingo; Bolzen, Philipp; Petri, Maximilian; Krettek, Christian; Teebken, Omke

2015-01-01

Background: Blunt trauma of the thoracic aorta is a rare but potentially life-threatening entity. Intimal tears are a domain of non-operative management, whereas all other types of lesions should be repaired urgently. There is now a clear trend favoring minimally invasive stent grafting over open surgical repair. Objectives: The aim of the present study was to retrospectively evaluate the mortality and morbidity with either treatment option. Therefore, a retrospective observational study was performed to compare two different treatment methods at two different time periods at one trauma center. Patients and Methods: Between 1977 and 2012, all severely injured patients referred to our level 1 trauma center were screened for blunt aortic injuries. We compared baseline characteristics, 30-day and overall mortality, morbidity, duration of intensive care treatment, procedure time, and transfusion of packed red blood between patients who underwent open surgical or stent repair. Results: During the observation period, 45 blunt aortic injuries were recorded. The average Injury Severity Score (ISS) was 41.8 (range 29 - 68). Twenty-five patients underwent Open Repair (OR), and another 20 patients were scheduled to emergency stent grafting. The 30-day mortality in the surgical and stent groups were 5/25 (20%) and 2/20 (10%), respectively. The average time for open surgery was 151 minutes; the mean time for stent grafting was 67 minutes (P = 0.001). Postoperative stay on the intensive care unit was between one and 59 days (median 10) in group one and between four and 50 days in group two (median 26)(P = 0.03). Patients undergoing OR required transfusion of 6.0 units of packed red cells in median; patients undergoing stent grafting required a median of 2.0 units of packed red cells (P < 0.001). In the stent grafting group, 30-day mortality was 10% (2/20). Conclusions: Due to more sophisticated diagnostic tools and surgical approaches, mortality and morbidity of blunt aortic injuries were significantly reduced over the years compared to thoracic endovascular aortic repair and OR over two different time periods. PMID:26848470

A Qualitative Study of Multidisciplinary Providers' Experiences With the Transfer Process for Injured Children and Ideas for Improvement.

PubMed

Gawel, Marcie; Emerson, Beth; Giuliano, John S; Rosenberg, Alana; Minges, Karl E; Feder, Shelli; Violano, Pina; Morrell, Patricia; Petersen, Judy; Christison-Lagay, Emily; Auerbach, Marc

2018-02-01

Most injured children initially present to a community hospital, and many will require transfer to a regional pediatric trauma center. The purpose of this study was 1) to explore multidisciplinary providers' experiences with the process of transferring injured children and 2) to describe proposed ideas for process improvement. This qualitative study involved 26 semistructured interviews. Subjects were recruited from 6 community hospital emergency departments and the trauma and transport teams of a level I pediatric trauma center in New Haven, Conn. Participants (n = 34) included interprofessional providers from sending facilities, transport teams, and receiving facilities. Using the constant comparative method, a multidisciplinary team coded transcripts and collectively refined codes to generate recurrent themes across interviews until theoretical saturation was achieved. Participants reported that the transfer process for injured children is complex, stressful, and necessitates collaboration. The transfer process was perceived to involve numerous interrelated components, including professions, disciplines, and institutions. The 5 themes identified as areas to improve this transfer process included 1) Creation of a unified standard operating procedure that crosses institutions/teams, 2) Enhancing 'shared sense making' of all providers, 3) Improving provider confidence, expertise, and skills in caring for pediatric trauma transfer cases, 4) Addressing organization and environmental factors that may impede/delay transfer, and 5) Fostering institutional and personal relationships. Efforts to improve the transfer process for injured children should be guided by the experiences of and input from multidisciplinary frontline emergency providers.

Geriatric Assault Victims Treated at U.S. Trauma Centers: Five-Year Analysis of the National Trauma Data Bank

PubMed Central

Rosen, Tony; Clark, Sunday; Bloemen, Elizabeth M.; Mulcare, Mary R.; Stern, Michael E.; Hall, Jeffrey E.; Flomenbaum, Neal; Lachs, Mark S.; Eachempati, Soumitra R.

2016-01-01

Introduction While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them to geriatric victims of and younger accidental injury assault victims. Patients and Methods We conducted a retrospective analysis of the 2008–2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable “intent of injury.” Results 3,564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18–59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults. Conclusions Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population. PMID:27720184

Variation in Blood Transfusion and Coagulation Management in Traumatic Brain Injury at the Intensive Care Unit: A Survey in 66 Neurotrauma Centers Participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study.

PubMed

Huijben, Jilske A; van der Jagt, Mathieu; Cnossen, Maryse C; Kruip, Marieke J H A; Haitsma, Iain K; Stocchetti, Nino; Maas, Andrew I R; Menon, David K; Ercole, Ari; Maegele, Marc; Stanworth, Simon J; Citerio, Giuseppe; Polinder, Suzanne; Steyerberg, Ewout W; Lingsma, Hester F

2017-11-21

Our aim was to describe current approaches and to quantify variability between European intensive care units (ICUs) in patients with traumatic brain injury (TBI). Therefore, we conducted a provider profiling survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The ICU Questionnaire was sent to 68 centers from 20 countries across Europe and Israel. For this study, we used ICU questions focused on 1) hemoglobin target level (Hb-TL), 2) coagulation management, and 3) deep venous thromboembolism (DVT) prophylaxis. Seventy-eight participants, mostly intensivists and neurosurgeons of 66 centers, completed the ICU questionnaire. For ICU-patients, half of the centers (N = 34; 52%) had a defined Hb-TL in their protocol. For patients with TBI, 26 centers (41%) indicated an Hb-TL between 70 and 90 g/L and 38 centers (59%) above 90 g/L. To treat trauma-related hemostatic abnormalities, the use of fresh frozen plasma (N = 48; 73%) or platelets (N = 34; 52%) was most often reported, followed by the supplementation of vitamin K (N = 26; 39%). Most centers reported using DVT prophylaxis with anticoagulants frequently or always (N = 62; 94%). In the absence of hemorrhagic brain lesions, 14 centers (21%) delayed DVT prophylaxis until 72 h after trauma. If hemorrhagic brain lesions were present, the number of centers delaying DVT prophylaxis for 72 h increased to 29 (46%). Overall, a lack of consensus exists between European ICUs on blood transfusion and coagulation management. The results provide a baseline for the CENTER-TBI study, and the large between-center variation indicates multiple opportunities for comparative effectiveness research.

Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis.

PubMed

Banerjee, Aman; Duane, Therese M; Wilson, Sean P; Haney, Starre; O'Neill, Patrick J; Evans, Heather L; Como, John J; Claridge, Jeffrey A

2013-07-01

This study aimed to evaluate if variation in management of blunt splenic injury (BSI) among Level I trauma centers is associated with different outcomes related to the use of splenic artery embolization (SAE). All adult patients admitted for BSI from 2008 to 2010 at 4 Level I trauma centers were reviewed. Use of SAE was determined, and outcomes of spleen salvage and nonoperative management (NOM) failure were evaluated. A priori, a 10% SAE rate was used to group centers into high- or low-use groups. There were 1,275 BSI patients. There were intercenter differences in age, injury severity, and grade of spleen injury (Spleen Injury Scale [SIS]). Mortality was similar by center; however, BSI treatment varied significantly by center. Overall, SAE use was highest at center A compared with B, C, and D (19%, 11%, 1%, and 4%, respectively; p < 0.01). High SAE use centers had significantly higher spleen salvage rates and fewer NOM failures. Differences in the use of SAE (25% vs. 2%, p < 0.01) and salvage rate (67% vs. 56%, p = 0.03) were most dramatic between high- and low-use SAE centers for Grade 3 and 4 injured spleens. In patients who received initial NOM, multivariate logistic regression analysis showed that SAE was an independent predictor of spleen salvage (odds ratio, 5; 95% confidence interval, 1.8-13.5; p < 0.01) as were lower age, lower SIS, and Injury Severity Score (ISS). Patients treated at high SAE use centers were more likely to leave the hospital with their spleen in situ (odds ratio, 3; 95% confidence interval, 1.7-6.3; p < 0.01). Significant practice variation exists in the use of SAE in treating BSI at Level I trauma centers. Centers with higher rates of SAE use have higher spleen salvage and less NOM failure. SAE was shown to be an independent predictor of spleen salvage. Therapeutic study, level IV.

Variation in treatment of blunt splenic injury in Dutch academic trauma centers.

PubMed

Olthof, Dominique C; Luitse, Jan S K; de Rooij, Philippe P; Leenen, Loek P H; Wendt, Klaus W; Bloemers, Frank W; Goslings, J Carel

2015-03-01

The incidence of splenectomy after trauma is institutionally dependent and varies from 18% to as much as 40%. This is important because variation in management influences splenic salvage. The aim of this study was to investigate whether differences exist between Dutch level 1 trauma centers with respect to the treatment of these injuries, and if variation in treatment was related to splenic salvage, spleen-related reinterventions, and mortality. Consecutive adult patients who were admitted between January 2009 and December 2012 to five academic level 1 trauma centers were identified. Multinomial logistic regression was used to measure the influence of hospital on treatment strategy, controlling for hemodynamic instability on admission, high grade (American Association for the Surgery of Trauma 3-5) splenic injury, and injury severity score. Binary logistic regression was used to quantify differences among hospitals in splenic salvage rate. A total of 253 patients were included: 149 (59%) were observed, 57 (23%) were treated with splenic artery embolization and 47 (19%) were operated. The observation rate was comparable in all hospitals. Splenic artery embolization and surgery rates varied from 9%-32% and 8%-28%, respectively. After adjustment, the odds of operative management were significantly higher in one hospital compared with the reference hospital (adjusted odds ratio 4.98 [1.02-24.44]). The odds of splenic salvage were significantly lower in another hospital compared with the reference hospital (adjusted odds ratio 0.20 [0.03-1.32]). Although observation rates were comparable among the academic trauma centers, embolization and surgery rates varied. A nearly 5-fold increase in the odds of operative management was observed in one hospital, and another hospital had significantly lower odds of splenic salvage. The development of a national guideline is recommended to minimalize splenectomy after trauma. Copyright © 2015 Elsevier Inc. All rights reserved.

A safe haven for the injured? Urban trauma care at the intersection of healthcare, law enforcement, and race.

PubMed

Jacoby, Sara F; Richmond, Therese S; Holena, Daniel N; Kaufman, Elinore J

2018-02-01

Patients with traumatic injuries often interact with police before and during hospitalization, particularly when their injuries are due to violence. People of color are at highest risk for violent injuries and have the poorest outcomes after injury. The purpose of this study was to describe how injured, Black patients perceived their interactions with police and what these perceptions reveal about police involvement within trauma care systems. We combined data from two qualitative studies to achieve this aim. The first was ethnographic fieldwork that followed Black trauma patients in the hospital through the physical and emotional aftermath of their injuries. The second was a qualitative, descriptive study of how patients experienced trauma resuscitation in the emergency department (ED). Both studies were conducted between 2012 and 2015 at the Trauma Center at Penn, an academic medical center in Philadelphia, Pennsylvania, United States. The present study includes data from 24 adult, Black participants undergoing treatment for injury. We reanalyzed all interview data related to law enforcement encounters from the scene of injury through inpatient hospitalization and coded data using a constant comparative technique from grounded theory. Participants described law enforcement encounters at the scene of injury and during transport to the hospital, in the ED, and over the course of inpatient care. Injured participants valued police officers' involvement when they perceived that officers provided safety at the scene, speed of transport to the hospital, or support and information after injury. Injured participants also found police questioning to be stressful and, at times, disrespectful or conflicting with clinical care. Communities, trauma centers, and professional societies have the opportunity to enact policies that standardize law enforcement access in trauma centers and balance patients' health, privacy, and legal rights with public safety needs. Copyright © 2017 Elsevier Ltd. All rights reserved.

Gender differences among recidivist trauma patients.

PubMed

Kwan, Rita O; Cureton, Elizabeth L; Dozier, Kristopher C; Victorino, Gregory P

2011-01-01

Gender differences among trauma recidivist patients are not well-understood. We hypothesized that males are more likely to be repeatedly involved in the trauma system and have a shorter time to recurrence between repeat episodes of injury compared with females. A retrospective analysis of trauma patients treated at an urban university-based trauma center was performed. Variables including gender, race, insurance status, age, mechanism of injury, outcomes, and injury secondary to domestic violence were compared. Differences were compared using χ(2) tests and log-rank (Mantel-Cox) Kaplan-Meier cumulative event curves. We identified 689 trauma recidivist patients (4.0% of all trauma visits) over a 10-y period. Compared to single-visit patients, recidivist patients were more likely to be male (87% versus 73%), uninsured (78% versus 66%), and have injuries secondary to assaults (54% versus 37%) (P < 0.05). Time from the first to second trauma visit was shorter for females compared with males (23 ± 2.5 versus 30 ± 1.2 mo, P < 0.02). Additionally, female recidivists were more likely to be involved in blunt trauma than were male recidivists (69% versus 43%, P < 0.001). Furthermore, domestic violence was identified in a higher proportion of female recidivist patients than female single-visit patients (3.5% versus 1.6%, P < 0.0003). Contrary to our hypothesis, female recidivist trauma patients have a much shorter time to recurrence for a second traumatic injury than do males. Female recidivists have a high likelihood of assault-associated injuries and domestic violence. Trauma centers should screen for domestic violence among trauma patients to aid in preventing further repeat episodes of injury. Copyright © 2011 Elsevier Inc. All rights reserved.

Maryland's Helicopter Emergency Medical Services Experience From 2001 to 2011: System Improvements and Patients' Outcomes.

PubMed

Hirshon, Jon Mark; Galvagno, Samuel M; Comer, Angela; Millin, Michael G; Floccare, Douglas J; Alcorta, Richard L; Lawner, Benjamin J; Margolis, Asa M; Nable, Jose V; Bass, Robert R

2016-03-01

Helicopter emergency medical services (EMS) has become a well-established component of modern trauma systems. It is an expensive, limited resource with potential safety concerns. Helicopter EMS activation criteria intended to increase efficiency and reduce inappropriate use remain elusive and difficult to measure. This study evaluates the effect of statewide field trauma triage changes on helicopter EMS use and patient outcomes. Data were extracted from the helicopter EMS computer-aided dispatch database for in-state scene flights and from the state Trauma Registry for all trauma patients directly admitted from the scene or transferred to trauma centers from July 1, 2000, to June 30, 2011. Computer-aided dispatch flights were analyzed for periods corresponding to field triage protocol modifications intended to improve system efficiency. Outcomes were separately analyzed for trauma registry patients by mode of transport. The helicopter EMS computer-aided dispatch data set included 44,073 transports. There was a statewide decrease in helicopter EMS usage for trauma patients of 55.9%, differentially affecting counties closer to trauma centers. The Trauma Registry data set included 182,809 patients (37,407 helicopter transports, 128,129 ambulance transports, and 17,273 transfers). There was an increase of 21% in overall annual EMS scene trauma patients transported; ground transports increased by 33%, whereas helicopter EMS transports decreased by 49%. Helicopter EMS patient acuity increased, with an attendant increase in patient mortality. However, when standardized with W statistics, both helicopter EMS- and ground-transported trauma patients showed sustained improvement in mortality. Modifications to state protocols were associated with decreased helicopter EMS use and overall improved trauma patient outcomes. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Major genitourinary-related bicycle trauma: Results from 20 years at a level-1 trauma center.

PubMed

Osterberg, E Charles; Awad, Mohannad A; Gaither, Thomas W; Sanford, Thomas; Alwaal, Amjad; Hampson, Lindsay A; Yoo, Jennie; McAninch, Jack W; Breyer, Benjamin N

2017-01-01

Epidemiological studies have shown that bicycle trauma is associated with genitourinary (GU) injuries. Our objective is to characterize GU-related bicycle trauma admitted to a level I trauma center. We queried a prospective trauma registry for bicycle injuries over a 20-year period. Patient demographics, triage data, operative interventions and hospital details were collected. In total, 1659 patients were admitted with major bicycle trauma. Of these, 48 cases involved a GU organ, specifically the bladder (n=7), testis (n=6), urethra (n=3), adrenal (n=4) and/or kidneys (n=36). The median age of cyclists with GU injuries was 29 (range 5-70). More men were injured versus women (35 versus 13). GU-related bicycle trauma involved a motor vehicle in 52% (25/48) of injuries. The median injury severity score for GU-related bicycle trauma was 17 (range 1-50). The median number of concomitant organ injuries was 2 (range 0-6), the most common of which was the lungs (13/48, 27%) and ribs (13/48, 27%). The majority of GU injured cyclists were admitted to an ICU (15/48, 31%) or hospital floor (12/48, 25%). Operative intervention for a GU-related trauma was low (12/48, 25%). The most common GU organ injured was the kidney (36/48, 75%) however most were managed nonoperatively (33/36, 92%). Bladder injuries most often required operative intervention (6/7, 86%). Mortality following GU-related bicycle trauma was low (2/48, 4%). In a large series of bicycle trauma, GU organs were injured in 3% of cases. The majority of cases were managed non-operatively and mortality was low. Published by Elsevier Ltd.

A Civilian/Military Trauma Institute: National Trauma Coordinating Center

DTIC Science & Technology

2012-10-01

the variation in practices for DVT screening, and there was another paper which talks about variation in practices about pain management for rib ...pelvic fractures , and long bone extremity fractures (femur or tibia). TBI was chosen as it is the most common cause of death and disability in...trauma patients, while hemorrhage is the second leading cause of death. Fractures were chosen as they represent a common injury in trauma patients. These

How formative courses about damage control surgery and non-operative management improved outcome and survival in unstable politrauma patients in a Mountain Trauma Center.

PubMed

Bellanova, Giovanni; Buccelletti, Francesco; Berletti, Riccardo; Cavana, Marco; Folgheraiter, Giorgio; Groppo, Francesca; Marchetti, Chiara; Marzano, Amelia; Massè, Alessandro; Musetti, Antonio; Pelanda, Tina; Ricci, Nicola; Tugnoli, Gregorio; Papadia, Damiano; Ramponi, Claudio

2016-01-01

Aim of this study is to analyze how the starting of Course of Trauma in our hospital improved survival and organization in management of polytraumatized patients. We analysed all major trauma patients (Injury Severity Score (Injury Severity Score (ISS)> 15) treated at Emergency Department of the Santa Chiara Hospital between January 2011 and December 2014. The training courses (TC) were named "management of polytrauma" (MP) and "clinical cases discussion" (CCD), and started in November 2013. We divided the patients between two groups: before November 2013 (pre-TC group) and after November 2013 (post-TC group). MTG's courses (EMC accredited), CCD and MP courses started in November 2013. The target of these courses was the multidisciplinary management of polytrauma patient; the courses were addressed to general surgeons, anaesthesiologists, radiologists, orthopaedics and emergency physicians. Respectively 110 and 78 doctors were formed in CCD's and MP's courses. Patients directly transported to our trauma centre rose from 67.5% to 83% (p<0,005), and E-FAST grew from 15.6% in the pre-TC group to 51.3% in the post-TC group. Time of access in operatory theatre decreased from 62 to 44 minutes. Early Mortality (within 48 hours from the hospital arrival) was 9% in the pre-TC group and 4.5% in the post-tc group (p<0.005). Be needed to complete our goal. Further analysis and possible comparison with other trauma centers be needed to complete our goal Our results show that in our experience the multidisciplinary approach to polytrauma patients increased early survival and improved outcome with an evidence of worker's satisfaction. However, the best practice would ask to start with the approval of procedures and guidelines by the hospital governance, followed by clinical practice changes, in order to create a dedicated emergency and trauma surgery group. Damage Control Surgery, Non Operative Management, Trauma Course, Trauma Team, Trauma Center.

Implementation of a nationwide trauma network for the care of severely injured patients.

PubMed

Ruchholtz, Steffen; Lefering, Rolf; Lewan, Ulrike; Debus, Florian; Mand, Carsten; Siebert, Hartmut; Kühne, Christian A

2014-06-01

Regional differences in the care of severely injured patients remain problematic in industrial countries. In 2006, the German Society for Trauma Surgery initiated the foundation of regional networks between trauma centers in a TraumaNetwork (TNW). The TNW consisted of five major elements as follows: (a) a whitebook on the treatment of severely injured patients; (b) evidence-based guidelines (S3); (c) local audits; (d) contracts of interhospital cooperation among all participating hospitals; and (e) TraumaRegister documentation. TNW hospitals are classified according to local audit results as supraregional (STC), regional (RTC), or local (LTC) trauma centers by criteria concerning staff, equipment, admission capacity, and responsibility. Five hundred four German trauma centers (TCs) were certified by the end of December 2012. By then, 37 regional TNWs, with a mean of 13.6 TCs, were established, covering approximately 80% of the country's territory. Of the hospitals, 92 were acknowledged as STCs, 210 as RTCs, and 202 as LTCs.In 2012, 19,124 patients were documented by the certified TCs. Fifty-seven percent of the patients were treated in STCs, 34% in RTCs, and 9% in LTCs. The mean (SD) Injury Severity Score (ISS) was highest in STCs (21 [13]), compared with 18 (12) in RTCs and 16 (10) in LTCs. There were differences in expected mortality (based on Revised Injury Severity Classification) according to the differences in the severity of trauma among the different categories, but in all types, the expected mortality was significantly higher than the observed mortality (differences in STCs, 1.8%; RTCs, 1.4%; LTCs, 2.0%). According to our findings, it is possible to successfully structure and standardize the care of severely injured patients in a nationwide trauma system. Better outcomes than expected were observed in all categories of TNW hospitals. Epidemiologic study, level III. Therapeutic/care management study, level IV.

Analyzing fat embolism syndrome in trauma patients at AIIMS Apex Trauma Center, New Delhi, India

PubMed Central

Gupta, Babita; D’souza, Nita; Sawhney, Chhavi; Farooque, Kamran; Kumar, Ajeet; Agrawal, Pramendra; Misra, M C

2011-01-01

Background: Fat embolism syndrome (FES) is a constellation of symptoms and signs subsequent to orthopedic trauma. Materials and Methods: The clinical profile of FES in the trauma population was studied over 2 years and 8 months. Results: The incidence of FES among all patients with long bone and pelvic fractures was 0.7% (12). The mean injury severity score was 10.37 (SD 1.69) (range 9-14). The diagnosis of FES was made by clinical and laboratory criteria. Hypoxia was the commonest presentation (92%). The average days of onset of symptoms were 3.5 (SD1.29) days. Management included ventilator support in 75%, average ventilator days being 7.8 (SD 4.08) days. The average ICU stay and hospital stay were 9.1 days and 29.7 days, respectively. A mortality of 8.3% (1) was observed. Conclusion: Fat embolism remains a diagnosis of exclusion and is a clinical dilemma. Clinically apparent FES is unusual and needs high index of suspicion, especially in long bone and pelvic fractures. PMID:21887021

Chronic stressors and trauma: prospective influences on the course of bipolar disorder

PubMed Central

Gershon, A.; Johnson, S. L.; Miller, I.

2013-01-01

Background Exposure to life stress is known to adversely impact the course of bipolar disorder. Few studies have disentangled the effects of multiple types of stressors on the longitudinal course of bipolar I disorder. This study examines whether severity of chronic stressors and exposure to trauma are prospectively associated with course of illness among bipolar patients. Method One hundred and thirty-one participants diagnosed with bipolar I disorder were recruited through treatment centers, support groups and community advertisements. Severity of chronic stressors and exposure to trauma were assessed at study entry with in-person interviews using the Bedford College Life Event and Difficulty Schedule (LEDS). Course of illness was assessed by monthly interviews conducted over the course of 24 months (over 3000 assessments). Results Trauma exposure was related to more severe interpersonal chronic stressors. Multiple regression models provided evidence that severity of overall chronic stressors predicted depressive but not manic symptoms, accounting for 7.5% of explained variance. Conclusions Overall chronic stressors seem to be an important determinant of depressive symptoms within bipolar disorder, highlighting the importance of studying multiple forms of life stress. PMID:23419615

Does Weather Matter? The Effect of Weather Patterns and Temporal Factors on Pediatric Orthopedic Trauma Volume

PubMed Central

Livingston, Kristin S.; Miller, Patricia E.; Lierhaus, Anneliese; Matheney, Travis H.; Mahan, Susan T.

2016-01-01

Objectives: Orthopaedists often speculate how weather and school schedule may influence pediatric orthopedic trauma volume, but few studies have examined this. This study aims to determine: how do weather patterns, day, month, season and public school schedule influence the daily frequency of pediatric orthopedic trauma consults and admissions? Methods: With IRB approval, orthopedic trauma data from a level 1 pediatric trauma center, including number of daily orthopedic trauma consults and admissions, were collected from July 2009 to March 2012. Historical weather data (high temperatures, precipitation and hours of daylight), along with local public school schedule data were collected for the same time period. Univariate and multivariate regression models were used to show the average number of orthopedic trauma consults and admissions as a function of weather and temporal variables. Results: High temperature, precipitation, month and day of the week significantly affected the number of daily consults and admissions. The number of consults and admissions increased by 1% for each degree increase in temperature (p=0.001 and p<0.001, respectively), and decreased by 21% for each inch of precipitation (p<0.001, p=0.006). Daily consults on snowy days decreased by an additional 16% compared to days with no precipitation. November had the lowest daily consult and admission rate, while September had the highest. Daily consult rate was lowest on Wednesdays and highest on Saturdays. Holiday schedule was not independently significant. Conclusion: Pediatric orthopedic trauma consultations and admissions are highly linked to temperature and precipitation, as well as day of the week and time of year. PMID:27990193

Pacopampa: Early evidence of violence at a ceremonial site in the northern Peruvian highlands

PubMed Central

Uzawa, Kazuhiro; Seki, Yuji; Morales Chocano, Daniel

2017-01-01

Objectives Pacopampa, a ceremonial complex in Peru’s northern highlands, reveals early evidence of trauma in the Middle to Late Formative Period coinciding with the emergence of social stratification in the area. We examine the prevalence of trauma in human remains found at the site and present evidence of the circumstances surrounding the deaths of individuals who lived during the early stages of Andean civilization. Materials and methods The materials are the remains of 104 individuals (38 non-adult and 66 adult) from the Middle to Late Formative Periods. We explored trauma macroscopically and recorded patterns based on skeletons’ locations, age at death, sex, social class, and chronology. Results We detected trauma in remains over the Middle to Late Formative Periods. While the prevalence of trauma was minimal in the Middle Formative Period, skeletons from the subsequent era exhibit more severe disturbances. However, all the skeletons show signs of healing and affected individuals experienced a low degree of trauma. Discussion Given the archaeological context (the remains were recovered from sites of ceremonial practices), as well as the equal distribution of trauma among both sexes and a lack of defensive architecture, it is plausible that rituals, rather than organized warfare or raids, caused most of the exhibited trauma. Pacopampa was home to a complex society founded on ritual activity in a ceremonial center: this is indicated by the presence of ritual violence in a society that built impressively large, ceremonial architecture and developed social stratification without any political control of surplus agricultural goods. PMID:28957380

Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol.

PubMed

Pannu, Gurpal S; Shah, Mitesh P; Herman, Marty J

Cervical spine clearance in the pediatric trauma patient represents a particularly challenging task. Unfortunately, standardized clearance protocols for pediatric cervical clearance are poorly reported in the literature and imaging recommendations demonstrate considerable variability. With the use of a web-based survey, this study aims to define the methods utilized by pediatric trauma centers throughout North America. Specific attention was given to the identification of personnel responsible for cervical spine care, diagnostic imaging modalities used, and the presence or absence of a written pediatric cervical spine clearance protocol. A 10-question electronic survey was given to members of the newly formed Pediatric Cervical Spine Study Group, all of whom are active POSNA members. The survey was submitted via the online service SurveyMonkey (https://www.surveymonkey.com/r/7NVVQZR). The survey assessed the respondent's institution demographics, such as trauma level and services primarily responsible for consultation and operative management of cervical spine injuries. In addition, respondents were asked to identify the protocols and primary imaging modality used for cervical spine clearance. Finally, respondents were asked if their institution had a documented cervical spine clearance protocol. Of the 25 separate institutions evaluated, 21 were designated as level 1 trauma centers. Considerable variation was reported with regards to the primary service responsible for cervical spine clearance. General Surgery/Trauma (44%) is most commonly the primary service, followed by a rotating schedule (33%), Neurosugery (11%), and Orthopaedic Surgery (8%). Spine consults tend to be seen most commonly by a rotating schedule of Orthopaedic Surgery and Neurosurgery. The majority of responding institutions utilize computed tomographic imaging (46%) as the primary imaging modality, whereas 42% of hospitals used x-ray primarily. The remaining institutions reported using a combination of x-ray and computed tomographic imaging. Only 46% of institutions utilize a written, standardized pediatric cervical spine clearance protocol. This study demonstrates a striking variability in the use of personnel, imaging modalities and, most importantly, standardized protocol in the evaluation of the pediatric trauma patient with a potential cervical spine injury. Cervical spine clearance protocols have been shown to decrease the incidence of missed injuries, minimize excessive radiation exposure, decrease the time to collar removal, and lower overall associated costs. It is our opinion that development of a task force or multicenter research protocol that incorporates existing evidence-based literature is the next best step in improving the care of children with cervical spine injuries. Level 4-economic and decision analyses.

Meta-analysis of Dropout in Treatments for Post-traumatic Stress Disorder

PubMed Central

Imel, Zac E.; Laska, Kevin; Jakcupcak, Matthew; Simpson, Tracy L.

2013-01-01

Objective Many patients dropout of treatments for Post-traumatic stress disorder (PTSD) and some clinicians believe that ‘trauma focused’ treatments increase dropout. Method We conducted a meta-analysis of dropout among active treatments in clinical trials for PTSD (42 studies; 17 direct comparisons). Results The average dropout rate was 18%, but it varied significantly across studies. Group modality and greater number of sessions, but not trauma focus, predicted increased dropout. When the meta-analysis was restricted to direct comparisons of active treatments, there were no differences in dropout. Differences in trauma focus between treatments in the same study did not predict dropout. However, trauma focused treatments resulted in higher dropout as compared to Present Centered Therapy (PCT) – a treatment originally designed as a control, but now listed as a research supported intervention for PTSD. Conclusion Dropout varies between active interventions for PTSD across studies, but differences are primarily driven by differences between studies. There do not appear to be systematic differences across active interventions when they are directly compared in the same study. The degree of clinical attention placed on the traumatic event does not appear to be a primary cause of dropout from active treatments. However comparisons of PCT may be an exception to this general pattern, perhaps due to a restriction of variability in trauma focus among comparisons of active treatments. More research is needed comparing trauma focused interventions to trauma avoidant treatments such as PCT. PMID:23339535

Association of depressive symptomology and psychological trauma with diabetes control among older American Indian women: Does social support matter?

PubMed Central

Noonan, Carolyn; Gonzales, Kelly; Winchester, Blythe; Bradley, Vickie L.

2017-01-01

Aims Among older American Indian women with type 2 diabetes (T2DM), we examined the association between mental health and T2DM control and if social support modifies the association. Methods Survey data were linked to T2DM medical record information. Mental health measures were the Center for Epidemiologic Studies – Depression Scale and the National Anxiety Disorders Screening Day instrument. T2DM control was all HbA1c values taken post mental health measures. Results There was not a significant association between depressive symptomatology and higher HbA1c although increased depressive symptomatology was associated with higher HbA1c values among participants with low social support. There was a significant association between psychological trauma and higher HbA1c values 12 months [mean 7.5, 95% CI 7.0–8.0 for no trauma vs. mean 7.0, 95% CI 6.3–7.6 for trauma with no symptoms vs. mean 8.4, 95% CI 7.7–9.1 for trauma with =1 symptom(s)] and 6 months later [mean 7.2, 95% CI 6.7–7.7 for no trauma vs. mean HbA1c 6.8, 95% CI 6.2–7.4 for trauma with no symptoms vs. mean 8.4, 95% CI 7.6–9.2 for trauma with ≥1 symptom(s)]. High social support attenuated the association between psychological trauma and HbA1c values. Conclusions T2DM programs may consider activities that would strengthen participants’ social support and thereby building on an intrinsic community strength. PMID:28161383

Perspectives on trauma-informed care from mothers with a history of childhood maltreatment: a qualitative study.

PubMed

Muzik, Maria; Ads, Menatalla; Bonham, Caroline; Lisa Rosenblum, Katherine; Broderick, Amanda; Kirk, Rosalind

2013-12-01

Women who experienced abuse or neglect as children are more likely to have health problems during pregnancy and postpartum, but can be reluctant to seek help due to a lack of trauma-informed services. As part of a larger mixed method study, this component aimed to obtain qualitative data from trauma-exposed new mothers about their health care preferences during the perinatal period with the ultimate goal to design personalized, supportive interventions. Fifty-two trauma-exposed mothers completed a semi-structured interview at seven months postpartum about health care preferences including ideas for programs that promote wellness, thoughts about the influences of being a new mother and possible names for a program serving trauma-exposed mothers. Interviews were transcribed and coded using N-Vivo. Participants described ambivalence about seeking help but also a sincere desire for healing, coupled with hope for the future. This tension was apparent in the discussions highlighting the importance of access to experienced, nonjudgmental, and knowledgeable health and social care staff and volunteers, the wish for both formal, integrated physical and mental health services, and for informal opportunities to meet other trauma-exposed mothers in a non-stigmatizing, child-friendly setting. Finally, positive relationship-building, respect, and safety were identified as key elements of services critical to counteract trauma-related shame and mistrust in others. Services for trauma-exposed mothers should acknowledge the normal ambivalence surrounding seeking help, but promote hope-affirming practices in a family-centered, safe, non-clinical setting that involves children, builds social support, and provides peer interaction. Program names should reflect optimism and healing rather than trauma. Copyright © 2013 Elsevier Ltd. All rights reserved.

Evaluation of a Mature Trauma System

PubMed Central

Durham, Rodney; Pracht, Etienne; Orban, Barbara; Lottenburg, Larry; Tepas, Joseph; Flint, Lewis

2006-01-01

Introduction: An effective trauma system should offer patients triaged to a trauma center (TC) a survival advantage and cost-effective treatment. Three questions were asked: 1) Does treatment at a TC versus a nontrauma center (NTC) improve survival? 2) Is the system cost-effective? 3) Is access to the system equitable? Methods: The 2003 Florida discharge database identified patients with ICD9 codes 800 to 959. Survival risk ratios (SRR) were calculated using1999–2000 data and ICISS were produced for each code. Using 2003 data, mortality rates were calculated for matched patients at TCs and NTCs. Instrumental variables methodology was used to account for differences in mortality risks of patients triaged to TCs versus NTCs. Logistic regression analysis was used to determine differences in mortality. Charge/cost ratios were analyzed to compute the cost care and cost/life saved. Accessibility to a TC within 85 minutes of injury was assessed. Results: Treatment at a TC was associated with an 18% reduction in mortality. Mean costs of care in TCs and NTCs were $11,910 and $6019, respectively. Dividing the mean cost difference by the reduction in mortality yields a cost of $34,887/life saved. A total of 42% of patients returned to work within 24 months of injury. Using an expected median of 19 years of employment for a 33-year-old individual and proposed state funding figures for the trauma system, a life saved results in an approximate annual cost to the state of between $100 and $500. Currently, 95% of citizens of the state have access to the trauma system within 85 minutes of injury; however, only 38% of trauma patients are triaged to a TC. Addition of 3 TCs would increase these percentages to 99% and 65%. Conclusions: Triage to a Florida TC is associated with a decreased risk of death. Moreover, cost/life year saved is favorable when compared with societal expenditures for other health problems. Improved deployment of TCs is necessary to optimize access. This assessment methodology is a useful model for evaluation of mature trauma systems. PMID:16772781

The effect of hospital care on early survival after penetrating trauma.

PubMed

Clark, David E; Doolittle, Peter C; Winchell, Robert J; Betensky, Rebecca A

2014-12-01

The effectiveness of emergency medical interventions can be best evaluated using time-to-event statistical methods with time-varying covariates (TVC), but this approach is complicated by uncertainty about the actual times of death. We therefore sought to evaluate the effect of hospital intervention on mortality after penetrating trauma using a method that allowed for interval censoring of the precise times of death. Data on persons with penetrating trauma due to interpersonal assault were combined from the 2008 to 2010 National Trauma Data Bank (NTDB) and the 2004 to 2010 National Violent Death Reporting System (NVDRS). Cox and Weibull proportional hazards models for survival time (t SURV ) were estimated, with TVC assumed to have constant effects for specified time intervals following hospital arrival. The Weibull model was repeated with t SURV interval-censored to reflect uncertainty about the precise times of death, using an imputation method to accommodate interval censoring along with TVC. All models showed that mortality was increased by older age, female sex, firearm mechanism, and injuries involving the head/neck or trunk. Uncensored models showed a paradoxical increase in mortality associated with the first hour in a hospital. The interval-censored model showed that mortality was markedly reduced after admission to a hospital, with a hazard ratio (HR) of 0.68 (95% CI 0.63, 0.73) during the first 30 min declining to a HR of 0.01 after 120 min. Admission to a verified level I trauma center (compared to other hospitals in the NTDB) was associated with a further reduction in mortality, with a HR of 0.93 (95% CI 0.82, 0.97). Time-to-event models with TVC and interval censoring can be used to estimate the effect of hospital care on early mortality after penetrating trauma or other acute medical conditions and could potentially be used for interhospital comparisons.

Optimizing the assessment of pediatric injury severity in low-resource settings: Consensus generation through a modified Delphi analysis.

PubMed

St-Louis, Etienne; Deckelbaum, Dan Leon; Baird, Robert; Razek, Tarek

2017-06-01

Although a plethora of pediatric injury severity scoring systems is available, many of them present important challenges and limitations in the low resource setting. Our aim is to generate consensus among a group of experts regarding the optimal parameters, outcomes, and methods of estimating injury severity for pediatric trauma patients in low resource settings. A systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. Qualitative data was extracted from the systematic review, including scoring parameters, settings and outcomes. In order to establish consensus regarding which of these elements are most adapted to pediatric patients in low-resource settings, they were subjected to a modified Delphi survey for external validation. The Delphi process is a structured communication technique that relies on a panel of experts to develop a systematic, interactive consensus method. We invited a group of 38 experts, including adult and pediatric surgeons, emergency physicians and anesthesiologists trauma team leaders from a level 1 trauma center in Montreal, Canada, and a pediatric referral trauma hospital in Santiago, Chile to participate in two successive rounds of our survey. Consensus was reached regarding various features of an ideal pediatric trauma score. Specifically, our experts agreed pediatric trauma scoring tool should differ from its adult counterpart, that it can be derived from point of care data available at first assessment, that blood pressure is an important variable to include in a predictive model for pediatric trauma outcomes, that blood pressure is a late but specific marker of shock in pediatric patients, that pulse rate is a more sensitive marker of hemodynamic instability than blood pressure, that an assessment of airway status should be included as a predictive variable for pediatric trauma outcomes, that the AVPU classification of neurologic status is simple and reliable in the acute setting, and more so than GCS at all ages. Therefore, we conclude that an opportunity exists to develop a new pediatric trauma score, combining the above consensus-generating ideas, that would be best adapted for use in low-resource settings. Copyright © 2017 Elsevier Ltd. All rights reserved.

Management of pericardial fluid in blunt trauma: variability in practice and predictors of operative outcome in patients with computed tomography evidence of pericardial fluid

PubMed Central

Witt, Cordelie E.; Linnau, Ken F.; Maier, Ronald V.; Rivara, Frederick P.; Vavilala, Monica S.; Bulger, Eileen M.; Arbabi, Saman

2017-01-01

Background The objectives of this study were to assess current variability in management preferences for blunt trauma patients with pericardial fluid, and to identify characteristics associated with operative intervention for patients with pericardial fluid on admission computed tomography (CT) scan. Methods This was a mixed-methods study of blunt trauma patients with pericardial fluid. The first portion was a research survey of members of the Eastern Association for the Surgery of Trauma conducted in 2016, in which surgeons were presented with four clinical scenarios of blunt trauma patients with pericardial fluid. The second portion of the study was a retrospective evaluation of all blunt trauma patients ≥14 years treated at our Level I trauma center between 1/1/2010 and 11/1/2015 with pericardial fluid on admission CT scan. Results For the survey portion of our study, 393 surgeons responded (27% response rate). There was significant variability in management preferences for scenarios depicting trace pericardial fluid on CT with concerning hemodynamics, and for scenarios depicting hemopericardium intraoperatively. For the separate retrospective portion of our study, we identified 75 blunt trauma patients with pericardial fluid on admission CT scan. Seven underwent operative management; six of these had hypotension and/or electrocardiogram changes. In multivariable analysis, pericardial fluid amount was a significant predictor of receiving pericardial window (relative risk for one category increase in pericardial fluid amount: 3.99, 95% CI 1.47-10.81) but not of mortality. Conclusions There is significant variability in management preferences for patients with pericardial fluid from blunt trauma, indicating a need for evidence-based research. Our institutional data suggest that patients with minimal to small amounts of pericardial fluid without concerning clinical findings may be observed. Patients with moderate to large amounts of pericardial fluid who are clinically stable with normal hemodynamics may also appear appropriate for observation, although confirmation in larger studies is needed. Patients with hemodynamic instability should undergo operative exploration. Level of Evidence Level IV, Therapeutic/Care Management PMID:28129264

Transforming trauma healthcare delivery in rural areas by use of an integrated call center.

PubMed

Agrawal, Deepak

2012-01-01

There is poor penetration of trauma healthcare delivery in rural areas. On the other hand, mobile penetration in India is now averaging 80% with most families having access to mobile phone. The aim of this study was to assess the implementation and socioeconomic impact of a call center in providing healthcare delivery for patients with head and spinal injuries. This was a prospective observational study carried out over a 6-month period at a level I trauma Center in New Delhi, India. A nine-seater call center was outsourced to a private company and the hospital's electronic medical records were integrated with the call-center operations. The call center was given responsibility of maintaining appointments and scheduling clinics for the whole hospital as well as ensuring follow-up visits. Trained call-center staff handled simple patient queries and referred the rest via email to concerned doctors. A telephonic survey was done prior to the start of call-center operations and after 3 months to assess for user satisfaction. The initial cost of outsourcing the call center was Rs 1.6 lakhs (US$ 4000), with a recurring cost of Rs 80,000 (US$ 2000) per month. A total of 484 patients were admitted in the department of Neurosurgery during the study period. Of these, 63% (n=305) were from rural areas. Patients' overall experience for clinic visits improved markedly following implementation of call center. Patient satisfaction for follow-up visits increased from a mean of 32-96%. Ninety-five percent patients reported a significant decrease in waiting time in clinics 80.4% reporting improved doctor-patient interaction. A total of 52 visits could be postponed/cancelled for patients living in far flung areas resulting in major socioeconomic benefits to these families. As shown by our case study, call centers have the potential to revolutionize delivery of trauma healthcare to rural areas in an extremely cost-effective manner.

Before the bombing: High burden of traumatic injuries in Kunduz Trauma Center, Kunduz, Afghanistan

PubMed Central

Shah, Safieh; Isaakidis, Petros; Das, Mrinalini; Kyaw, Nang Thu Thu; Zaheer, Sattar; Qasemy, Abdul Qayeum; Zakir, Mutallib; Mahama, Gbane; Van Overloop, Catherine; Dominguez, Lynette

2017-01-01

Background Médecins Sans Frontières (MSF) has been providing healthcare in Afghanistan since 1981 including specialized health services for trauma patients in Kunduz Trauma Center (KTC) from 2011. On October 3rd, 2015, a US airstrike hit the KTC, killing 42 people including 14 MSF staff. This study aims to demonstrate the impact on healthcare provision, after hospital destruction, by assessing the extent of care provided for trauma and injuries by the MSF KTC and to report on treatment outcomes from January 2014 to June 2015, three months prior to the bombing. Methods This is a descriptive, retrospective review of hospital records. All patients with traumatic injuries registered in the Emergency Department (ED) or hospitalized in In-Patients Department (IPD) and/or Intensive Care Unit (ICU) of KTC between January 2014 and June 2015 were included in the study. Results A total of 35647 patients were registered in KTC during the study period. 3199 patients registered in the ED were children aged <5 years and 310 of them were admitted including 47 to the ICU. 77.5% patients were from Kunduz province and the remaining were from other provinces. The average length of stay was 7.3 days and 3.3 days while the bed occupancy rate was an average 91.1% and 75.8% in IPD and ICU, respectively. Of 4605 IPD patients, 105 (2.3%) developed complications. Among those admitted to the ICU, 12.6% patients died. About one-third surgical interventions were carried out on an urgent basis and the major proportion (45.8%) of surgical procedures was wound surgery followed by orthopedic surgery (27.0%). Conclusions This study highlights the high burden of traumatic injuries in Kunduz province and MSF Trauma Center’s contribution to saving lives, preventing disabilities and alleviating suffering among adults and children within the region. The bombing and destruction of KTC has resulted in a specific gap in critical healthcare services for the local communities in the health system of this war-ravaged region. This suggests the urgent need for reconstruction and re-opening of the center. PMID:28282377

Which future for traumatology in Europe?

PubMed

Rommens, P M

2014-01-01

The last decades have been characterized by rapid changes in society, medicine and surgery. There is a distinct evolution towards specialization and super-specialization. Trauma surgery also evolves towards a specialty, focused on the care of the injured. To optimize the quality of care and meet the needs of patients and care providers, a well-structured trauma surgery training program as well as the regionalization of trauma care with the implementation of Level I trauma centers are needed. The core competence of the European trauma surgeon is the coordination of the early management of the severely injured and the treatment of muskuloskeletal trauma, which represent the most common pathologies in our countries.

Tips for Teachers during Times of Trauma.

ERIC Educational Resources Information Center

Adkins, Myrna Ann; Harper, Eric

This guide for teachers in times of trauma was updated after the events of September 11, 2001--the terrorist attacks on the World Trade Center and the Pentagon. These traumatic events could cause refugees to experience trauma or become re-traumatized. For many refugees, their English-as-a-Second-Language (ESL) programs are the places where they…

Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes.

PubMed

Wandling, Michael W; Nathens, Avery B; Shapiro, Michael B; Haut, Elliott R

2016-11-01

Rapid transport to definitive care ("scoop and run") versus field stabilization in trauma remains a topic of debate and has resulted in variability in prehospital policy. We aimed to identify trauma systems frequently using a true "scoop and run" police transport approach and to compare mortality rates between police and ground emergency medical services (EMS) transport. Using the National Trauma Databank (NTDB), we identified adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Hospitals were grouped into their respective cities and regional trauma systems. Patients directly transported by police or ground EMS to trauma centers in the 100 most populous US trauma systems were included. Frequency of police transport was evaluated, identifying trauma systems with high utilization. Mortality rates and risk-adjusted odds ratio for mortality for police versus EMS transport were derived. Of 88,564 total patients, 86,097 (97.2%) were transported by EMS and 2,467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS. After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit). Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS. Risk-adjusted mortality was no different (OR = 1.01, 95% CI: 0.68-1.50). Using trauma system-level analyses, patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport. The majority of prehospital police transport in penetrating trauma occurs in three trauma systems. These cities represent ideal sites for additional system-level evaluation of prehospital transport policies. Prognostic/epidemiologic study, level III.

Criminal Behavior and Repeat Violent Trauma: A Case-Control Study.

PubMed

Nanney, John T; Conrad, Erich J; McCloskey, Michael; Constans, Joseph I

2015-09-01

Repeat violent injury is common among young urban men and is increasingly a focus of trauma center-based injury prevention efforts. Though understanding risk factors for repeat violent injury may be critical in designing such interventions, this knowledge is limited. This study aims to determine which criminal behaviors, both before and after the initial trauma, predict repeat violent trauma. Gun, violent, and drug crimes are expected to increase risk of subsequent violent injury among victims of violence. A case-control design examined trauma registry and publicly available criminal data for all male patients aged <40 years presenting for violent trauma between April 2006 and December 2011 (N=1,142) to the sole Level 1 trauma center in a city with high rates of violence. Logistic regression was used to determine criminal behaviors predictive of repeat violent injury. Data were obtained and analyzed between January 2013 and June 2014. Regarding crimes committed before the first injury, only drug crime (OR=5.32) predicted repeat violent trauma. With respect to crimes committed after the initial injury, illegal gun possession (OR=2.70) predicted repeat victimization. Initiating gun (OR=3.53) or drug crime (OR=5.12) was associated with increased risk. Prior drug involvement may identify young male victims of violence as at high risk of repeat violent injury. Gun carrying and initiating drug involvement after the initial injury may increase risk of repeat injury and may be important targets for interventions aimed at preventing repeat violent trauma. Published by Elsevier Inc.

Investigating the relationship between weather and violence in Baltimore, Maryland, USA.

PubMed

Michel, Samuel J; Wang, Han; Selvarajah, Shalini; Canner, Joseph K; Murrill, Matthew; Chi, Albert; Efron, David T; Schneider, Eric B

2016-01-01

It is a common refrain at major urban trauma centers that caseloads increase in the heat of the summer. Several previous studies supported this assertion, finding trauma admissions and crime to correlate positively with temperature. We examined links between weather and violence in Baltimore, MD, through trauma presentation to Johns Hopkins Hospital and crime reports filed with the Baltimore Police Department. Crime data were obtained from the Baltimore City Police Department from January 1, 2008 to March 31, 2013. Trauma data were obtained from a prospectively collected registry of all trauma patients presenting to Johns Hopkins Hospital from January 1, 2007 to March 31, 2013. Weather data were obtained from the National Climatic Data Center. Correlation coefficients were calculated and negative binomial regression was used to elucidate the independent associations of weather and temporal variables with the trauma and crime data. When adjusting for temporal and meteorological factors, maximum daily temperature was positively associated with total trauma, intentional injury, and gunshot wounds presenting to Johns Hopkins Hospital along with total crime, violent crime, and homicides in Baltimore City. Associations of average wind speed, daily precipitation, and daily snowfall with trauma and crime were far weaker and, when significant, nearly universally negative. Maximum daily temperature is the most important weather factor associated with violence and trauma in our study period and location. Our findings suggest potential implications for hospital staffing to be explored in future studies. Copyright © 2015 Elsevier Ltd. All rights reserved.

Journalists and trauma: a brief overview.

PubMed

Czech, Ted

2004-01-01

In the past decade, journalism experts realized what those in the fields of emergency response and management have known for much longer: That journalists could be psychologically affected by the traumatic events they covered. Although a fledging field of study, groups such as the Dart Center for Journalism and Trauma, based at the University of Washington, in Seattle, WA, have dedicated themselves to advocating the ethical and thorough reporting of trauma, educating working journalists about trauma and serving as a forum for journalists to discuss topics related to covering traumatic events. The three major studies conducted on the subject--focusing on print journalists, photojournalists, and war journalists--have discovered that journalists can suffer sleeplessness, flashbacks, and in most extreme cases, posttraumatic stress disorder. According to Dr. Roger Simpson, director of the Dart Center, there is much work still to be done on the subject.

Dissecting delays in trauma care using corporate lean six sigma methodology.

PubMed

Parks, Jennifer K; Klein, Jorie; Frankel, Heidi L; Friese, Randall S; Shafi, Shahid

2008-11-01

The Institute of Medicine has identified trauma center overcrowding as a crisis. We applied corporate Lean Six Sigma methodology to reduce overcrowding by quantifying patient dwell times in trauma resuscitation units (TRU) and to identify opportunities for reducing them. TRU dwell time of all patients treated at a Level I trauma center were measured prospectively during a 3-month period (n = 1,184). Delays were defined as TRU dwell time >6 hours. Using personnel trained in corporate Lean Six Sigma methodology, we created a detailed process map of patient flow through our TRU and measured time spent at each step prospectively during a 24/7 week-long time study (n = 43). Patients with TRU dwell time below the median (3 hours) were compared with those with longer dwell times to identify opportunities for improvement. TRU delays occurred in 183 of 1,184 trauma patients (15%), and peaked on days with >15 patients or with presence of five simultaneous patients. However, 135 delays (74%) occurred on days when

Adrenal trauma: Elvis Presley Memorial Trauma Center experience.

PubMed

Mehrazin, Reza; Derweesh, Ithaar H; Kincade, Matthew C; Thomas, Adam C; Gold, Robert; Wake, Robert W

2007-11-01

Adrenal gland injury is a potentially devastating event if unrecognized in the treatment course of a trauma patient. We reviewed our single-center experience and outcomes in patients with adrenal gland trauma. We performed a retrospective review of all patients presenting with trauma to the Regional Medical Center at Memphis who had adrenal gland injuries from January 1991 through March 2006. Each chart was reviewed with attention to the demographics, associated injuries, complications, and outcomes. Patients were stratified into two subgroups according to age (35 years or younger and older than 35 years) to allow for an age-based comparison between the two groups. Of 58,000 patients presenting with trauma, 130 (0.22%) were identified with adrenal injuries, of which 8 (6.2%) were isolated and 122 (93.8%) were not. Of these 130 patients, 125 (96.2%) had their injury diagnosed by computed tomography and 5 (3.8%) had their injury diagnosed during exploratory laparotomy. Right-sided injuries predominated (78.5%), with six (4.6%) bilateral. Four patients (3.1%) underwent adrenalectomy. Seven patients (5.4%) with adrenal injuries died. One patient (0.77%) required chronic steroid therapy. Patients older than 35 years were more likely to have complications such as deep venous thrombosis, pneumonia, and urinary tract infections. Patient age of 35 years or younger was associated with a significantly increased incidence of liver lacerations. Adrenal gland injury is uncommon, although mostly associated with greater injury severity. Although adding to morbidity, most are self-limited and do not require intervention.

National Trauma Institute: A National Coordinating Center for Trauma Research Funding

DTIC Science & Technology

2013-10-01

identified as the key regulator of iron homeostasis, and plays a major role in how and why anemia develops. Hepcidin reduces iron availability by: (1...cells. High levels of hepcidin induce a state of functional iron deficiency . Hepcidin is increased in states of inflammation, and likely plays an...elevated in trauma, this will confirm that inability to use iron stores is key to the anemia of trauma. Dr Napolitano suspects that hepcidin will be

Role of ERCP in pediatric blunt abdominal trauma: a case series at a level one pediatric trauma center.

PubMed

Garvey, Erin M; Haakinson, Danielle J; McOmber, Mark; Notrica, David M

2015-02-01

There is no consensus regarding the appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) in pediatric trauma. We report our experience with ERCP for management of pediatric pancreatic and biliary injury following blunt abdominal trauma. A retrospective chart review was performed for pediatric patients with blunt abdominal trauma from July 2008 through December 2012 at our pediatric trauma center. For patients who underwent ERCP, demographics, injury characteristics, diagnostic details, procedures performed, length of stay, total parenteral nutrition use, and complications were reviewed. There were 532 patients identified: 115 hepatic injuries, 25 pancreatic injuries and one gall bladder injury. Nine patients (mean age 7.8 years) underwent ERCP. Seven (78%) had pancreatic injuries, while two (22%) had bilateral hepatic duct injuries. The median time to diagnosis was one day (range, 0-12). Diagnostic ERCP only was performed in three patients, two of which proceeded to distal pancreatectomy. Five patients had stents placed (two biliary and three pancreatic) and four sphincterotomies were performed. Despite pancreatic stenting, one patient required distal pancreatectomy for persistent leak. Median length of stay was 11 days. Pediatric pancreatic and biliary ductal injuries following blunt abdominal trauma are uncommon. ERCP can safely provide definitive treatment for some patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Evaluation of trauma care using TRISS method: the role of adjusted misclassification rate and adjusted w-statistic.

PubMed

Llullaku, Sadik S; Hyseni, Nexhmi Sh; Bytyçi, Cen I; Rexhepi, Sylejman K

2009-01-15

Major trauma is a leading cause of death worldwide. Evaluation of trauma care using Trauma Injury and Injury Severity Score (TRISS) method is focused in trauma outcome (deaths and survivors). For testing TRISS method TRISS misclassification rate is used. Calculating w-statistic, as a difference between observed and TRISS expected survivors, we compare our trauma care results with the TRISS standard. The aim of this study is to analyze interaction between misclassification rate and w-statistic and to adjust these parameters to be closer to the truth. Analysis of components of TRISS misclassification rate and w-statistic and actual trauma outcome. The component of false negative (FN) (by TRISS method unexpected deaths) has two parts: preventable (Pd) and non-preventable (nonPd) trauma deaths. Pd represents inappropriate trauma care of an institution; otherwise nonpreventable trauma deaths represents errors in TRISS method. Removing patients with preventable trauma deaths we get an Adjusted misclassification rate: (FP + FN - Pd)/N or (b+c-Pd)/N. Substracting nonPd from FN value in w-statistic formula we get an Adjusted w-statistic: [FP-(FN - nonPd)]/N, respectively (FP-Pd)/N, or (b-Pd)/N). Because adjusted formulas clean method from inappropriate trauma care, and clean trauma care from the methods error, TRISS adjusted misclassification rate and adjusted w-statistic gives more realistic results and may be used in researches of trauma outcome.

Feasibility Study and Demonstration Project for Joint Military/Civilian Trauma Institute with a Burn Center

DTIC Science & Technology

2008-10-01

Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std. Z39.18 3 Table of Contents ...Protocols and Restrictive Blood Transfusion Strategies on Glucose Measurement in American Burn Association ( ABA ) Verified Burn 13 Centers. Journal...civilian experts in trauma care as well as policy makers and include: CAPT (Ret) Frank Butler, Col (Ret) Donald Jenkins, COL (Ret) John Holcomb, Dr. Basil

Major Extremity Trauma Research Consortium (METRC) 2011 Annual Report

DTIC Science & Technology

2011-01-01

military treatment centers (MTFs). METRC is designed to meet these needs. Anchored by a Data Coordinating Center at the Johns Hopkins Bloomberg...talus or crush injuries only). Excluded from the registry are hip fractures in patients 60 years or older and fractures to the wrist, hand, ankle ...OUTLET: Outcomes following severe distal tibia, ankle and/or foot trauma: comparison of limb salvage vs. transtibial amputation STATUS: Master protocol

Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center

PubMed Central

Wang, Hao; Coppola, Marco; Robinson, Richard D.; Scribner, James T.; Vithalani, Veer; de Moor, Carrie E.; Gandhi, Raj R.; Burton, Mandy; Delaney, Kathleen A.

2013-01-01

Background It has been found that significantly different clinical outcomes occur in trauma patients with different mechanisms of injury. Ground level falls (GLF) are usually considered “minor trauma” with less injury occurred in general. However, it is not uncommon that geriatric trauma patients sustain cervical spine (C-spine) fractures with other associated injuries due to GLF or less. The aim of this study is to determine the injury patterns and the roles of clinical risk factors in these geriatric trauma patients. Methods Data were reviewed from the institutional trauma registry of our local level 1 trauma center. All patients had sustained C-spine fracture(s). Basic clinical characteristics, the distribution of C-spine fracture(s), and mechanism of injury in geriatric patients (65 years or older) were compared with those less than 65 years old. Furthermore, different clinical variables including age, gender, Glasgow coma scale (GCS), blood alcohol level, and co-existing injuries were analyzed by multivariate logistic regression in geriatric trauma patients due to GLF and internally validated by random bootstrapping technique. Results From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). Furthermore, 53.96% (75/139) geriatric patients had sustained C-spine fractures due to GLF with more upper C-spine fractures (C1 and C2). Only 3.2% of those had positive blood alcohol levels compared with 52.9% of younger patients (P < 0.001). In addition, 6.34% of geriatric patients due to GLF had intracranial pathology (ICP) which was one of the most common co-injuries with C-spine fractures. Logistic regression analysis showed the adjusted odds ratios of 1.17 (age) and 91.57 (male) in geriatric GLF patients to predict this co-injury pattern of C-spine fracture and ICP. Conclusion Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients. PMID:23519239

Trauma center maturity measured by an analysis of preventable and potentially preventable deaths: there is always something to be learned….

PubMed

Matsumoto, Shokei; Jung, Kyoungwon; Smith, Alan; Coimbra, Raul

2018-06-23

To establish the preventable and potentially preventable death rates in a mature trauma center and to identify the causes of death and highlight the lessons learned from these cases. We analyzed data from a Level-1 Trauma Center Registry, collected over a 15-year period. Data on demographics, timing of death, and potential errors were collected. Deaths were judged as preventable (PD), potentially preventable (PPD), or non-preventable (NPD), following a strict external peer-review process. During the 15-year period, there were 874 deaths, 15 (1.7%) and 6 (0.7%) of which were considered PPDs and PDs, respectively. Patients in the PD and PPD groups were not sicker and had less severe head injury than those in the NPD group. The time-death distribution differed according to preventability. We identified 21 errors in the PD and PPD groups, but only 61 (7.3%) errors in the NPD group (n = 853). Errors in judgement accounted for the majority and for 90.5% of the PD and PPD group errors. Although the numbers of PDs and PPDs were low, denoting maturity of our trauma center, there are important lessons to be learned about how errors in judgment led to deaths that could have been prevented.

[Polytrauma in children and adolescents. Choice of the primary care clinic and importance of pediatric traumatology competence centers].

PubMed

Debus, F; Lefering, R; Frink, M; Kühne, C; Mand, C; Ruchholtz, S

2015-05-01

The number of (seriously) injured children increased again for the first time in 2011. The aim of this study was to analyse differences compared to multiple injured adults and to show the reality of daily treatment. All cases of the DGU Trauma Registry from the years 1997 to 2010 were examined. The documented cases were divided into different the age groups. The study investigated, e.g. the mechanism of accident, injury pattern, the number of hospital and ICU days, and lethality. At 38.8% the largest percentage of severely injured children and adolescents belongs to the group of 16-17 year olds. The group of 0-5 year olds (15.9%) has the lowest percentage. The most common accident cause was traffic accidents (58.5%). The mechanism of accident and the injury patterns changes with age. Younger patients are often treated in supraregional trauma centers (0-5 year olds: 78.2% vs. 16-17 year olds: 73.1% vs. > 65 years: 63.2%). The average lethality rate was 14.8% (16.3% RISC). The percentage of severely injured children in the overall population is only 7.4%. Because the majority of patients are primarily treated in supraregional trauma centers, trauma centers with specialisation in paediatric traumatology are mandatory.

The complications of trauma and their associated costs in a level I trauma center.

PubMed

O'Keefe, G E; Maier, R V; Diehr, P; Grossman, D; Jurkovich, G J; Conrad, D

1997-08-01

To estimate the expected costs for acute trauma care, to quantify the costs associated with the development of complications in injury victims, and to determine the deficit incurred by patients in whom complications develop. A retrospective, cohort design. A referral trauma center. A total of 12,088 patients admitted to a single regional trauma center during a period of 5 years. This is an observational study, and no interventions specific to this study are included in the design. (1) The expected costs for injury victims based on readily available clinical data. (2) The costs associated with the most important complications of trauma. (3) The effect of complications on inadequate reimbursement for trauma care. The expected costs were estimated using a linear model incorporating demographic variables and measures of injury severity. The expected costs averaged $14,567, and the observed costs averaged $15,032. Six complications were important predictors of cost. These included adult respiratory distress syndrome, acute kidney failure, sepsis, pneumonia, decubitus ulceration, and wound infections. For 1201 individuals with these complications, the predicted costs averaged $23,266 and the observed costs averaged $47,457. The mean excess costs for a single complication ranged from $6669 to $18,052. Multiple complications led to greater increases in excess cost, averaging $110,007 for the 62 patients with 3 or more complications. Costs exceeded reimbursement to a much greater degree in those in whom any of the 6 complications developed. Expected hospital costs can be estimated using admission clinical data. Each of 6 complications was associated with enormous increases in costs, indicating their importance as a cause of avoidable expenditures in injury victims and identifying situations in which reimbursement may not be adequate.

Epidemiology of Aquatic and Recreational Water Sport Injuries: A Case-Control Analysis.

PubMed

Kane, Ian; Ong, Alvin; Radcliff, Kris E; Austin, Luke S; Maltenfort, Mitchell; Tjoumakaris, Fotios

2015-09-01

The purposes of the current investigation are to evaluate the epidemiology of water sport injuries at a coastal tertiary trauma center and to determine the association of these activities with spinal column injury and to determine whether aquatic trauma injuries differ significantly from those that occur terrestrially. A retrospective review of a consecutive series of 105 patients with aquatic-based mechanisms of injury admitted to a Level II trauma center over a 3-year period, as well as a matched control cohort with terrestrial-based mechanisms of injury, was conducted. Patients were treated at a Level II trauma center from January 1, 2008, to December 31, 2010. All patients received a full trauma work-up on arrival. Patients were identified retrospectively from a prospectively collected database (N=5298). Eligible patients were identified from billing/coding data as having mechanisms of injury related to an aquatic setting. Patients were evaluated using standard trauma protocols. Spinal column and cord injury occurrence and differences between groups were reviewed. Personal watercrafts accounted for the majority of injuries (n=39). Cervical (33.3%), closed-head (25.7%), and thoracolumbar (21.9%) injuries accounted for the majority of injury types. The cervical spinal column and the spinal cord were at an increased risk of injury in the aquatic injury cohort (P<.0001). The current data show the high incidence of spinal column and cord injuries in this patient population relative to controls. Practitioners who care for trauma patients near an aquatic environment should be aware of the high prevalence of these injuries, with proper spinal cord preservation protocols in place to optimize outcome. Copyright 2015, SLACK Incorporated.

Hazard Regression Models of Early Mortality in Trauma Centers

PubMed Central

Clark, David E; Qian, Jing; Winchell, Robert J; Betensky, Rebecca A

2013-01-01

Background Factors affecting early hospital deaths after trauma may be different from factors affecting later hospital deaths, and the distribution of short and long prehospital times may vary among hospitals. Hazard regression (HR) models may therefore be more useful than logistic regression (LR) models for analysis of trauma mortality, especially when treatment effects at different time points are of interest. Study Design We obtained data for trauma center patients from the 2008–9 National Trauma Data Bank (NTDB). Cases were included if they had complete data for prehospital times, hospital times, survival outcome, age, vital signs, and severity scores. Cases were excluded if pulseless on admission, transferred in or out, or ISS<9. Using covariates proposed for the Trauma Quality Improvement Program and an indicator for each hospital, we compared LR models predicting survival at 8 hours after injury to HR models with survival censored at 8 hours. HR models were then modified to allow time-varying hospital effects. Results 85,327 patients in 161 hospitals met inclusion criteria. Crude hazards peaked initially, then steadily declined. When hazard ratios were assumed constant in HR models, they were similar to odds ratios in LR models associating increased mortality with increased age, firearm mechanism, increased severity, more deranged physiology, and estimated hospital-specific effects. However, when hospital effects were allowed to vary by time, HR models demonstrated that hospital outliers were not the same at different times after injury. Conclusions HR models with time-varying hazard ratios reveal inconsistencies in treatment effects, data quality, and/or timing of early death among trauma centers. HR models are generally more flexible than LR models, can be adapted for censored data, and potentially offer a better tool for analysis of factors affecting early death after injury. PMID:23036828

Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury: a national trauma data bank analysis.

PubMed

Safavi, Arash; Skarsgard, Erik D; Rhee, Peter; Zangbar, Bardiya; Kulvatunyou, Narong; Tang, Andrew; O'Keeffe, Terence; Friese, Randall S; Joseph, Bellal

2016-03-01

Nonoperative management of hemodynamically stable children with Solid Organ Injury (SOI) has become standard of care. The aim of this study is to identify differences in management of children with SOI treated at Adult Trauma Centers (ATC) versus Pediatric Trauma Centers (PTC). We hypothesized that patients treated at ATC would undergo more procedures than PTC. Patients younger than 18 years old with isolated SOI (spleen, liver, kidney) who were treated at level I-II ATC or PTC were identified from the 2011-2012 National Trauma Data Bank. The primary outcome measure was the incidence of operative management. Data was analyzed using multivariate logistic regression analysis. Procedures were defined as surgery or transarterial embolization (TAE). 6799 children with SOI (spleen: 2375, liver: 2867, kidney: 1557) were included. Spleen surgery was performed more frequently at ATC than PTC {101 (7.7%) vs. 52 (4.9%); P=0.007}. After adjusting for potential confounders (grade of injury, age, gender and injury severity score), admission at ATC was associated with higher odds of splenic surgery (OR: 1.5, 95% CI: 1.02-2.25; p=0.03). 11 and 8 children underwent kidney and liver operations respectively. TAE was performed in 17 patients with splenic, 34 with liver and 14 with kidney trauma. There was no practice variation between ATC and PTC regarding kidney and liver operations or TAE incidence. Operative management for SOI was more often performed at ATC. The presence of significant disparity in the management of children with splenic injuries justifies efforts to use these surgeries as a reported national quality indicator for trauma programs. Published by Elsevier Inc.

Improving communication in level 1 trauma centers: replacing pagers with smartphones.

PubMed

Joseph, Bellal; Pandit, Viraj; Khreiss, Mohammad; Aziz, Hassan; Kulvatunyou, Narong; Tang, Andrew; Wynne, Julie; O'Keeffe, Terence; Friese, Randall S; Weinstein, Ronald S; Rhee, Peter

2013-03-01

Communication among healthcare providers continues to change, and 90% of healthcare providers are now carrying cellular phones. Compared with pagers, the rate and amount of information immediately available via cellular phones are far superior. Wireless devices such as smartphones are ideal in acute trauma settings as they can transfer patient information quickly in a coordinate manner to all the team members responsible for patient care. A questionnaire survey was distributed among all the trauma surgeons, surgery residents, and nurse practitioners who were a part of the trauma surgery team at a Level 1 trauma center. Answers to each question were recorded on a 5-point Likert scale. The completed survey questionnaires were analyzed using Statistical Package for Social Sciences software (SPSS version 17; SPSS, Inc., Chicago, IL). The respondents had an overall positive experience with the usage of the third-generation (3G) smartphones, with 94% of respondents in favor of having wireless means of communication at a Level 1 trauma center. Of respondents, 78% found the device very user friendly, 98% stated that use of smartphones had improved the speed and quality of communication, 96% indicated that 3G smartphones were a useful teaching tool, 90% of the individuals felt there was improvement in the physician's response time to both routine and critical patients, and 88% of respondents were aware of the rules and regulations of the Health Insurance Portability and Accountability Act. Smartphones in an acute trauma setting are easy to use and improve the means of communication among the team members by providing accurate and reliable information in real time. Smartphones are effective in patient follow-up and as a teaching tool. Strict rules need to be used to govern the use of smartphones to secure the safety and secrecy of patient information.

Trauma centrality and PTSD in veterans returning from Iraq and Afghanistan.

PubMed

Brown, Adam D; Antonius, Daniel; Kramer, Michael; Root, James C; Hirst, William

2010-08-01

Research has demonstrated that the extent to which an individual integrates a traumatic event into their identity ("trauma centrality") positively correlates with posttraumatic stress disorder (PTSD) symptom severity. No research to date has examined trauma centrality in individuals exposed to combat stress. This study investigated trauma centrality using the abridged Centrality of Event Scale (Berntsen & Rubin, 2006) among Operation Enduring Freedom/Operation Iraqi Freedom combat veterans (n = 46). Multiple regression analyses demonstrated that trauma centrality predicted PTSD symptoms. Trauma centrality and PTSD symptoms remained significantly correlated when controlling for depression in subgroups of veterans with or without probable PTSD. This study replicates and extends findings that placing trauma at the center of one's identity is associated with PTSD symptomatology.

Predictors of Secondary Attention-Deficit/Hyperactivity Disorder in Children and Adolescents 6 to 24 Months after Traumatic Brain Injury

ERIC Educational Resources Information Center

Max, Jeffrey E.; Schachar, Russell J.; Levin, Harvey S.; Ewing-Cobbs, Linda; Chapman, Sandra B.; Dennis, Maureen; Saunders, Ann; Landis, Julie

2005-01-01

Objective: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). Method: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively from 6 to…

Nonparametric estimation of median survival times with applications to multi-site or multi-center studies.

PubMed

Rahbar, Mohammad H; Choi, Sangbum; Hong, Chuan; Zhu, Liang; Jeon, Sangchoon; Gardiner, Joseph C

2018-01-01

We propose a nonparametric shrinkage estimator for the median survival times from several independent samples of right-censored data, which combines the samples and hypothesis information to improve the efficiency. We compare efficiency of the proposed shrinkage estimation procedure to unrestricted estimator and combined estimator through extensive simulation studies. Our results indicate that performance of these estimators depends on the strength of homogeneity of the medians. When homogeneity holds, the combined estimator is the most efficient estimator. However, it becomes inconsistent when homogeneity fails. On the other hand, the proposed shrinkage estimator remains efficient. Its efficiency decreases as the equality of the survival medians is deviated, but is expected to be as good as or equal to the unrestricted estimator. Our simulation studies also indicate that the proposed shrinkage estimator is robust to moderate levels of censoring. We demonstrate application of these methods to estimating median time for trauma patients to receive red blood cells in the Prospective Observational Multi-center Major Trauma Transfusion (PROMMTT) study.

Nonparametric estimation of median survival times with applications to multi-site or multi-center studies

PubMed Central

Choi, Sangbum; Hong, Chuan; Zhu, Liang; Jeon, Sangchoon; Gardiner, Joseph C.

2018-01-01

We propose a nonparametric shrinkage estimator for the median survival times from several independent samples of right-censored data, which combines the samples and hypothesis information to improve the efficiency. We compare efficiency of the proposed shrinkage estimation procedure to unrestricted estimator and combined estimator through extensive simulation studies. Our results indicate that performance of these estimators depends on the strength of homogeneity of the medians. When homogeneity holds, the combined estimator is the most efficient estimator. However, it becomes inconsistent when homogeneity fails. On the other hand, the proposed shrinkage estimator remains efficient. Its efficiency decreases as the equality of the survival medians is deviated, but is expected to be as good as or equal to the unrestricted estimator. Our simulation studies also indicate that the proposed shrinkage estimator is robust to moderate levels of censoring. We demonstrate application of these methods to estimating median time for trauma patients to receive red blood cells in the Prospective Observational Multi-center Major Trauma Transfusion (PROMMTT) study. PMID:29772007

Clinical Gestalt and the Prediction of Massive Transfusion after Trauma

PubMed Central

Pommerening, Matthew J.; Goodman, Michael D.; Holcomb, John B.; Wade, Charles E.; Fox, Erin E.; del Junco, Deborah J.; Brasel, Karen J.; Bulger, Eileen M.; Cohen, Mitch J.; Alarcon, Louis H.; Schreiber, Martin A.; Myers, John G.; Phelan, Herb A.; Muskat, Peter; Rahbar, Mohammad; Cotton, Bryan A.

2016-01-01

Introduction Early recognition and treatment of trauma patients requiring massive transfusion (MT) has been shown to reduce mortality. While many risk factors predicting MT have been demonstrated, there is no universally accepted method or algorithm to identify these patients. We hypothesized that even among experienced trauma surgeons, the clinical gestalt of identifying patients who will require MT is unreliable. Methods Transfusion and mortality outcomes after trauma were observed at 10 U.S. Level-1 trauma centers in patients who survived ≥30 minutes after admission and received ≥1 unit of RBC within 6 hours of arrival. Subjects who received ≥ 10 units within 24 hours of admission were classified as MT patients. Trauma surgeons were asked the clinical gestalt question “Is the patient likely to be massively transfused?” ten minutes after the patients arrival. The performance of clinical gestalt to predict MT was assessed using chi-square tests and ROC analysis to compare gestalt to previously described scoring systems. Results Of the 1,245 patients enrolled, 966 met inclusion criteria and 221 (23%) patients received MT. 415 (43%) were predicted to have a MT and 551(57%) were predicted to not have MT. Patients predicted to have MT were younger, more often sustained penetrating trauma, had higher ISS scores, higher heart rates, and lower systolic blood pressures (all p < 0.05). Gestalt sensitivity was 65.6% and specificity was 63.8%. PPV and NPV were 34.9% and 86.2% respectively. Conclusion Data from this large multicenter trial demonstrates that predicting the need for MT continues to be a challenge. Because of the increased mortality associated with delayed therapy, a more reliable algorithm is needed to identify and treat these severely injured patients earlier. Level of Evidence II; Diagnostic study - Development of diagnostic criteria on basis of consecutive patients (with universally applied reference standard) PMID:25682314

Clinical practice guidelines (CPGs) reduce costs in the management of isolated splenic injuries at pediatric trauma centers.

PubMed

Gutierrez, Ivan M; Zurakowski, David; Chen, Qiaoli; Mooney, David P

2013-02-01

The American Pediatric Surgical Association Trauma Committee proposed the use of a clinical practice guideline (CPG) for the non-operative management of isolated splenic injuries in 1998. An analysis was conducted to determine the financial impact of CPGs on the management of these injuries. The Pediatric Health Information System database, which contains data from 44 children's hospitals, was used to identify children who sustained a graded isolated splenic injury between June 2005 and June 2010. Demographics, length of stay (LOS), readmission rates, and laboratory, imaging, procedural, and total cost data were determined for all hospitals verified as a pediatric trauma center by the American College of Surgeons and/or designated by their local authority. Comparisons were made between facilities self-identifying as having a splenic injury management CPG and those without a CPG. Children (1,154) with isolated splenic injuries (grades 1-4) were cared for in 26 pediatric trauma centers: 20 with a CPG and 6 without (non-CPG). Median costs were significantly lower at CPG than non-CPG centers for imaging (US $163 vs. US $641, P < .001), laboratory (US $629 vs. US $1,044, P < .001), and total hospital stay (US $9,868 vs. US $10,830, P < .001). The median LOS for CPG and non-CPG centers were similar (3 vs. 2 days, P = .38), as were readmission rates within 90 days (3.1 vs. 5.1 %, P = .21). Multiple linear regression indicated that LOS (P < .001) and utilization of a CPG (P = .007) are significant independent predictors of total cost. Utilization of a CPG to manage children with isolated splenic injuries at a pediatric trauma center results in significantly reduced imaging, laboratory, and total hospital costs independent of patient age, gender, grade, and LOS.

Causes of Stranding and Mortality, and Final Disposition of Loggerhead Sea Turtles (Caretta caretta) Admitted to a Wildlife Rehabilitation Center in Gran Canaria Island, Spain (1998-2014): A Long-Term Retrospective Study

PubMed Central

Orós, Jorge; Montesdeoca, Natalia; Camacho, María; Arencibia, Alberto; Calabuig, Pascual

2016-01-01

Aims The aims of this study were to analyze the causes of stranding of 1,860 loggerhead turtles (Caretta caretta) admitted at the Tafira Wildlife Rehabilitation Center in Gran Canaria Island, Spain, from 1998 to 2014, and to analyze the outcomes of the rehabilitation process to allow meaningful auditing of its quality. Methods Primary causes of morbidity were classified into seven categories: entanglement in fishing gear and/or plastics, ingestion of hooks and monofilament lines, trauma, infectious disease, crude oil, other causes, and unknown/undetermined. Final dispositions were calculated as euthanasia (Er), unassisted mortality (Mr), and release (Rr) rates. Time to death (Td) for euthanized and dead turtles, and length of stay for released (Tr) turtles were evaluated. Results The most frequent causes of morbidity were entanglement in fishing gear and/or plastics (50.81%), unknown/undetermined (20.37%), and ingestion of hooks (11.88%). The final disposition of the 1,634 loggerhead turtles admitted alive were: Er = 3.37%, Mr = 10.34%, and Rr = 86.29%. Er was significantly higher in the trauma category (18.67%) compared to the other causes of admission. The highest Mr was observed for turtles admitted due to trauma (30.67%). The highest Rr was observed in the crude oil (93.87%) and entanglement (92.38%) categories. The median Tr ranged from 12 days (unknown) to 70 days (trauma). Conclusions This survey is the first large-scale epidemiological study on causes of stranding and mortality of Eastern Atlantic loggerheads and demonstrates that at least 71.72% of turtles stranded due to anthropogenic causes. The high Rr (86.29%) emphasizes the importance of marine rehabilitation centers for conservation purposes. The stratified analysis by causes of admission of the three final disposition rates, and the parameters Td and Tr should be included in the outcome research of the rehabilitation process of sea turtles in order to allow comparative studies between marine rehabilitation centers around the world. PMID:26901623

Implementing CBT for Traumatized Children and Adolescents after September 11: Lessons Learned from the Child and Adolescent Trauma Treatments and Services (CATS) Project

ERIC Educational Resources Information Center

Journal of Clinical Child and Adolescent Psychology, 2007

2007-01-01

The Child and Adolescent Trauma Treatments and Services Consortium (CATS) was the largest youth trauma project associated with the September 11 World Trade Center disaster. CATS was created as a collaborative project involving New York State policymakers; academic scientists; clinical treatment developers; and routine practicing clinicians,…

Chronic Childhood Trauma, Mental Health, Academic Achievement, and School-Based Health Center Mental Health Services

ERIC Educational Resources Information Center

Larson, Satu; Chapman, Susan; Spetz, Joanne; Brindis, Claire D.

2017-01-01

Background: Children and adolescents exposed to chronic trauma have a greater risk for mental health disorders and school failure. Children and adolescents of minority racial/ethnic groups and those living in poverty are at greater risk of exposure to trauma and less likely to have access to mental health services. School-based health centers…

The Association between the Working Alliance with Adolescent Girls in Residential Care and Their Trauma-Related Symptoms in Emerging Adulthood

ERIC Educational Resources Information Center

Ayotte, Marie-Hélène; Lanctôt, Nadine; Tourigny, Marc

2017-01-01

Background: Until now, the relations between the working alliance and trauma-related symptoms have received little or no study in residential-care settings. However, considering the high prevalence of past experiences of interpersonal trauma among young people in residential centers, it is essential to examine this issue more closely. Objective:…

Link for Injured Kids: A Patient-Centered Program of Psychological First Aid After Trauma.

PubMed

Ramirez, Marizen; Toussaint, Maisha; Woods-Jaeger, Briana; Harland, Karisa; Wetjen, Kristel; Wilgenbusch, Tammy; Pitcher, Graeme; Jennissen, Charles

2017-08-01

Injury, the most common type of pediatric trauma, can lead to a number of adverse psychosocial outcomes, including posttraumatic stress disorder. Currently, few evidence-based parent programs exist to support children hospitalized after a traumatic injury. Using methods in evaluation and intervention research, we completed a formative research study to develop a new program of psychological first aid, Link for Injured Kids, aimed to educate parents in supporting their children after a severe traumatic injury. Using qualitative methods, we held focus groups with parents and pediatric trauma providers of children hospitalized at a Level I Children's Hospital because of an injury in 2012. We asked focus group participants to describe reactions to trauma and review drafts of our intervention materials. Health professionals and caregivers reported a broad spectrum of emotional responses by their children or patients; however, difficulties were experienced during recovery at home and upon returning to school. All parents and health professionals recommended that interventions be offered to parents either in the emergency department or close to discharge among admissions. Results from this study strongly indicate a need for posttrauma interventions, particularly in rural settings, to support families of children to address the psychosocial outcomes in the aftermath of an injury. Findings presented here describe the process of intervention development that responds to the needs of an affected population.

Youth and trauma: terror, war, murder, incest, rape, and suicide.

PubMed

Halligan, Fredrica R

2009-09-01

College students in the United States post-9/11 face a different world than did their predecessors. In short vignettes this article reveals some of the numerous traumas that have been reported in a full-service counseling center at a small state university. Exploration of the impact of traumas past and present is interwoven with commentary on the impact of systems dynamics. A brief theoretical exploration is included of post-trauma resilience and the ongoing sense of threat that many traumatized persons experience.

Nursing role innovations: improved outcomes in a trauma center.

PubMed

Holmquist, P J; Yamamoto, L; DiDonna, D; Sise, M J

1996-01-01

Trauma systems operate on the principle that people with severe injuries require special medical capabilities if they are to have their best chance of recovery. However, optimal trauma care is threatened by the problems of inadequate financial reimbursement. This threatens the ability to deliver trauma patient care. A variety of strategies is necessary to continue to provide care. Two specific nursing role innovations provide the opportunity to improve the ability to provide coordinated, efficient, and cost-effective quality care.

Variation in intensive care unit utilization and mortality after blunt splenic injury.

PubMed

Kaufman, Elinore J; Wiebe, Douglas J; Martin, Niels D; Pascual, Jose L; Reilly, Patrick M; Holena, Daniel N

2016-06-15

Although trauma patients are frequently cared for in the intensive care unit (ICU), admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission. We conducted a retrospective cohort study of patients treated for blunt splenic injuries from 2011-2014 at 30 level I and II Pennsylvania trauma centers. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman's rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement between high and low-ICU-utilization centers. Of 2587 patients with blunt splenic injuries, 63.9% (1654) were admitted to the ICU. Median injury severity score was 17 overall, 13 for non-ICU patients and 17 for ICU patients (P < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9%-87.3%. Risk-adjusted mortality rates ranged from 1.2%-9.6%. There was no correlation between observed-to-expected ratios for ICU utilization and mortality (Spearman's rho = -0.2595, P = 0.2103). Proportionately fewer ICU patients received critical care procedures at high-utilization centers than at low-utilization centers. Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality. Copyright © 2016 Elsevier Inc. All rights reserved.

Field triage and patient maldistribution in a mass-casualty incident.

PubMed

Zoraster, Richard M; Chidester, Cathy; Koenig, William

2007-01-01

Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005. A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident. The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 "Immediate" patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 "Immediate" patients, two patients per center, while the 25 closest community hospitals offered to accept 75 "Immediate" patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients. The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for "Immediates", and that they were distributed about equally between community hospitals and trauma centers.

Assessment of Osteoporosis in Injured Older Women Admitted to a Safety-Net Level One Trauma Center: A Unique Opportunity to Fulfill an Unmet Need

PubMed Central

Young, Elisabeth S.; Reed, May J.; Pham, Tam N.; Gross, Joel A.; Taitsman, Lisa A.

2017-01-01

Background Older trauma patients often undergo computed tomography (CT) as part of the initial work-up. CT imaging can also be used opportunistically to measure bone density and assess osteoporosis. Methods In this retrospective cohort study, osteoporosis was ascertained from admission CT scans in women aged ≥65 admitted to the ICU for traumatic injury during a 3-year period at a single, safety-net, level 1 trauma center. Osteoporosis was defined by established CT-based criteria of average L1 vertebral body Hounsfield units <110. Evidence of diagnosis and/or treatment of osteoporosis was the primary outcome. Results The study cohort consisted of 215 women over a 3-year study period, of which 101 (47%) had evidence of osteoporosis by CT scan criteria. There were no differences in injury severity score, hospital length of stay, cost, or discharge disposition between groups with and without evidence of osteoporosis. Only 55 (59%) of the 94 patients with osteoporosis who survived to discharge had a documented osteoporosis diagnosis and/or corresponding evaluation/treatment plan. Conclusion Nearly half of older women admitted with traumatic injuries had underlying osteoporosis, but 41% had neither clinical recognition of this finding nor a treatment plan for osteoporosis. Admission for traumatic injury is an opportunity to assess osteoporosis, initiate appropriate intervention, and coordinate follow-up care. Trauma and acute care teams should consider assessment of osteoporosis in women who undergo CT imaging and provide a bridge to outpatient services. PMID:29234352

System care improves trauma outcome: patient care errors dominate reduced preventable death rate.

PubMed

Thoburn, E; Norris, P; Flores, R; Goode, S; Rodriguez, E; Adams, V; Campbell, S; Albrink, M; Rosemurgy, A

1993-01-01

A review of 452 trauma deaths in Hillsborough County, Florida, in 1984 documented that 23% of non-CNS trauma deaths were preventable and occurred because of inadequate resuscitation or delay in proper surgical care. In late 1988 Hillsborough County organized a County Trauma Agency (HCTA) to coordinate trauma care among prehospital providers and state-designated trauma centers. The purpose of this study was to review county trauma deaths after the inception of the HCTA to determine the frequency of preventable deaths. 504 trauma deaths occurring between October 1989 and April 1991 were reviewed. Through committee review, 10 deaths were deemed preventable; 2 occurred outside the trauma system. Of the 10 deaths, 5 preventable deaths occurred late in severely injured patients. The preventable death rate has decreased to 7.0% with system care. The causes of preventable deaths have changed from delayed or inadequate intervention to postoperative care errors.

Complication Rates among Trauma Centers

PubMed Central

Ang, Darwin N; Rivara, Frederick P; Nathens, Avery; Jurkovich, Gregory J; Maier, Ronald V; Wang, Jin; MacKenzie, Ellen J

2009-01-01

Background To examine the association between patient complications and admission to level 1 trauma centers (TC) compared to non-trauma centers (NTC). Study Design A retrospective cohort study of data derived from the National Study on the Costs and Outcomes of Trauma (NSCOT). Patients were recruited from 18 level 1 TC and 51 NTC in 15 regions encompassing 14 states. Trained study nurses, using standardized forms, abstracted the medical records of the patients. The overall number of complications per patient was identified as well as the presence or absence of 13 specific complications. Results Patients treated in TC were more likely to have any complication compared to NTC with an adjusted relative risk (RR) of 1.34 (95% CI 1.03, 1.74). For individual complications, only urinary tract infection RR 1.94 (95% CI 1.07, 3.17) was significantly higher in TC. TC patients were more likely to have three or more complications, RR 1.83 (95% CI 1.16, 2.90). Treatment variables that are surrogates for markers of injury severity, such as use of pulmonary artery catheters, multiple operations, massive transfusions (> 2,500mL packed red blood cells), and invasive brain catheters, occurred significantly more often in TC. Conclusions Trauma centers have a slightly higher incidence rate of complications even after adjusting for patient case mix. Aggressive treatment may account for a significant portion of TC-associated complications. PA catheter use and intubation had the most influence on overall TC complication rates. Further study is needed to provide accurate benchmark measures of complication rates and to determine their causes. PMID:19854399

Injury patterns among various age and gender groups of trauma patients in southern Iran

PubMed Central

Bolandparvaz, Shahram; Yadollahi, Mahnaz; Abbasi, Hamid Reza; Anvar, Mehrdad

2017-01-01

Abstract Administrative data from trauma referral centers are useful sources while studying epidemiologic aspects of injuries. We aimed to provide a hospital-based view of injuries in Shiraz considering victims’ age and gender, using administrative data from trauma research center. A cross-sectional registry-based study of adult trauma patients (age ≥15 years) sustaining injury through traffic accidents, violence, and unintentional incidents was conducted. Information was retrieved from 3 hospital administrative databases. Data on demographics, injury mechanisms, injured body regions, and injury descriptions; outcomes of hospitalization; and development of nosocomial infections were recorded. Injury Severity Score (ISS) was calculated by crosswalking from ICD-10 (International Classification of Diseases) injury diagnosis codes to AIS-98 (Abbreviated Injury Scale) severity codes. Patients were compared based on age groups and gender differences. A total of 47,295 trauma patients with a median age of 30 (interquartile range: 24–44 years) were studied, of whom 73.1% were male and the remaining 26.9% were female (M/F = 2.7:1.0). The most common injury mechanisms in the male group were car and motorcycle accidents whereas females were mostly victims of falls and pedestrian accidents (P < .01). As age increased, a shift from transportation-related to unintentionally caused injuries occurred. Overall, young men had their most severe injuries on head, whereas elderly women suffered more severe extremity injuries. Injury severity was similar between men and women; however, elderly had a significantly higher ISS. Although incidence of nosocomial infections was independent of victims’ age and gender, elderly men had a significantly higher mortality rate. Based on administrative data from our trauma center, male gender and age >65 years are associated with increased risk of injury incidence, prolonged hospitalizations, and in-hospital death following trauma. Development of a regional trauma surveillance system may provide further opportunities for studying injuries and evaluating preventive actions. PMID:29019874

Injury patterns among various age and gender groups of trauma patients in southern Iran: A cross-sectional study.

PubMed

Bolandparvaz, Shahram; Yadollahi, Mahnaz; Abbasi, Hamid Reza; Anvar, Mehrdad

2017-10-01

Administrative data from trauma referral centers are useful sources while studying epidemiologic aspects of injuries. We aimed to provide a hospital-based view of injuries in Shiraz considering victims' age and gender, using administrative data from trauma research center.A cross-sectional registry-based study of adult trauma patients (age ≥15 years) sustaining injury through traffic accidents, violence, and unintentional incidents was conducted. Information was retrieved from 3 hospital administrative databases. Data on demographics, injury mechanisms, injured body regions, and injury descriptions; outcomes of hospitalization; and development of nosocomial infections were recorded. Injury Severity Score (ISS) was calculated by crosswalking from ICD-10 (International Classification of Diseases) injury diagnosis codes to AIS-98 (Abbreviated Injury Scale) severity codes. Patients were compared based on age groups and gender differences.A total of 47,295 trauma patients with a median age of 30 (interquartile range: 24-44 years) were studied, of whom 73.1% were male and the remaining 26.9% were female (M/F = 2.7:1.0). The most common injury mechanisms in the male group were car and motorcycle accidents whereas females were mostly victims of falls and pedestrian accidents (P < .01). As age increased, a shift from transportation-related to unintentionally caused injuries occurred. Overall, young men had their most severe injuries on head, whereas elderly women suffered more severe extremity injuries. Injury severity was similar between men and women; however, elderly had a significantly higher ISS. Although incidence of nosocomial infections was independent of victims' age and gender, elderly men had a significantly higher mortality rate.Based on administrative data from our trauma center, male gender and age >65 years are associated with increased risk of injury incidence, prolonged hospitalizations, and in-hospital death following trauma. Development of a regional trauma surveillance system may provide further opportunities for studying injuries and evaluating preventive actions.

The epidemiological profile of candidemia at an Indian trauma care center.

PubMed

Tak, Vibhor; Mathur, Purva; Varghese, Prince; Gunjiyal, Jacinta; Xess, Immaculata; Misra, Mahesh C

2014-07-01

Candida spp. is a common cause of bloodstream infections. Candidemia is a potentially fatal infection that needs urgent intervention to salvage the patients. Trauma patients are relatively young individuals with very few comorbidities, and the epidemiology of candidemia is relatively unknown in this vulnerable and growing population. In this study, we report the epidemiology of candidemia in a tertiary care Trauma Center of India. The study was conducted from January 2009 to July 2012. All patients from whose blood samples a Candida spp. was recovered were included in this study. A detailed history and follow up of the patients was done. The isolates of Candida were identified to the species level. The speciation was done by conventional methods, including morphology on Corn Meal Agar, color development on Triphenyl Tetrazolium Chloride Agar and CHROMagar, and germ tube tests. The VITEK 2 YST ID colorometric card, a fully automated identification system was also used. Antifungal susceptibility was performed using the VITEK 2 system. A total of 212 isolates of the Candida species were recovered from blood samples of 157 patients over the study period. Candida tropicalis, 82 (39%), was the most common, followed by C. parapsilosis, 43 (20%), C. albicans, 29 (14%), C. glabrata, 24 (11%), C. rugosa, 20 (9%), C. hemulonii,; 6 (3%), C. guilliermondii, 4 (2%), C. famata, 3 (1.5%), and C. lusitaniae 1 (0.5%). Out of all the candidemia patients, 68 (43%) had a fatal outcome. Fluconazole and Amphotericin B resistance was seen in seven (3.3%) and seven (3.3%) of the isolates, respectively. Candidemia is a significant cause of mortality in trauma patients in our center, with C. tropicalis and C. parapsilosis being the predominant pathogens. Resistance to antifungal drugs is a matter of concern. Better hospital infection control practices and good antibiotic stewardship policies could possibly help in reducing the morbidity and mortality associated with candidemia.

Acute care nurse practitioners in trauma care: results of a role survey and implications for the future of health care delivery.

PubMed

Noffsinger, Dana L

2014-01-01

The role of acute care nurse practitioners (ACNPs) in trauma care has evolved over time. A survey was performed with the aim of describing the role across the United States. There were 68 respondents who depicted the typical trauma ACNP as being a 42-year-old woman who works full-time at a level I American College of Surgeons verified trauma center. Trauma ACNPs typically practice with 80% of their time for clinical care and are based on a trauma and acute care surgery service. They are acute care certified and hold several advanced certifications to supplement their nursing license.

Hospital trauma level's association with outcomes for injured pregnant women and their neonates in Washington state, 1995–2012

PubMed Central

Distelhorst, John Thomas; Soltis, Michele A.; Krishnamoorthy, Vijay; Schiff, Melissa A.

2017-01-01

Background: Trauma occurs in 8% of all pregnancies. To date, no studies have evaluated the effect of the hospital's trauma designation level as it relates to birth outcomes for injured pregnant women. Methods: This population-based, retrospective cohort study evaluated the association between trauma designation levels and injured pregnancy birth outcomes. We linked Washington State Birth and Fetal Death Certificate data and the Washington State Comprehensive Hospital Abstract Recording System. Injury was identified using the International Classification of Diseases, Ninth Revision injury diagnosis and external causation codes. The association was analyzed using logistic regression to estimate odds ratios and 95% confidence intervals (CIs). Results: We identified 2492 injured pregnant women. Most birth outcomes studied, including placental abruption, induction of labor, premature rupture of membranes, cesarean delivery, maternal death, gestational age <37 weeks, fetal distress, fetal death, neonatal respiratory distress, and neonatal death, showed no association with trauma hospital level designation. Patients at trauma Level 1–2 hospitals had a 43% increased odds of preterm labor (95% CI: 1.15–1.79) and a 66% increased odds of meconium at delivery (95% CI: 1.05–2.61) compared to those treated at Level 3–4 hospitals. Patients with an injury severity score >9, treated at trauma Level 1–2 hospitals, had an aOR of low birth weight, <2500 g, of 2.52 (95% CI: 1.12–5.64). Conclusions: The majority of birth outcomes for injured patients had no association with hospitalization at a Level 1–2 compared to a Level 3–4 trauma center. PMID:28971027

The application of mixed methods designs to trauma research.

PubMed

Creswell, John W; Zhang, Wanqing

2009-12-01

Despite the use of quantitative and qualitative data in trauma research and therapy, mixed methods studies in this field have not been analyzed to help researchers designing investigations. This discussion begins by reviewing four core characteristics of mixed methods research in the social and human sciences. Combining these characteristics, the authors focus on four select mixed methods designs that are applicable in trauma research. These designs are defined and their essential elements noted. Applying these designs to trauma research, a search was conducted to locate mixed methods trauma studies. From this search, one sample study was selected, and its characteristics of mixed methods procedures noted. Finally, drawing on other mixed methods designs available, several follow-up mixed methods studies were described for this sample study, enabling trauma researchers to view design options for applying mixed methods research in trauma investigations.

Estimate of mortality reduction with implementation of advanced automatic collision notification.

PubMed

Lee, Ellen; Wu, Jingshu; Kang, Thomas; Craig, Matthew

2017-05-29

Advanced Automatic Collision Notification (AACN) is a system on a motor vehicle that notifies a public safety answering point (PSAP), either directly or through a third party, that the vehicle has had a crash. AACN systems enable earlier notification of a motor vehicle crash and provide an injury prediction that can help dispatchers and first responders make better decisions about how and where to transport the patient, thus getting the patient to definitive care sooner. The purposes of the current research are to identify the target population that could benefit from AACN, and to develop a reasonable estimate range of potential lives saved with implementation of AACN within the vehicle fleet. Data from the Fatality Analysis Reporting System (FARS) years 2009-2015 and National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) years 2000-2015 were obtained. FARS data were used to determine absolute estimates of the target population who may receive benefit from AACN. These estimates accounted for a number of factors, such as whether a fatal occupant had nearby access to a trauma center and also was correctly identified by the injury severity prediction algorithm as having a "high probability of severe injury." NASS-CDS data were used to provide relative comparisons among subsets of the population. Specifically, relative survival rate ratios between occupants treated at trauma centers versus at non-trauma centers were determined using the nonparametric Kaplan-Meier estimator. Finally, the fatality reduction rate associated with trauma center care was combined with the previously published fatality reduction rate for faster notification time to develop a range for possible lives saved. Two relevant target populations were identified. A larger subset of 6893 fatalities can benefit only from earlier notification associated with AACN. A smaller subgroup of between 1495 and 2330 fatalities can benefit from both earlier notification and change in treatment destination (i.e., non-trauma center to trauma center). A Kaplan-Meier life curve and a multiple proportional hazard model were used to predict the benefits associated with transport to a trauma center. The resulting range for potential lives saved annually was 360 to 721. This analysis provides the estimates of lives that could potentially be saved with full implementation of AACN and universal cell coverage availability. This represents a fatality reduction of approximately 1.6% to 3.3% per year, and more than double the lives saved by earlier notification alone. In conclusion, AACN is a postcrash technology with a promising potential for safety benefit. AACN is therefore a key component of integrated safety systems that aim to protect occupants across the entire crash spectrum.

Transparent and Open Discussion of Errors Does Not Increase Malpractice Risk in Trauma Patients

PubMed Central

Stewart, Ronald M.; Corneille, Michael G.; Johnston, Joe; Geoghegan, Kathy; Myers, John G.; Dent, Daniel L.; McFarland, Marilyn; Alley, Joshua; Pruitt, Basil A.; Cohn, Stephen M.

2006-01-01

Objective: We set out to determine if there is an increased medical malpractice lawsuit rate when trauma patient cases are presented at an open, multidisciplinary morbidity and mortality conference (M&M). Introduction: Patient safety proponents emphasize the importance of transparency with respect to medical errors. In contrast, the tort system focuses on blame and punishment, which encourages secrecy. Our question: Can the goals of the patient safety movement be met without placing care providers and healthcare institutions at unacceptably high malpractice risk? Methods: The trauma registry, a risk management database, along with the written minutes of the trauma morbidity and mortality conference (M&M) were used to determine the number and incidence of malpractice suits filed following full discussion at an open M&M conference at an academic level I trauma center. Results: A total of 20,749 trauma patients were admitted. A total of 412 patients were discussed at M&M conference and a total of seven lawsuits were filed. Six of the patients were not discussed at M&M prior to the lawsuit being filed. One patient was discussed at M&M prior to the lawsuit being filed. The incidence of lawsuit was calculated in three groups: all trauma patients, all trauma patients with complications, and all patients presented at trauma M&M conference. The ratio of lawsuits filed to patients admitted and incidence in the three groups is as follows: All Patients, 7 lawsuits/20,479 patients (4.25 lawsuits/100,000 patients/year); M&M Presentation, 1 lawsuit/421 patients (29.6 lawsuits/100,000 patients/year); All Trauma Complications, 7 lawsuits/6,225 patients (14 lawsuits/100,000 patients/year). Patients with a complication were more likely to sue (P < 0.01); otherwise, there were no statistical differences between groups. Conclusions: A transparent discussion of errors, complications, and deaths does not appear to lead to an increased risk of lawsuit. PMID:16632999

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience

PubMed Central

Xu, Min Li; Lopez, Joseph

2016-01-01

Background: Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center. Methods: We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes. Results: There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients. Conclusions: The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients. PMID:26877626

“Do You Expect Me to Receive PTSD Care in a Setting Where Most of the Other Patients Remind Me of the Perpetrator?”: Home-Based Telemedicine to Address Barriers to Care Unique to Military Sexual Trauma and Veterans Affairs Hospitals

PubMed Central

Gilmore, Amanda K.; Davis, Margaret T.; Grubaugh, Anouk; Resnick, Heidi; Birks, Anna; Denier, Carol; Muzzy, Wendy; Tuerk, Peter; Acierno, Ron

2016-01-01

Home-based telemedicine (HBT) is a validated method of evidence-based treatment delivery for posttraumatic stress disorder (PTSD), and justification for its use has centered on closing gaps related to provider availability and distance to treatment centers. However, another potential use of HBT may be to overcome barriers to care that are inherent to the treatment environment, such as with female veterans who have experienced military sexual trauma (MST) and who must present to VA Medical Centers where the majority of patients share features with perpetrator (e.g. gender, clothing) and may function as reminders of the trauma. Delivering evidence-based therapies to female veterans with MST-related PTSD via HBT can provide needed treatment to this population. This manuscript describes an ongoing federally funded randomized controlled trial comparing Prolonged Exposure (PE) delivered in-person to PE delivered via HBT. Outcomes include session attendance, satisfaction with services, and clinical and quality of life indices. It is hypothesized that based on intent-to-treat analyses, HBT delivery of PE will be more effective than SD at improving both clinical and quality of life outcomes at post, 3-, and 6-month follow-up. This is because ‘dose received’, that is fewer sessions missed, and lower attrition, will be observed in the HBT group. Although the current manuscript focuses on female veterans with MST-related PTSD, implications for other populations facing systemic barriers are discussed. PMID:26992740

"Do you expect me to receive PTSD care in a setting where most of the other patients remind me of the perpetrator?": Home-based telemedicine to address barriers to care unique to military sexual trauma and veterans affairs hospitals.

PubMed

Gilmore, Amanda K; Davis, Margaret T; Grubaugh, Anouk; Resnick, Heidi; Birks, Anna; Denier, Carol; Muzzy, Wendy; Tuerk, Peter; Acierno, Ron

2016-05-01

Home-based telemedicine (HBT) is a validated method of evidence-based treatment delivery for posttraumatic stress disorder (PTSD), and justification for its use has centered on closing gaps related to provider availability and distance to treatment centers. However, another potential use of HBT may be to overcome barriers to care that are inherent to the treatment environment, such as with female veterans who have experienced military sexual trauma (MST) and who must present to VA Medical Centers where the majority of patients share features with perpetrator (e.g. gender, clothing) and may function as reminders of the trauma. Delivering evidence-based therapies to female veterans with MST-related PTSD via HBT can provide needed treatment to this population. This manuscript describes an ongoing federally funded randomized controlled trial comparing Prolonged Exposure (PE) delivered in-person to PE delivered via HBT. Outcomes include session attendance, satisfaction with services, and clinical and quality of life indices. It is hypothesized that based on intent-to-treat analyses, HBT delivery of PE will be more effective than SD at improving both clinical and quality of life outcomes at post, 3-, and 6-month follow-up. This is because 'dose received', that is fewer sessions missed, and lower attrition, will be observed in the HBT group. Although the current manuscript focuses on female veterans with MST-related PTSD, implications for other populations facing systemic barriers are discussed. Copyright © 2016 Elsevier Inc. All rights reserved.

Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations.

PubMed

McNamara, Caitlin; Mironova, Irina; Lehman, Erik; Olympia, Robert P

2017-06-01

Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure. To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature. We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation. Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%). Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness. Copyright © 2016 Elsevier Inc. All rights reserved.

Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center.

PubMed

Lubbert, Pieter H W; Kaasschieter, Edgar G; Hoorntje, Lidewij E; Leenen, Loek P H

2009-12-01

Trauma teams responsible for the first response to patients with multiple injuries upon arrival in a hospital consist of medical specialists or resident physicians. We hypothesized that 24-hour video registration in the trauma room would allow for precise evaluation of team functioning and deviations from Advanced Trauma Life Support (ATLS) protocols. We analyzed all video registrations of trauma patients who visited the emergency room of a Level I trauma center in the Netherlands between September 1, 2000, and September 1, 2002. Analysis was performed with a score list based on ATLS protocols. From a total of 1,256 trauma room presentations, we found a total of 387 video registrations suitable for analysis. The majority of patients had an injury severity score lower than 17 (264 patients), whereas 123 patients were classified as multiple injuries (injury severity score >or=17). Errors in team organization (omission of prehospital report, no evident leadership, unorganized resuscitation, not working according to protocol, and no continued supervision of the patient) lead to significantly more deviations in the treatment than when team organization was uncomplicated. Video registration of diagnostic and therapeutic procedures by a multidisciplinary trauma team facilitates an accurate analysis of possible deviations from protocol. In addition to identifying technical errors, the role of the team leader can clearly be analyzed and related to team actions. Registration strongly depends on availability of video tapes, timely started registration, and hardware functioning. The results from this study were used to develop a training program for trauma teams in our hospital that specifically focuses on the team leader's functioning.

Prehospital care for multiple trauma patients in Germany.

PubMed

Maegele, Marc

2015-01-01

For the German speaking countries, Tscherne's definition of "polytrauma" which represents an injury of at least two body regions with one or a combination being life-threatening is still valid. The timely and adequate management including quick referral of the trauma patient into a designated trauma center may limit secondary injury and may thus improve outcomes already during the prehospital phase of care. The professional treatment of multiple injured trauma patients begins at the scene in the context of a well structured prehospital emergency medical system. The "Primary Survey" is performed by the emergency physician at the scene according to the Prehospital Trauma Life Support (PHTLS)-concept. The overall aim is to rapidly assess and treat life-threatening conditions even in the absence of patient history and diagnosis ("treat-first-what-kills-first"). If no immediate treatment is necessary, a "Secondary Sur- vey" follows with careful and structured body examination and detailed assessment of the trauma mechanism. Massive and life-threatening states of hemorrhage should be addressed immediately even disregarding the ABCDE-scheme. Critical trauma patients should be referred without any delay ("work and go")toTR-DGU® certified trauma centers of the local trauma networks. Due to the difficult pre- hospital environment the number of quality studies in the field is low and, as consequence, the level of evidence for most recommendations is also low. Much information has been obtained from different care systems and the interchangeability of results is limited. The present article provides a synopsis of rec- ommendations for early prehospital care for the severely injured based upon the 2011 updated multi- disciplinary S3-Guideline "Polytrauma/Schwerstverletzten Behandlung", the most recently updated European Trauma guideline and the current PHTLS-algorithms including grades of recommendation whenever possible.

A population-based analysis of injury-related deaths and access to trauma care in rural-remote Northwest British Columbia.

PubMed

Simons, Richard; Brasher, Penelope; Taulu, Tracey; Lakha, Nasira; Molnar, Nadine; Caron, Nadine; Schuurman, Nadine; Evans, David; Hameed, Morad

2010-07-01

Injury rates and injury mortality rates are generally higher in rural and remote communities compared with urban jurisdictions as has been shown to be the case in the rural-remote area of Northwest (NW) British Columbia (BC). The purpose of study was to identify: (1) the place and timing of death following injury in NW BC, (2) access to and quality of local trauma services, and (3) opportunities to improve trauma outcomes. Quantitative data from demographic and geographic databases, the BC Trauma Registry, Hospital discharge abstract database, and the BC Coroner's Office, along with qualitative data from chart reviews of selected major trauma cases, and interviews with front-line trauma care providers were collated and analyzed for patients sustaining injury in NW BC from April 2001 to March 2006. The majority of trauma deaths (82%) in NW BC occur prehospital. Patients arriving alive to NW hospitals have low hospital mortality (1.0%), and patients transferring from NW BC to tertiary centers have better outcomes than matched patients achieving direct entry into the tertiary center by way of geographic proximity. Access to local trauma services was compromised by: incident discovery, limited phone service (land lines/cell), incomplete 911 emergency medical services system access, geographical and climate challenges compounded by limited transportation options, airport capabilities and paramedic training level, dysfunctional hospital no-refusal policies, lack of a hospital destination policies, and lack of system leadership and coordination. Improving trauma outcomes in this rural-remote jurisdiction requires a systems approach to address root causes of delays in access to care, focusing on improved access to emergency medical services, hospital bypass and destination protocols, improved transportation options, advanced life support transfer capability, and designated, coordinated local trauma services.

The Santa Monica crash: an urban multicasualty event.

PubMed

McGory, Marcia; Cryer, H Gill; Chandler, Charles; Cohen, Marilyn; Hiatt, Jonathan R

2004-10-01

Mass casualty events provide dramatic challenges for trauma centers and trauma systems. We analyzed the management of victims and assessed the response of the UCLA Healthcare System to the Santa Monica multicasualty event of July 16, 2003, when an elderly man drove his car through a crowded outdoor market and injured 73 people, 10 of whom died (eight at the scene). Of the victims, 26 were treated at UCLA (n = 15) and Santa Monica (n = 11) Medical Centers. Fourteen patients (54%) were female; average age was 41.9 years (range 7 months to 88 years). Fifteen patients were treated in the ER only, and 11 patients required admission. Of the latter, 10 (91%) had multisystem injuries, most commonly musculoskeletal, which occurred in nine patients (82%). Seven patients required immediate operations (orthopedic in six and a pericardial window in one). Three patients required delayed operations (orthopedic and plastic surgery). Most surgical and medical specialties were needed in consultation. Average LOH was 11.8 (range 2-23) days. Mean ISS was 21.2 (range 1-75). There were six complications (three early and three late) and one death from head injury. Seven patients (64%) required rehabilitation. We conclude that mass casualty victims have multisystem injuries of variable severity, which underscores the importance of trauma centers and trauma systems. The large trauma scene and particular need for orthopedic services were notable features of this event.

Children and terror casualties receive preference in ICU admissions.

PubMed

Peleg, Kobi; Rozenfeld, Michael; Dolev, Eran

2012-03-01

Trauma casualties caused by terror-related events and children injured as a result of trauma may be given preference in hospital emergency departments (EDs) due to their perceived importance. We investigated whether there are differences in the treatment and hospitalization of terror-related casualties compared to other types of injury events and between children and adults injured in terror-related events. Retrospective study of 121 608 trauma patients from the Israel Trauma Registry during the period of October 2000-December 2005. Of the 10 hospitals included in the registry, 6 were level I trauma centers and 4 were regional trauma centers. Patients who were hospitalized or died in the ED or were transferred between hospitals were included in the registry. All analyses were controlled for Injury Severity Score (ISS). All patients with ISS 1-24 terror casualties had the highest frequency of intensive care unit (ICU) admissions when compared with patients after road traffic accidents (RTA) and other trauma. Among patients with terror-related casualties, children were admitted to ICU disproportionally to the severity of their injury. Logistic regression adjusted for injury severity and trauma type showed that both terror casualties and children have a higher probability of being admitted to the ICU. Injured children are admitted to ICU more often than other age groups. Also, terror-related casualties are more frequently admitted to the ICU compared to those from other types of injury events. These differences were not directly related to a higher proportion of severe injuries among the preferred groups.

[Challenges of implementing a geriatric trauma network : A regional structure].

PubMed

Schoeneberg, Carsten; Hussmann, Bjoern; Wesemann, Thomas; Pientka, Ludger; Vollmar, Marie-Christin; Bienek, Christine; Steinmann, Markus; Buecking, Benjamin; Lendemans, Sven

2018-04-01

At present, there is a high percentage and increasing tendency of patients presenting with orthogeriatric injuries. Moreover, significant comorbidities often exist, requiring increased interdisciplinary treatment. These developments have led the German Society of Trauma Surgery, in cooperation with the German Society of Geriatrics, to establish geriatric trauma centers. As a conglomerate hospital at two locations, we are cooperating with two external geriatric clinics. In 2015, a geriatric trauma center certification in the form of a conglomerate network structure was agreed upon for the first time in Germany. For this purpose, the requirements for certification were observed. Both structure and organization were defined in a manual according to DIN EN ISO 9001:2015. Between 2008 and 2016, an increase of 70% was seen in geriatric trauma cases in our hospital, with a rise of up to 360% in specific diagnoses. The necessary standards and regulations were compiled and evaluated from our hospitals. After successful certification, improvements were necessary, followed by a planned re-audit. These were prepared by multiprofessional interdisciplinary teams and implemented at all locations. A network structure can be an alternative to classical cooperation between trauma and geriatric units in one clinic and help reduce possible staffing shortage. Due to the lack of scientific evidence, future evaluations of the geriatric trauma register should reveal whether network structures in geriatric trauma surgery lead to a valid improvement in medical care.

A model for identifying and ranking need for trauma service in nonmetropolitan regions based on injury risk and access to services.

PubMed

Schuurman, Nadine; Bell, Nathaniel; Hameed, Morad S; Simons, Richard

2008-07-01

Timely access to definitive trauma care has been shown to improve survival rates after severe injury. Unfortunately, despite development of sophisticated trauma systems, prompt, definitive trauma care remains unavailable to over 50 million North Americans, particularly in rural areas. Measures to quantify social and geographic isolation may provide important insights for the development of health policy aimed at reducing the burden of injury and improving access to trauma care in presently under serviced populations. Indices of social deprivation based on census data, and spatial analyses of access to trauma centers based on street network files were combined into a single index, the Population Isolation Vulnerability Amplifier (PIVA) to characterize vulnerability to trauma in socioeconomically and geographically diverse rural and urban communities across British Columbia. Regions with a sufficient core population that are more than one hour travel time from existing services were ranked based on their level of socioeconomic vulnerability. Ten regions throughout the province were identified as most in need of trauma services based on population, isolation and vulnerability. Likewise, 10 communities were classified as some of the least isolated areas and were simultaneously classified as least vulnerable populations in province. The model was verified using trauma services utilization data from the British Columbia Trauma Registry. These data indicate that including vulnerability in the model provided superior results to running the model based only on population and road travel time. Using the PIVA model we have shown that across Census Urban Areas there are wide variations in population dependence on and distances to accredited tertiary/district trauma centers throughout British Columbia. Many of the factors that influence access to definitive trauma care can be combined into a single quantifiable model that researchers in the health sector can use to predict where to place new services. The model can also be used to locate optimal locations for any basket of health services.

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center.

PubMed

Zargaran, Eiman; Spence, Richard; Adolph, Lauren; Nicol, Andrew; Schuurman, Nadine; Navsaria, Pradeep; Ramsey, Damon; Hameed, S Morad

2018-03-14

Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity. To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools. This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013. The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital. The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell's Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]). Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data.

Decreasing prevalence and seasonal variation of gunshot trauma in raptors admitted to the wildlife center of Virginia: 1993-2002.

PubMed

Richards, Jean; Lickey, Adrienne; Sleeman, Jonathan M

2005-09-01

A retrospective study was conducted to identify the epidemiologic factors associated with gunshot injuries in raptors presented to the Wildlife Center of Virginia from 1993 to 2002. Of the 3,156 raptors admitted, 118 raptors (3.7%), representing 15 species, were admitted with gunshot trauma as the primary cause of morbidity and mortality. The majority of cases consisted of four species: red-tailed hawk (Buteo jamaicensis; 47%), red-shouldered hawk (Buteo lineatus; 14%), turkey vulture (Cathartes aura; 10%), and bald eagle (Haliaeetus leucocephalus; 8%). For species with greater than 40 admissions during the study period, the proportion of gunshot trauma of all causes of morbidity and mortality ranged from <1% to 11%. Greater numbers of raptors with gunshot trauma were admitted during the fall and winter months (75%) compared with the spring and summer (25%). A significant decrease in the absolute number of gunshot cases per year was observed over the time period studied. The population-level effect of gunshot trauma is unknown for these species; however, it appears to be minor compared with other causes of morbidity and mortality.

Blood Product Utilization Among Trauma and Nontrauma Massive Transfusion Protocols at an Urban Academic Medical Center.

PubMed

Patel, Eshan U; Ness, Paul M; Marshall, Christi E; Gniadek, Thomas; Efron, David T; Miller, Peter M; Zeitouni, Joseph A; King, Karen E; Bloch, Evan M; Tobian, Aaron A R

2017-09-01

Hospital-wide massive transfusion protocols (MTPs) primarily designed for trauma patients may lead to excess blood products being prepared for nontrauma patients. This study characterized blood product utilization among distinct trauma and nontrauma MTPs at a large, urban academic medical center. A retrospective study of blood product utilization was conducted in patients who required an MTP activation between January 2011 and December 2015 at an urban academic medical center. Trauma MTP containers included 6 red blood cell (RBC) units, 5 plasma units, and 1 unit of apheresis platelets. Nontrauma MTP containers included 6 RBC and 3 plasma units. There were 334 trauma MTP activations, 233 nontrauma MTP activations, and 77 nontrauma MTP activations that subsequently switched to a trauma MTP ("switched activations"). All nontrauma MTP activations were among bleeding patients who did not have a traumatic injury (100% [233/233]). Few patients with a nontrauma activation required ad hoc transfusion of RBC units (1.3% [95% confidence interval {CI}, 0.3%-3.7%]) or plasma (3.4% [95% CI, 1.5%-6.7%]), and only 45.5% (95% CI, 39.0%-52.1%) required ad hoc transfusion of apheresis platelets. Compared to trauma and switched activations, nontrauma activations transfused a lower median number of RBC, plasma, and apheresis platelet units (P < .001 for all comparisons). There was also a lower median number of prepared but unused plasma units for nontrauma activations (3; [interquartile range {IQR}, 3-5]) compared to trauma (7; [IQR, 5-10]; P < .001) and switched activations (8; [IQR, 5-11]; P < .001). The median number of unused apheresis platelet units was 1 (IQR, 1-2) for trauma activations and 0 (IQR, 0-1) for switched activations. There was a high proportion of trauma and switched activations in which all of the prepared apheresis platelet units were unused (28.1% [95% CI, 23.4%-33.3%] and 9.1% [95% CI, 3.7%-17.8%], respectively). The majority of initial nontrauma MTP activations did not require a switch to a trauma MTP. Patients remaining under a nontrauma MTP activation were associated with a lower number of transfused and unused plasma and apheresis platelet units. Future studies evaluating the use of hospital-wide nontrauma MTPs are warranted since an MTP designed for nontrauma patient populations may yield a key strategy to optimize blood product utilization in comparison to a universal MTP for both trauma and nontrauma patients.

Usage of Riot Control Agents and other methods resulting in physical and psychological injuries sustained during civil unrest in Turkey in 2013.

PubMed

Unuvar, Umit; Yilmaz, Deniz; Ozyildirim, Ilker; Dokudan, Erenc Y; Korkmaz, Canan; Doğanoğlu, Senem; Kutlu, Levent; Fincanci, Sebnem Korur

2017-01-01

Turkey has experienced a wave of demonstrations in the summer of 2013, called Gezi Park Demonstrations. Between 31 May and 30 August, 297 people who had been subjected to trauma by several methods of demonstration control and Riot Control Agents applied to the Human Rights Foundation of Turkey Rehabilitation Centers to receive treatment/rehabilitation and/or documentation. 296 patients except one 5-year-old child were included in the study. Of the 296 patients; 175 were male, 120 were female, and one was a transgender individual. The highest number of applications was received by the Istanbul center with 216 patients. The mean age of applicants was 33.85, and the age range was 15-71 years. While 268 of applicants (91%) stated that they had been exposed to Riot Control Agents, 62 patients suffered only chemical exposure who had no other traumatic injuries whereas 234 patients suffered at least one blunt trauma injury. Blunt trauma injuries are due to being shot by gas canisters in 127 patients (43%), by plastic bullets in 31 patients (10%). 59 patients (20%) were severely beaten, and 30 patients (10%) were injured by pressurized cold water ejected by water cannons. Thirteen patients (4.4%) suffered injuries that caused loss of vision or eye. Psychiatric evaluations were carried out for 117 patients while 43% of them were diagnosed with Acute Stress Disorder. Post Traumatic Stress Disorder and Major Depressive Disorder followed this diagnosis. This study includes the medical evaluation of injuries allegedly sustained during Gezi Park demonstrations in 2013 as a result of several methods of demonstration control and/or by being exposed to Riot Control Agents. The aim is to discuss different types of injuries due to those methods and health consequences of Riot Control Agents. Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

Non-trauma surgical emergencies in adults: Spectrum, challenges and outcome of care

PubMed Central

Ibrahim, N.A.; Oludara, M.A.; Ajani, A.; Mustafa, I.; Balogun, R.; Idowu, O.; Osuoji, R.; Omodele, F.O.; Aderounmu, A.O.A.; Solagberu, B.A.

2015-01-01

Introduction Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. Methods A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. Results Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. Conclusion Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital. PMID:26566434

Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications.

PubMed

Xu, Han; Jie, Li; Kejian, Sun; Xiaojun, He; Chengli, Liu; Hongyi, Zhang; Yalin, Kong

2017-11-20

BACKGROUND Conflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT. MATERIAL AND METHODS Medical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed. RESULTS No significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group. CONCLUSIONS Hemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course.

Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications

PubMed Central

Xu, Han; Jie, Li; Kejian, Sun; Xiaojun, He; Chengli, Liu; Hongyi, Zhang; Yalin, Kong

2017-01-01

Background Conflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT. Material/Methods Medical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed. Results No significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group. Conclusions Hemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course. PMID:29155699

Impact of prehospital transfer strategies in major trauma and head injury: systematic review, meta-analysis, and recommendations for study design.

PubMed

Pickering, Alastair; Cooper, Katy; Harnan, Susan; Sutton, Anthea; Mason, Suzanne; Nicholl, Jonathan

2015-01-01

It is unclear whether trauma patients should be transferred initially to a trauma center or local hospital. A systematic review and meta-analysis assessed the evidence for direct transport to specialist centers (SCs) versus initial stabilization at non-SCs (NSCs) for major trauma or moderate-to-severe head injury. Nine databases were searched from 1988 to 2012. Limitations in the study design informed recommendations for future studies. Of 19 major trauma studies, five (n = 19,910) included patients not transferred to SCs and adjusted for case mix. Meta-analysis showed no difference in mortality for initial triage to NSCs versus SCs (odds ratio [OR] 1.03; 95% confidence interval [CI], 0.85-1.23). Within studies excluding patients not transferred to SCs, unadjusted analyses of mortality nonsignificantly favored transfer via NSCs (16 studies; n = 37,079; OR, 0.83; 95% CI, 0.68-1.01), whereas adjusted analysis nonsignificantly favored direct triage to SCs (9 studies; n = 34,266; OR, 1.18; 95% CI, 0.96-1.44). Of 11 head injury studies, all excluded patients not transferred to SCs and half were in remote locations. There was no significant mortality difference between initial triage to NSCs versus SCs within adjusted analyses (3 studies; n = 1,507; OR, 0.74; 95% CI, 0.31-1.79) or unadjusted analyses (10 studies; n = 3,671; OR, 0.87; 95% CI, 0.62-1.23). This systematic review demonstrated no difference in outcomes for direct transport to a trauma center versus initial triage to a local hospital. Many studies had significant limitations in the design, and heterogeneity was high. Recommendations for future studies include the following: (i) inclusion of patients not transferred to SCs and those dying during transport; (ii) clear description of centers plus transport distances/times; (iii) adjustments for case mix; and (iv) assessment of morbidity and mortality. Systematic review, level IV.

The Epidemiology of Emergency Department Trauma Discharges in the United States.

PubMed

DiMaggio, Charles J; Avraham, Jacob B; Lee, David C; Frangos, Spiros G; Wall, Stephen P

2017-10-01

Injury-related morbidity and mortality is an important emergency medicine and public health challenge in the United States. Here we describe the epidemiology of traumatic injury presenting to U.S. emergency departments (EDs), define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries. We conducted a secondary retrospective, repeated cross-sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all-payer ED survey database in the United States. Main outcomes and measures were survey-adjusted counts, proportions, means, and rates with associated standard errors (SEs) and 95% confidence intervals. We plotted annual age-stratified ED discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level I or II trauma center care with injury fatality using a multivariable survey-adjusted logistic regression analysis that controlled for age, sex, injury severity, comorbid diagnoses, and teaching hospital status. There were 181,194,431 (SE = 4,234) traumatic injury discharges from U.S. EDs between 2006 and 2012. There was a mean year-to-year decrease of 143 (95% CI = -184.3 to -68.5) visits per 100,000 U.S. population during the study period. The all-age, all-cause case-fatality rate for traumatic injuries across U.S. EDs during the study period was 0.17% (SE = 0.001%). The case-fatality rate for the most severely injured averaged 4.8% (SE = 0.001%), and severely injured patients were nearly four times as likely to be seen in Level I or II trauma centers (relative risk = 3.9 [95% CI = 3.7 to 4.1]). The unadjusted risk ratio, based on group counts, for the association of Level I or II trauma centers with mortality was risk ratio = 4.9 (95% CI = 4.5 to 5.3); however, after sex, age, injury severity, and comorbidities were accounted for, Level I or II trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 [95% CI = 0.79 to 1.18]). There were notable changes at the extremes of age in types and causes of ED discharges for traumatic injury between 2009 and 2012. Age-stratified rates of diagnoses of traumatic brain injury increased 29.5% (SE = 2.6%) for adults older than 85 and increased 44.9% (SE = 1.3%) for children younger than 18. Firearm-related injuries increased 31.7% (SE = 0.2%) in children 5 years and younger. The total inflation-adjusted cost of ED injury care in the United States between 2006 and 2012 was $99.75 billion (SE = $0.03 billion). Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the United States. Level I or II trauma centers remain a bulwark against the tide of severe trauma in the United States, but the types and causes of traumatic injury in the United States are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm-related trauma presenting increased challenges. © 2017 by the Society for Academic Emergency Medicine.

Pediatric pancreatic trauma: trending toward nonoperative management?

PubMed

Cuenca, Alex G; Islam, Saleem

2012-11-01

Pancreatic trauma is rare in children and optimal care has not been defined. We undertook this study to review the cumulative experience from three centers. After obtaining Institutional Review Board approval at each site, the trauma registries of three institutions were searched for pancreatic injuries. The charts were reviewed and data pertaining to demographics, hospital course, and outcome were obtained and analyzed. During the study period, a total of 79 pancreatic injuries were noted. The most common mechanism of injury was motor vehicle crash (44%) followed by child abuse (11%) and bicycle crashes (11%). Computed tomographic (CT) scans were obtained in 95 per cent with peripancreatic fluid the most common finding. Median Injury Severity Score (ISS) was 9, whereas median organ injury score was 2, and a higher grade correlated with need for operation (P = 0.001). Pancreatic operations were performed in 32 patients, whereas nonoperative management was noted in 47 cases. We noted no differences in length of stay, age, ISS, or initial blood pressure in operative versus nonoperatively managed cases. Pancreatic injuries were rare in children with trauma. CT scans were the most common method of diagnosis. Nonoperative management appeared to be safe and was more common, especially for the lower grade injuries.

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ghelfi, Julien, E-mail: JGhelfi@chu-grenoble.fr; Frandon, Julien, E-mail: JFrandon2@chu-grenoble.fr; Barbois, Sandrine, E-mail: SBarbois@chu-grenoble.fr

IntroductionMesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding.Materials and MethodsThe medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, andmore » the complications of embolization.ResultsSix endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration.ConclusionIn mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia.« less

The Effect of Perioperative Rescue Transesophageal Echocardiography on the Management of Trauma Patients

PubMed Central

Griffee, Matthew J.; Singleton, Andrew; Zimmerman, Joshua M.; Morgan, David E.; Nirula, Raminder

2018-01-01

To evaluate the effect of rescue transesophageal echocardiography (TEE) on the management of trauma patients, we reviewed imaging and charts of unstable trauma patients at a level I trauma center. Critical rescue TEE findings included acute right ventricular failure, stress cardiomyopathy, type B aortic dissection, mediastinal air, and dynamic left ventricular outflow tract obstruction. Left ventricular filling was classified as low (underfilled) in 57% of all cases. Rescue TEE revealed a variety of new diagnoses and led to a change in resuscitation strategy about half of the time. PMID:27301053

Distribution of specialized care centers in the United States.

PubMed

Wang, Henry E; Yealy, Donald M

2012-11-01

As a recommended strategy for optimally managing critical illness, regionalization of care involves matching the needs of the target population with available hospital resources. The national supply and characteristics of hospitals providing specialized critical care services is currently unknown. We seek to characterize the current distribution of specialized care centers in the United States. Using public data linked with the American Hospital Association directory and US Census, we identified US general acute hospitals providing specialized care for ST-segment elevation myocardial infarction (STEMI) (≥40 annual primary percutaneous coronary interventions reported in Medicare Hospital Compare), stroke (The Joint Commission certified stroke centers), trauma (American College of Surgeons or state-designated, adult or pediatric, level I or II), and pediatric critical care (presence of a pediatric ICU) services. We determined the characteristics and state-level distribution and density of specialized care centers (centers per state and centers per state population). Among 4,931 acute care hospitals in the United States, 1,325 (26.9%) provided one of the 4 defined specialized care services, including 574 STEMI, 763 stroke, 508 trauma, and 457 pediatric critical care centers. Approximately half of the 1,325 hospitals provided 2 or more specialized services, and one fifth provided 3 or 4 specialized services. There was variation in the number of each type of specialized care center in each state: STEMI median 7 interquartile range (IQR 2 to 14), stroke 8 (IQR 3 to 17), trauma 6 (IQR 3 to 11), pediatric specialized care 6 (IQR 3 to 11). Similarly, there was variation in the number of each type of specialized care center per population: STEMI median 1 center per 585,135 persons (IQR 418,729 to 696,143), stroke 1 center per 412,188 persons (IQR 321,604 to 572,387), trauma 1 center per 610,589 persons (IQR 406,192 to 917,588), and pediatric critical care 1 center per 665,282 persons (IQR 441,525 to 942,254). The national distribution patterns differed for each type of specialized care center. The distribution of specialized care centers varies across the United States. These observations highlight unanswered questions about the regional organization of specialized care in the United States. Copyright © 2012. Published by Mosby, Inc.

Trauma with Injury Severity Score of 75: Are These Unsurvivable Injuries?

PubMed Central

Peng, Jin; Wheeler, Krista; Shi, Junxin; Groner, Jonathan Ira; Haley, Kathryn Jo; Xiang, Huiyun

2015-01-01

Trauma patients with an ISS=75 have been deliberately excluded from some trauma studies because they were assumed to have "unsurvivable injuries." This study aimed to assess the true mortality among patients with an ISS=75, and to examine the characteristics and primary diagnoses of these patients. Retrospective review of the 2006-2010 U.S. Nationwide Emergency Department Sample (NEDS) generated 2,815 patients with an ISS=75 for analysis, representing an estimated 13,569 patients in the country. Dispositions from the emergency department and hospital for these patients were tabulated by trauma center level. Survivors and non-survivors were compared using Pearson's chi-square test. Primary diagnosis codes of these patients were tabulated by mortality status. Overall, about 48.6% of patients with an ISS=75 were discharged alive, 25.8% died and 25.6% had unknown mortality status. The mortality risks of these patients did not vary significantly across different levels of trauma centers (15.6% vs. 13.0%, P = 0.16). Non-survivors were more likely than survivors to: be male (81.2% vs. 74.4%, P < 0.0001), be over 65 years (20.3% vs. 10.2%, P < 0.0001), be uninsured (33.8% vs. 19.1%), have at least one chronic condition (58.0% vs. 43.7%, P <0.0001), sustain life-threatening injuries (79.2% vs. 49.4%, P<0.0001), sustain penetrating injuries (42.0% vs. 25.9%, P<0.0001), and have injuries caused by motor vehicle crashes (32.9% vs. 21.1%, P<0.0001) or firearms (21.9% vs. 4.4%, P<0.0001). The most frequent diagnosis code was 862.8 (injury to multiple and unspecified intrathoracic organs, without mention of open wound into cavity). Our results revealed that at least half of patients with an ISS=75 survived, demonstrating that the rationale for excluding patients with an ISS=75 from analysis is not always justified. To avoid bias and inaccurate results, trauma researchers should examine the mortality status of patients with an ISS=75 before exclusion, and explicitly describe their method of generating ISS scores. PMID:26230931

Terrorism: a public health threat with a trauma system response.

PubMed

Jacobs, Lenworth M; Burns, Karyl J; Gross, Ronald I

2003-12-01

The threat of mass casualties and widespread infectious disease caused by terrorism is now a challenge for our government and public health system. Funds have been granted to the states by the Centers for Disease Control and Prevention and the Health Resources and Services Administration to establish bioterrorism preparedness and response capabilities. Hartford Hospital has been designated as a Center of Excellence for Bioterrorism Preparedness by the Commissioner of the Connecticut Department of Public Health. The Center of Excellence has implemented strategies to prepare for a possible bioterrorist attack. A unique model that combines epidemiology and traumatology is being used to guide the preparedness activities. Although the focus of the grant from the Connecticut Department of Public Health is bioterrorism, the application of the model can apply to preparation for all terrorist events. Implementation of strategies indicates that bioterrorism preparedness is well underway. Similar initiatives should be achievable by other trauma systems throughout the country. A Center of Excellence for Bioterrorism Preparedness in Connecticut is successfully modifying a trauma system to meet the challenge of a new public health threat, terrorism.

The impact of missing trauma data on predicting massive transfusion

PubMed Central

Trickey, Amber W.; Fox, Erin E.; del Junco, Deborah J.; Ning, Jing; Holcomb, John B.; Brasel, Karen J.; Cohen, Mitchell J.; Schreiber, Martin A.; Bulger, Eileen M.; Phelan, Herb A.; Alarcon, Louis H.; Myers, John G.; Muskat, Peter; Cotton, Bryan A.; Wade, Charles E.; Rahbar, Mohammad H.

2013-01-01

INTRODUCTION Missing data are inherent in clinical research and may be especially problematic for trauma studies. This study describes a sensitivity analysis to evaluate the impact of missing data on clinical risk prediction algorithms. Three blood transfusion prediction models were evaluated utilizing an observational trauma dataset with valid missing data. METHODS The PRospective Observational Multi-center Major Trauma Transfusion (PROMMTT) study included patients requiring ≥ 1 unit of red blood cells (RBC) at 10 participating U.S. Level I trauma centers from July 2009 – October 2010. Physiologic, laboratory, and treatment data were collected prospectively up to 24h after hospital admission. Subjects who received ≥ 10 RBC units within 24h of admission were classified as massive transfusion (MT) patients. Correct classification percentages for three MT prediction models were evaluated using complete case analysis and multiple imputation. A sensitivity analysis for missing data was conducted to determine the upper and lower bounds for correct classification percentages. RESULTS PROMMTT enrolled 1,245 subjects. MT was received by 297 patients (24%). Missing percentage ranged from 2.2% (heart rate) to 45% (respiratory rate). Proportions of complete cases utilized in the MT prediction models ranged from 41% to 88%. All models demonstrated similar correct classification percentages using complete case analysis and multiple imputation. In the sensitivity analysis, correct classification upper-lower bound ranges per model were 4%, 10%, and 12%. Predictive accuracy for all models using PROMMTT data was lower than reported in the original datasets. CONCLUSIONS Evaluating the accuracy clinical prediction models with missing data can be misleading, especially with many predictor variables and moderate levels of missingness per variable. The proposed sensitivity analysis describes the influence of missing data on risk prediction algorithms. Reporting upper/lower bounds for percent correct classification may be more informative than multiple imputation, which provided similar results to complete case analysis in this study. PMID:23778514

Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center.

PubMed

Kansas, Bryan T; Eddy, Michael J; Mydlo, Jack H; Uzzo, Robert G

2004-10-01

Patients with penetrating trauma often have multiorgan involvement that may complicate the management of any single organ system. Here we review the incidence of associated injuries in patients with penetrating renal trauma and our extended experience treating these patients at a busy inner city trauma center. All trauma cases presenting to Temple University Trauma Center during a 6-year period were identified through our institutional databases and were reviewed (5,276). Penetrating trauma represented 41% of all cases (2,163). Of these we identified 123 patients with penetrating renal trauma (5.7%). A total of 93 cases were available for review. Multiorgan injury was staged in the operating room if patients were hemodynamically unstable or radiographically if they were stable. Renal injuries were staged by high dose, single shot excretory urogram in patients taken immediately to surgery or by computerized tomography if stable. Renal injuries were classified using the American Association for Surgery of Trauma (AAST) grading system. AAST classifications were subcategorized for purposes of streamlining. Grade 1 and 2 injuries were grouped as low grade, grades 3 and 4 nonvascular injuries were grouped as intermediate grade, and AAST grade 4 vascular and grade 5 injuries were grouped as high grade. Demographic, clinical and intraoperative variables, as well as number and severity of associated injuries, were then assessed to determine the relationship with various renal surgical outcomes including the requirement of surgical intervention, type of surgical intervention, need for nephrectomy and associated adverse outcomes. The median age of injured patients was 28 years (range 14 to 80). The majority of victims were male (93%). The mechanism of injury was predominantly gunshot wound (GSW, 86%) while 14% were due to stab wounds. Renal injuries were low grade (19%), intermediate grade (44%) and high grade (37%). Nearly all patients with penetrating renal injury had associated multiorgan injury (94.6%). Associated injuries for penetrating renal trauma on the right side predominately involved the liver, small bowel and vertebra while injury to the left kidney was most often associated with trauma to the stomach, colon and spleen. Patients suffered extensive renal injury as evidenced by the high rate of intraoperative urinomas (30.1%) and hematomas (97.5%) identified. In the absence of an expanding hematoma and/or hemodynamic instability, associated injuries by themselves did not increase the risk of nephrectomy. Despite multiorgan penetrating injury 54% of kidneys were salvageable. Isolated penetrating trauma to the kidney is rare. The majority of patients with penetrating renal trauma have associated adjacent organ injuries that may complicate treatment. In the absence of an expanding hematoma with hemodynamic instability, associated multiorgan injuries did not increase the risk of nephrectomy. With appropriate radiographic and/or surgical staging, it is possible to repair and salvage many of these kidneys despite extensive associated intraabdominal trauma.

Etiology of Hypopituitarism in Adult Patients: The Experience of a Single Center Database in the Serbian Population

PubMed Central

Pekić, S.; Miljić, D.; Popović, V.; Stojanović, M.; Petakov, M.

2017-01-01

There are only a few published studies related to the population-based etiology of hypopituitarism. New risks for developing hypopituitarism have been recognized in the last 10 years. Aim. To present data regarding the etiology of hypopituitarism collected in a tertiary center over the last decade. This is a cross-sectional database study. Patients and Methods. We included 512 patients (pts) with hypopituitarism, with a mean age of 45.9 ± 1.7 yrs (range: 18–82; male: 57.9%). Results. Nonfunctional pituitary adenomas were presented in 205 pts (40.5%), congenital causes in 74 pts (14.6%), while acromegaly and prolactinomas were presented in 37 (7.2%) and 36 (7.0%) patients, respectively. Craniopharyngiomas were detected in 30 pts (5.9%), and head trauma due to trauma brain injury-TBI and subarachnoid hemorrhage-SAH in 27 pts (5.4%). Survivors of hemorrhagic fever with renal syndrome (HFRS) and those with previous cranial irradiation were presented in the same frequency (18 pts, 3.5% each). Conclusion. The most common causes of hypopituitarism in our database are pituitary adenomas. Increased awareness of the other causes of pituitary dysfunction, such as congenital, head trauma, extrapituitary cranial irradiation, and infections, is the reason for a higher frequency of these etiologies of hypopituitarism in the presented database. PMID:28702053

Appraising the spectrum of firework trauma and the related laws during Diwali in North India

PubMed Central

Venkatesh, Ramesh; Gurav, Prachi; Tibrewal, Shailja; Agarwal, Manisha; Dubey, Suneeta; Mathur, Umang; Ganesh, Suma; Das, Sima

2017-01-01

Purpose: To evaluate the epidemiological characteristics and outcomes of ocular injuries resulting from the use of firecrackers during the Diwali festival in all age groups. Materials and Methods: A single-center, retrospective, hospital-based case series presenting with ocular trauma consequent to fireworks usage in a tertiary eye care center in North India during the 5 days of Diwali festival from 2011 to 2015 was conducted. Results: A total of 53 eyes of 45 patients were included in the study, out of which the vast majority (39/87%) were males. The mean age was 20.55 years. Almost an equal number of bystanders (25/55.5%) were affected as compared to people handling the fireworks (20/44.44%). Five (9.43%) eyes had open-globe injury, whereas 48 (90.56%) eyes had closed-globe injury. Eighteen (33.96%) eyes underwent surgical intervention. Thirty-three (62.26%) eyes had final vision >20/200 with eight (15.09%) eyes being vision <3/60 in the affected eye. Conclusion: Firework-related ocular trauma can lead to serious visual impairment. Mandatory legislative laws pertaining to the manufacture, sale, and use of fireworks and creating public awareness can reduce the incidence of this preventable cause of blindness in the society. Initiating new policies for retailers involved in sale of these firecrackers can also bring in decrease of such morbidities. PMID:28345570

A population-based survival assessment of categorizing level III and IV rural hospitals as trauma centers.

PubMed

Arthur, Melanie; Newgard, Craig D; Mullins, Richard J; Diggs, Brian S; Stone, Judith V; Adams, Annette L; Hedges, Jerris R

2009-01-01

Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse. To determine if there is improved survival among injured patients hospitalized in states that categorize rural hospitals as trauma centers. We analyzed a retrospective cohort of injured patients included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 1997 to 1999. We used generalized estimating equations to compare survival among injured patients hospitalized in states that categorize rural hospitals as Level III and IV trauma centers versus those that do not. Multivariable models adjusted for important confounders, including patient demographics, co-morbid conditions, injury severity, and hospital-level factors. There were 257,044 admitted patients from 7 states with a primary injury diagnosis, of whom 64,190 (25%) had a "serious" index injury, 32,763 (13%) were seriously injured (by ICD-9 codes), and 12,435 (5%) were very seriously injured (by ICD-9 codes). There was no survival benefit associated with rural hospital categorization among all patients with a primary injury diagnosis or for those with specific index injuries. However, seriously injured patients (by ICD-9 codes) had improved survival when hospitalized in a categorizing state (OR for mortality 0.72, 95% confidence interval [CI] 0.53-0.97; OR for very seriously injured 0.68, 95% CI 0.52-0.90). There was no survival benefit to categorizing rural hospitals among a broad, heterogeneous group of hospitalized patients with a primary injury diagnosis; however the most seriously injured patients did have increased survival in such states.

[Chest trauma: who, how and what?].

PubMed

Molnár, F Tamás

2012-10-01

A chest-trauma management system, tagged as the "Pécs model" in a tertiary referral center is described with extensive references to the state of the art in thoracic trauma. Chest drainage has utmost importance in primary therapy as well as in surgical decision making (diagnosis). Thoracotomy is a general surgical competence, just as damage control is. Definitive treatment and management of sequelae, however, requires competence in thoracic surgery. Multidisciplinarity is underscored.

Statewide real-time in-flight trauma patient vital signs collection system.

PubMed

Hu, Peter F; Mackenzie, Colin; Dutton, Richard; Sen, Ayan; Xiao, Yan; Handley, Christopher; Ho, Danny; Scalea, Thomas

2008-11-06

Continuous recorded in-flight vital signs monitoring and life-saving interventions linked to outcomes may provide better understanding of pre-hospital triage, care management and patient responses during the 'golden hour' of trauma care. Evaluation of 157 patients' vital signs data collected from our statewide network has identified episodes of physiological decompensation which holds promise for creation of new triage algorithms and enhanced trauma center preparedness.

Modifications to the Trauma Recovery and Empowerment Model (TREM) for Substance-Abusing Women with Histories of Violence: Outcomes and Lessons Learned at a Colorado Substance Abuse Treatment Center

ERIC Educational Resources Information Center

Toussaint, Danielle W.; VanDeMark, Nancy R.; Bornemann, Angela; Graeber, Carla J.

2007-01-01

A growing body of literature demonstrates the co-occurrence of posttraumatic stress disorder and substance use disorder for females seeking substance abuse treatment. Nonetheless, relatively few trauma-specific treatments have been implemented or evaluated with this population. In this quasi-experimental study (N = 170), the Trauma Recovery and…

Chronic Childhood Trauma, Mental Health, Academic Achievement, and School-Based Health Center Mental Health Services.

PubMed

Larson, Satu; Chapman, Susan; Spetz, Joanne; Brindis, Claire D

2017-09-01

Children and adolescents exposed to chronic trauma have a greater risk for mental health disorders and school failure. Children and adolescents of minority racial/ethnic groups and those living in poverty are at greater risk of exposure to trauma and less likely to have access to mental health services. School-based health centers (SBHCs) may be one strategy to decrease health disparities. Empirical studies between 2003 and 2013 of US pediatric populations and of US SBHCs were included if research was related to childhood trauma's effects, mental health care disparities, SBHC mental health services, or SBHC impact on academic achievement. Eight studies show a significant risk of mental health disorders and poor academic achievement when exposed to childhood trauma. Seven studies found significant disparities in pediatric mental health care in the US. Nine studies reviewed SBHC mental health service access, utilization, quality, funding, and impact on school achievement. Exposure to chronic childhood trauma negatively impacts school achievement when mediated by mental health disorders. Disparities are common in pediatric mental health care in the United States. SBHC mental health services have some showed evidence of their ability to reduce, though not eradicate, mental health care disparities. © 2017, American School Health Association.

Overcrowded motor vehicle trauma from the smuggling of illegal immigrants in the desert of the Southwest.

PubMed

Lumpkin, Mary F; Judkins, Dan; Porter, John M; Latifi, Rifat; Williams, Mark D

2004-12-01

Overcrowded motor vehicle crashes caused by the very active criminal enterprise of smuggling illegal immigrants in the desert of the Southwest is a recent and under-recognized trauma etiology. A computerized database search from 1990 through 2003 of local newspaper reports of overcrowded motor vehicle crashes along the 281 miles of Arizona's border with Mexico was conducted. This area was covered by two level I trauma centers, but since July 2003 is now served only by the University Medical Center. Each of these crashes involved a single motor vehicle in poor mechanical shape packed with illegal immigrants. Speeding out of control on bad tires, high-speed rollovers result in ejection of most passengers. Since 1999, there have been 38 crashes involving 663 passengers (an average of 17 per vehicle) with an injury rate of 49 per cent and a mortality rate of 9 per cent. This relatively recent phenomenon (no reports from before 1998) of trauma resulting from human smuggling is lethal and demonstrates the smugglers' wanton disregard for human life, particularly when facing apprehension. Even a few innocent bystanders have been killed. These crashes overwhelm a region's trauma resources and must be recognized when planning the distribution of trauma resources to border states.

Are patients being transferred to level-I trauma centers for reasons other than medical necessity?

PubMed

Koval, Kenneth J; Tingey, Chad W; Spratt, Kevin F

2006-10-01

In the United States, the Emergency Medical Treatment and Active Labor Act defines broad guidelines regarding interhospital transfer of patients who have sought care in the emergency department. However, patient transfers for nonmedical reasons are still considered a common practice. The purpose of this study was to evaluate the possible risk factors for hospital transfer in a population of patients unlikely to require transfer to a level-I center for medical reasons. A retrospective case-control national database study was performed with use of data from the National Trauma Data Bank (version 4.3). The study group consisted of patients with low Injury Severity Scores (< or =9) who were transferred to a level-I trauma center from another hospital. The controls were patients with low Injury Severity Scores who were treated at any hospital that was lower than a level-I trauma center and were not transferred. Hypothesized risk factors for hospital transfer were the age, gender, race, and insurance status of the patient; the time of day the transfer was received; and the number and type of comorbidities. The total sample included 97,393 patients, 21% of whom were transferred to a level-I trauma center. The odds ratios adjusted for all risk factors indicated that transfer rates were higher for male patients compared with female patients (adjusted odds ratio = 1.46), children compared with seniors (3.54), blacks compared with whites (1.28), evening or night transfers compared with morning or afternoon transfers (2.25), patients with Medicaid compared with those with other types of insurance (2.02), and for those with one or more comorbidities compared with those with no comorbidity (2.79). These results suggest the need for prospective studies to further investigate the relationships between hospital transfer and medical and nonmedical factors.

Operation CeaseFire-New Orleans: an infectious disease model for addressing community recidivism from penetrating trauma.

PubMed

McVey, Erin; Duchesne, Juan C; Sarlati, Siavash; O'Neal, Michael; Johnson, Kelly; Avegno, Jennifer

2014-07-01

CeaseFire, using an infectious disease approach, addresses violence by partnering hospital resources with the community by providing violence interruption and community-based services for an area roughly composed of a single city zip code (70113). Community-based violence interrupters start in the trauma center from the moment penetrating trauma occurs, through hospital stay, and in the community after release. This study interprets statistics from this pilot program, begun May 2012. We hypothesize a decrease in penetrating trauma rates in the target area compared with others after program implementation. This was a 3-year prospective data collection of trauma registry from May 2010 to May 2013. All intentional, target area, penetrating trauma treated at our Level I trauma center received immediate activation of CeaseFire personnel. Incidences of violent trauma and rates of change, by zip code, were compared with the same period for 2 years before implementation. During this period, the yearly incidence of penetrating trauma in Orleans Parish increased. Four of the highest rates were found in adjacent zip codes: 70112, 70113, 70119, and 70125. Average rates per 100,000 were 722.7, 523.6, 286.4, and 248, respectively. These areas represent four of the six zip codes citywide that saw year-to-year increases in violent trauma during this period. Zip 70113 saw a lower rate of rise in trauma compared with 70112 and a higher but comparable rise compared with that of 70119 and 70125. Hospital-based intervention programs that partner with culturally appropriate personnel and resources outside the institution walls have potential to have meaningful impact over the long term. While few conclusions of the effect of such a program can be drawn in a 12-month period, we anticipate long-term changes in the numbers of penetrating injuries in the target area and in the rest of the city as this program expands. Therapeutic study, level IV.

Risk Factors for Venous Thromboembolism in Pediatric Trauma Patients and Validation of a Novel Scoring System: The Risk of Clots in Kids with Trauma (ROCKIT score)

PubMed Central

Yen, Jennifer; Van Arendonk, Kyle J.; Streiff, Michael B.; McNamara, LeAnn; Stewart, F. Dylan; Conner G, Kim G; Thompson, Richard E.; Haut, Elliott R.; Takemoto, Clifford M.

2017-01-01

OBJECTIVES Identify risk factors for venous thromboembolism (VTE) and develop a VTE risk assessment model for pediatric trauma patients. DESIGN, SETTING, AND PATIENTS We performed a retrospective review of patients 21 years and younger who were hospitalized following traumatic injuries at the John Hopkins level 1 adult and pediatric trauma center (1987-2011). The clinical characteristics of patients with and without VTE were compared, and multivariable logistic regression analysis was used to identify independent risk factors for VTE. Weighted risk assessment scoring systems were developed based on these and previously identified factors from patients in the National Trauma Data Bank (NTDB 2008-2010); the scoring systems were validated in this cohort from Johns Hopkins as well as a cohort of pediatric admissions from the NTDB (2011-2012). MAIN RESULTS Forty-nine of 17,366 pediatric trauma patients (0.28%) were diagnosed with VTE after admission to our trauma center. After adjusting for potential confounders, VTE was independently associated with older age, surgery, blood transfusion, higher Injury Severity Score (ISS), and lower Glasgow Coma Scale (GCS) score. These and additional factors were identified in 402,329 pediatric patients from the NTDB from 2008-2010; independent risk factors from the logistic regression analysis of this NTDB cohort were selected and incorporated into weighted risk assessment scoring systems. Two models were developed and were cross-validated in 2 separate pediatric trauma cohorts: 1) 282,535 patients in the NTDB from 2011 to 2012 2) 17,366 patients from Johns Hopkins. The receiver operator curve using these models in the validation cohorts had area under the curves that ranged 90% to 94%. CONCLUSIONS VTE is infrequent after trauma in pediatric patients. We developed weighted scoring systems to stratify pediatric trauma patients at risk for VTE. These systems may have potential to guide risk-appropriate VTE prophylaxis in children after trauma. PMID:26963757

Vascular Trauma Operative Experience is Inadequate in General Surgery Programs.

PubMed

Yan, Huan; Maximus, Steven; Koopmann, Matthew; Keeley, Jessica; Smith, Brian; Virgilio, Christian de; Kim, Dennis Y

2016-05-01

Vascular injuries may be challenging, particularly for surgeons who have not received formal vascular surgery fellowship training. Lack of experience and improper technique can result in significant complications. The objective of this study was to examine changes in resident experience with operative vascular trauma over time. A retrospective review was performed using Accreditation Council for Graduate Medical Education (ACGME) case logs of general surgery residents graduating between 2004 and 2014 at 2 academic, university-affiliated institutions associated with level 1 trauma centers. The primary outcome was number of reported vascular trauma operations, stratified by year of graduation and institution. A total of 112 residents graduated in the study period with a median 7 (interquartile range 4.5-13.5) vascular trauma cases per resident. Fasciotomy and exposure and/or repair of peripheral vessels constituted the bulk of the operative volume. Linear regression showed no significant trend in cases with respect to year of graduation (P = 0.266). Residents from program A (n = 53) reported a significantly higher number of vascular trauma cases when compared with program B (n = 59): 12.0 vs. 5.0 cases, respectively (P < 0.001). Level 1 trauma center verification does not guarantee sufficient exposure to vascular trauma. The operative exposure in program B is reflective of the national average of 4.0 cases per resident as reported by the ACGME, and this trend is unlikely to change in the near future. Fellowship training may be critical for surgeons who plan to work in a trauma setting, particularly in areas lacking vascular surgeons. Copyright © 2016 Elsevier Inc. All rights reserved.

The Initial Response to the Boston Marathon Bombing

PubMed Central

Gates, Jonathan D.; Arabian, Sandra; Biddinger, Paul; Blansfield, Joe; Burke, Peter; Chung, Sarita; Fischer, Jonathan; Friedman, Franklin; Gervasini, Alice; Goralnick, Eric; Gupta, Alok; Larentzakis, Andreas; McMahon, Maria; Mella, Juan; Michaud, Yvonne; Mooney, David; Rabinovici, Reuven; Sweet, Darlene; Ulrich, Andrew; Velmahos, George; Weber, Cheryl; Yaffe, Michael B.

2017-01-01

Objective We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. Background Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. Methods A collaborative effort among Boston’s trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. Results A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. Conclusions Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes. PMID:25386862

Isolated transient loss of consciousness is an indicator of significant injury.

PubMed

Owings, J T; Wisner, D H; Battistella, F D; Perlstein, J; Walby, W F; Tharratt, R S

1998-09-01

To determine if isolated transient loss of consciousness is an indicator of significant injury. University-based level I trauma center. Phase 1 retrospective case series of all patients with trauma admitted directly from the emergency department to the operating room or an intensive care unit who had transient loss of consciousness as their only trauma triage criterion. Phase 2 prospective case series of all trauma patients transported by emergency medical system personnel with transient loss of consciousness as their only trauma triage criterion. Emergency operation and intensive care unit admission. Phase 1: From January 1, 1992, to March 31, 1995, we admitted 10255 patients with trauma. Three hundred seven (3%) met the enrollment criteria and were admitted to the operating room (n = 168) or intensive care unit (n = 139). Of these, 58 (18.9%) were taken to the operating room emergently to manage life-threatening injuries: 11 (4%) had craniotomies and 47 (15%) had non-neurosurgical operations. Phase 2: From July 1 to December 31, 1996, 2770 trauma patients were transported to our facility; 135 (4.9%) met the enrollment criteria. Forty-one (30.4%) of these required admission, and 6 (4.4%) were taken emergently to the operating room from the emergency department (1 [1%] for a craniotomy, 3 [2.2%] for intra-abdominal bleeding, and 2 [1.5%] for other procedures). Two (1.5%) of the 135 patients died. Patients with isolated transient loss of consciousness are at significant risk of critical surgical and neurosurgical injuries. These patients should be triaged to trauma centers or hospitals with adequate imaging, surgical, and neurosurgical resources.

The Effects of Pediatric Advanced Life Support Guidelines on Pediatric Trauma Airway Management.

PubMed

Sperka, Jana; Hanson, Sheila J; Hoffmann, Raymond G; Dasgupta, Mahua; Meyer, Michael T

2016-08-01

Recent Pediatric Advanced Life Support (PALS) guidelines have deemphasized the use of advanced airways in short transport. It is unclear if guideline recommendations have altered practice. We sought to determine if a temporal change exists in the number of prehospital pediatric trauma intubations since the 2005 PALS guidelines update. This is an institutional review board-approved, retrospective, single-center study. Reviewed all pediatric trauma activations where patients younger than 19 years were intubated at the scene, en route or at the level 1 trauma center during 2006 to 2011. Specific complications collected were esophageal intubations, mainstem intubations and need for re-intubations. There were 1012 trauma activations, 1009 pediatric patients, 300 (29.7%) intubated during transport to Children's Hospital of Wisconsin Pediatric Trauma Center (PTC) or upon arrival. Mean age of 9.5 ± 5.9 years. Fifty-seven percent (n = 172) were intubated before PTC, 31.7% (n = 95) field intubations, 25.7% (n = 77) outside facility intubations. 44% (n = 132) at PTC. Age was not a significant variable. There was no difference in the proportion of injured children requiring intubation who were intubated before arrival to the PTC. Those intubated in the field versus a facility had significantly increased mortality (P = 0.0002), longer hospital days (P = 0.0004) including intensive care unit days (P = 0.0003) and ventilator days (P = 0.0003) even when adjusted for illness severity. There was no significant change in the proportion of pretrauma room intubations following the 2005 PALS guidelines even when adjusted for illness or injury severity. Children injured farther from the PTC and more severely injured children were more likely to be intubated before arrival at the PTC.

Scarf-related injuries at a major trauma center in northern India.

PubMed

Singh, Pritish; Kumar, Ashok; Shekhawat, Vishal

2017-04-01

Scarf is a long loose piece of cloth worn around the neck and shoulder. Despite cultural association of this apparel, it is part of numerous injury episodes of varying enormity. Entanglement of loose scarf in spoke wheels of bike, tricycle, belt driven machines like sugarcane juice machine, thresher, grinding machines, etc is observed both in social and industrial milieu. This study aims to investigate the scarf-related injuries at a major trauma center in northern India. From June 2013 to May 2015, a hospital-based prospective observational study was done in patients who presented to a level 1 trauma center in northern India with the mode of injury involving scarf around the neck. Demographic profile, mode of trauma, contributing factors, injury pattern, and the early management as well as early complications were recorded. There were 76 injuries directly related from scarf with the mean age of patients being 32.4 years. The most common primary factor involved was rotating wheel of motorbike/tricycle (46.1%), followed by belt driven machines (28.9%). The spectrum of injuries was diverse, including minor abrasions or lacerations (53.9%), large lacerations (15.8%), fractures and spine trauma (18.4%), mangled extremity and amputations (7.9%) and death (3.9%). More severe injury patterns were noted with belt driven machines. Scarf-related injuries constitute a sizable proportion of trauma, with varying degrees of severity. Devastating consequences in significant proportion of cases dictate the call for a prevention plan comprising both educational and legislative measures. Urgent preventive measures targeting scarf-related injuries will help reduce mortality and morbidity. Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Declining trend in the use of repeat computed tomography for trauma patients admitted to a level I trauma center for traffic-related injuries.

PubMed

Psoter, Kevin J; Roudsari, Bahman S; Graves, Janessa M; Mack, Christopher; Jarvik, Jeffrey G

2013-06-01

To evaluate the trend in utilization of repeat (i.e. ≥2) computed tomography (CT) and to compare utilization patterns across body regions for trauma patients admitted to a level I trauma center for traffic-related injuries (TRI). We linked the Harborview Medical Center trauma registry (1996-2010) to the billing department data. We extracted the following variables: type and frequency of CTs performed, age, gender, race/ethnicity, insurance status, injury mechanism and severity, length of hospitalization, intensive care unit (ICU) admission and final disposition. TRIs were defined as motor vehicle collisions, motorcycle, bicycle and pedestrian-related injuries. Logistic regression was used to evaluate the association between utilization of different body region repeat (i.e. ≥2) CTs and year of admission, adjusting for patient and injury-related characteristics that could influence utilization patterns. A total of 28,431 patients were admitted for TRIs over the study period and 9499 (33%) received repeat CTs. From 1996 to 2010, the proportion of patients receiving repeat CTs decreased by 33%. Relative to 2000 and adjusting for other covariates, patients with TRIs admitted in 2010 had significantly lower odds of undergoing repeat head (OR=0.61; 95% CI: 0.49-0.76), pelvis (OR=0.37; 95% CI: 0.27-0.52), cervical spine (OR=0.23; 95% CI: 0.12-0.43), and maxillofacial CTs (OR=0.24; 95% CI: 0.10-0.57). However, they had higher odds of receiving repeat thoracic CTs (OR=1.86; 95% CI: 1.02-3.38). A significant decrease in the utilization of repeat CTs was observed in trauma patients presenting with traffic-related injuries over a 15-year period. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Six-month Follow Up of the Injured Trauma Survivor Screen (ITSS): Clinical Implications and Future Directions.

PubMed

Hunt, Joshua C; Chesney, Samantha A; Brasel, Karen; deRoon-Cassini, Terri A

2018-04-17

The Injured Trauma Survivor Screen (ITSS) has been shown to predict PTSD and depression risk at one-month after traumatic injury. This study explored the ability of the ITSS to predict chronic distress after injury, as well as the impact of combining the ITSS with an additional screening measure. Patients were enrolled following admission to a Level 1 trauma center. Baseline measurements were collected during initial hospitalization, and follow-up measures were collected an average of 6.5 months after injury. Receiver Operating Characteristic (ROC) curve analyses were run to determine predictive accuracy, controlling for participants who had mental health intervention and for those who experienced additional potentially psychologically traumatic events since their injury event. Utilizing a cut score of 2, the ITSS PTSD scale had a sensitivity of 85.42%, specificity 67.35%, NPV 91.9% and PPV 51.4%. The Combined PTSD risk group (risk positive on the baseline ITSS and the PTSD Checklist for the DSM-5) had a sensitivity of 72.92%, specificity 81.63%, NPV 88.2% and PPV 61.6%. Also utilizing a cut score of 2, the ITSS Depression scale had a sensitivity of 72.50%, specificity 70.29%, NPV 91.1% and PPV 37.9%. The 9-item ITSS, which takes approximately five minutes to administer, is a stable screening tool for predicting those most at risk for PTSD and/or depression six-months after admission to a Level 1 trauma center following traumatic injury. The Combined PTSD risk group data provide evidence that symptom evaluation by a psychologist can improve specificity. These results further inform the recommendation of the American College of Surgeons Committee on Trauma regarding PTSD and depression screening in trauma centers. Prognostic study, Level III.

Limitations in Prehospital Communication Between Trauma Helicopter, Ambulance Services, and Dispatch Centers.

PubMed

Harmsen, Annelieke Maria Karien; Giannakopoulos, Georgios; Franschman, Gaby; Christiaans, Herman; Bloemers, Frank

2017-04-01

Prehospital communication with Emergency Medical Services (EMS) is carried out in hectic situations. Proper communication among all medical personal is required to enhance collaboration, to provide the best care and enable shared situational awareness. The objective of this article was to give insight into current Dutch prehospital emergency care communication among all EMS and evaluate the usage of a new physician staffed helicopter EMS (P-HEMS) cancellation model. Trauma-related P-HEMS dispatches between November 1, 2014 and May 31, 2015 for the Lifeliner 1 were included; a random sample of 100 dispatches was generated. Tape recordings on all verbal prehospital communication between the dispatch center, EMS, and P-HEMS were transcribed and analyzed. Qualitative content analysis was performed, using open coding to code key messages. Ninety-two tape recordings were analyzed. The most frequent reason for P-HEMS dispatch was suspicion of brain injury (24%). The cancellation model was followed in 66%, overruled in 9%, and not applicable in 25%. The main reason for not adhering to the model was hemodynamic stability. In 5% of P-HEMS dispatches, a complete ABCD (airway, breathing, circulation, disability) methodology was used for handover, in 9% a complete Situation-Background-Assessment-Recommendation technique, in 2% a complete Mechanism-Injuries-Signs-Treatment method was used. The other handovers were incomplete. Prehospital handover between EMS on-scene and P-HEMS often entails insufficient information. The cancellation model for P-HEMS is frequently used and promotes adequate information transfer. To increase joined decision-making, more patient and situational information needs to be handed over. Standardization of prehospital trauma handovers will facilitate this and improve trauma patient's outcome. Copyright © 2016 Elsevier Inc. All rights reserved.

Chest computed tomography for penetrating thoracic trauma after normal screening chest roentgenogram.

PubMed

Mollberg, Nathan M; Wise, Stephen R; De Hoyos, Alberto L; Lin, Fang-Ju; Merlotti, Gary; Massad, Malek G

2012-06-01

Chest computed tomography (CCT) is a method of screening for intrathoracic injuries in hemodynamically stable patients with penetrating thoracic trauma. The objective of this study was to examine the changes in utilization of CCT over time and evaluate its contribution to guiding therapeutic intervention. A level 1 trauma center registry was queried between 2006 and 2011. Patients undergoing CCT in the emergency department after penetrating thoracic trauma as well as patients undergoing thoracic operations for penetrating thoracic trauma were identified. Patient demographics, operative indications, use of CCT, injuries, and hospital admissions were analyzed. In all, 617 patients had CCTs performed, of whom 61.1% (371 of 617) had a normal screening plain chest radiograph (CXR). In 14.0% (51 of 371) of these cases, the CCT revealed findings not detected on screening CXR. The majority of these injuries were occult pneumothoraces or hemothoraces (84.3%; 43 of 51), of which 27 (62.8%) underwent tube thoracostomy. In only 0.5% (2 of 371), did the results of CCT alone lead to an operative indication: exploration for hemopericardium. The use of CCT in our patients significantly increased overall (28.8% to 71.4%) as well as after a normal screening CXR (23.3% to 74.6%) over the study period. The use of CCT for penetrating thoracic trauma increased 3.5-fold during the study period with a concurrent increase in findings of uncertain clinical significance. Patients with a normal screening CXR should be triaged with 3-hour delayed CXR, serial physical examinations, and focused assessment with sonography for trauma; and CCT should only be used selectively as a diagnostic modality. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Severity-Adjusted Mortality in Trauma Patients Transported by Police

PubMed Central

Band, Roger A.; Salhi, Rama A.; Holena, Daniel N.; Powell, Elizabeth; Branas, Charles C.; Carr, Brendan G.

2018-01-01

Study objective Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia. Methods This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Results Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. Conclusion We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care. PMID:24387925

Characteristics and visual outcomes of patients hospitalized for ocular trauma in central China: 2006–2011

PubMed Central

Qi, Ying; Zhang, Feng-Yan; Peng, Guang-Hua; Zhu, Yu; Wan, Guang-Ming; Wang, Wen-Zhan; Ma, Jing; Ren, Shi-Jie

2015-01-01

AIM To complete the data of ocular trauma in central China, as a well-known tertiary referral center for ocular trauma, we documented the epidemiological characteristics and visual outcomes of patients hospitalized for ocular trauma in this region. METHODS A retrospective study of patients hospitalized for ocular trauma in central China from 2006 to 2011 was performed. RESULTS This study included 5964 eyes of 5799 patients. The average age was 35.5±21.8y with a male-to-female ratio of 2.8:1. The most common age was 45-59y age group. Most patients were farmers and workers (51.9%). The most common injuries were firework related (24.5%), road traffic related (24.2%), and work related (15.0%). Among the most common causative agents were firecrackers (24.5%), followed by metal/knife/scissors (21.4%). Most injuries occurred in January (14.2%), February (27.0%), and August (10.0%). There were 8.5% patients with ocular injuries combined with other injuries. The incidence of open ocular injuries (4585 eyes, 76.9%) was higher than closed ocular injuries (939 eyes, 15.7%). The incidences of chemical and thermal ocular injuries were 1.2% and 0.6%. Ocular trauma score (OTS) predicted final visual acuity at non light perception (NLP), 20/200-20/50 and 20/40 with a sensitivity of 100%, and light perception (LP)/hand motion (HM) and 1/200-19/200 with a specificity of 100%. CONCLUSIONS This study provides recent epidemiological data of patients hospitalized for ocular trauma in central China. Some factors influencing the visual outcome include time interval between injury and visit to the clinic, wound location, open or closed globe injury, initial visual acuity, and OTS. PMID:25709927

A 2D threshold of the condylar-C1 interval to maximize identification of patients at high risk for atlantooccipital dislocation using computed tomography.

PubMed

Ravindra, Vijay M; Riva-Cambrin, Jay; Horn, Kevin P; Ginos, Jason; Brockmeyer, Russell; Guan, Jian; Rampton, John; Brockmeyer, Douglas L

2017-04-01

OBJECTIVE Measurement of the occipital condyle-C1 interval (CCI) is important in the evaluation of atlantooccipital dislocation (AOD) in pediatric trauma patients. The authors studied a large cohort of children with and without AOD to identify a 2D measurement threshold that maximizes the diagnostic yield of the CCI on cervical spine CT scans obtained in trauma patients. METHODS This retrospective, single-center study included all children who underwent CT of the cervical spine at Primary Children's Hospital from January 1, 2011, through December 31, 2014, for trauma evaluation. Bilateral CCI measurements in the coronal (3 measurements per side) and sagittal (4 measurements per side) planes were recorded. Using an iterative method, the authors determined optimal cutoffs for the maximal CCI in each plane in relation to AOD. The primary outcome was AOD requiring occipitocervical fusion. RESULTS A total of 597 pediatric patients underwent cervical spine CT for trauma evaluation: 578 patients without AOD and 19 patients with AOD requiring occipitocervical fusion. The authors found a statistically significant correlation between CCI and age (p < 0.001), with younger patients having higher CCIs. Using a 2D threshold requiring a sagittal CCI ≥ 2.5 mm and a coronal CCI ≥ 3.5 mm predicted AOD with a sensitivity of 95%, a specificity of 73%, positive predictive value of 10.3%, and negative predictive value of 99%. The accuracy of this 2D threshold was 84%. CONCLUSIONS In the present study population, age-dependent differences in the CCI were found on CT scans of the cervical spine in a large cohort of patients with and without AOD. A 2D CCI threshold as a screening method maximizes identification of patients at high risk for AOD while minimizing unnecessary imaging studies in children being evaluated for trauma.

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center

PubMed Central

Zargaran, Eiman; Spence, Richard; Adolph, Lauren; Nicol, Andrew; Schuurman, Nadine; Navsaria, Pradeep; Ramsey, Damon

2018-01-01

Importance Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity. Objective To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools. Design, Setting, and Participants This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013. Main Outcomes and Measures The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital. Results The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell’s Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]). Conclusions and Relevance Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data. PMID:29541765

Variation in DVT prophylaxis for adolescent trauma patients: a survey of the Society of Trauma Nurses.

PubMed

O'Brien, Sarah H; Haley, Kathy; Kelleher, Kelly J; Wang, Wei; McKenna, Christine; Gaines, Barbara A

2008-01-01

We performed a survey of the Society of Trauma Nurses to explore current practice patterns for deep venous thrombosis prophylaxis in adolescent trauma patients and analyzed responses from 133 institutions. The majority of adult prophylaxis protocols include older adolescents. Only 41% of adult programs identified patient age as "very" important in prophylaxis decision making. Pelvic fracture, spinal cord injury, and expected immobilization were rated most important. Pharmacologic prophylaxis in 11- to 15-year-olds was infrequent, with 60% of centers using never or rarely. Use was much higher but variable among older adolescents. No consensus on deep venous thrombosis prophylaxis in adolescent trauma emerged from our survey.

Western Trauma Association Critical Decisions in Trauma: Management of rib fractures.

PubMed

Brasel, Karen J; Moore, Ernest E; Albrecht, Roxie A; deMoya, Marc; Schreiber, Martin; Karmy-Jones, Riyad; Rowell, Susan; Namias, Nicholas; Cohen, Mitchell; Shatz, David V; Biffl, Walter L

2017-01-01

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with rib fractures. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.

A population-based study of the association of medical manpower with county trauma death rates in the United States.

PubMed Central

Rutledge, R; Fakhry, S M; Baker, C C; Weaver, N; Ramenofsky, M; Sheldon, G F; Meyer, A A

1994-01-01

OBJECTIVE: To determine the association between measures of medical manpower available to treat trauma patients and county trauma death rates in the United States. The primary hypothesis was that greater availability of medical manpower to treat trauma injury would be associated with lower trauma death rates. SUMMARY BACKGROUND DATA: When viewed from the standpoint of the number of productive years of life lost, trauma has a greater effect on health care and lost productivity in the United States than any disease. Allocation of health care manpower to treat injuries seems logical, but studies have not been done to determine its efficacy. The effect of medical manpower and hospital resource allocation on the outcome of injury in the United States has not been fully explored or adequately evaluated. METHODS: Data on trauma deaths in the United States were obtained from the National Center for Health Statistics. Data on the number of surgeons and emergency medicine physicians were obtained from the American Hospital Association and the American Medical Association. Data on physicians who have participated in the American College of Surgeons (ACS) Advanced Trauma Life Support Course (ATLS) were obtained from the ACS. Membership information for the American Association for Surgery of Trauma (AAST) was obtained from that organization. Demographic data were obtained from the United States Census Bureau. Multivariate stepwise linear regression and cluster analysis were used to model the county trauma death rates in the United States. The Statistical Analysis System (Cary, NC) for statistical analysis was used. RESULTS: Bivariate and multivariate analyses showed that a variety of medical manpower measures and demographic factors were associated with county trauma death rates in the United States. As in other studies, measures of low population density and high levels of poverty were found to be strongly associated with increased trauma death rates. After accounting for these variables, using multivariate analysis and cluster analysis, an increase in the following medical manpower measures were associated with decreased county trauma death rates: number of board-certified general surgeons, number of board-certified emergency medicine physicians, number of AAST members, and number of ATLS-trained physicians. CONCLUSIONS: This study confirms previous work that showed a strong relation among measures of poverty, rural setting, and increased county trauma death rates. It also found that counties with more board-certified surgeons per capita and with more surgeons with an increased interest (AAST membership) or increased training (ATLS) in trauma care have lower per-capita trauma death rates.(ABSTRACT TRUNCATED AT 400 WORDS) Images Figure 1. PMID:8185404

Preparing Global Trauma Nurses for Leadership Roles in Global Trauma Systems.

PubMed

Muñiz, Sol Angelica; Lang, Richard W; Falcon, Lisa; Garces-King, Jasmine; Willard, Suzanne; Peck, Gregory L

Trauma leads to 5.7 million annual deaths globally, accounting for 25%-33% of global unintentional deaths and 90% of the global trauma burden in low- and middle-income countries. The Lancet Commission on Global Surgery and the World Health Organization assert that emergent and essential surgical capacity building and trauma system improvement are essential to address the global burden of trauma. In response, the Rutgers Global Surgery program, the School of Nursing and Medicine, and the Robert Wood Johnson University Hospital faculty collaborated in the first Interprofessional Models in Global Injury Care and Education Symposium in June 2016. This 2-week symposium combined lectures, high-fidelity simulation, small group workshops, site visits to Level I trauma centers, and a 1-day training course from the Panamerican Trauma Society. The aim was to introduce global trauma nurses to trauma leadership and trauma system development. After completing the symposium, 10 nurses from China, Colombia, Kenya, Puerto Rico, and Uruguay were surveyed. Overall, 88.8% of participants reported high levels of satisfaction with the program and 100% stated being very satisfied with trauma lectures. Symposia, such as that developed and offered by Rutgers University, prepare nurses to address trauma within system-based care and facilitate trauma nursing leadership in their respective countries.

76 FR 36135 - Agency Information Collection Activities; Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-21

... serves multiple practical purposes: (1) To collect and analyze descriptive, outcome, and service... on access to high-quality, trauma-informed care; (3) to evaluate NCTSN centers' training and... below. Descriptive and Clinical Outcomes In order to describe the children served, their trauma...

Trauma Registry of the Pan-American Trauma Society: One year of experience in two hospitals in southwest Colombia.

PubMed

Ordoñez, Carlos A; Morales, Mónica; Rojas-Mirquez, Johanna Carolina; Bonilla-Escobar, Francisco Javier; Badiel, Marisol; Miñán Arana, Fernando; González, Adolfo; Pino, Luis Fernando; Uribe-Gómez, Amadeus; Herrera, Mario Alain; Gutiérrez-Martínez, Maria Isabel; Puyana, Juan Carlos; Abutanos, Michael; Ivatury, Rao R

2016-09-30

Trauma information systems are needed to improve decision making and to identify potential areas of intervention. To describe the first year of experience with a trauma registry in two referral centers in southwest Colombia. The study was performed in two referral centers in Cali. Patients with traumatic injuries seen between January 1 and December 31, 2012, were included. The collected information included demographics, mechanism of trauma, injury severity score (ISS), and mortality. A descriptive analysis was carried out. A total of 17,431 patients were registered, of which 67.8% were male with an average age of 30 (±20) years. Workplace injuries were the cause of emergency consultations in 28.2% of cases, and falls were the most common mechanism of trauma (37.3%). Patients with an ISS ≥15 were mostly found in the 18-35-year age range (6.4%). Most patients who suffered a gunshot wound presented an ISS ≥15. A total of 2.5% of all patients died, whereas the mortality rate was 54% among patients with an ISS ≥15 and a gunshot wound. Once the trauma registry was successfully implemented in two institutions in Cali, the primary causes of admission were identified as falls and workplace injuries. The most severely compromised patients were in the population range between 18 and 35 years of age. The highest mortality was caused by gunshot wounds.

Injury patterns of child abuse: Experience of two Level 1 pediatric trauma centers.

PubMed

Yu, Yangyang R; DeMello, Annalyn S; Greeley, Christopher S; Cox, Charles S; Naik-Mathuria, Bindi J; Wesson, David E

2018-05-01

This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers. We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries. Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001). Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority. Retrospective Review. II. Copyright © 2018. Published by Elsevier Inc.

Endotoxemia Following Multiple Trauma: Risk Factors and Prognostic Implications.

PubMed

Charbonney, Emmanuel; Tsang, Jennifer Y; Li, Yangmei; Klein, David; Duque, Patricia; Romaschin, Alexander; Marshall, John C

2016-02-01

To evaluate the prevalence and time course of systemic endotoxemia following severe multiple trauma, to define its risk factors, and to explore the correlation between post-trauma endotoxemia and organ dysfunction. Prospective single-center cohort study. Emergency department and ICU of adult tertiary care level I trauma center. Forty-eight severely injured (Injury Severity Score ≥ 16) patients, admitted to ICU within 24 hours of injury. None. Endotoxemia was not evident on initial presentation, but developed subsequently in 75% of patients, even in the absence of Gram-negative infection. Nonsurviving patients had higher endotoxin levels than survivors on day 1 (endotoxemia, 0.48 vs 0.28; p = 0.048). Shock at admission, or surgery within the first 48 hours after trauma, was associated with higher endotoxin levels and predicted subsequent maximal endotoxemia, after adjusting for other significant covariates. Maximal endotoxemia levels were higher in patients who developed organ dysfunction, reflected in a cumulative Multiple Organ Dysfunction Score greater than 25, and patients with an intermediate endotoxemia level (≥ 0.4) had more cardiovascular dysfunction. It is the first study to detect increasing levels of endotoxemia following multiple trauma. Shock and early surgery predict the development of endotoxemia; endotoxemia is particularly associated with cardiovascular dysfunction. However, Gram-negative infections are uncommon in these patients, suggesting that the gastrointestinal tract is the dominant reservoir of endotoxin. Endotoxin may be an appropriate therapeutic target in patients who have sustained severe multiple trauma.

Pelvic fracture in multiple trauma: A 67-case series.

PubMed

Caillot, M; Hammad, E; Le Baron, M; Villes, V; Leone, M; Flecher, X

2016-12-01

Severe pelvic trauma remains associated with elevated mortality, largely due to hemorrhagic shock. The main study objective was to test for correlation between fracture type and mortality. The secondary objective was to assess the efficacy in terms of mortality of multidisciplinary management following a decision-tree in multiple trauma victims admitted to a level 1 trauma center. Between July 2011 and July 2013, 534 severe trauma patients were included in a single-center continuous prospective observational study. All patients with hemorrhagic shock received early treatment by pelvic binder. Patients with active bleeding on full-body CT or persisting hemorrhagic shock underwent arteriography with or without embolization. Pelvic trauma was graded on the Tile classification. The principle end-point was mortality. Median age was 40 years (range, 26-48 years), with a 79% male/female sex ratio. Thirty-two of the 67 patients with pelvic trauma (48%) were in hemorrhagic shock at admission. Median injury severity score (ISS) was 36 (range, 24-43). On the Tile classification, 22 patients (33%) were grade A, 33 (49%) grade B and 12 (18%) grade C. Overall mortality was 19%, and 42% in case of hemorrhagic shock. Mortality was significantly higher with Tile C than A or B (58% vs. 9.1% and 12.1%, respectively; P=0.001). Vertical shear fracture (Tile C) was associated with greater mortality from hemorrhagic shock. IV, case series. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Safety of the use of group A plasma in trauma: the STAT study.

PubMed

Dunbar, Nancy M; Yazer, Mark H

2017-08-01

Use of universally ABO-compatible group AB plasma for trauma resuscitation can be challenging due to supply limitations. Many centers are now using group A plasma during the initial resuscitation of traumatically injured patients. This study was undertaken to evaluate the impact of this practice on mortality and hospital length of stay (LOS). Seventeen trauma centers using group A plasma in trauma patients of unknown ABO group participated in this study. Eligible patients were group A, B, and AB trauma patients who received at least 1 unit of group A plasma. Data collected included patient sex, age, mechanism of injury, Trauma Injury Severity Score (TRISS) probability of survival, and number of blood products transfused. The main outcome of this study was in-hospital mortality differences between group B and AB patients compared to group A patients. Data on early mortality (≤24 hr) and hospital LOS were also collected. There were 354 B and AB patients and 809 A patients. The two study groups were comparable in terms of age, sex, TRISS probability of survival, and total number of blood products transfused. The use of group A plasma during the initial resuscitation of traumatically injured patients of unknown ABO group was not associated with increased in-hospital mortality, early mortality, or hospital LOS for group B and AB patients compared to group A patients. These results support the practice of issuing thawed group A plasma for the initial resuscitation of trauma patients of unknown ABO group. © 2017 AABB.

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.

PubMed

Leonard, Kenji L; Borst, Gregory M; Davies, Stephen W; Coogan, Michael; Waibel, Brett H; Poulin, Nathaniel R; Bard, Michael R; Goettler, Claudia E; Rinehart, Shane M; Toschlog, Eric A

2016-06-01

No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.

Is Treating Oral and Maxillofacial Trauma Profitable? An Analysis of Hospital and Surgeon Reimbursement at an Academic Medical Center.

PubMed

DeLuke, Dean M; Agarwal, Vickas; Holleman, Trevor; Carrico, Caroline K; Laskin, Daniel M

2017-02-01

During the past 2 decades, there has been a marked decrease in the willingness of community-based oral and maxillofacial surgeons to participate in trauma call. Although many factors can influence the decision not to take trauma call, 1 primary disincentive is the perception that managing facial trauma might be profitable for the hospital, but not profitable for the surgeon. The purpose of this study was to compare the profitability of facial trauma management for the hospital and the surgeon at the Virginia Commonwealth University (VCU) Medical Center (Richmond, VA). In this retrospective cohort study, records were collected for patients who were seen for primary trauma management by the Department of Oral and Maxillofacial Surgery at VCU (VCUOMS) from June 2011 through July 2014. Cost and reimbursement data were analyzed for these patients from the VCU Health System (VCUHS) and the VCUOMS. For the hospital, actual cost data were provided; for the surgeon, cost was calculated based on an average overhead of 50%. For uniformity, patients were excluded if they remained in the hospital for longer than a 23-hour observation period. Patients younger than 18 years also were excluded. In total, 169 patients met the inclusion criteria. There was a statistically relevant difference in the percentage of costs recouped and the actual profit. The average percentage of costs recouped was 230% for the VCUHS versus 47% for the VCUOMS. This amounts to an average profit per case of $3,461 for the hospital versus a loss of $1,162 for the surgeon. The results of this study indicate that in the VCU Medical Center, maxillofacial trauma yields a net profit for the hospital and a net loss for the operating surgeon. Although the results are limited to outpatient management at 1 academic institution, they suggest that hospitals in some settings might be in a position to incentivize surgeons for trauma management. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Developing a Minimum Data Set for an Information Management System to Study Traffic Accidents in Iran

PubMed Central

Mohammadi, Ali; Ahmadi, Maryam; Gharagozlu, Alireza

2016-01-01

Background: Each year, around 1.2 million people die in the road traffic incidents. Reducing traffic accidents requires an exact understanding of the risk factors associated with traffic patterns and behaviors. Properly analyzing these factors calls for a comprehensive system for collecting and processing accident data. Objectives: The aim of this study was to develop a minimum data set (MDS) for an information management system to study traffic accidents in Iran. Materials and Methods: This descriptive, cross-sectional study was performed in 2014. Data were collected from the traffic police, trauma centers, medical emergency centers, and via the internet. The investigated resources for this study were forms, databases, and documents retrieved from the internet. Forms and databases were identical, and one sample of each was evaluated. The related internet-sourced data were evaluated in their entirety. Data were collected using three checklists. In order to arrive at a consensus about the data elements, the decision Delphi technique was applied using questionnaires. The content validity and reliability of the questionnaires were assessed by experts’ opinions and the test-retest method, respectively. Results: An (MDS) of a traffic accident information management system was assigned to three sections: a minimum data set for traffic police with six classes, including 118 data elements; a trauma center with five data classes, including 57 data elements; and a medical emergency center, with 11 classes, including 64 data elements. Conclusions: Planning for the prevention of traffic accidents requires standardized data. As the foundation for crash prevention efforts, existing standard data infrastructures present policymakers and government officials with a great opportunity to strengthen and integrate existing accident information systems to better track road traffic injuries and fatalities. PMID:27247791

Trauma deaths in the first hour: are they all unsalvageable injuries?

PubMed

MacLeod, Jana B A; Cohn, Stephen M; Johnson, E William; McKenney, Mark G

2007-02-01

With the advent of trauma systems, time to definitive care has been decreased. We hypothesized that a subset of patients who are in extremis from the time of prehospital transport to arrival at the trauma center, and who ultimately die early after arrival, may in fact have a potentially salvageable single-organ injury. We reviewed all deaths that occurred in the first hour after hospital admission. Trauma registry, medical records, and autopsy reports for 556 patients were evaluated. The median time to arrival was 39 minutes, and the median Injury Severity Score was 29. Blunt injuries (53%) were most commonly auto-accident injuries (134 of 285 patients; 47%). Penetrating wounds (42%) were mostly gunshot wounds to the chest (73 of 233 patients; 31%). For patients with initial vital signs, the most common cause of death was isolated brain injury (26 patients; 28%). Possibly survivable injuries (single organ or vessel) occurred in 35 (38%) patients, of which 4 were isolated spleen injuries (4%). Some patients with potentially survivable single organ injuries did not have associated head injuries. An aggressive approach is warranted on patients with detectable vital signs on at least one occasion in the field but who arrive at the trauma center in extremis.

[Awareness of the methods of primary and secondary childbirth trauma prevention among parturients].

PubMed

Veverková, A; Kališ, V; Rušavý, Z

2017-01-01

To evaluate the awareness of fresh mothers regarding the primary prevention of pelvic floor disorders after childbirth. The secondary objective was to identify sources of information, reality of childbirth trauma prevention and attitude to pelvic floor muscle training. Prospective survey study. Department of Gynecology and Obstetrics, University Hospital and Medical Faculty in Pilsen, Charles University. We included 202 women after a vaginal delivery at our center from 6/2015 to 12/2015. These women completed anonymous questionnaire with six questions. 83% of respondents were informed regarding the possibility of primary prevention of childbirth, nulliparas were informed better (88%). The main source of information was the Internet (46%), while only 5% of women received information from their doctor. Despite the high awareness of postpartum trauma prevention, less than half of interviewed women actually performed it (35%). The most widely used method was the massage of the perineum (29%), vaginal dilatation balloons were used less (7%) and alternative methods were pursued by only 4% of women. Experience with pelvic floor muscle exercises had 79% of women, while 90% wanted to exercise after the delivery. Awareness of mothers regarding primary and secondary prevention of pelvic floor disorders is satisfactory. Nevertheless, the information from doctors is inadequate. Despite high awareness, the antepartum prevention methods are used relatively rarely. The study clearly shows the level of awareness and reality of primary and secondary prevention of pelvic floor disorders in our region.

Benchmarking Outcomes in the Critically Injured Trauma Patient and the Effect of Implementing Standard Operating Procedures

PubMed Central

Cuschieri, Joseph; Johnson, Jeffrey L.; Sperry, Jason; West, Michael A.; Moore, Ernest E.; Minei, Joseph P.; Bankey, Paul E.; Nathens, Avery B.; Cuenca, Alex G.; Efron, Philip A.; Hennessy, Laura; Xiao, Wenzhong; Mindrinos, Michael N.; McDonald-Smith, Grace P.; Mason, Philip H.; Billiar, Timothy R.; Schoenfeld, David A.; Warren, H. Shaw; Cobb, J. Perren; Moldawer, Lyle L.; Davis, Ronald W.; Maier, Ronald V.; Tompkins, Ronald G.

2012-01-01

Objective To determine and compare outcomes with accepted benchmarks in trauma care at seven academic Level I trauma centers in which patients were treated based on a series of standard operating procedures (SOPs). Background Injury remains the leading cause of death for those under 45 years of age. We describe the baseline patient characteristics and well-defined outcomes of persons hospitalized in the United States for severe blunt trauma. Methods We followed 1,637 trauma patients from 2003–2009 up to 28 hospital days using SOPs developed at the onset of the study. An extensive database on patient and injury characteristics, clinical treatment, and outcomes was created. These data were compared with existing trauma benchmarks. Results The study patients were critically injured and in shock. SOP compliance improved 10–40% during the study period. Multiple organ failure and mortality rates were 34.8% and 16.7% respectively. Time to recovery, defined as the time until the patient was free of organ failure for at least two consecutive days, was developed as a new outcome measure. There was a reduction in mortality rate in the cohort during the study that cannot be explained by changes in the patient population. Conclusions This study provides the current benchmark and the overall positive effect of implementing SOPs for severely injured patients. Over the course of the study, there were improvements in morbidity and mortality and increasing compliance with SOPs. Mortality was surprisingly low, given the degree of injury, and improved over the duration of the study, which correlated with improved SOP compliance. PMID:22470077

Access to specialist care: Optimizing the geographic configuration of trauma systems

PubMed Central

Jansen, Jan O.; Morrison, Jonathan J.; Wang, Handing; He, Shan; Lawrenson, Robin; Hutchison, James D.; Campbell, Marion K.

2015-01-01

BACKGROUND The optimal geographic configuration of health care systems is key to maximizing accessibility while promoting the efficient use of resources. This article reports the use of a novel approach to inform the optimal configuration of a national trauma system. METHODS This is a prospective cohort study of all trauma patients, 15 years and older, attended to by the Scottish Ambulance Service, between July 1, 2013, and June 30, 2014. Patients underwent notional triage to one of three levels of care (major trauma center [MTC], trauma unit, or local emergency hospital). We used geographic information systems software to calculate access times, by road and air, from all incident locations to all candidate hospitals. We then modeled the performance of all mathematically possible network configurations and used multiobjective optimization to determine geospatially optimized configurations. RESULTS A total of 80,391 casualties were included. A network with only high- or moderate-volume MTCs (admitting at least 650 or 400 severely injured patients per year, respectively) would be optimally configured with a single MTC. A network accepting lower-volume MTCs (at least 240 severely injured patients per year) would be optimally configured with two MTCs. Both configurations would necessitate an increase in the number of helicopter retrievals. CONCLUSION This study has shown that a novel combination of notional triage, network analysis, and mathematical optimization can be used to inform the planning of a national clinical network. Scotland’s trauma system could be optimized with one or two MTCs. LEVEL OF EVIDENCE Care management study, level IV. PMID:26335775

Lessons From the Boston Marathon Bombing: An Orthopaedic Perspective on Preparing for High-Volume Trauma in an Urban Academic Center.

PubMed

Tobert, Daniel; von Keudell, Arvind; Rodriguez, Edward K

2015-10-01

The 2013 Boston Marathon bombing resulted in a mass casualty event that tested the limits of Boston-area trauma centers. The explosions, 12 seconds apart, led to the rapid influx of 124 patients with primarily lower extremity injuries in 5 different adult level 1 trauma centers. This study aimed to examine the existing hospital systems in place for disaster scenarios at the time of the event and identify areas for improvement. Preparation before the Boston Marathon bombing included coordinating the delivery of patients to area facilities and creating a framework for response at an institutional level. These simulations, coupled with the fact that the explosions occurred at a nexus of medical facilities, helped provide impactful care preventing any fatalities in patients who arrived at a Boston hospital that day. The experience at our institution led to the implementation of a more robust communication infrastructure and reinforced the value of preparatory drills. Within the Orthopaedic Surgery Department, we developed a more robust organizational hierarchy for mass casualty events and implemented a multitrauma follow-up clinic. We believe that it is the responsibility of every hospital to have systems in place to handle the rapid arrival of patients with multiple-trauma, and we hope that others can learn from our experience.

Implementation of a CT Scan Practice Guideline for Pediatric Trauma Patients Reduces Unnecessary Scans Without Impacting Outcomes.

PubMed

McGrew, Patrick R; Chestovich, Paul J; Fisher, Jay D; Kuhls, Deborah A; Fraser, Douglas R; Patel, Purvi P; Katona, Chad W; Saquib, Syed; Fildes, John J

2018-05-04

Computed Tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the utility of CT scan guidelines in the management of pediatric trauma. This study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT utilization before and after CT-guideline implementation. Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis utilizing published criteria from the Pediatric Emergency Care and Research Network (PECARN). There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age<15) trauma patients seen in our TC from 2010-2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay (LOS), readmissions, and mortality. Categorical and continuous variables were analyzed with Chi-square and Wilcoxon rank-sum tests, respectively. P<0.05 was considered significant. We identified 1934 patients: 1106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8% respectively (p<0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged. Implementation of a pediatric CT guideline significantly decreases CT utilization, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children. Level IV, Therapeutic Study.

Addressing alcohol-impaired driving : training physicians to detect and counsel their patients who drink heavily

DOT National Transportation Integrated Search

2000-07-01

Alcohol is the most common chronic disease in trauma patients, and one of the most common in patients treated in primary care. Studies have shown that brief counseling intervention in trauma centers and primary care clinics are efficient in reducing ...

Cecostomy

MedlinePlus

... a physician at another Johns Hopkins Member Hospital: Howard County General Sibley Memorial Hospital Suburban Hospital Connect ... Center: Pediatric Trauma Find Additional Treatment Centers at: Howard County General Sibley Memorial Hospital Suburban Hospital Maryland ...

Pulp calcification in traumatized primary teeth: prevalence and associated factors.

PubMed

Mello-Moura, A C V; Bonini, G A V C; Zardetto, C G D C; Rodrigues, C R M D; Wanderley, M T

2011-01-01

To establish the prevalence of pulp calcifications in 946 patients at the Research and Clinical Center of Dental Trauma in Primary Teeth. The clinical and radiographic records of l675 traumatized primary teeth were evaluated. Statistical analysis was performed using chi-square and univariate logistic regression. 197 (20.8%) patients showed pulp calcification (PC). A total of 250 (14.9%) calcified teeth were observed In most teeth, PC appeared within the first 12 months following trauma. PC prevalence was higher in cases of repeated trauma (29.6%) than in single trauma (16.4%), p < 0.05, with a 2.14 chance of showing pulp calcification when a child suffered recurrent trauma. Most teeth showing calcified pulp, suffered trauma to the supportive tissue (67.4%), being statistically significant in relation to the trauma to dental tissue (p < 0.05). PC is a sequelae in cases of trauma to the primary dentition; teeth that suffered recurrent traumatic injuries show higher risk of presenting.

Laparoscopic surgery for trauma: the realm of therapeutic management.

PubMed

Zafar, Syed N; Onwugbufor, Michael T; Hughes, Kakra; Greene, Wendy R; Cornwell, Edward E; Fullum, Terrence M; Tran, Daniel D

2015-04-01

The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Patient choice in the selection of hospitals by 9-1-1 emergency medical services providers in trauma systems.

PubMed

Newgard, Craig D; Mann, N Clay; Hsia, Renee Y; Bulger, Eileen M; Ma, O John; Staudenmayer, Kristan; Haukoos, Jason S; Sahni, Ritu; Kuppermann, Nathan

2013-09-01

Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis. This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. "Serious injury" was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings. A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols. Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis. © 2013 by the Society for Academic Emergency Medicine.

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care.

PubMed

Oyeniyi, Blessing T; Fox, Erin E; Scerbo, Michelle; Tomasek, Jeffrey S; Wade, Charles E; Holcomb, John B

2017-01-01

Over the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center. Records at an urban Level 1 trauma center were reviewed. Two time periods (2005-2006 and 2012-2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05. 7080 patients (498 deaths) were examined in 2005-2006, while 8767 patients (531 deaths) were reviewed in 2012-2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for >91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p<0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24h. Unadjusted mortality dropped from 7.0% to 6.1 (p=0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p<0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9-8.2) to 5.8% (95% CI: 5.3-6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0-7.2) to 4.7 (95% CI: 4.2-5.1). Over the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts. Copyright © 2016 Elsevier Ltd. All rights reserved.

Assessing the gap between the acute trauma workload and the capacity of a single rural health district in South Africa. What are the implications for systems planning?

PubMed

Clarke, D L; Aldous, C; Thomson, S R

2014-06-01

This study focuses on a single rural health district in South Africa, and attempts to establish the burden of disease and to review the capacity of the district hospitals to deal with this load. Ethical approval to undertake this study was obtained from both the University of Kwa-Zulu Natal and the Department of Health. The audit was performed over a 6-month period in the four district hospitals of rural Sisonke District. There were four components to this audit. 1. Information on the hospital incidence of acute trauma in Sisonke was also sourced from the epidemiology unit of the Department of Health in Pietermaritzburg 2. Each of the district hospitals was visited and the medical manager was interviewed. The medical manager was asked to complete the World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. (SAT). 3. The operative registers were reviewed to determine the number of index cases for trauma. This information was used to determine the unmet need of acute trauma in the district. 4. Each hospital was classified according to the Trauma Society of South Africa (TSSA) guidelines for levels of trauma care. The annual incidence of trauma in the Sisonke District is estimated to be 1,590 per 100,000 population. Although there appeared to be adequate infrastructure in the district hospitals, the SAT revealed significant deficits in terms of capacity of staff to adequately treat and triage acute trauma patients. There is a significant unmet need for trauma care in Sisonke. The four district hospitals can best be classified as Level IV centers of trauma care. There is a significant burden of trauma in the Sisonke District, yet the capacity to deal with this burden is inadequate. Although the physical infrastructure is adequate, the deficits relate to human resources. The strategic choices are between enhancing the district hospitals' capacity to deal with acute trauma, or deciding to bypass them completely and deliver all acute trauma patients to large regional trauma centers. If the first option is chosen, urgent intervention is required to build up the human resource capacity of district hospitals.

Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services.

PubMed

Wandling, Michael W; Nathens, Avery B; Shapiro, Michael B; Haut, Elliott R

2018-02-01

Time to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes. To evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems. Retrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle. In-hospital mortality. Of the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR,  0.45; 95% CI, 0.36-0.56) and stab wound (OR,  0.32; 95% CI, 0.20-0.52) subgroups. Private vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

Reconstructive surgery for complex midface trauma using titanium miniplates: Le Fort I fracture of the maxilla, zygomatico-maxillary complex fracture and nasomaxillary complex fracture, resulting from a motor vehicle accident.

PubMed

Nicholoff, T J; Del Castillo, C B; Velmonte, M X

Maxillofacial injuries resulting from trauma can be a challenge to the Maxillo-Facial Surgeon. Frequent causes of these injuries are attributed to automobile accidents, physical altercations, gunshot wounds, home accidents, athletic injuries, work injuries and other injuries. Motor vehicle accidents tend to be the primary cause of most midface fractures and lacerations due to the face hitting the dashboard, windshield and steering wheel or the back of the front seat for passengers in the rear. Seatbelts have been shown to drastically reduce the incidence and severity of these injuries. In the United States seatbelt laws have been enacted in several states thus markedly impacting on the reduction of such trauma. In the Philippines rare is the individual who wears seat belts. Metro city traffic, however, has played a major role in reducing daytime MVA related trauma, as usually there is insufficient speed in traffic areas to cause severe impact damage, the same however cannot be said for night driving, or for driving outside of the city proper where it is not uncommon for drivers to zip into the lane of on-coming traffic in order to overtake the car in front ... often at high speeds. Thus, the potential for severe maxillofacial injuries and other trauma related injuries increases in these circumstances. It is however unfortunate that outside of Metro Manila or other major cities there is no ready access to trauma or tertiary care centers, thus these injuries can be catastrophic if not addressed adequately. With the exception of Le Fort II and III craniofacial fractures, most maxillofacial injuries are not life threatening by themselves, and therefore treatment can be delayed until more serious cerebral or visceral, potentially life threatening injuries are addressed first. Our patient was involved in an MVA in Zambales, seen and stabilized in a provincial primary care center initially, then referred to a provincial secondary care center for further stabilization before his transfer to Manila and then ultimately to our Maxillo-Facial Unit. There was a two week-plus delay in the definitive management because of this. As a result of the delay, fibrous tissue and bone callus formation occurred between the various fracture lines, thus once definitive fracture management was attempted, it took on a more reconstructive nature. Hospital based Oral and Maxillo-Facial Surgeons are uniquely trained to manage all aspects of the maxillo-facial trauma, and their dental background uniquely qualifies them in functional restoration of lower and midface fractures where occlusion plays a most important role. Likewise, their training in clinical medicine which is usually integrated into their residency education (12 months or more) puts them in a unique position to comfortably manage the basic medical needs of these patients. In instances where trauma may affect other regions of the body, an inter-multi-disciplinary approach may be taken or consults called for. In this instance, an opthalmology consult was important. In fresh trauma, often seen in major trauma centers (i.e. overseas), a "Trauma Team" is on standby 24 hours a day, and is prepared to assess and manage trauma patients almost immediately upon their arrival in the ER. The trauma team is usually composed of a Trauma Surgeon who is a general surgeon with subspecialty training in traumatology who assesses and manages the visceral injuries, an Orthopedic Surgeon who manages fractures of the extremities, a Neurosurgeon for cerebral injuries and an Oral and Maxillo-Facial Surgeon for facial injuries. In some institutions, facial trauma call is alternated between the "three major head and neck specialty services", namely Oral and Maxillo-facial Surgery, Otolaryngology-Head & Neck Surgery and Plastic & Reconstructive Surgery. (ABSTRACT TRUNCATED)

Survey of 2582 Cases of Acute Orthopedic Trauma

PubMed Central

Soleymanha, Mehran; Mobayen, Mohammadreza; Asadi, Kamran; Adeli, Alborz; Haghparast-Ghadim-Limudahi, Zahra

2014-01-01

Background: Orthopedic injuries are among the most common causes of mortality, morbidity, hospitalization, and economic burden in societies. Objectives: In this research, we study the prevalence of different types of trauma requiring orthopedic surgery. Patients and Methods: We conducted a cross-sectional study on 2582 patients with acute orthopedic injuries admitted to the orthopedic emergency ward at the Poursina Hospital (a referral center in Guilan province (northern Iran), during December 2010 through September 2011. Patients were examined and the data collection form was filled for each patient. Data were analyzed by SPSS software version 19 and were listed in tables. Results: Of 2582 included cases, 1940 were male and 642 were female, with a mean age of 34.5 years. Most injuries were seen in the 25 to 44 year age group from rural areas. The highest frequency of trauma related to falls. On the other hand, bicycling and shooting had the lowest frequencies. There were 18 cases with limb amputation. Overall, 66.5% of patients had fractures, 5% had soft tissue lacerations, and 10% had dislocations. Conclusions: Identification of risk factors and methods of prevention is one of the most important duties of healthcare systems. Devising plans to minimize these risk factors and familiarizing people with them is prudent. PMID:25717444

Inpatients with gunshot wounds to the face.

PubMed

Sun, Gordon H; Patil, Yash J; Harmych, Brian M; Hom, David B

2012-01-01

Microvascular free tissue transfer (FTT) is an increasingly used method of reconstruction for traumatic defects of the head and neck. We describe the immediate management, FTT reconstruction techniques, and outcomes of 6 individuals who sustained maxillofacial gunshot trauma and were treated at a single tertiary-care level I trauma center. All 6 patients were white men with a mean age of 33 years. The mandible, nose, and orbital contents were the most frequently affected critical structures. All patients initially underwent primary wound debridement and tracheostomy, with concurrent maxillomandibular wire fixation and/or midface or mandible plate fixation in 5 patients. The mean time from injury to definitive FTT was 38 days. Five patients underwent fibula osteocutaneous FTT and 1 underwent radial forearm fasciocutaneous FTT. One patient also underwent concurrent local tissue rearrangement and pedicled flap surgery for nasal reconstruction. The mean hospital length of stay after FTT was 6 days. All FTT survived without necrosis. Oral incompetence and poor cosmesis from undesirable scarring patterns were the most common long-term complications. In summary, successful reconstruction of head and neck defects caused by gunshot trauma begins with airway stabilization, wound management, and bony fracture reduction and fixation. Definitive microvascular FTT is a useful method of repairing traumatic head and neck defects, although long-term functional and cosmetic complications may still occur.

Ground-level falls: 9-year cumulative experience in a regionalized trauma system

PubMed Central

Cade, Angela; King, Brad; Berne, John; Fernandez, Luis; Norwood, Scott

2012-01-01

Ground-level falls (GLFs) are the leading cause of nonfatal hospitalized injuries in the US. We hypothesized that risk-adjusted mortality would not vary between levels of trauma center verification if regional triage functioned appropriately. Data were collected from our regional trauma registry for the years 2001 through 2009. A multilevel mixed-effects logistic regression model was developed to compare risk-adjusted mortality rates by trauma center level and by year. GLF patients numbered 8202 over 9 years with 2.1% mortality. Mean age was 74.5 years and mean probability of death was 0.021 (95% confidence interval [CI], 0.020–0.021). The level I center–treated patients had the highest probability of death (0.033) compared to levels II and III/IV patients (0.023 and 0.018, respectively; P < 0.001), with the highest mortality (6.0%, 3.1%, and 1.1% for levels I, II, and III/IV; P < 0.001). The adjusted odds ratio of mortality was lowest at the level I center (0.71; 95% CI, 0.56–0.91), while no difference existed between level II (1.17; 95% CI, 0.90–1.51) and level III/IV centers (1.22; 95% CI, 0.90–1.66). The 95% CIs for risk-adjusted mortality by year overlapped the 1.0 reference line for each year from 2002 to 2009. In conclusion, regional risk-adjusted mortality for GLF has varied little since 2002. More study is warranted to understand the lower risk-adjusted GLF mortality at the level I center for this growing patient population. PMID:22275774

Centers for Disease Control and Prevention injury research agenda: identification of acute care research topics of interest to the Centers for disease Control and Prevention--National Center for Injury Prevention and Control.

PubMed

Jurkovich, Gregory J; Rivara, Frederick P; Johansen, Jennifer M; Maier, Ronald V

2004-05-01

The purpose of this report is to identify the most important research questions pertaining to the acute care of the injured patient using a Web-based Delphi technique to achieve expert opinion consensus. Experts in trauma care from the United States and Canada (n =39) generated structured research questions and then ranked these questions in order of importance, using a Web-based survey for question generation, question ranking, and a Delphi technique of consensus. Guidelines for question construction and ranking specified that participants considered questions that fall within the interest and domain of the Centers for Disease Control (CDC)-National Center for Injury Prevention and Control (NCIPC). One hundred thirty-seven questions in 18 distinct categories of interest were initially generated. After two rounds of merging, collating, reassessing, and ranking by significance and importance, 25 research questions were deemed most important and significant in the care of the injured patient. Ten of these (40%) were considered to be appropriate issues for the CDC-NCIPC to address and fund, dealing with injury prevention strategies, trauma systems design and funding, the epidemiology of injury, and global outcome determinants. These 25 questions were also reviewed with consideration given to the most likely source of federal funding of investigations. This report identifies the areas of trauma care in which research efforts might best be directed. Fully 40% of the key research questions could be considered to fall under the interest and auspices of the CDC-NCIPC. The remaining questions cover a broad range of topics and likely funding sources, emphasizing the need for a coordinated oversight of research funding in trauma care.

[The Main Gate Syndrome: a new format in mass-casualty victim "surge" management?].

PubMed

Sockeel, P; De Saint Roman, C; Massoure, M-P; Nadaud, J; Cinquetti, G; Chatelain, E

2008-01-01

Recent suicide bombings pose the novel problem for Trauma Centers of the massive simultaneous arrival of many gravely wounded patients. We report the experience of the French-German Military Trauma Group, a Level 2 Trauma Center, in Afghanistan during the wave of suicide bombings in February 2007. Fourteen casualties were received. A first triage was carried out by the U S Army Level I group prior to evacuation. A second surgical triage was carried out with systematic ultrasound exam. Four cases (ISS>25) were re-categorized and underwent emergency surgical procedures. Suicide bombing in crowded locations near an evacuation hospital may overwhelm the medical resources of the receiving center. It has been referred to as "The Main Gate Syndrome." We introduced the novel concept of a semi-evacuation hospital or receiving center where a second surgical triage was carried out. These exceptional circumstances require open-minded flexibility, a tailored approach, and close cooperation between surgeons and anesthetists to share experience, opinions, and ideas. In the setting of mass casualties, emergency ultrasound exam was shown to be a valuable and effective tool by virtue of its mobility, reproducibility, and immediate results.

Challenges in the Management of Geriatric Trauma: A Case Report.

PubMed

Gaebel, Ashley; Keiser, Megan

This article describes geriatric trauma and commonly associated difficulties emphasizing both the epidemiology and assessment of geriatric trauma. There is little data guiding decisions for trauma patients 65 years or older, as there are many unique characteristics to the geriatric population, including comorbidities, medications, and the aging physiology. The geriatric population in the United States has been steadily climbing for the last 20 years and is projected to continue on this trend. Although each patient presents differently, there remains a need for the consistent utilization of standard guidelines to help dictate care for geriatric patients, particularly for patients not receiving care at a trauma center. This review uses a case study about an elderly woman with many comorbidities, followed by a comprehensive discussion of geriatric trauma and the challenges that result from a lack of guideline utilization to direct management.

Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center.

PubMed

Nandipati, Kalyana C; Allamaneni, Shyam; Kakarla, Ravindra; Wong, Alfredo; Richards, Neil; Satterfield, James; Turner, James W; Sung, Kae-Jae

2011-05-01

Early identification of pneumothorax is crucial to reduce the mortality in critically injured patients. The objective of our study is to investigate the utility of surgeon performed extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax. We prospectively analysed 204 trauma patients in our level I trauma center over a period of 12 (06/2007-05/2008) months in whom EFAST was performed. The patients' demographics, type of injury, clinical examination findings (decreased air entry), CXR, EFAST and CT scan findings were entered into the data base. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated. Of 204 patients (mean age--43.01+/-19.5 years, sex--male 152, female 52) 21 (10.3%) patients had pneumothorax. Of 21 patients who had pneumothorax 12 were due to blunt trauma and 9 were due to penetrating trauma. The diagnosis of pneumothorax in 204 patients demonstrated the following: clinical examination was positive in 17 patients (true positive in 13/21, 62%; 4 were false positive and 8 were false negative), CXR was positive in 16 (true positive in 15/19, 79%; 1 false positive, 4 missed and 2 CXR not performed before chest tube) patients and EFAST was positive in 21 patients (20 were true positive [95.2%], 1 false positive and 1 false negative). In diagnosing pneumothorax EFAST has significantly higher sensitivity compared to the CXR (P=0.02). Surgeon performed trauma room extended FAST is simple and has higher sensitivity compared to the chest X-ray and clinical examination in detecting pneumothorax. Published by Elsevier Ltd.

Who will cover the cost of undocumented immigrant trauma care?

PubMed

Mitchell, Christopher D; Truitt, Michael S; Shifflette, Vanessa K; Johnson, Van; Mangram, Alicia J; Dunn, Ernest L

2012-03-01

Health care reform under the "Patient Protection and Affordable Care Act" (PPACA) will lead to changes in reimbursement. Although this legislation provides a mechanism for uninsured Americans to obtain coverage, it excludes undocumented immigrants (UDI). Reimbursement for UDIs comes from the disproportionate share hospital (DSH) program and was previously supported by Section-1011 of the 2003 Medicare Modernization Act (S1011). The PPACA details a cut of DSH funds starting in 2014. This could impose a significant financial burden on trauma centers. From May 2005 to May 2008, we retrospectively reviewed all trauma-related emergency room visits by UDIs. We quantified charges for three entities: emergency department physicians, trauma surgeons, and the hospital. We applied our average institutional collection rate to these charges and compared these projected collections with the actual collections. Over a three-year period, we identified 1,325 trauma UDIs. The financial records revealed a projected emergency department physicians collection of $452,686, a projected trauma surgeons collection of $1.2 million, and a projected hospital collection of $6.9 million (total $8.6 million). Actual funding from S1011 provided $1.7 million and DSH provided $1.9 million (total $3.6 million). Texas State Funding and UDI self-payment contributed $611,082. Overall, our institution had a reimbursement discrepancy of $4.3 million with DSH/S1011 assistance. This increased to $6.0 million after the termination of S1011 and may increase to $7.9 million under PPACA. These figures underestimate the total cost of UDI trauma care as it only includes three entities. Our data represent a fraction of national figures. Failure to address these issues could result in ongoing financial problems for trauma centers. II, economic and decision analysis.

ACR appropriateness criteria blunt chest trauma.

PubMed

Chung, Jonathan H; Cox, Christian W; Mohammed, Tan-Lucien H; Kirsch, Jacobo; Brown, Kathleen; Dyer, Debra Sue; Ginsburg, Mark E; Heitkamp, Darel E; Kanne, Jeffrey P; Kazerooni, Ella A; Ketai, Loren H; Ravenel, James G; Saleh, Anthony G; Shah, Rakesh D; Steiner, Robert M; Suh, Robert D

2014-04-01

Imaging is paramount in the setting of blunt trauma and is now the standard of care at any trauma center. Although anteroposterior radiography has inherent limitations, the ability to acquire a radiograph in the trauma bay with little interruption in clinical survey, monitoring, and treatment, as well as radiography's accepted role in screening for traumatic aortic injury, supports the routine use of chest radiography. Chest CT or CT angiography is the gold-standard routine imaging modality for detecting thoracic injuries caused by blunt trauma. There is disagreement on whether routine chest CT is necessary in all patients with histories of blunt trauma. Ultimately, the frequency and timing of CT chest imaging should be site specific and should depend on the local resources of the trauma center as well as patient status. Ultrasound may be beneficial in the detection of pneumothorax, hemothorax, and pericardial hemorrhage; transesophageal echocardiography is a first-line imaging tool in the setting of suspected cardiac injury. In the blunt trauma setting, MRI and nuclear medicine likely play no role in the acute setting, although these modalities may be helpful as problem-solving tools after initial assessment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.

The Trauma-Sensitive Teacher

ERIC Educational Resources Information Center

Craig, Susan E.

2016-01-01

According to the National Center for Mental Health Promotion and Youth Violence Prevention, about one quarter of children in the United States will witness or experience a traumatic event before the age of four. In this article, Susan E. Craig explains how these early trauma histories prime a child's brain to expect certain experiences,…

76 FR 53138 - Agency Information Collection Activities: Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-25

... serves multiple practical purposes: (1) To collect and analyze descriptive, outcome, and service... impact on access to high-quality, trauma-informed care; (3) to evaluate NCTSI centers' training and... below. Descriptive and Clinical Outcomes In order to describe the children served, their trauma...

Unfolding Case-Based Practicum Curriculum Infusing Crisis, Trauma, and Disaster Preparation

ERIC Educational Resources Information Center

Greene, Catie A.; Williams, Amy E.; Harris, Pamela N.; Travis, Sterling P.; Kim, Sharon Y.

2016-01-01

The authors evaluated an unfolding case-based approach to a practicum in counseling course infusing crisis, trauma, and disaster preparation for changes in students' crisis self-efficacy across a semester. The course, informed by constructivist-developmental pedagogy and centered on the unfolding case, resulted in significant increases in…

Medical Readiness. Efforts Are Underway for DOD Training in Civilian Trauma Centers.

ERIC Educational Resources Information Center

General Accounting Office, Washington, DC. National Security and International Affairs Div.

This report evaluates a Department of Defense (DOD) demonstration program that would provide trauma care training for military medical personnel through one or more public or nonprofit hospitals. Specifically, it examines DOD's actions to meet legislative requirements of the demonstration program; identifies other initiatives aimed at training…

Comparison of the predictive performance of the BIG, TRISS, and PS09 score in an adult trauma population derived from multiple international trauma registries

PubMed Central

2013-01-01

Background The BIG score (Admission base deficit (B), International normalized ratio (I), and Glasgow Coma Scale (G)) has been shown to predict mortality on admission in pediatric trauma patients. The objective of this study was to assess its performance in predicting mortality in an adult trauma population, and to compare it with the existing Trauma and Injury Severity Score (TRISS) and probability of survival (PS09) score. Materials and methods A retrospective analysis using data collected between 2005 and 2010 from seven trauma centers and registries in Europe and the United States of America was performed. We compared the BIG score with TRISS and PS09 scores in a population of blunt and penetrating trauma patients. We then assessed the discrimination ability of all scores via receiver operating characteristic (ROC) curves and compared the expected mortality rate (precision) of all scores with the observed mortality rate. Results In total, 12,206 datasets were retrieved to validate the BIG score. The mean ISS was 15 ± 11, and the mean 30-day mortality rate was 4.8%. With an AUROC of 0.892 (95% confidence interval (CI): 0.879 to 0.906), the BIG score performed well in an adult population. TRISS had an area under ROC (AUROC) of 0.922 (0.913 to 0.932) and the PS09 score of 0.825 (0.915 to 0.934). On a penetrating-trauma population, the BIG score had an AUROC result of 0.920 (0.898 to 0.942) compared with the PS09 score (AUROC of 0.921; 0.902 to 0.939) and TRISS (0.929; 0.912 to 0.947). Conclusions The BIG score is a good predictor of mortality in the adult trauma population. It performed well compared with TRISS and the PS09 score, although it has significantly less discriminative ability. In a penetrating-trauma population, the BIG score performed better than in a population with blunt trauma. The BIG score has the advantage of being available shortly after admission and may be used to predict clinical prognosis or as a research tool to risk stratify trauma patients into clinical trials. PMID:23844754

Clot formation is associated with fibrinogen and platelet forces in a cohort of severely-injured Emergency Department trauma patients

PubMed Central

White, Nathan J.; Newton, Jason C.; Martin, Erika J.; Mohammed, Bassem M.; Contaifer, Daniel; Bostic, Jessica L.; Brophy, Gretchen M.; Spiess, Bruce D.; Pusateri, Anthony E.; Ward, Kevin R.; Brophy, Donald F.

2015-01-01

Introduction Anticoagulation, fibrinogen consumption, fibrinolytic activation, and platelet dysfunction all interact to produce different clot formation responses after trauma. However, the relative contributions of these coagulation components to overall clot formation remains poorly defined. We examined for sources of heterogeneity in clot formation responses after trauma. Methods Blood was sampled in the Emergency Department from patients meeting trauma team activation criteria at an urban trauma center. Plasma prothrombin time (PT) ≥ 18 sec was used to define traumatic coagulopathy. Mean kaolin-activated thrombelastography (TEG) parameters were calculated and tested for heterogeneity using Analysis of Means (ANOM). Discriminant analysis and forward stepwise variable selection with linear regression were used to determine if PT, fibrinogen, platelet contractile force (PCF), and D-Dimer concentration, representing key mechanistic components of coagulopathy, each contribute to heterogeneous TEG responses after trauma. Results Of 95 subjects, 16% met criteria for coagulopathy. Coagulopathic subjects were more severely injured with greater shock, and received more blood products in the first 8 hours compared to non-coagulopathic subjects. Mean (SD) TEG maximal amplitude (MA) was significantly decreased in the coagulopathic group=57.5 (4.7) mm, vs. 62.7 (4.7), T test p<0.001. The MA also exceeded the ANOM predicted upper decision limit for the non-coagulopathic group and the lower decision limit for the coagulopathic group at alpha=0.05, suggesting significant heterogeneity from the overall cohort mean. Fibrinogen and PCF best discriminated TEG MA using discriminant analysis. Fibrinogen, PCF, and D-Dimer were primary covariates for TEG MA using regression analysis. Conclusion Heterogeneity in TEG-based clot formation in Emergency Department trauma patients was linked to changes in MA. Individual parameters representing fibrin polymerization, platelet contractile forces, and fibrinolysis were primarily associated with TEG MA after trauma and should be the focus of early hemostatic therapies. PMID:25643013

Neuro-, Trauma -, or Med/Surg-ICU: Does it matter where polytrauma patients with TBI are admitted? Secondary analysis of AAST-MITC decompressive craniectomy study

PubMed Central

Scalea, Tom; Sperry, Jason; Coimbra, Raul; Vercruysse, Gary; Jurkovich, Gregory J; Nirula, Ram

2016-01-01

Introduction Patients with non-traumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without TBI fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU. Methods This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head CT scans of patients with Glasgow Coma Scale (GCS) ≤13 and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU-type and survival and calculate the probability of death for increasing ISS. Polytrauma patients (ISS > 15) with TBI and isolated TBI patients (other AIS < 3) were analyzed separately. Results There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Prior to adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit-type, age and ISS remained independent predictors of death. Unit-type modified the effect of ISS on mortality. TBI-polytrauma patients admitted to a TICU had improved survival across increasing ISS (Fig1). Survival for isolated TBI patients was similar between TICU and NICU. Med/Surg ICU carried the greatest probability of death. Conclusion Polytrauma patients with TBI have lower mortality risk when admitted to a Trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a Neuro ICU compared to a Trauma ICU. Med/Surg ICU admission carries the highest mortality risk. PMID:28225527

Quality and Dose Optimized CT Trauma Protocol - Recommendation from a University Level-I Trauma Center.

PubMed

Kahn, Johannes; Kaul, David; Böning, Georg; Rotzinger, Roman; Freyhardt, Patrick; Schwabe, Philipp; Maurer, Martin H; Renz, Diane Miriam; Streitparth, Florian

2017-09-01

Purpose  As a supra-regional level-I trauma center, we evaluated computed tomography (CT) acquisitions of polytraumatized patients for quality and dose optimization purposes. Adapted statistical iterative reconstruction [(AS)IR] levels, tube voltage reduction as well as a split-bolus contrast agent (CA) protocol were applied. Materials and Methods  61 patients were split into 3 different groups that differed with respect to tube voltage (120 - 140 kVp) and level of applied ASIR reconstruction (ASIR 20 - 50 %). The CT protocol included a native acquisition of the head followed by a single contrast-enhanced acquisition of the whole body (64-MSCT). CA (350 mg/ml iodine) was administered as a split bolus injection of 100 ml (2 ml/s), 20 ml NaCl (1 ml/s), 60 ml (4 ml/s), 40 ml NaCl (4 ml/s) with a scan delay of 85 s to detect injuries of both the arterial system and parenchymal organs in a single acquisition. Both the quantitative (SNR/CNR) and qualitative (5-point Likert scale) image quality was evaluated in parenchymal organs that are often injured in trauma patients. Radiation exposure was assessed. Results  The use of IR combined with a reduction of tube voltage resulted in good qualitative and quantitative image quality and a significant reduction in radiation exposure of more than 40 % (DLP 1087 vs. 647 mGyxcm). Image quality could be improved due to a dedicated protocol that included different levels of IR adapted to different slice thicknesses, kernels and the examined area for the evaluation of head, lung, body and bone injury patterns. In synopsis of our results, we recommend the implementation of a polytrauma protocol with a tube voltage of 120 kVp and the following IR levels: cCT 5mm: ASIR 20; cCT 0.625 mm: ASIR 40; lung 2.5 mm: ASIR 30, body 5 mm: ASIR 40; body 1.25 mm: ASIR 50; body 0.625 mm: ASIR 0. Conclusion  A dedicated adaptation of the CT trauma protocol (level of reduction of tube voltage and of IR) according to the examined body region (head, lung, body, bone) combined with a split bolus CA injection protocol allows for a high-quality CT examination and a relevant reduction of radiation exposure in the examination of polytraumatized patients Key Points   · Dedicated adaption of the CT trauma protocol allows for an optimized examination.. · Different levels of iterative reconstruction, tube voltage and the CA injection protocol are crucial.. · A reduction of radiation exposure of more than 40 % with good image quality is possible.. Citation Format · Kahn J, Kaul D, Böning G et al. Quality and Dose Optimized CT Trauma Protocol - Recommendation from a University Level-I Trauma Center. Fortschr Röntgenstr 2017; 189: 844 - 854. © Georg Thieme Verlag KG Stuttgart · New York.

Comparing Methodologies for Evaluating Emergency Medical Services Ground Transport Access to Time-critical Emergency Services: A Case Study Using Trauma Center Care.

PubMed

Doumouras, Aristithes G; Gomez, David; Haas, Barbara; Boyes, Donald M; Nathens, Avery B

2012-09-01

The regionalization of medical services has resulted in improved outcomes and greater compliance with existing guidelines. For certain "time-critical" conditions intimately associated with emergency medicine, early intervention has demonstrated mortality benefits. For these conditions, then, appropriate triage within a regionalized system at first diagnosis is paramount, ideally occurring in the field by emergency medical services (EMS) personnel. Therefore, EMS ground transport access is an important metric in the ongoing evaluation of a regionalized care system for time-critical emergency services. To our knowledge, no studies have demonstrated how methodologies for calculating EMS ground transport access differ in their estimates of access over the same study area for the same resource. This study uses two methodologies to calculate EMS ground transport access to trauma center care in a single study area to explore their manifestations and critically evaluate the differences between the methodologies. Two methodologies were compared in their estimations of EMS ground transport access to trauma center care: a routing methodology (RM) and an as-the-crow-flies methodology (ACFM). These methodologies were adaptations of the only two methodologies that had been previously used in the literature to calculate EMS ground transport access to time-critical emergency services across the United States. The RM and ACFM were applied to the nine Level I and Level II trauma centers within the province of Ontario by creating trauma center catchment areas at 30, 45, 60, and 120 minutes and calculating the population and area encompassed by the catchments. Because the methodologies were identical for measuring air access, this study looks specifically at EMS ground transport access. Catchments for the province were created for each methodology at each time interval, and their populations and areas were significantly different at all time periods. Specifically, the RM calculated significantly larger populations at every time interval while the ACFM calculated larger catchment area sizes. This trend is counterintuitive (i.e., larger catchment should mean higher populations), and it was found to be most disparate at the shortest time intervals (under 60 minutes). Through critical evaluation of the differences, the authors elucidated that the ACFM could calculate road access in areas with no roads and overestimates access in low-density areas compared to the RM, potentially affecting delivery of care decisions. Based on these results, the authors believe that future methodologies for calculating EMS ground transport access must incorporate a continuous and valid route through the road network as well as use travel speeds appropriate to the road segments traveled; alternatively, we feel that variation in methods for calculating road distances would have little effect on realized access. Overall, as more complex models for calculating EMS ground transport access become used, there needs to be a standard methodology to improve and to compare it to. Based on these findings, the authors believe that this should be the RM. © 2012 by the Society for Academic Emergency Medicine.

Epidemiology and Outcomes of Non-compressible Torso Hemorrhage

DTIC Science & Technology

2013-01-01

a r t i c l e i n f o Article history : Received 4 January 2013 Received in revised form 15 April 2013 Accepted 30 May 2013 Available online 21 June...military definition of NCTH, which incorporates anatomic and physiological criteria, to a civilian population treated at trauma centers in the US. Methods...injury (Glasgow Coma Scale, injury type, Injury Severity Score, anatomic region), and clinical (major surgical procedure, need for transfusion, and

Implementing screening, brief intervention, and referral for alcohol and drug use: the trauma service perspective.

PubMed

Sise, Michael J; Sise, C Beth; Kelley, Dorothy M; Simmons, Charles W; Kelso, Dennis J

2005-09-01

Most trauma surgeons are unfamiliar with screening, brief intervention, and referral (SBIR) programs for substance use disorders, and few trauma centers provide them. This report describes how an urban private-teaching hospital adapted a protocol from an existing emergency department-based program to include patients treated by the trauma service. We recorded the rates of SBIR completion and reasons for failure during each phase of the implementation, interviewed trauma service staff and health educators to assess attitudes toward the program, and evaluated patient satisfaction surveys. By adding SBIR staff to the trauma outpatient clinic and to trauma morning rounds, the capture rate increased from 12 to 71%. Most screened patients (59%) were found at risk for problems or probably dependent on alcohol or drugs. Trauma service staff and health educators reported high satisfaction with the program. Patients reported higher satisfaction with SBIR. SBIR services can be effectively integrated into all components of a busy, urban trauma service by adding specially trained health educators to the trauma service staff. This collaboration provides effective SBIR services to both trauma and emergency service patients without interfering with patient flow or medical procedures. The relatively high percentage of patients at risk for alcohol or drug problems supports the inclusion of routine alcohol and drug screening for all eligible trauma patients.

Pretrauma Center Red Blood Cell Transfusion Is Associated With Reduced Mortality and Coagulopathy in Severely Injured Patients With Blunt Trauma

PubMed Central

Brown, Joshua B.; Cohen, Mitchell J.; Minei, Joseph P.; Maier, Ronald V.; West, Michaela A.; Billiar, Timothy R.; Peitzman, Andrew B.; Moore, Ernest E.; Cuschieri, Joseph; Sperry, Jason L.; Inflammation, The

2014-01-01

Objective To evaluate the association of pretrauma center (PTC) red blood cell (RBC) transfusion with outcomes in severely injured patients. Background Hemorrhage remains a major driver of mortality. Little evidence exists supporting PTC interventions to mitigate this. Methods Blunt injured patients in shock arriving at a trauma center within 2 hours of injury were included from the Glue Grant database. Subjects were dichotomized by PTC RBC transfusion. Outcomes included 24-hour mortality, 30-day mortality, and trauma-induced coagulopathy [(TIC), admission international normalized ratio >1.5]. Cox regression and logistic regression determined the association of PTC RBC transfusion with outcomes. To address baseline differences, propensity score matching was used. Results Of 1415 subjects, 50 received PTC RBC transfusion. Demographics and injury severity score were similar. The PTC RBC group received 1.3 units of RBCs (median), and 52% were scene transports. PTC RBC transfusion was associated with a 95% reduction in odds of 24-hour mortality [odds ratio (OR) = 0.05; 95% confidence interval (CI), 0.01–0.48; P < 0.01], 64% reduction in the risk of 30-day mortality [hazard ratio = 0.36; 95% CI, 0.15–0.83; P = 0.02], and 88% reduction in odds of TIC (OR = 0.12; 95% CI, 0.02–0.79; P = 0.03). The matched cohort included 113 subjects (31% PTC RBC group). Baseline characteristics were similar. PTC RBC transfusion was associated with a 98% reduction in odds of 24-hour mortality (OR = 0.02; 95% CI, 0.01–0.69; P = 0.04), 88% reduction in the risk of 30-day mortality (hazard ratio = 0.12; 95% CI, 0.03–0.61; P = 0.01), and 99% reduction in odds of TIC (OR = 0.01; 95% CI, 0.01–0.95; P = 0.05). Conclusions PTC RBC administration was associated with a lower risk of 24-hour mortality, 30-day mortality, and TIC in severely injured patients with blunt trauma, warranting further prospective study. PMID:24670858

[In-patient hypnotherapeutic trauma exposure for posttraumatic stress disorder: a case report].

PubMed

Elsig, Claudia; Schopper, Christian; Anthony, Marion; Gramigna, Ronald; Böker, Heinz

2002-03-01

This paper describes the treatment of a patient with the diagnoses of a borderline personality disorder and posttraumatic stress disorder (DSM-IV and ICD-10) within the setting of a psychiatric ward spezializing in depression. For purposes of controlled re-exposure to the patient's trauma, a hypnotherapeutic method was chosen. A significant reduction of symptoms, in particular the intrusions and the hyperarousal, was observed. Of great importance in the successful outcome of this case is the integration of hypnotherapy into a multi-dimensional treatment concept including group therapy, physical therapy and anxiety-reducing self-management therapy. This approach facilitated the development of trust and security in the patient required for the hypnotherapeutic intervention and minimized the splitting tendencies specific to borderline patients. Further discussion is centered on the difficulties arising in the context of an emergency ward setting with its high intensity atmosphere encompassing the danger of retraumatization of this special group of patients. Finally several aspects of the clinical implications of this method are addressed.

Suicide Bombing Attacks

PubMed Central

Almogy, Gidon; Belzberg, Howard; Mintz, Yoaz; Pikarsky, Alon K.; Zamir, Gideon; Rivkind, Avraham I.

2004-01-01

Objective: To review the experience of a large-volume trauma center in managing and treating casualties of suicide bombing attacks. Summary Background Data: The threat of suicide bombing attacks has escalated worldwide. The ability of the suicide bomber to deliver a relatively large explosive load accompanied by heavy shrapnel to the proximity of his or her victims has caused devastating effects. Methods: The authors reviewed and analyzed the experience obtained in treating victims of suicide bombings at the level I trauma center of the Hadassah University Hospital in Jerusalem, Israel from 2000 to 2003. Results: Evacuation is usually rapid due to the urban setting of these attacks. Numerous casualties are brought into the emergency department over a short period. The setting in which the device is detonated has implications on the type of injuries sustained by survivors. The injuries sustained by victims of suicide bombing attacks in semi-confined spaces are characterized by the degree and extent of widespread tissue damage and include multiple penetrating wounds of varying severity and location, blast injury, and burns. Conclusions: The approach to victims of suicide bombings is based on the guidelines for trauma management. Attention is given to the moderately injured, as these patients may harbor immediate life-threatening injuries. The concept of damage control can be modified to include rapid packing of multiple soft-tissue entry sites. Optimal utilization of manpower and resources is achieved by recruiting all available personnel, adopting a predetermined plan, and a centrally coordinated approach. Suicide bombing attacks seriously challenge the most experienced medical facilities. PMID:15075644

Using a Checklist to Improve Family Communication in Trauma Care.

PubMed

Dennis, Bradley M; Nolan, Tracy L; Brown, Cecil E; Vogel, Robert L; Flowers, Kristin A; Ashley, Dennis W; Nakayama, Don K

2016-01-01

Modern concepts of patient-centered care emphasize effective communication with patients and families, an essential requirement in acute trauma settings. We hypothesized that using a checklist to guide the initial family conversation would improve the family's perception of the interaction. Institutional Review Board-approved, prospective pre/post study involving families of trauma patients admitted to our Level I trauma center for >24 hours. In the control group, families received information according to existing practices. In the study group, residents gave patient information to a first-degree family member using a checklist that guided the interaction. The checklist included a physician introduction, patient condition, list of known injuries, admission unit or intensive care unit, any consultants involved, plans for additional studies or operations, and opportunity for family to ask questions. An 11-item survey was administered 24 to 48 hours after admission to each group that evaluated the trauma team's communication in the areas of physician introduction, patient condition, ongoing treatment, and family perception of the interaction. Responses were on a Likert scale and analyzed using the Wilcoxon-Mann-Whitney test. There were 130 patients in each group. The study group had significantly (P < 0.05) better responses in 8 of 11 items surveyed: physician spoke to family, physician introduction, understanding of their relative's injuries, admitting unit, consultants involved, urgent surgical procedures required, ongoing diagnostic studies, and understanding of the treatment plan. In conclusion, using a checklist improves the perception of the initial communication between the trauma team and family members of trauma patients, especially their understanding of the treatment plan.

Balancing risk and benefit: maintenance of a thawed Group A plasma inventory for trauma patients requiring massive transfusion.

PubMed

Mehr, Chelsea R; Gupta, Rajan; von Recklinghausen, Friedrich M; Szczepiorkowski, Zbigniew M; Dunbar, Nancy M

2013-06-01

Transfusion of plasma and red blood cell (RBC) units in a balanced ratio approximating 1:1 has been shown in retrospective studies to be associated with improved outcomes for trauma patients. Our low-volume rural trauma center uses a trauma-activated transfusion algorithm. Plasma is thawed upon activation to avoid wastage. However, the time required for plasma thawing has made achievement of a 1:1 ratio early in resuscitation challenging. In this study, the time required for plasma thawing is characterized, and a potential solution is proposed. A retrospective chart study of 38 moderately and massively transfused (≥6 U in the first 24 hours) trauma patients admitted from January 2008 to March 2012 was performed. We evaluated the time required to dispense plasma and the number of RBCs dispensed before plasma in these patients. The average time between the dispense of RBCs and plasma was 26 minutes (median, 28; range, 0-48 minutes). The average number of RBCs dispensed before plasma was 8 U (median, 7 U; range, 0-24 U). Nearly one third of massively transfused patients had 10 RBCs or greater dispensed before plasma was available. There exists the potential for delayed plasma availability owing to time required for thawing, which may compromise the ability to provide balanced plasma to RBC transfusion to trauma patients. Maintenance of a thawed Group AB plasma inventory may not be operationally feasible for rural centers with low trauma volumes. Use of a thawed Group A plasma inventory is a potential alternative to ensure rapid plasma availability. Therapeutic study, level V.

Trauma facilities in Denmark - a nationwide cross-sectional benchmark study of facilities and trauma care organisation.

PubMed

Weile, Jesper; Nielsen, Klaus; Primdahl, Stine C; Frederiksen, Christian A; Laursen, Christian B; Sloth, Erik; Mølgaard, Ole; Knudsen, Lars; Kirkegaard, Hans

2018-03-27

Trauma is a leading cause of death among adults aged < 44 years, and optimal care is a challenge. Evidence supports the centralization of trauma facilities and the use multidisciplinary trauma teams. Because knowledge is sparse on the existing distribution of trauma facilities and the organisation of trauma care in Denmark, the aim of this study was to identify all Danish facilities that care for traumatized patients and to investigate the diversity in organization of trauma management. We conducted a systematic observational cross-sectional study. First, all hospitals in Denmark were identified via online services and clarifying phone calls to each facility. Second, all trauma care manuals on all facilities that receive traumatized patients were gathered. Third, anesthesiologists and orthopedic surgeons on call at all trauma facilities were contacted via telephone for structured interviews. A total of 22 facilities in Denmark were found to receive traumatized patients. All facilities used a trauma care manual and all had a multidisciplinary trauma team. The study found three different trauma team activation criteria and nine different compositions of teams who participate in trauma care. Training was heterogeneous and, beyond the major trauma centers, databases were only maintained in a few facilities. The study established an inventory of the existing Danish facilities that receive traumatized patients. The trauma team activation criteria and the trauma teams were heterogeneous in both size and composition. A national database for traumatized patients, research on nationwide trauma team activation criteria, and team composition guidelines are all called for.

The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review.

PubMed

Tyroch, Alan H; McGuire, Emmett L; McLean, Susan F; Kozar, Rosemary A; Gates, Keith A; Kaups, Krista L; Cook, Charles; Cowgill, Sarah M; Griswold, John A; Sue, Larry A; Craun, Michael L; Price, Jan

2005-05-01

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.

Universal Screening for Intimate Partner and Sexual Violence in Trauma Patients - What About the Men? An EAST Multicenter Trial.

PubMed

Zakrison, Tanya L; Rattan, Rishi; Milian Valdés, Davel; Ruiz, Xiomara; Gelbard, Rondi; Cline, John; Turay, David; Luo-Owen, Xian; Namias, Nicholas; George, Jessica; Yeh, Dante; Pust, Daniel; Williams, Brian H

2018-02-14

A recent EAST-supported, multicenter trial demonstrated a similar rate of intimate partner and sexual violence (IPSV) between male and female trauma patients, regardless of mechanism. Our objective was to perform a subgroup analysis of our affected male cohort as this remains an understudied group in the trauma literature. We conducted a recent EAST-supported, cross-sectional, multicenter trial over one year (03/15-04/16) involving four Level I trauma centers throughout the United States. We performed universal screening of adult trauma patients using the validated HITS (Hurt, Insult, Threaten, Scream) and SAVE (sexual violence) screening surveys. Risk factors for male patients were identified. Chi-squared test compared categorical variables with significance at p<0.05. Parametric data is presented as mean +/-standard deviation. A total of 2,034 trauma patients were screened, of which 1,281 (63%) were men. Of this cohort, 119 men (9.3%) screened positive for intimate partner violence, 14.1% for IPSV and 6.5% for sexual violence. On categorical analysis of the HITS screen, the proportion of men that were physically hurt was 4.8% compared to 4.3% for women (p = 0.896). A total of 4.8% of men screened positive for both intimate partner and sexual violence. The total proportion of men who presented with any history of intimate partner violence, sexual violence or both (IPSV) was 15.8%. More men affected by penetrating trauma screened positive for IPSV (p < 0.00001). IPSV positivity in men was associated with mental illness, substance abuse, and trauma recidivism. One out of every twenty men that present to trauma centers is a survivor of both intimate partner and sexual violence, with one out of every six men experiencing some form of violence. Men are at similar risk for physical abuse as women when this intimate partner violence occurs. IPSV is associated with penetrating trauma in men. Support programs for this population may potentially impact associated mental illness, substance abuse, trauma recidivism and even societal-level violence. III STUDY TYPE: Diagnostic.

Drug use and childhood-, military- and post-military trauma exposure among women and men veterans.

PubMed

Kelley, Michelle L; Brancu, Mira; Robbins, Allison T; D'Lima, Gabrielle M; Strauss, Jennifer L; Curry, John F; Fairbank, John A; Runnals, Jennifer

2015-07-01

The current study was undertaken to examine whether posttraumatic stress symptoms (PTSS) and depressive symptoms mediated the association between trauma exposure (combat-related trauma and non-combat traumas occurring before, during, and after military service), and drug abuse symptoms use among male and female veterans. Participants were 2304 (1851 male, 453 female) veterans who took part in a multi-site research study conducted through the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center (VISN 6 MIRECC). Path analytic models were used to determine the association between problematic past-year drug use and combat-related and non-combat trauma experienced before, during, or after the military and whether current post-traumatic stress symptoms or depressive symptoms mediated these associations. For both male and female veterans, depressive symptoms significantly mediated the effects of pre- and post-military trauma on drug abuse symptoms. Mental health providers who work with trauma-exposed Iraq and Afghanistan era veterans should assess for drug use, depressive symptoms, and life-span trauma (i.e., not only combat-related traumas) as part of a thorough trauma-based assessment for both men and women. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

THE EPIDEMIOLOGY OF EMERGENCY DEPARTMENT THORACOTOMY IN A STATEWIDE TRAUMA SYSTEM: DOES CENTER VOLUME MATTER?

PubMed

Dumas, Ryan P; Seamon, Mark J; Smith, Brian P; Yang, Wei; Cannon, Jeremy W; Schwab, C William; Reilly, Patrick M; Holena, Daniel N

2018-04-17

The relationship between high volume and improved outcomes has been described for a host of elective high-impact, low-frequency procedures, but there are little data to support such a relationship in high-impact low-frequency procedures in trauma. Using emergency department thoracotomy (EDT) as a model, we hypothesized that patients presenting to centers with higher institutional volumes of EDT would have improved survival referent to those presenting to lower volume institutions. We queried the Pennsylvania Trauma Outcomes Study (PTOS) registry from 2007-2015 for all EDTs performed at level I and II centers identified by ICD-9 procedure codes and a location stamp indicating the emergency department. We examined patient-level risk factors for survival in univariate regression and multivariable regression models. Centers were divided into tertiles of mean annual EDT volume and the association between mean annual EDT volume and patient survival was examined using logistic regression after controlling for patient factors. 1,399 emergency department thoracotomies were performed at 28 centers. Overall survival was 6.8%. After controlling for patient age, mechanism of injury, signs of life, and injury severity, patients presenting to centers in the highest tertile of volume had significantly higher odds of survival compared to patients presenting to centers in the lowest tertile of volume (OR 4.56, 95% CI 1.43-14.50). Patients presenting to centers with higher mean annual volume of EDTs have improved survival compared to those presenting to institutions with lower mean annual EDT volume. Efforts to understand the etiology of this finding may lead to interventions to improve outcomes at lower volume centers. Level 3: Retrospective cohort study.

Etiologies of pediatric craniofacial injuries: a comparison of injuries involving all-terrain vehicles and golf carts.

PubMed

White, Lauren C; McKinnon, Brian J; Hughes, C Anthony

2013-03-01

To determine incidence and etiologies of craniofacial injuries in the pediatric population through comparison of injuries caused by all-terrain vehicles and golf cart trauma. Case series with chart review. Level 1 trauma center. Retrospective review of pediatric traumas at a tertiary academic medical center from 2003 to 2012 identified 196 patients whose injuries resulted from accidents involving either all-terrain vehicles or golf carts. Data was collected and variables such as age, gender, driver vs. passenger, location of accident, Glasgow coma scale, Injury severity scale, Abbreviated injury scale, and presence or absence of helmet use were examined. 196 pediatric patients were identified: 68 patients had injuries resulting from golf cart accidents, and 128 patients from ATV accidents. 66.4% of ATV-related traumas were male, compared to 52.9% of golf cart-related traumas. Ages of injured patients were similar between the two modalities with average age of ATV traumas 10.8 (±4.0) years and golf cart traumas 10.0 (±4.6) years. Caucasians were most commonly involved in both ATV (79.7%) and golf cart traumas (85.3%). 58.6% of all ATV related trauma and 69.1% of all golf cart trauma resulted in craniofacial injuries. The most common craniofacial injury was a closed head injury with brief loss of consciousness, occurring in 46.1% of the ATV traumas and 54.4% of the golf cart traumas. Temporal bone fractures were the second most common type of craniofacial injury, occurring in 5.5% of ATV accidents and 7.4% of the golf cart traumas. Length of hospital stay and, cases requiring surgery and severity scores were similar between both populations. Intensive care admissions and injury severity scores approached but not reach statistical significance (0.096 and 0.083, respectively). The only statistically significant differences between the two modalities were helmet use (P=0.00018%) and days requiring ventilator assistance (P=0.025). ATVs and golf carts are often exempt from the safety features and regulations required of motor vehicles, and ATV and golf cart accidents represent a significant portion of pediatric traumas. This study found that ATV and golf cart accidents contribute significantly to craniofacial trauma requiring hospitalization, with resultant morbidity and mortality. Further investigation of these injuries and their prevention in the pediatric population is needed before efforts to promote effective safety regulations for such vehicles in the future can be addressed. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis: A prospective observational study of two centers.

PubMed

Shackford, Steven R; Cipolle, Mark D; Badiee, Jayraan; Mosby, Danielle L; Knudson, M Margaret; Lewis, Paul R; McDonald, Victoria S; Olson, Erik J; Thompson, Kimberly A; Van Gent, Jan-Michael; Zander, Ashley L

2016-05-01

Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in trauma. Controversy exists regarding the use of lower extremity duplex ultrasound screening and surveillance (LEDUS). Advocates cite earlier diagnosis and treatment of deep venous thrombosis (DVT) to prevent clot propagation and pulmonary embolism (PE). Opponents argue that LEDUS identifies more DVT (surveillance bias) but does not reduce the incidence of PE. We sought to determine the magnitude of surveillance bias associated with LEDUS and test the hypothesis that LEDUS does not decrease the incidence of PE after injury. We compared data from two Level 1 trauma centers: Scripps Mercy Hospital, which used serial LEDUS, and Christiana Care Health System, which used LEDUS only for symptomatic patients. Beginning in 2013, both centers prospectively collected data on demographics, injury severity, and VTE risk for patients admitted for more than 48 hours. Both centers used mechanical and pharmacologic prophylaxis based on VTE risk assessment. Scripps Mercy treated 772 patients and Christiana Care treated 454 patients with similar injury severity and VTE risk. The incidence of PE was 0.4% at both centers. The odds of a DVT diagnosis were 5.3 times higher (odds ratio, 5.3; 95% confidence interval, 2.5-12.9; p < 0.0001) for patients admitted to Scripps Mercy than for patients admitted to Christiana Care. Of the 80 patients who developed DVT, PE, or both, 99% received prophylaxis before the event. Among those who received pharmacologic prophylaxis, the VTE rates between the two centers were not statistically significantly different (Scripps Mercy, 11% vs. Christiana Care, 3%; p = 0.06). The odds of a diagnosis of DVT are increased significantly when a program of LEDUS is used in trauma patients. Neither pharmacologic prophylaxis nor mechanical prophylaxis is completely effective in preventing VTE in trauma patients. VTE should not be considered a "never event" in this cohort. Prognostic/epidemiologic study, level III; therapeutic study, level III.

Patient and Trauma Center Characteristics Associated with Helicopter Emergency Medical Services Transport for Patients with Minor Injuries in the United States

PubMed Central

Cheung, Brian H.; Delgado, M. Kit; Staudenmayer, Kristan L.

2015-01-01

Background Helicopter emergency medical services (EMS) transport is expensive, and previous work has shown that cost-effective use of this resource is dependent on the proportion of minor injuries flown. To understand how over-triage to helicopter EMS versus ground EMS can be reduced, it is important to understand factors associated with helicopter transport of patients with minor injuries. Objectives The aim was to characterize patient and hospital characteristics associated with helicopter transport of patients with minor injuries. Methods This was a retrospective analysis of adults ≥18 years who were transported by helicopter to Level I/II trauma centers from 2009 through 2010 as identified in the National Trauma Data Bank. Minor injuries were defined as all injuries scored at an Abbreviated Injury Scale (AIS) < 3. Patient and hospital characteristics associated of being flown with only minor injuries were compared in an unadjusted and adjusted fashion. Hierarchical, multivariate logistic regression was used to adjust for patient demographics, mechanism of injury, presenting physiology, injury severity, urban-rural location of injury, total EMS time, hospital characteristics, and region. Results A total of 24,812 records were identified, corresponding to 76,090 helicopter transports. The proportion of helicopter transports with only minor injuries was 36% (95% confidence interval [CI] = 34% to 39%). Patient characteristics associated with being flown with minor injuries included being uninsured (odds ratio [OR] 1.36, 95% CI = 1.26 to 1.47), injury by a fall (OR 1.32, 95% CI = 1.20 to 1.45), or other penetrating trauma (OR 2.52, 95% CI = 2.12 to 3.00). Being flown with minor injuries was more likely if the patient was transported to a trauma center that also received a high proportion of patients with minor injuries by ground EMS (OR 1.89, 95% CI = 1.58 to 2.26) or a high proportion of EMS traffic by helicopter (OR 1.35, 95% CI = 1.02 to 1.78). No significant association with urban-rural scene location, or total EMS time was found. Conclusions Better recognizing which patients with falls and penetrating trauma have serious injuries that could benefit from being flown may lead to the more cost-effective use of helicopter EMS. More research is needed to determine why patients without insurance, who are most at risk for high out-of-pocket expenses from helicopter EMS, are at higher risk for being flown when only having minor injuries. This suggests that interventions to optimize cost-effectiveness of helicopter transport will likely require an evaluation of helicopter triage guidelines in the context of regional and patient needs. PMID:25377400

Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

PubMed

Cnossen, Maryse C; Polinder, Suzanne; Lingsma, Hester F; Maas, Andrew I R; Menon, David; Steyerberg, Ewout W

2016-01-01

The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches.

Management of pediatric blunt splenic injury at a rural trauma center.

PubMed

Bird, Julio J; Patel, Nirav Y; Mathiason, Michelle A; Schroeppel, Thomas J; D'huyvetter, Cecile J; Cogbill, Thomas H

2012-10-01

Patterns for nonoperative management of pediatric blunt splenic injuries (BSIs) vary significantly within and between institutions. The indications for repeated imaging, duration of activity restrictions, as well as the impact of volume and type of trauma center (pediatric vs. adult) on outcomes remain unclear. A retrospective review of all patients younger than 16 years with BSI managed at a rural American College of Surgeons-verified adult Level II trauma center from January 1995 to December 2008 was completed. Patients were identified from the trauma registry by DRG International Classification of Diseases-9th Rev. (865.00-865.09) and management codes (41.5, 41.43, and 41.95). Variables reviewed included demographics, mechanism of injury, Injury Severity Score, grade of splenic injury, degree of hemoperitoneum, presence of arterial phase contrast blush on computed tomography at admission, admission and nadir hemoglobin level, blood transfused, length of stay, disposition, outpatient clinical and radiographic follow-up, interval of return to unrestricted activity, and clinical outcomes. During the 13-year study period, 38 children with BSI were identified. Thirty-seven (97%) were successfully managed nonoperatively. Median grade of splenic injury was 3 (range, 1-5); 73% had moderate-to-large hemoperitoneum. Median Injury Severity Score was 10 (range, 4-34). Three patients with isolated contrast blush on initial computed tomography were successfully managed nonoperatively with no angiographic intervention. One patient failed nonoperative management and underwent successful splenorrhaphy. All patients were discharged home. Thirty-day mortality was zero. Median follow-up duration was 5.5 years, with no late complications identified. Of the patients successfully managed nonoperatively, 92% had their follow-up at our institution; 74% underwent subsequent imaging, and none resulted in intervention or alteration of management plan. Pediatric BSI can be managed in adult trauma centers with success rates of nonoperative management comparable to dedicated children's hospitals. Routine follow-up imaging is not necessary. Overall splenic injury salvage rate in our experience was 100%. Therapeutic/epidemiologic study, level IV.

Does a single specialty intensive care unit make better business sense than a multi-specialty intensive care unit? A costing study in a trauma center in India.

PubMed

Kumar, Parmeshwar; Jithesh, Vishwanathan; Gupta, Shakti Kumar

2015-01-01

Though intensive care units (ICUs) only account for 10% of hospital beds, they consume nearly 22% of hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. To evaluate and compare the cost of intensive care delivery between multi-specialty and neurosurgery ICU in an apex trauma care facility in India. The study was conducted in a polytrauma and neurosurgery ICU at a 203 bedded level IV trauma care facility in New Delhi, India from May, 2012 to June 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Fisher's two-tailed t-test. Total cost/bed/day for the multi-specialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU was Rs. 14,306.7/-, manpower constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Quantification of expenditure in running an ICU in a trauma center would assist healthcare decision makers in better allocation of resources. Although multi-specialty ICUs are more expensive, other factors will also play a role in defining the kind of ICU that need to be designed.

Comparisons of survival predictions using survival risk ratios based on International Classification of Diseases, Ninth Revision and Abbreviated Injury Scale trauma diagnosis codes.

PubMed

Clarke, John R; Ragone, Andrew V; Greenwald, Lloyd

2005-09-01

We conducted a comparison of methods for predicting survival using survival risk ratios (SRRs), including new comparisons based on International Classification of Diseases, Ninth Revision (ICD-9) versus Abbreviated Injury Scale (AIS) six-digit codes. From the Pennsylvania trauma center's registry, all direct trauma admissions were collected through June 22, 1999. Patients with no comorbid medical diagnoses and both ICD-9 and AIS injury codes were used for comparisons based on a single set of data. SRRs for ICD-9 and then for AIS diagnostic codes were each calculated two ways: from the survival rate of patients with each diagnosis and when each diagnosis was an isolated diagnosis. Probabilities of survival for the cohort were calculated using each set of SRRs by the multiplicative ICISS method and, where appropriate, the minimum SRR method. These prediction sets were then internally validated against actual survival by the Hosmer-Lemeshow goodness-of-fit statistic. The 41,364 patients had 1,224 different ICD-9 injury diagnoses in 32,261 combinations and 1,263 corresponding AIS injury diagnoses in 31,755 combinations, ranging from 1 to 27 injuries per patient. All conventional ICD-9-based combinations of SRRs and methods had better Hosmer-Lemeshow goodness-of-fit statistic fits than their AIS-based counterparts. The minimum SRR method produced better calibration than the multiplicative methods, presumably because it did not magnify inaccuracies in the SRRs that might occur with multiplication. Predictions of survival based on anatomic injury alone can be performed using ICD-9 codes, with no advantage from extra coding of AIS diagnoses. Predictions based on the single worst SRR were closer to actual outcomes than those based on multiplying SRRs.

Engagement in Trauma-Specific CBT for Youth Post-9/11

ERIC Educational Resources Information Center

Rodriguez, James; Hoagwood, Kimberly Eaton; Gopalan, Geetha; Olin, Serene; McKay, Mary M.; Marcus, Sue M.; Radigan, Marleen; Chung, Michelle; Legerski, Joanna

2013-01-01

Treatment participation was examined among youth enrolled in an evaluation of cognitive behavioral therapy (CBT) for trauma following the 9/11 World Trade Center disaster. Staff at nine agencies serving a predominantly low-income, ethnically diverse population were trained to deliver CBT and structured engagement strategies. A total of 445 youth…

38 CFR 17.2000 - Vet Center services.

Code of Federal Regulations, 2014 CFR

2014-07-01

... and referral, military sexual trauma counseling and referral, bereavement counseling, and outreach. A... Centers § 17.2000 Vet Center services. (a) Eligibility for readjustment counseling. Upon request, VA will provide readjustment counseling to the following individuals: (1) A veteran who served on active duty in a...

Management of blunt hepatic trauma at a Connecticut Level I trauma center.

PubMed

Scalora, Matthew A; Gross, Ronald I; Burns, Karyl J

2007-10-01

This study examined the management of patients with hepatic trauma treated at a Level I trauma center in Connecticut from January 1, 2003 to December 31, 2003. Forty-four patients over the age of 16 years sustained blunt liver injury and were brought to Hartford Hospital during the study period. Eight of these patients died; three of these deaths occurred in the emergency department (ED) shortly after arrival. Thirty-four patients (82.9%) with blunt liver injuries were managed nonoperatively. Only one of these patients died, not as a direct result of hepatic injury. The average Injury Severity Score (ISS) for these patients decreased as the injury grade increased but this was not statistically significant (P=0.684). A moderate positive and statistically significant relationship was noted between the length of hospital stay and the ISS (r=0.597, P=0.000). Our findings suggest that the current standard of care for most patients with blunt hepatic injuries is nonoperative management. It is the rare and most severely injured patient that will require operative management. As reported in the literature, mortality for these patients remains unchanged.

Interruptions in a level one trauma center: a case study.

PubMed

Brixey, Juliana J; Tang, Zhihua; Robinson, David J; Johnson, Craig W; Johnson, Todd R; Turley, James P; Patel, Vimla L; Zhang, Jiajie

2008-04-01

The emergency department has been characterized as interrupt-driven. Government agencies and patient safety organizations recognize that interruptions contribute to medical errors. The purpose of this study was to observe, record, and contextualize activities and interruptions experienced by physicians and Registered Nurses (RNs) working in a Level One Trauma Center. A case study that relied on an ethnographic study design using the shadowing method. A convenience sample of physicians and RNs, each with at least 6 months of experience in the Emergency Department (ED), were asked to participate. In these kinds of detailed qualitative investigations, it is quite common to have a small sample size. Ethical approval: Approval was obtained from institutional ethic committees prior to initiating the study. Community consent was obtained from the ED staff through in-service education. All observations were made in the trauma section of the ED of a tertiary teaching hospital. The hospital is situated in a major medical center in the Gulf Coast region of the United States of America (USA). Five attending ED physicians were observed for a total of 29h, 31min. Eight RNs were shadowed for a total of 40 h, 9min. Interruptions and activities were categorized using the Hybrid Method to Categorize Interruptions and Activities (HyMCIA). Registered Nurses received slightly more interruptions per hour than physicians. People, pagers, and telephones were identified as mediums through which interruptions were delivered. The physical environment was found to contribute to interruptions in workflow because of physical design and when supplies were not available. Physicians and RNs usually returned to the original, interrupted activity more often than leaving the activity unfinished. This research provides an enhanced understanding of interruptions in workflow in the ED, the identification of work constraints, and the need to develop interventions to manage interruptions. It is crucial that interruptions be delivered in such a way that there is minimal negative impact on performance. The significance and importance of the interruption must always be weighed against the negative impact that it has on smooth, efficient workflow.

Citywide trauma experience in Mwanza, Tanzania: a need for urgent intervention

PubMed Central

2013-01-01

Background Trauma remains a leading cause of morbidity and mortality in resource limited countries. There is paucity of published reports on trauma care in Tanzania, particularly the study area. This study was carried out to describe our experiences in trauma management outlining the etiological spectrum, injury characteristics and treatment outcome of trauma patients at our local setting and compare our results with those from other centers in the world. Methods A descriptive prospective study of trauma patients was conducted at Bugando Medical Centre from April 2010 to March 2012. Statistical data analysis was done using SPSS software version 17.0. Results A total of 5672 trauma patients were enrolled in the study. The male to female ratio was 2.3: 1. The majority of patients were in the 2nd decade of life. Road traffic accident was the most common cause of trauma accounting for 60.7% of cases. The majority of patients (76.6%) sustained blunt injuries. Musculoskeletal (68.5%) and head/neck (52.6%) were the most frequent body region injured. Soft tissue injuries (open wounds) and fractures were the most common injuries accounting for 82.8% and 76.8% respectively. Majority of patients (74.4%) were treated surgically with wound debridement (94.0%) being the most frequently performed procedure. Postoperative complications were recorded in 31.5% of cases. The overall median duration of hospitalization was 26 days (range 1 day to 144 days). Mortality rate was 16.7%. Patients who had polytrauma, burn injuries and those who had tetanus and long bone fractures stayed longer in the hospital and this was statistically significant (P < 0.001), whereas the age > 65 years, severe trauma, admission Systolic Blood Pressure < 90 mmHg, presence of tetanus, severe head injury, the duration of loss of consciousness, the need for intensive care unit admission and finding of space occupying lesion on CT scan of the brain significantly influenced mortality (P < 0.001). Conclusion Trauma resulting from road traffic accidents remains a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of road traffic accidents is necessary to reduce the incidence of trauma in this region. PMID:24499566

ABO Blood Type A Is Associated With Increased Risk of ARDS in Whites Following Both Major Trauma and Severe Sepsis

PubMed Central

Meyer, Nuala J.; Shashaty, Michael G. S.; Feng, Rui; Lanken, Paul N.; Gallop, Robert; Kaplan, Sandra; Herlim, Maximilian; Oz, Nathaniel L.; Hiciano, Isabel; Campbell, Ana; Holena, Daniel N.; Reilly, Muredach P.; Christie, Jason D.

2014-01-01

Background: ABO glycosyltransferases catalyze antigen modifications on various glycans and glycoproteins and determine the ABO blood types. Blood type A has been associated with increased risk of vascular diseases and differential circulating levels of proteins related to inflammation and endothelial function. The objective of this study was to determine the association of ABO blood types with ARDS risk in patients with major trauma and severe sepsis. Methods: We conducted prospective cohort studies in two populations at an urban tertiary referral, level I trauma center. Critically ill patients (n = 732) presenting after major trauma were followed for 5 days for ARDS development. Additionally, 976 medical patients with severe sepsis were followed for 5 days for ARDS. Multivariable logistic regression was used to adjust for confounders. Results: ARDS developed in 197 of the 732 trauma patients (27%). Blood type A was associated with increased ARDS risk among whites (37% vs 24%; adjusted OR, 1.88; 95% CI, 1.14-3.12; P = .014), but not blacks (adjusted OR, 0.61; 95% CI, 0.33-1.13; P = .114). ARDS developed in 222 of the 976 patients with severe sepsis (23%). Blood type A was also associated with an increased ARDS risk among whites (31% vs 21%; adjusted OR, 1.67; 95% CI, 1.08-2.59; P = .021) but, again, not among blacks (adjusted OR, 1.17; 95% CI, 0.59-2.33; P = .652). Conclusions: Blood type A is associated with an increased risk of ARDS in white patients with major trauma and severe sepsis. These results suggest a role for ABO glycans and glycosyltransferases in ARDS susceptibility. PMID:24385226

Prognostic value of Sequential Organ Failure Assessment and Simplified Acute Physiology II Score compared with trauma scores in the outcome of multiple-trauma patients.

PubMed

Fueglistaler, Philipp; Amsler, Felix; Schüepp, Marcel; Fueglistaler-Montali, Ida; Attenberger, Corinna; Pargger, Hans; Jacob, Augustinus Ludwig; Gross, Thomas

2010-08-01

Prospective data regarding the prognostic value of the Sequential Organ Failure Assessment (SOFA) score in comparison with the Simplified Acute Physiology Score (SAPS II) and trauma scores on the outcome of multiple-trauma patients are lacking. Single-center evaluation (n = 237, Injury Severity Score [ISS] >16; mean ISS = 29). Uni- and multivariate analysis of SAPS II, SOFA, revised trauma, polytrauma, and trauma and ISS scores (TRISS) was performed. The 30-day mortality was 22.8% (n = 54). SOFA day 1 was significantly higher in nonsurvivors compared with survivors (P < .001) and correlated well with the length of intensive care unit stay (r = .50, P < .001). Logistic regression revealed SAPS II to have the best predictive value of 30-day mortality (area under the receiver operating characteristic = .86 +/- .03). The SOFA score significantly added prognostic information with regard to mortality to both SAPS II and TRISS. The combination of critically ill and trauma scores may increase the accuracy of mortality prediction in multiple-trauma patients. 2010 Elsevier Inc. All rights reserved.

In view of standardization: comparison and analysis of initial management of severely burned patients in Germany, Austria and Switzerland.

PubMed

Münzberg, Matthias; Ziegler, Benjamin; Fischer, Sebastian; Wölfl, Christoph Georg; Grützner, Paul Alfred; Kremer, Thomas; Kneser, Ulrich; Hirche, Christoph

2015-02-01

Initial treatment of severely injured patients in German speaking trauma centers follows precise sequences. Several guidelines and training courses ensure a constant quality in providing evidence-based treatment for these patients. Similar standards, algorithms and guidelines for the treatment of severely burned patients are lacking. This raises the question about the current standard of care for burn victims in German speaking burn centers. In order to achieve standardization, as a first step this study surveys principles of burn room organization and management in these burn centers. A questionnaire including 40 questions regarding burn room organization, personnel structure and qualification, infrastructural conditions and quality management was developed and sent to 21 level one burn centers in Germany, Austria and Switzerland. The rate of returned questionnaires was 81%. The analysis revealed varying personnel and infrastructural conditions in participating burn centers. Indications for admission to the burn room and admission procedures itself are different throughout surveyed hospitals. Individual standard operating procedure (SOP) for burn trauma admissions was available in most burn centers and nearly all participants register their burn trauma cases using an in-house burn register. The survey suggests a lack of standardization in personnel structure, infrastructure and treatment approach for the initial clinical care of severely burned patients in burn centers across the German speaking countries. Further evaluation of existing protocols and international standards in burn care is inevitable to develop standardized guidelines for burn care and to improve quality of care. Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.

Health literacy and quality of physician-trauma patient communication: Opportunity for improvement.

PubMed

Dameworth, Jonathan L; Weinberg, Jordan A; Goslar, Pamela W; Stout, Dana J; Israr, Sharjeel; Jacobs, Jordan V; Gillespie, Thomas L; Thompson, Terrell M; Petersen, Scott R

2018-07-01

Although physician-patient communication and health literacy (HL) have been studied in diverse patient groups, there has been little focus on trauma patients. A quality improvement project was undertaken at our Level I trauma center to improve patient perception of physician-patient communication, with consideration of the effect of HL. We report the first phase of this project, namely the reference level of satisfaction with physician-patient communication as measured by levels of interpersonal care among patients at an urban Level I trauma center. Level I trauma center patients were interviewed during hospitalization (August 2016 to January 2017). Short Assessment of Health Literacy tool was used to stratify subjects by deficient versus adequate HL. Interpersonal Processes of Care survey was administered to assess perception of physician-patient communication. This survey allowed patients to rate physician-patient interaction across six domains: "clarity," "elicited concerns," "explained results," "worked together (on decision making)," "compassion and respect," and "lack of discrimination by race/ethnicity." Each is scored on a five-point scale. Frequencies of "top-box" (5/5) scores were compared for significance (p < 0.05) between HL-deficient and HL-adequate patients. One hundred ninety-nine patients participated. Average age was 42 years, 33% female. Forty-nine (25%) patients had deficient HL. The majority of patients in both groups rated communication below 5/5 across all domains except "compassion and respect" and "lack of discrimination by race/ethnicity." Health literacy-deficient patients were consistently less likely to give physicians top-box scores, most notably in the "elicited concerns" domain (35% vs. 54%, p = 0.012). Health literacy-deficient patients appear relatively less satisfied with physician communication, particularly with respect to perceiving that their concerns are being heard. Overall, however, the majority of patients in both groups were unlikely to score physician communication in the "top box." Efforts to improve physician-trauma patient communication are warranted, with attention directed toward meeting the needs of HL-deficient patients. Prognostic/Epidemiologic, level I.

Effect of Geriatric-Specific Trauma Triage Criteria on Outcomes in Injured Older Adults: A Statewide Retrospective Cohort Study.

PubMed

Caterino, Jeffrey M; Brown, Nicole V; Hamilton, Maya W; Ichwan, Brian; Khaliqdina, Salman; Evans, David C; Darbha, Subrahmanyan; Panchal, Ashish R; Shah, Manish N

2016-10-01

To evaluate the effect on outcomes of the Ohio Department of Public Safety statewide geriatric triage criteria, established in 2009 for emergency medical services (EMS) to use for injured individuals aged 70 and older. Retrospective cohort study of the Ohio Trauma Registry. All hospitals in Ohio. Individuals aged 70 and older in the Ohio Trauma Registry from January 2006 through December 2011, 3 years before and 3 years after criteria adoption (N = 34,499). Primary outcomes were in-hospital mortality and discharge to home. Criteria effects were assessed using chi-square tests, multivariable logistic regression, interrupted time series plots, and multivariable segmented regression models. After geriatric criteria were adopted, the proportion of older adults qualifying for trauma center transport increased from 44% to 58%, but EMS transport rates did not change (44% vs 45%). There was no difference in unadjusted mortality (7.1% vs 6.6%) (P = .10). In adjusted analyses, subjects with an injury severity score (ISS) less than 10 had lower mortality after adoption (3.0% vs 2.5%) (odds ratio (OR) = 0.81, 95% confidence interval (CI) = 0.70-0.95, P = .01). Discharge to home increased after adoption in the adjusted analysis (OR = 1.06, 95% CI = 1.01-1.11, P = .02). There were no time-dependent changes for either outcome. Although the proportion of older adults meeting criteria for trauma center transport substantially increased with geriatric triage criteria, there were no increases in trauma center transports. Adoption of statewide geriatric triage guidelines did not decrease mortality in more severely injured older adults but was associated with slightly lower mortality in individuals with mild injuries (ISS <10) and with more individuals discharged to home. Improving outcomes in injured older adults will require further attention to implementation and use of geriatric-specific criteria. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

A survey assessment of the level of preparedness for domestic terrorism and mass casualty incidents among Eastern Association for the Surgery of Trauma members.

PubMed

Ciraulo, David L; Frykberg, Eric R; Feliciano, David V; Knuth, Thomas E; Richart, Charles M; Westmoreland, Christy D; Williams, Kathryn A

2004-05-01

The goal of this survey was to establish a benchmark for trauma surgeons' level of operational understanding of the command structure for a pre-hospital incident, a mass casualty incident (MCI), and weapons of mass destruction (WMD). The survey was distributed before the World Trade Center destruction on September 11, 2001. The survey was developed by the authors and reviewed by a statistician for clarity and performance. The survey was sent to the membership of the 2000 Eastern Association for the Surgery of Trauma spring mailing, with two subsequent mailings and a final sampling at the Eastern Association for the Surgery of Trauma 2001 meeting. Of 723 surveys mailed, 243 were returned and statistically analyzed (significance indicated by p < 0.05). No statistical difference existed between level of designation of a trauma center (state or American College of Surgeons) and a facility's level of pre-paredness for MCIs or WMD. Physicians in communities with chemical plants, railways, and waterway traffic were statistically more likely to work at facilities with internal disaster plans addressing chemical and biological threats. Across all variables, physicians with military training were significantly better prepared for response to catastrophic events. With the exception of cyanide (50%), less than 30% of the membership was prepared to manage exposure to a nerve agent, less than 50% was prepared to manage illness from intentional biological exposure, and only 73% understood and were prepared to manage blast injury. Mobile medical response teams were present in 46% of the respondents' facilities, but only 30% of those teams deployed a trauma surgeon. Approximately 70% of the membership had been involved in an MCI, although only 60% understood the command structure for a prehospital incident. Only 33% of the membership had training regarding hazardous materials. Of interest, 76% and 65%, respectively, felt that education about MCIs and WMD should be included in residency training. A facility's level of pre-paredness for MCIs or WMD was not related to level of designation as a trauma center, but may be positively influenced by local physicians with prior military background. Benchmark information from this survey will provide the architecture for the development and implementation of further training in these areas for trauma surgeons.

Trauma patients meeting both Centers for Disease Control and Prevention's definitions for ventilator-associated pneumonia had worse outcomes than those meeting only one.

PubMed

Younan, Duraid; Griffin, Russell; Swain, Thomas; Pittet, Jean-Francois; Camins, Bernard

2017-08-01

The Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) replaced its old definition for ventilator-associated pneumonia (VAP) with the ventilator-associated events algorithm in 2013. We sought to compare the outcome of trauma patients meeting the definitions for VAP in the two modules. Trauma patients with blunt or penetrating injuries and with at least 2 d of ventilator support were identified from the trauma registry from 2013 to 2014. VAP was determined using two methods: (1) VAP as defined by the "old," clinically based NHSN definition and (2) possible VAP as defined by the updated "new" NHSN definition. Cohen's kappa statistic was determined to compare the two definitions for VAP. To compare demographic and clinical outcomes, the chi-square and Student's t-tests were used for categorical and continuous variables, respectively. From 2013 to 2014, there were 1165 trauma patients admitted who had at least 2 d of ventilator support. Seventy-eight patients (6.6%) met the "new" NHSN definition for possible VAP, 361 patients (30.9%) met the "old" definition of VAP, and 68 patients (5.8%) met both definitions. The kappa statistic between VAP as defined by the "new" and "old" definitions was 0.22 (95% confidence interval, 0.17-0.27). There were no differences in age, gender, race, or injury severity score when comparing patients who met the different definitions. Those satisfying both definitions had longer ventilator support days (P = 0.0009), intensive care unit length of stay (LOS; P = 0.0003), and hospital LOS (P = 0.0344) when compared with those meeting only one definition. There was no difference in mortality for those meeting both and those meeting the old definition for VAP; patients meeting both definitions had higher respiratory rate at arrival (P = 0.0178). There was no difference in mortality between patients meeting the "old" and "new" NHSN definitions for VAP; those who met "both" definitions had longer ventilator support days, intensive care unit, and hospital LOS. Copyright © 2017 Elsevier Inc. All rights reserved.

Effectiveness of trauma team on medical resource utilization and quality of care for patients with major trauma.

PubMed

Wang, Chih-Jung; Yen, Shu-Ting; Huang, Shih-Fang; Hsu, Su-Chen; Ying, Jeremy C; Shan, Yan-Shen

2017-07-24

Trauma is one of the leading causes of death in Taiwan, and its medical expenditure escalated drastically. This study aimed to explore the effectiveness of trauma team, which was established in September 2010, on medical resource utilization and quality of care among major trauma patients. This was a retrospective study, using trauma registry data bank and inpatient medical service charge databases. Study subjects were major trauma patients admitted to a medical center in Tainan during 2009 and 2013, and was divided into case group (from January, 2011 to August, 2013) and comparison group (from January, 2009 to August, 2010). Significant reductions in several items of medical resource utilization were identified after the establishment of trauma team. In the sub-group of patients who survived to discharge, examination, radiology and operation charges declined significantly. The radiation and examination charges reduced significantly in the subcategories of ISS = 16 ~ 24 and ISS > 24 respectively. However, no significant effectiveness on quality of care was identified. The establishment of trauma team is effective in containing medical resource utilization. In order to verify the effectiveness on quality of care, extended time frame and extra study subjects are needed.

Speaking the same language: underestimating financial impact when using diagnosis-related group versus ICD-9-based definitions for trauma inclusion criteria.

PubMed

Deppe, Sharon; Truax, Christopher B; Opalek, Judy M; Santanello, Steven A

2009-04-01

Hospital accounting methods use diagnosis-related group (DRG) data to identify patients and derive financial analyses and reports. The National Trauma Data Bank and trauma programs identify patients with trauma by International Classification of Diseases, Ninth Edition (ICD-9)-based definitions for inclusion criteria. These differing methods of identifying patients result in economic reports that vary significantly and fail to accurately identify the financial impact of trauma services. Routine financial data were collected for patients admitted to our Trauma Service from July 1, 2005 to June 30, 2006 using two methods of identifying the cases; by trauma DRGs and by trauma registry database inclusion criteria. The resulting data were compared and stratified to define the financial impact on hospital charges, reimbursement, costs, contribution to margin, downstream revenue, and estimated profit or loss. The results also defined the impact on supporting services, market share and total revenue from trauma admissions, return visits, discharged trauma alerts, and consultations. A total of 3,070 patients were identified by the trauma registry as meeting ICD-9 inclusion criteria. Trauma-associated DRGs accounted for 871 of the 3,070 admissions. The DRG-driven data set demonstrated an estimated profit of $800,000 dollars; the ICD-9 data set revealed an estimated 4.8 million dollar profit, increased our market share, and showed substantial revenue generated for other hospital service lines. Trauma DRGs fail to account for most trauma admissions. Financial data derived from DRG definitions significantly underestimate the trauma service line's financial contribution to hospital economics. Accurately identifying patients with trauma based on trauma database inclusion criteria better defines the business of trauma.

The Banner of Hope and Solidarity After Mass Murder.

PubMed

Summers, Shane M

2018-04-17

On November 5, 2017, Brooke Army Medical Center emergency department (ED) was faced with the unthinkable: the deadliest mass shooting in Texas history, where 26 souls lost their lives attending church services in Sutherland Springs. That Sunday morning our trauma center received eight gunshot wound victims, 2 of whom were minors. Without warning, our residents faced a situation that they had only read about in textbooks. The residents led the trauma resuscitations that day and did so brilliantly. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Non-operative management of blunt trauma in abdominal solid organ injuries: a prospective study to evaluate the success rate and predictive factors of failure.

PubMed

Hashemzadeh, S H; Hashemzadeh, K H; Dehdilani, M; Rezaei, S

2010-06-01

Over the past several years, non-operative management (NOM) has increasingly been recommended for the care of selected blunt abdominal solid organ injuries. No prospective study has evaluated the rate of NOM of blunt abdominal trauma in the northwest of Iran. The objective of our study was to evaluate the success rate of this kind of management in patients who do not require emergency surgery. This prospective study was carried out in Imam Khomeini Hospital (as a referral center of trauma) at Tabriz University of Medical Sciences, Iran, between 20 March 2004 and 20 March 2007. All trauma patients who had suffered an injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis, using the Student's t test or the c2 test. During the three years of the study, 98 patients (83 males and 15 females) with blunt trauma were selected to NOM for renal, hepatic and splenic injuries. Mean age was 26.1+/-17.7 years (range, 2 to 89) and mean injury severity score (ISS) was 14.5+/-7.4. The success rate of NOM was 93.8%. Fifty-one patients (43 males, 8 females; mean ISS, 14.2+/-5.8) underwent NOM of splenic trauma; 38 patients (33 males, 5 females; mean ISS, 12.9+/-8.2) hepatic trauma, and nine patients (7 males, 2 females; mean ISS, 22.2+/-7.6) renal trauma. Six patients underwent laparotomy due to the failure of NOM. The success rates of this treatment were 94.1%, 94.7% and 88.8% for the spleen, liver and kidney injuries, respectively. Age, female gender and ISS were significant predictors of the failure of NOM (P<0.05). According to the authors NOM can be successfully performed for the hemodynamically stable patients with solid organ blunt trauma. The study indicates that the rates of NOM vary in relation to the severity of the organ injury. This suggests trauma centers should use this approach.

Air versus ground transport of the major trauma patient: a natural experiment.

PubMed

McVey, Jennifer; Petrie, David A; Tallon, John M

2010-01-01

1) To compare the outcomes of adult trauma patients transported to a level I trauma center by helicopter vs. ground ambulance. 2) To determine whether using a unique "natural experiment" design to obtain the ground comparison group will reduce potential confounders. Outcomes in adult trauma patients transported to a tertiary care trauma center by air were compared with outcomes in a group of patients who were accepted by the online medical control physician for air transport, but whose air missions were aborted for aviation reasons (weather, maintenance, out on a mission); these patients were subsequently transported by ground ambulance instead. Outcomes were also analyzed for a third ground control group composed of all other adult trauma patients transported by ground during this time period. Data were collected by retrospective database review of trauma patients transferred between July 1, 1997, and June 30, 2003. Outcomes were measured by Trauma Injury Severity Score (TRISS) analysis. Z and W scores were calculated. Three hundred ninety-seven missions were flown by LifeFlight during the study period vs. 57 in the clinical accept-aviation abort ground transport group. The mean ages, gender distributions, mechanisms of injury, and Injury Severity Scores (ISSs) were similar in the two groups. Per 100 patients transported, 5.61 more lives were saved in the air group vs. the clinical accept-aviation abort ground transport group (Z = 3.37). As per TRISS analysis, this is relative to the expected mortality seen with a similar group in the Major Trauma Outcomes Study (MTOS). The Z score for the clinical accept-aviation abort ground transport group was 0.4. The 1,195 patients in the third all-other ground control group had a higher mean age, lower mean ISS, and worse outcomes according to TRISS analysis (W = -2.02). This unique natural experiment led to better matched air vs. ground cohorts for comparison. As per TRISS analysis, air transport of the adult major trauma patient is associated with significantly improved survival as compared with ground transport.

Are drowned donors marginal donors? A single pediatric center experience.

PubMed

Kumm, Kayla R; Galván, N Thao N; Koohmaraie, Sarah; Rana, Abbas; Kueht, Michael; Baugh, Katherine; Hao, Liu; Yoeli, Dor; Cotton, Ronald; O'Mahony, Christine A; Goss, John A

2017-09-01

Drowning, a common cause of death in the pediatric population, is a potentially large donor pool for OLT. Anecdotally, transplant centers have deemed these organs high risk over concerns for infection and graft dysfunction. We theorized drowned donor liver allografts do not portend worse outcomes and therefore should not be excluded from the donation pool. We reviewed our single-center experience of pediatric OLTs between 1988 and 2015 and identified 33 drowned donor recipients. These OLTs were matched 1:2 to head trauma donor OLTs from our center. A chart review assessed postoperative peak AST and ALT, incidence of HAT, graft and recipient survival. Recipient survival at one year between patients with drowned donor vs head trauma donor allografts was not statistically significant (94% vs 97%, P=.63). HAT incidence was 6.1% in the drowned donor group vs 7.6% in the control group (P=.78). Mean postoperative peak AST and ALT was 683 U/L and 450 U/L for drowned donors vs 1119 U/L and 828 U/L in the matched cohort. These results suggest drowned donor liver allografts do not portend worse outcomes in comparison with those procured from head trauma donors. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Prehospital helicopter transport and survival of patients with traumatic brain injury.

PubMed

Bekelis, Kimon; Missios, Symeon; Mackenzie, Todd A

2015-03-01

To investigate the association of helicopter transport with survival of patients with traumatic brain injury (TBI), in comparison with ground emergency medical services (EMS). Helicopter utilization and its effect on the outcomes of TBI remain controversial. We performed a retrospective cohort study involving patients with TBI who were registered in the National Trauma Data Bank between 2009 and 2011. Regression techniques with propensity score matching were used to investigate the association of helicopter transport with survival of patients with TBI, in comparison with ground EMS. During the study period, there were 209,529 patients with TBI who were registered in the National Trauma Data Bank and met the inclusion criteria. Of these patients, 35,334 were transported via helicopters and 174,195 via ground EMS. For patients transported to level I trauma centers, 2797 deaths (12%) were recorded after helicopter transport and 8161 (7.8%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival [OR (odds ratio), 1.95; 95% confidence interval (CI), 1.81-2.10; absolute risk reduction (ARR), 6.37%]. This persisted after propensity score matching (OR, 1.88; 95% CI, 1.74-2.03; ARR, 5.93%). For patients transported to level II trauma centers, 1282 deaths (10.6%) were recorded after helicopter transport and 5097 (7.3%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (OR, 1.81; 95% CI, 1.64-2.00; ARR 5.17%). This again persisted after propensity score matching (OR, 1.73; 95% CI, 1.55-1.94; ARR, 4.69). Helicopter transport of patients with TBI to level I and II trauma centers was associated with improved survival, in comparison with ground EMS.

Acute Trauma Factor Associations With Suicidality Across the First 5 Years After Traumatic Brain Injury.

PubMed

Kesinger, Matthew R; Juengst, Shannon B; Bertisch, Hillary; Niemeier, Janet P; Krellman, Jason W; Pugh, Mary Jo; Kumar, Raj G; Sperry, Jason L; Arenth, Patricia M; Fann, Jesse R; Wagner, Amy K

2016-08-01

To determine whether severity of head and extracranial injuries (ECI) is associated with suicidal ideation (SI) or suicide attempt (SA) after traumatic brain injury (TBI). Factors associated with SI and SA were assessed in this inception cohort study using data collected 1, 2, and 5 years post-TBI from the National Trauma Data Bank and Traumatic Brain Injury Model Systems (TBIMS) databases. Level I trauma centers, inpatient rehabilitation centers, and the community. Participants with TBI from 15 TBIMS Centers with linked National Trauma Data Bank trauma data (N=3575). Not applicable. SI was measured via the Patient Health Questionnaire 9 (question 9). SA in the last year was assessed via interview. ECI was measured by the Injury Severity Scale (nonhead) and categorized as none, mild, moderate, or severe. There were 293 (8.2%) participants who had SI without SA and 109 (3.0%) who had SA at least once in the first 5 years postinjury. Random effects logit modeling showed a higher likelihood of SI when ECI was severe (odds ratio=2.73; 95% confidence interval, 1.55-4.82; P=.001). Drug use at time of injury was also associated with SI (odds ratio=1.69; 95% confidence interval, 1.11-2.86; P=.015). Severity of ECI was not associated with SA. Severe ECI carried a nearly 3-fold increase in the odds of SI after TBI, but it was not related to SA. Head injury severity and less severe ECI were not associated with SI or SA. These findings warrant additional work to identify factors associated with severe ECI that make individuals more susceptible to SI after TBI. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Mountain biking injuries requiring trauma center admission: a 10-year regional trauma system experience.

PubMed

Kim, Peter T W; Jangra, Dalbhir; Ritchie, Alec H; Lower, Mary Ellen; Kasic, Sharon; Brown, D Ross; Baldwin, Greg A; Simons, Richard K

2006-02-01

Mountain biking has become an increasingly popular recreational and competitive sport with increasingly recognized risks. The purpose of this study was to review a population based approach to serious injuries requiring trauma center admission related to mountain biking, identify trends and develop directions for related injury prevention programs. Three trauma centers in the Greater Vancouver area exclusively serve a major mountain bike park and the North Shore Mountains biking trails. The Trauma Registries and the patient charts were reviewed for mountain bike injuries from 1992 to 2002. The data were analyzed according to demographics, distribution, and severity of injuries, and need for operative intervention. Findings were reviewed with injury prevention experts and regional and national mountain-biking stakeholders to provide direction to injury prevention programs. A total of 1,037 patients were identified as having bicycling-related injuries. Of these, 399 patients sustained 1,092 injuries while mountain biking. There was a threefold increase in the incidence of mountain biking injuries over a 10-year period. Young males were most commonly affected. Orthopedic injuries were most common (46.5%) followed by head (12.2%), spine (12%), chest (10.3%), facial (10.2%), abdominal (5.4%), genitourinary (2.2%), and neck injuries (1%). High operative rate was observed: 38% of injuries and 66% of patients required surgery. One patient died from his injuries. Injury prevention programs were developed and successfully engaged the target population. Mountain biking is a growing cause of serious injuries. Young males are principally at risk and serious injuries result from intended activity and despite protective equipment. Injury prevention programs were developed to address these concerns.

Morbidity associated with golf-related injuries among children: findings from a pediatric trauma center.

PubMed

Vitale, Melissa A; Mertz, Kristen J; Gaines, Barbara; Zuckerbraun, Noel S

2011-01-01

To describe injuries due to golf-related activities among pediatric patients requiring hospital admission. We conducted a retrospective analysis of all sports-related injuries from 2000 to 2006 using a level 1 trauma center database. Of 1005 children admitted with sports-related injuries, 60 (6%) had golf-related injuries. The mean injury severity score was significantly higher for golf-related injuries (11.0) than that for all other sports-related injuries (6.8). Most golf-related injuries occurred in children younger than 12 years (80%), at home (48%), and by a strike from a club (57%) and resulted in trauma to the head or neck (68%). Golf-related injuries, although an infrequent cause of sports-related injuries, have the potential to result in severe injuries, especially in younger children. Preventive efforts should target use of golf clubs by younger children in the home setting.

The Fort Hood Massacre: Lessons learned from a high profile mass casualty.

PubMed

Wild, Jeffrey; Maher, Janae; Frazee, Richard C; Craun, Michael L; Davis, Matthew L; Childs, Ed W; Smith, Randall W

2012-06-01

On November 5, 2009, an army psychiatrist at Fort Hood in Killeen, TX, allegedly opened fire at the largest US military base in the world, killing 13 and wounding 32. Data from debriefing sessions, news media, and area hospitals were reviewed. Ten patients were initially transferred to the regional Level I trauma center. The remainder of the shooting victims were triaged to two other local regional hospitals. National news networks broadcasted the Level I trauma center's referral phone line which resulted in more than 1,300 calls. The resulting difficulties in communication led to the transfer of two victims (one critical) to a regional hospital without a trauma designation. Triage at the scene was compromised by a lack of a secure environment, leading to undertriage of several patients. Overload of routine communication pathways compounded the problem, suggesting redundancy is crucial. Prognostic study, level V. Copyright © 2012 by Lippincott Williams & Wilkins.

Liver transplantation for severe hepatic trauma: Experience from a single center

PubMed Central

Delis, Spiros G; Bakoyiannis, Andreas; Selvaggi, Gennaro; Weppler, Debbie; Levi, David; Tzakis, Andreas G

2009-01-01

Liver transplantation has been reported in the literature as an extreme intervention in cases of severe and complicated hepatic trauma. The main indications for liver transplant in such cases were uncontrollable bleeding and postoperative hepatic insufficiency. We here describe four cases of orthotopic liver transplantation after penetrating or blunt liver trauma. The indications were liver failure, extended liver necrosis, liver gangrene and multiple episodes of gastrointestinal bleeding related to portal hypertension, respectively. One patient died due to postoperative cerebral edema. The other three patients recovered well and remain on immunosuppression. Liver transplantation should be considered as a saving procedure in severe hepatic trauma, when all other treatment modalities fail. PMID:19340909

Assessment of trauma quality improvement activities at public hospitals in Thailand.

PubMed

Fuangworawong, Phuphit; LaGrone, Lacey N; Chadbunchachai, Witaya; Sornsrivichai, Vorasith; Mock, Charles N; Vavilala, Monica S

2016-09-01

Given the current exceptional burden of injury in Thailand, the proven efficacy of quality improvement programs, and the current scarcity of national-level information on trauma quality improvement program (TQIP) implementation in Thailand, we aimed to examine the use of TQIPs and barriers to TQIP adoption in Thai public trauma centers. We distributed a survey to 110 public hospitals which are designated to provide trauma care in Thailand. The survey assessed the presence or absence of the four core elements of the World Health Organization (WHO) recommended TQIPs (morbidity and mortality (M&M) conferences, preventable death panels, trauma registries, and audit filters), and provider perception of barriers and priorities in TQIP implementation. Responses were received from 80 (72%) respondents. Seventy-two (90%) reported having a trauma registry and seventy (88%) respondents reported use of audit filters. Seventy (88%) respondents reported conducting regular M&M conferences, and 45 (56%) respondents reported the presence of preventable death panels. Thirty-eight (48%) respondents reported presence of all four elements of WHO TQIPs. The most commonly reported barriers to implementing TQIPs were lack of interest (55; 68%) and lack of time (39; 48%)to implement TQIPs. Audit filters were reported by only 25 (31%) of respondents and optimization of audit filters was the most frequently identified next-step in further development of TQIP. Just under half of responding Thai public trauma centers reported implementation of all four elements of the WHO recommended TQIPs. Priority strategies to facilitate TQIP maturation in Thailand should address staff motivation, provision of staff time for TQIP development, and optimization of audit filter use to monitor quality of care. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

[Polytrauma and air rescue. A retrospective analysis of trauma care in eastern Austria exemplified by an urban trauma center].

PubMed

Weninger, P; Trimmel, H; Nau, T; Aldrian, S; König, F; Vécsei, V

2005-07-01

The aim of this study was a retrospective analysis of polytraumatized patients who were treated by a helicopter emergency medical service (HEMS) crew. This study was performed to evaluate the level of prehospital care provided for severely injured patients. Special consideration was given to treatment strategies of specific injuries which led to multiple injuries, defined as "polytrauma." From September 1992 to April 2001 data of 386 patients treated in the Department of Traumatology of the University of Vienna were collected. A total of 104 patients (26.9%) were transported by helicopter directly from the accident scene. This collective was analyzed demographically; relevant prehospital data such as therapeutic interventions and the early clinical course were examined. The mean Injury Severity Score (ISS) was 36.9: 70 (67.3%) patients were male and 34 (32.7%) female; the median age was 36.1 years. Traffic accidents were the most frequent trauma mechanism (78.9%) followed by falls from height (17.3%). The mean period between trauma and trauma emergency room was 0.73 h; 77 (74.0%) patients were intubated and mechanically ventilated at the scene and all patients received analgosedation. The mean preclinical fluid load was 1673 ml. The mean duration of treatment in the emergency room was 53 min. The mean length of intensive care was 8.6 days and the mortality rate was 19.2% within the first 24 h. Major trauma is an important cause for requesting a primary HEMS mission. As the results of this study show, immediate and invasive interventions at the scene lead to an improvement of vital functions at admission. For the patients' further course of treatment, the choice of a trauma center seems to be important, too.

Emergency CT for assessment and management of blunt traumatic splenic injuries at a Level 1 Trauma Center: 13-year study.

PubMed

Margari, Sergio; Garozzo Velloni, Fernanda; Tonolini, Massimo; Colombo, Ettore; Artioli, Diana; Allievi, Niccolò Ettore; Sammartano, Fabrizio; Chiara, Osvaldo; Vanzulli, Angelo

2018-05-12

To determine the relationship between multidetector computed tomography (MDCT) findings, management strategies, and ultimate clinical outcomes in patients with splenic injuries secondary to blunt trauma. This Institutional Review Board-approved study collected 351 consecutive patients admitted at the Emergency Department (ED) of a Level I Trauma Center with blunt splenic trauma between October 2002 and November 2015. Their MDCT studies were retrospectively and independently reviewed by two radiologists to grade splenic injuries according to the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) and to detect intraparenchymal (type A) or extraparenchymal (type B) active bleeding and/or contained vascular injuries (CVI). Clinical data, information on management, and outcome were retrieved from the hospital database. Statistical analysis relied on Student's t, chi-squared, and Cohen's kappa tests. Emergency multiphase MDCT was obtained in 263 hemodynamically stable patients. Interobserver agreement for both AAST grading of injuries and vascular lesions was excellent (k = 0.77). Operative management (OM) was performed in 160 patients (45.58% of the whole cohort), and high-grade (IV and V) OIS injuries and type B bleeding were statistically significant (p < 0.05) predictors of OM. Nonoperative management (NOM) failed in 23 patients out of 191 (12.04%). In 75% of them, NOM failure occurred within 30 h from the trauma event, without significant increase of mortality. Both intraparenchymal and extraparenchymal active bleeding were predictive of NOM failure (p < 0.05). Providing detection and characterization of parenchymal and vascular traumatic lesions, MDCT plays a crucial role for safe and appropriate guidance of ED management of splenic traumas and contributes to the shift toward NOM in hemodynamically stable patients.

Low hemorrhage-related mortality in trauma patients in a Level I trauma center employing transfusion packages and early thromboelastography-directed hemostatic resuscitation with plasma and platelets.

PubMed

Johansson, Pär I; Sørensen, Anne Marie; Larsen, Claus F; Windeløv, Nis A; Stensballe, Jakob; Perner, Anders; Rasmussen, Lars S; Ostrowski, Sisse R

2013-12-01

Hemorrhage accounts for most preventable trauma deaths, but still the optimal strategy for hemostatic resuscitation remains debated. This was a prospective study of adult trauma patients admitted to a Level I trauma center. Demography, Injury Severity Score (ISS), transfusion therapy, and mortality were registered. Hemostatic resuscitation was based on a massive transfusion protocol encompassing transfusion packages and thromboelastography (TEG)-guided therapy. A total of 182 patients were included (75% males, median age 43 years, ISS of 17, 92% with blunt trauma). Overall 28-day mortality was 12% with causes of death being exsanguinations (14%), traumatic brain injury (72%, two-thirds expiring within 24 hr), and other (14%). One-fourth, 16 and 15% of the patients, received red blood cells (RBCs), plasma, or platelets (PLTs) within 2 hours from admission and 68, 71, and 75%, respectively, of patients transfused within 24 hours received the respective blood products within the first 2 hours. In patients transfused within 24 hours, the median number of blood products at 2 hours was 5 units of RBCs, 5 units of plasma, and 2 units of PLT concentrates. Nonsurvivors had lower clot strength by kaolin-activated TEG and TEG functional fibrinogen and lower kaolin-tissue factor-activated TEG α-angle and lysis after 30 minutes compared to survivors. None of the TEG variables were independent predictors of massive transfusion or mortality. Three-fourths of the patients transfused with plasma or PLTs within 24 hours received these in the first 2 hours. Hemorrhage caused 14% of the deaths. We introduced transfusion packages and early TEG-directed hemostatic resuscitation at our hospital 10 years ago and this may have contributed to reducing hemorrhagic trauma deaths. © 2013 American Association of Blood Banks.

Abdominal Trauma Revisited.

PubMed

Feliciano, David V

2017-11-01

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Disaster nursing in the Oklahoma City bombing.

PubMed

Atkinson, R; Keylon, K; Odor, P S; Walker, G; Hunt, L

1995-10-01

The Oklahoma City Federal Building disaster quickly changed a routine day of eye surgical procedures into a chaotic trauma center for the victims with not only eye injuries, but multiple deep lacerations and other injuries. The devastating and disruptive effect of the bombing was stressful for the nursing staff who became disaster survivors of the emotional trauma involved.

The Effectiveness of Art Therapy Interventions in Reducing Post Traumatic Stress Disorder (PTSD) Symptoms in Pediatric Trauma Patients.

ERIC Educational Resources Information Center

Chapman, Linda M.; Morabito, Diane; Ladakakos, Chris; Schreier, Herbert; Knudson, M. Margaret

2001-01-01

Chapman Art Therapy Intervention (CATTI), an art therapy research project at an urban trauma center, was designed to reduce Post Traumatic Stress Disorder (PTSD) symptoms in pediatric patients. Early analysis does not indicate statistically significant differences in reduction of PTSD symptoms between experimental and control groups. Children…

Between Trauma and Perpetration: Psychoanalytical and Social Psychological Perspectives on Difficult Histories in the Israeli Context

ERIC Educational Resources Information Center

Goldberg, Tsafrir

2017-01-01

This study explores the applicability of psychoanalytic trauma-centered perspectives and social psychological intergroup comparison perspectives to difficult histories of the Israeli context. The study describes 2 test cases of difficult histories in the Jewish-Israeli context at the levels of curriculum policy, teachers, and learners. The first…

Complex Childhood Trauma and School Responses: A Case Study of the Impact of Professional Development in One Elementary School

ERIC Educational Resources Information Center

VanderWegen, Terrie A.

2013-01-01

The purpose of this qualitative case study was to examine one public elementary school in Spokane, Washington that has received significant complex trauma professional development training provided by Washington State University Area Health Education Center (WSU-AHEC). The study explored teachers', specialists', and the principal's perceptions of…

Trauma Spectrum Disorders: Emerging Perspectives on the Impact on Military and Veteran Families

ERIC Educational Resources Information Center

O'Donnell, Lolita; Begg, Lisa; Lipson, Linda; Elvander, Erika

2011-01-01

This article summarizes the findings from the Second Annual Trauma Spectrum Disorders Conference, which was held in December 2009 and was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in conjunction with the Department of Veterans Affairs and the National Institutes of Health. The conference…

Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: association with current symptomatology.

PubMed

Clancy, Carolina P; Graybeal, Anna; Tompson, Whitney P; Badgett, Kourtni S; Feldman, Michelle E; Calhoun, Patrick S; Erkanli, Alaattin; Hertzberg, Michael A; Beckham, Jean C

2006-09-01

This study examined whether trauma exposure before, during, and/or after military service contributed to current levels of post-traumatic stress disorder (PTSD) and adjustment. Further, we investigated whether trauma exposure before military service was mediated or moderated by military trauma in its effects on current PTSD and adjustment. In this retrospective study, archival data from the medical records of 422 male veterans diagnosed with PTSD between December 2001 and July 2004 at a Veterans Administration Medical Center PTSD clinic were analyzed. Measures included the Clinician-Administered PTSD Scale interview as well as self-report measures assessing trauma history, health problems, and general psychopathology (including PTSD). Findings indicated that nonmilitary-related trauma was prevalent in this sample (90%). Regression analyses for PTSD symptom severity revealed that age, greater combat exposure, and a history of physical assault after military service were significantly associated with more severe PTSD symptoms. Childhood physical abuse, adult sexual trauma, and a history of being physically assaulted during military service were also significantly associated with PTSD symptom severity. Mediational analyses indicated that childhood trauma was associated with both adult trauma and increased symptomatology on various outcome measures. Moderational analyses indicated that adult trauma exposure moderated the effect of childhood trauma exposure on health complaints. Results suggest that several variables, including age, greater combat exposure, and premilitary and postmilitary traumas, are associated with increased PTSD symptomatology. This finding underscores the importance of conducting a thorough assessment of trauma when diagnosing PTSD.

Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients

PubMed Central

Soja, Stacie L.; Pandharipande, Pratik P.; Fleming, Sloan B.; Cotton, Bryan A.; Miller, Leanna R.; Weaver, Stefanija G.; Lee, Byron T.; Ely, E. Wesley

2013-01-01

Objective To implement delirium monitoring, test reliability, and monitor compliance of performing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in trauma patients. Design and setting Prospective, observational study in a Level 1 trauma unit of a tertiary care, university-based medical center. Patients Acutely injured patients admitted to the trauma unit from February 1, 2006–April 16, 2006. Measurements and Results Following web-based teaching modules and group in-services, bedside nurses evaluated patients daily for depth of sedation with the Richmond Agitation-Sedation Scale (RASS) and for the presence of delirium with the CAM-ICU. On randomly assigned days over a 10-week period, evaluations by nursing staff were followed by evaluations by an expert evaluator of the RASS and the CAM-ICU, in order to assess compliance and reliability of the CAM-ICU in trauma patients. Following the audit period, the nurses completed a post-implementation survey. One thousand and eleven random CAM-ICU assessments were performed by the expert evaluator, within 1 hour of the bedside nurses’ assessments. Nurses completed the CAM-ICU assessments in 84% (849 of 1011) of evaluations. Overall agreement (κ) between nurses and the expert evaluator was 0.77 (0.721, 0.822; p<0.0001). In TBI patients κ was 0.75 (0.667, 0.829; p<0.0001), while in mechanically-ventilated patients κ was 0.62 (0.534, 0.704; p<0.0001). The survey revealed nurses were confident in performing the CAM-ICU, realized the importance of delirium, and were satisfied with the training they received. The survey also acknowledged obstacles to implementation including nursing time and failure of physicians/surgeons to address treatment approaches for delirium. Conclusions The CAM-ICU can be successfully implemented in a university-based trauma unit with high compliance and reliability. Quality improvement projects seeking to implement delirium monitoring would be wise to address potential pitfalls including time complaints and the negative impact of physician indifference regarding this form of organ dysfunction. PMID:18297270

Data driven linear algebraic methods for analysis of molecular pathways: application to disease progression in shock/trauma.

PubMed

McGuire, Mary F; Sriram Iyengar, M; Mercer, David W

2012-04-01

Although trauma is the leading cause of death for those below 45years of age, there is a dearth of information about the temporal behavior of the underlying biological mechanisms in those who survive the initial trauma only to later suffer from syndromes such as multiple organ failure. Levels of serum cytokines potentially affect the clinical outcomes of trauma; understanding how cytokine levels modulate intra-cellular signaling pathways can yield insights into molecular mechanisms of disease progression and help to identify targeted therapies. However, developing such analyses is challenging since it necessitates the integration and interpretation of large amounts of heterogeneous, quantitative and qualitative data. Here we present the Pathway Semantics Algorithm (PSA), an algebraic process of node and edge analyses of evoked biological pathways over time for in silico discovery of biomedical hypotheses, using data from a prospective controlled clinical study of the role of cytokines in multiple organ failure (MOF) at a major US trauma center. A matrix algebra approach was used in both the PSA node and PSA edge analyses with different matrix configurations and computations based on the biomedical questions to be examined. In the edge analysis, a percentage measure of crosstalk called XTALK was also developed to assess cross-pathway interference. In the node/molecular analysis of the first 24h from trauma, PSA uncovered seven molecules evoked computationally that differentiated outcomes of MOF or non-MOF (NMOF), of which three molecules had not been previously associated with any shock/trauma syndrome. In the edge/molecular interaction analysis, PSA examined four categories of functional molecular interaction relationships--activation, expression, inhibition, and transcription--and found that the interaction patterns and crosstalk changed over time and outcome. The PSA edge analysis suggests that a diagnosis, prognosis or therapy based on molecular interaction mechanisms may be most effective within a certain time period and for a specific functional relationship. Copyright © 2011 Elsevier Inc. All rights reserved.

Outcome after severe multiple trauma: a retrospective analysis

PubMed Central

2013-01-01

Background Aim of this study was to evaluate prognosis of severely injured patients. Methods All severely injured patients with an Injury Severity Score (ISS) ≥ 50 were identified in a 6-year-period between 2000 and 2005 in German Level 1 Trauma Center Murnau. Data was evaluated from German Trauma Registry and Polytrauma Outcome Chart of the German Society for Trauma Surgery and a personal interview to assess working ability and disability and are presented as average. Results 88 out of 1435 evaluated patients after severe polytrauma demonstrated an ISS ≥ 50 (6.5%), among them 23% women and 77% men. 66 patients (75%) had an ISS of 50-60, 14 (16%) 61-70, and 8 (9%) ≥ 70. In 27% of patients trauma was caused by motor bike accidents. 3.6 body regions were involved. Patients had to be operated 5.3 times and were treated 23 days in the ICU and stayed 73 days in hospital. Mortality rate was 36% and rate of multi-organ failure 28%. 15% of patients demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. 25% recovered well or at least moderately. 29 out of 56 survivors answered the POLO-chart. A personal interview was performed with 13 patients. The state of health was at least moderate in 72% of patients. In 48% interpersonal problems and in 41% severe pain was observed. In 57% of patients problems with working ability regarding duration, as well as quantitative and qualitative performance were observed. Symptoms of post-traumatic stress disorder were found in 41%. The more distal the lesions were located (foot/ankle) the more functional disability affected daily life. In only 15%, working ability was not impaired. 8 out of 13 interviewed patients demonstrated complete work disability. Conclusions Even severely injured patients after multiple trauma have a good prognosis. The ISS is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. PMID:23675931

Factors Associated with Complications in Older Adults with Isolated Blunt Chest Trauma

PubMed Central

Lotfipour, Shahram; Kaku, Shawn K.; Vaca, Federico E.; Patel, Chirag; Anderson, Craig L.; Ahmed, Suleman S.; Menchine, Michael D.

2009-01-01

Objective: To determine the prevalence of adverse events in elderly trauma patients with isolated blunt thoracic trauma, and to identify variables associated with these adverse events. Methods: We performed a chart review of 160 trauma patients age 65 and older with significant blunt thoracic trauma, drawn from an American College of Surgeons Level I Trauma Center registry. Patients with serious injury to other body areas were excluded to prevent confounding the cause of adverse events. Adverse events were defined as acute respiratory distress syndrome or pneumonia, unanticipated intubation, transfer to the intensive care unit for hypoxemia, or death. Data collected included history, physical examination, radiographic findings, length of hospital stay, and clinical outcomes. Results: Ninety-nine patients had isolated chest injury, while 61 others had other organ systems injured and were excluded. Sixteen patients developed adverse events [16.2% 95% confidence interval (CI) 9.5–24.9%], including two deaths. Adverse events were experienced by 19.2%, 6.1%, and 28.6% of those patients 65–74, 75–84, and ≥85 years old, respectively. The mean length of stay was 14.6 days in patients with an adverse event and 5.8 days in patients without. Post hoc analysis revealed that all 16 patients with an adverse event had one or more of the following: age ≥85, initial systolic blood pressure <90 mmHg, hemothorax, pneumothorax, three or more unilateral rib fractures, or pulmonary contusion (sensitivity 100%, CI 79.4–100%; specificity 38.6%, CI 28.1–49.9%). Conclusion: Adverse events from isolated thoracic trauma in elderly patients complicate 16% of our sample. These criteria were 100% sensitive and 38.5% specific for these adverse events. This study is a first step to identifying variables that might aid in identifying patients at high risk for serious adverse events. PMID:19561823

Data driven linear algebraic methods for analysis of molecular pathways: application to disease progression in shock/trauma

PubMed Central

McGuire, Mary F.; Iyengar, M. Sriram; Mercer, David W.

2012-01-01

Motivation Although trauma is the leading cause of death for those below 45 years of age, there is a dearth of information about the temporal behavior of the underlying biological mechanisms in those who survive the initial trauma only to later suffer from syndromes such as multiple organ failure. Levels of serum cytokines potentially affect the clinical outcomes of trauma; understanding how cytokine levels modulate intra-cellular signaling pathways can yield insights into molecular mechanisms of disease progression and help to identify targeted therapies. However, developing such analyses is challenging since it necessitates the integration and interpretation of large amounts of heterogeneous, quantitative and qualitative data. Here we present the Pathway Semantics Algorithm (PSA), an algebraic process of node and edge analyses of evoked biological pathways over time for in silico discovery of biomedical hypotheses, using data from a prospective controlled clinical study of the role of cytokines in multiple organ failure (MOF) at a major US trauma center. A matrix algebra approach was used in both the PSA node and PSA edge analyses with different matrix configurations and computations based on the biomedical questions to be examined. In the edge analysis, a percentage measure of crosstalk called XTALK was also developed to assess cross-pathway interference. Results In the node/molecular analysis of the first 24 hours from trauma, PSA uncovered 7 molecules evoked computationally that differentiated outcomes of MOF or non-MOF (NMOF), of which 3 molecules had not been previously associated with any shock / trauma syndrome. In the edge/molecular interaction analysis, PSA examined four categories of functional molecular interaction relationships – activation, expression, inhibition, and transcription – and found that the interaction patterns and crosstalk changed over time and outcome. The PSA edge analysis suggests that a diagnosis, prognosis or therapy based on molecular interaction mechanisms may be most effective within a certain time period and for a specific functional relationship. PMID:22200681

Revisiting the Pancreaticoduodenectomy for Trauma: a Single Institution’s Experience

PubMed Central

Thompson, Callie M.; Shalhub, Sherene; DeBoard, Zachary M.; Maier, Ronald V.

2013-01-01

STRUCTURED ABSTRACT Background Major pancreaticoduodenal injury can be devastating even if identified and controlled early. To date, both morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with reported mortalities of 31–50%. We sought to elucidate the impact of the initial operation in the management of severe pancreaticoduodenal injury. Methods A retrospective review of all patients presenting to a single level-one trauma center who required pancreaticoduodenectomy for trauma from 1996–2010. We collected demographic and in-hospital data and compared subjects based on their initial operation. Results Fifteen patients (median age 29 yrs, 93% male, median ISS=35) underwent pancreaticoduodenectomy following blunt (n =5) or penetrating trauma (n=10). Twelve (80%) underwent damage control surgery (DCS) +/− the initial stage of Whipple resection as their first operation. Three (20%) underwent a complete Whipple procedure, including reconstruction, as their first operation. Overall, 87% of patients (13 of 15) were acidotic, hypothermic and coagulopathic during their first operation. Average operative time was longer for the completion pancreaticoduodenectomy vs. DCS (460±98 mins vs. 243±112 mins). There were no overall differences in complication rates, although the two patients that did not suffer a complication had DCS. In-hospital mortality was 13% (n=2). Conclusions We present both the largest series of patients to date who underwent a DCS or staged-Whipple procedure for complex pancreaticoduodenal trauma and the largest series due to blunt trauma. Using a staged approach, we report the lowest mortality rate for such injuries in the literature; less than half of that reported in the most recent series (33%). Given the frequent occurrence and recognized detrimental impact of acidosis, hypothermia and coagulopathy in patients with severe pancreaticoduodenal trauma, and proven benefits of DCS, we propose that these patients should undergo initial damage control surgery and staged reconstruction. PMID:23823615

Causes of Admission for Raptors to the Tafira Wildlife Rehabilitation Center, Gran Canaria Island, Spain: 2003-13.

PubMed

Montesdeoca, Natalia; Calabuig, Pascual; Corbera, Juan A; Orós, Jorge

2016-07-01

We report the causes of morbidity of 2,458 free-living raptors admitted to the Tafira Wildlife Rehabilitation Center on Gran Canaria Island, Spain, during 2003-13. The seasonal cumulative incidences were investigated while considering estimates of the wild populations in the region. These methods were used as a more accurate approach to assess the potential ecologic impact of different causes of morbidity. The most frequently admitted species were the Eurasian Kestrel ( Falco tinnunculus ; 53.0%), the Eurasian Long-eared Owl ( Asio otus canariensis; 28.1%), the Canary Islands Common Buzzard ( Buteo buteo insularum; 8.0%), and the Eurasian Barn Owl ( Tyto alba ; 4.4%). The most frequent causes of admission were trauma (33.8%), orphaned-young birds (21.7%), unknown (18.4%), and metabolic/nutritional disease (11.1%). Local morbidity caused by glue trapping and entanglement in burr bristlegrass (Setaria adhaerens) had prevalences of 5.0% and 1.8%, respectively. The highest number of admissions during the breeding and nonbreeding seasons was observed for the Eurasian Barn Owl and the Barbary Falcon ( Falco pelegrinoides ), respectively, mainly due to trauma of unknown origin.

Dealing with the Effects of Trauma: A Self-Help Guide

MedlinePlus

... www. mentalhealth. samhsa. gov Consumer Organization and Networking Technical Assistance Center (CONTAC) P.O. Box 11000 Charleston, ... mhselfhelp. org Web site: www. mhselfhelp. org National Technical Assistance Center (NATC) National Association of State Mental ...

77 FR 75639 - Center for Scientific Review; Notice of Closed Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-21

... personal privacy. Name of Committee: Center for Scientific Review Special Emphasis Panel; Brain Trauma....306, Comparative Medicine; 93.333, Clinical Research, 93.306, 93.333, 93.337, 93.393-93.396, 93.837-93...

Modified Multivisceral Transplant After Acute Abdominal Trauma.

PubMed

Nikeghbalian, Saman; Alaa Eldin, Ahmed; Aliakbarian, Mohsen; Kazemi, Kourosh; Shamsaeefar, Alireza; Gholami, Siavash; Malekhosseini, Seyed Ali

2016-04-01

A 50-year-old man sustained blunt abdominal trauma in a motor vehicle accident. He underwent exploratory laparotomy on the day of trauma, and severe bleeding from the base of the small bowel mesentery was controlled by mass ligation and through-and-through suturing. After transfer to our center, repeat exploratory laparotomy showed ischemic small intestine, ischemic right colon, and severe pancreatic trauma. The severely injured organs were excised including the entire small bowel, pancreas, spleen, stomach, and right hemicolon. The next day, a modified multivisceral transplant was performed including stomach, pancreaticoduodenal complex, and small bowel transplant. Postoperative complications included an intra-abdominal collection that was drained percutaneously with ultrasonographic guidance and severe rejection that was treated with anti-thymocyte globulin. In summary, for select patients who have severe abdominal trauma may be treated with acute multivisceral transplant.

Principles of system design not realized for pediatric craniospinal trauma care in the United States.

PubMed

Piatt, Joseph

2018-04-20

OBJECTIVE An implicit expectation of the pioneers of trauma system design was that high clinical volume at select centers could lead to superior outcomes. There has been little study of the regionalization of pediatric craniospinal trauma care, and whether it continues to trend in the direction of regionalization is unknown. The motivating hypothesis for this study was that trauma system design in the United States is proceeding on a rational basis, producing hospital caseloads that are increasing over time and, because of geographic siting appropriate to the needs of catchment areas, in an increasingly uniform manner. METHODS Data were obtained from the Kids' Inpatient Database (KID) for 1997, 2000, 2003, 2006, 2009, and 2012. Cases of traumatic spinal injury (TSI) and severe traumatic brain injury (sTBI) were identified by ICD-9 diagnostic and procedural codes. Records of patients 18 years of age and older were excluded. Hospital caseloads and descriptive statistics were calculated for each year of the study, and trends were examined. The distributions of hospital caseloads were compared year with year and with simulations of idealized systems. RESULTS Caseloads of TSI trended upward and caseloads of sTBI were stable, despite a declining nationwide incidence of these conditions during the study period, so the pool of hospitals providing services for pediatric craniospinal trauma contracted to a degree. The distributions of hospital caseloads did not change, and in every year of the study large numbers of hospitals reported small numbers of discharges. In the last year of the study, a quarter of all children with TSI were discharged from hospitals that treated approximately 1 case or fewer every other month and a quarter of all children with sTBI were discharged from hospitals that treated 1 case or fewer every 3 months. CONCLUSIONS There has been no previous study of nationwide trends in pediatric craniospinal trauma caseloads. Analysis of hospital caseloads from 1997 through 2012 supports inference of a persisting geographical mismatch between population needs and the availability of services. These observations falsify the study hypothesis. A notable fraction of pediatric craniospinal trauma care continues to be rendered at low-caseload institutions. Novel quality assurance methods tailored to the needs of low-caseload institutions deserve development and study.

Development and pilot testing of an informed consent video for patients with limb trauma prior to debridement surgery using a modified Delphi technique.

PubMed

Lin, Yen-Ko; Chen, Chao-Wen; Lee, Wei-Che; Lin, Tsung-Ying; Kuo, Liang-Chi; Lin, Chia-Ju; Shi, Leiyu; Tien, Yin-Chun; Cheng, Yuan-Chia

2017-11-29

Ensuring adequate informed consent for surgery in a trauma setting is challenging. We developed and pilot tested an educational video containing information regarding the informed consent process for surgery in trauma patients and a knowledge measure instrument and evaluated whether the audiovisual presentation improved the patients' knowledge regarding their procedure and aftercare and their satisfaction with the informed consent process. A modified Delphi technique in which a panel of experts participated in successive rounds of shared scoring of items to forecast outcomes was applied to reach a consensus among the experts. The resulting consensus was used to develop the video content and questions for measuring the understanding of the informed consent for debridement surgery in limb trauma patients. The expert panel included experienced patients. The participants in this pilot study were enrolled as a convenience sample of adult trauma patients scheduled to receive surgery. The modified Delphi technique comprised three rounds over a 4-month period. The items given higher scores by the experts in several categories were chosen for the subsequent rounds until consensus was reached. The experts reached a consensus on each item after the three-round process. The final knowledge measure comprising 10 questions was developed and validated. Thirty eligible trauma patients presenting to the Emergency Department (ED) were approached and completed the questionnaires in this pilot study. The participants exhibited significantly higher mean knowledge and satisfaction scores after watching the educational video than before watching the video. Our process is promising for developing procedure-specific informed consent and audiovisual aids in medical and surgical specialties. The educational video was developed using a scientific method that integrated the opinions of different stakeholders, particularly patients. This video is a useful tool for improving the knowledge and satisfaction of trauma patients in the ED. The modified Delphi technique is an effective method for collecting experts' opinions and reaching a consensus on the content of educational materials for informed consent. Institutions should prioritize patient-centered health care and develop a structured informed consent process to improve the quality of care. The ClinicalTrials.gov Identifier is NCT01338480 . The date of registration was April 18, 2011 (retrospectively registered).

The impact of specialist trauma service on major trauma mortality.

PubMed

Wong, Ting Hway; Lumsdaine, William; Hardy, Benjamin M; Lee, Keegan; Balogh, Zsolt J

2013-03-01

Trauma services throughout the world have had positive effects on trauma-related mortality. Australian trauma services are generally more consultative in nature rather than the North American model of full trauma admission service. We hypothesized that the introduction of a consultative specialist trauma service in a Level I Australian trauma center would reduce mortality of the severely injured. A 10-year retrospective study (January 1, 2002-December 31, 2011) was performed on all trauma patients admitted with an Injury Severity Score (ISS) > 15. Patients were identified from the trauma registry, and data for age, sex, mechanism of injury, ISS, survival to discharge, and length of stay were collected. Mortality was examined for patients with severe injury (ISS > 15) and patients with critical injury (ISS > 24) and compared for the three periods: 2002-2004 (without trauma specialist), 2005-2007 (with trauma specialist), and 2008-2011 (with specialist trauma service). A total of 3,869 severely injured (ISS > 15) trauma patients were identified during the 10-year period. Of these, 2,826 (73%) were male, 1,513 (39%) were critically injured (ISS > 24), and more than 97% (3,754) were the victim of blunt trauma. Overall mortality decreased from 12.4% to 9.3% (relative risk, 0.75) from period one to period three and from 25.4% to 20.3% (relative risk, 0.80) for patients with critical injury. A 0.46% per year decrease (p = 0.018) in mortality was detected (odds ratio, 0.63; p < 0.001). For critically injured (ISS > 24), the trend was (0.61% per year; odds ratio, 0.68; p = 0.039). The introduction of a specialist trauma service decreased the mortality of patients with severe injury, the model of care should be considered to implement state- and nationwide in Australia. Epidemiologic study, level III.

Implementation of antibiotic use guidelines for fresh traumatic wound at Siriraj Hospital.

PubMed

Sirijatuphat, Rujipas; Choochan, Tanatchon; Siritongtaworn, Preecha; Sripojtham, Vipaporn; Thamlikitkul, Visanu

2015-03-01

To determine the effectiveness of implementing a clinical practice guideline (CPG) on antibiotic use for adults with fresh traumatic wounds who attended the trauma center at Siriraj Hospital, Bangkok. A prospective study of 600 adult patients who had fresh traumatic wounds (≤ 6 hours) was conducted at Siriraj Trauma Center from March 2013 to March 2014. The CPG was introduced to physicians, nurses and medical students by posting the CPG at the patient care areas of the trauma center. The outcomes were an appropriate classification of wounds according to the CPG recommendations, prevalence of antibiotic prescribing, incidence of wound infection and compliance with the CPG. Clean-contaminated wounds that did not need antibiotic treatment and clean-contaminated and contaminated wounds that required antibiotics were observed in 63.2, 6.7, and 30.1% ofthe patients, respectively. Antibiotics were given to 512 patients (85.3%). Infections occurred in six patients (1.0%). Antibiotic prescription according to CPG recommendations was observed for 243 patients (40.5%). The prevalence of antibiotic use in the CPG-compliant group (65.8%) was significantly less than that in the CPG-noncompliant group (98.6%) (p < 0.001). The patients in the CPG-compliant group had more contaminated wounds than those in the CPG-noncompliant group (51.4 vs. 15.7%, p < 0.001). The incidences of wound infection were very low in both groups and not significantly different (1.2 vs. 0.8%, p = 0.690). Antibiotic prophylaxis was necessary in less than 36.8% of adults with fresh traumatic wounds who attended Siriraj Trauma Center Compliance to CPG implementation using simple intervention seemed to be low. Adhering to CPG recommendations for antibiotic prophylaxis in adults with fresh traumatic wounds can reduce the unnecessary prescribing of antibiotics without increasing the rate of wound infection.

Mass casualty following unprecedented tornadic events in the Southeast: natural disaster outcomes at a Level I trauma center.

PubMed

Hartmann, Elizabeth H; Creel, Nathan; Lepard, Jacob; Maxwell, Robert A

2012-07-01

On April 27, 2011, an EF4 (enhanced Fujita scale) tornado struck a 48-mile path across northwest Georgia and southeast Tennessee. Traumatic injuries sustained during this tornado and others in one of the largest tornado outbreaks in history presented to the regional Level I trauma center, Erlanger Health System, in Chattanooga, TN. Patients were triaged per mass casualty protocols through an incident command center and triage officer. Medical staffing was increased to anticipate a large patient load. Records of patients admitted as a result of tornado-related injury were retrospectively reviewed and characterized by the injury patterns, demographics, procedures performed, length of stay, and complications. One hundred four adult patients were treated in the emergency department; of these, 28 (27%) patients required admission to the trauma service. Of those admitted, 16 (57%) were male with an age range of 21 to 87 years old and an average length of stay of 10.9 ± 11.8 days. Eleven (39%) patients required intensive care unit admissions. The most common injuries seen were those of soft tissue, bony fractures, and the chest. Interventions included tube thoracostomies, exploratory laparotomies, orthopedic fixations, soft tissue reconstructions, and craniotomy. All 28 patients admitted survived to discharge. Nineteen (68%) patients were discharged home, six (21%) went to a rehabilitation hospital, and three (11%) were transferred to skilled nursing facilities. Emergency preparedness and organization are key elements in effectively treating victims of natural disasters. Those victims who survive the initial tornadic event and present to a Level I trauma center have low mortality. Like in our experience, triage protocols need to be implemented to quickly and effectively manage mass injuries.

Soccer-related Facial Trauma: Multicenter Experience in 2 Brazilian University Hospitals

PubMed Central

Dini, Gal M.; Pereira, Max D.; Gurgel, Augusto; Bastos, Endrigo O.; Nagarkar, Purushottam; Gemperli, Rolf; Ferreira, Lydia M.

2014-01-01

Background: Soccer is the most popular sport in Brazil and a high incidence of related trauma is reported. Maxillofacial trauma can be quite common, sometimes requiring prolonged hospitalization and invasive procedures. To characterize soccer-related facial fractures needing surgery in 2 major Brazilian Centers. Methods: A retrospective review of trauma medical records from the Plastic Surgery Divisions at the Universidade Federal de São Paulo–Escola Paulista de Medicina and the Hospital das Clinicas–Universidade de São Paulo was carried out to identify patients who underwent invasive surgical procedures due to acute soccer-related facial fractures. Data points reviewed included gender, date of injury, type of fracture, date of surgery, and procedure performed. Results: A total of 45 patients (31 from Escola Paulista de Medicina and 14 from Universidade de São Paulo) underwent surgical procedures to address facial fractures between March 2000 and September 2013. Forty-four patients were men, and mean age was 28 years. The fracture patterns seen were nasal bones (16 patients, 35%), orbitozygomatic (16 patients, 35%), mandibular (7 patients, 16%), orbital (6 patients, 13%), frontal (1 patient, 2%), and naso-orbito-ethmoid (1 patient, 2%). Mechanisms of injury included collisions with another player (n = 39) and being struck by the ball (n = 6). Conclusions: Although it is less common than orthopedic injuries, soccer players do sustain maxillofacial trauma. Knowledge of its frequency is important to first responders, nurses, and physicians who have initial contact with patients. Missed diagnosis or delayed treatment can lead to facial deformities and functional problems in the physiological actions of breathing, vision, and chewing. PMID:25289361

Cellular microparticle and thrombogram phenotypes in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study: correlation with coagulopathy

PubMed Central

Matijevic, Nena; Wang, Yao-Wei W.; Wade, Charles E.; Holcomb, John B.; Cotton, Bryan A.; Schreiber, Martin A.; Muskat, Peter; Fox, Erin E.; del Junco, Deborah J.; Cardenas, Jessica C.; Rahbar, Mohammad H.; Cohen, Mitchell Jay

2014-01-01

Background Trauma-induced coagulopathy following severe injury is associated with increased bleeding and mortality. Injury may result in alteration of cellular phenotypes and release of cell-derived microparticles (MP). Circulating MPs are procoagulant and support thrombin generation (TG) and clotting. We evaluated MP and TG phenotypes in severely injured patients at admission, in relation to coagulopathy and bleeding. Methods As part of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, research blood samples were obtained from 180 trauma patients requiring transfusions at 5 participating centers. Twenty five healthy controls and 40 minimally injured patients were analyzed for comparisons. Laboratory criteria for coagulopathy was activated partial thromboplastin time (APTT) ≥35 sec. Samples were analyzed by Calibrated Automated Thrombogram to assess TG, and by flow cytometry for MP phenotypes [platelet (PMP), erythrocyte (RMP), leukocyte (LMP), endothelial (EMP), tissue factor (TFMP), and Annexin V positive (AVMP)]. Results 21.7% of patients were coagulopathic with the median (IQR) APTT of 44 sec (37, 53), and an Injury Severity Score of 26 (17, 35). Compared to controls, patients had elevated EMP, RMP, LMP, and TFMP (all p<0.001), and enhanced TG (p<0.0001). However, coagulopathic PROMMTT patients had significantly lower PMP, TFMP, and TG, higher substantial bleeding, and higher mortality compared to non-coagulopathic patients (all p<0.001). Conclusions Cellular activation and enhanced TG are predominant after trauma and independent of injury severity. Coagulopathy was associated with lower thrombin peak and rate compared to non-coagulopathic patients, while lower levels of TF-bearing PMPs were associated with substantial bleeding. PMID:25086657

Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient’s Arrival to the Emergency Room

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hörer, Tal M., E-mail: tal.horer@orebroll.se; Hebron, Dan; Swaid, Forat

PurposeTo describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care.MethodsWe briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management.ResultsThree severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management.ConclusionsThe interventional radiologist and themore » multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.« less

Motorcycle-related hospitalization of adolescents in a Level I trauma center in southern Taiwan: a cross-sectional study.

PubMed

Liang, Chi-Cheng; Liu, Hang-Tsung; Rau, Cheng-Shyuan; Hsu, Shiun-Yuan; Hsieh, Hsiao-Yun; Hsieh, Ching-Hua

2015-08-28

The aim of this study was to investigate and compare the injury pattern, mechanisms, severity, and mortality of adolescents and adults hospitalized for treatment of trauma following motorcycle accidents in a Level I trauma center. Detailed data regarding patients aged 13-19 years (adolescents) and aged 30-50 years (adults) who had sustained trauma due to a motorcycle accident were retrieved from the Trauma Registry System between January 1, 2009 and December 31, 2012. The Pearson's chi-squared test, Fisher's exact test, or the independent Student's t-test were performed to compare the adolescent and adult motorcyclists and to compare the motorcycle drivers and motorcycle pillion. Analysis of Abbreviated Injury Scale (AIS) scores revealed that the adolescent patients had sustained higher rates of facial, abdominal, and hepatic injury and of cranial, mandibular, and femoral fracture but lower rates of thorax and extremity injury; hemothorax; and rib, scapular, clavicle, and humeral fracture compared to the adults. No significant differences were found between the adolescents and adults regarding Injury Severity Score (ISS), New Injury Severity Score (NISS), Trauma-Injury Severity Score (TRISS), mortality, length of hospital stay, or intensive care unit (ICU) admission rate. A significantly greater percentage of adolescents compared to adults were found not to have worn a helmet. Motorcycle riders who had not worn a helmet were found to have a significantly lower first Glasgow Coma Scale (GCS) score, and a significantly higher percentage was found to present with unconscious status, head and neck injury, and cranial fracture compared to those who had worn a helmet. Adolescent motorcycle riders comprise a major population of patients hospitalized for treatment of trauma. This population tends to present with a higher injury severity compared to other hospitalized trauma patients and a bodily injury pattern differing from that of adult motorcycle riders, indicating the need to emphasize use of protective equipment, especially helmets, to reduce their rate and severity of injury.

"It takes a village" to raise research productivity: Impact of a Trauma Interdisciplinary Group for Research (TIGR) at an urban, Level 1 trauma center.

PubMed

Nesmith, Elizabeth G; Medeiros, Regina S; Ferdinand, Colville H B; Hawkins, Michael L; Holsten, Steven B; Dong, Yanbin; Zhu, Haidong

2013-07-01

Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, lab technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies like the National Institutes of Health (NIH). This paper describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an on-going NIH-funded study. We utilized a pre-test/post-test design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, threats) analysis was used to develop the intervention which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected N=150). Pre/Post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. Research products increased from N =12 to N=42; (~ 400%). Research proposals for federal funding increased from N=0 to N=3, with success rate of 66%. Participant screenings for the NIH-funded study increased from N=40 to N=313. Consents increased from N=14 to N=70. Lab service fees were reduced from $300/participant to $5/participant. Adding diversity to our scientific team via TIGR was exponentially successful in 1) improving research productivity, 2) reducing research costs, and 3) increasing research products and mentoring activities that the team prior to TIGR had not entertained. The team is now well-positioned to apply for more federally funded projects and more trauma clinicians are considering research careers than before.

"It takes a village" to raise research productivity: impact of a Trauma Interdisciplinary Group for Research at an urban, Level 1 trauma center.

PubMed

NeSmith, Elizabeth G; Medeiros, Regina S; Ferdinand, Colville H B; Hawkins, Michael L; Holsten, Steven B; Zhu, Haidong; Dong, Yanbin

2013-07-01

Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, laboratory technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies such as the National Institutes of Health (NIH). This article describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an ongoing NIH-funded study. We used a pretest/posttest design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, and threats) analysis was used to develop the intervention, which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected n = 150). Pre-TIGR/post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. Research products increased from 12 to 42 (approximately 400%). Research proposals for federal funding increased from 0 to 3, with success rate of 66%. Participant screenings for the NIH-funded study increased from 40 to 313. Consents increased from 14 to 70. Laboratory service fees were reduced from $300 per participant to $5 per participant. Adding diversity to our scientific team via TIGR was exponentially successful in (1) improving research productivity, (2) reducing research costs, and (3) increasing research products and mentoring activities that the team before TIGR had not entertained. The team is now well positioned to apply for more federally funded projects, and more trauma clinicians are considering research careers than before.

The impact of short prehospital times on trauma center performance benchmarking: An ecologic study.

PubMed

Byrne, James P; Mann, N Clay; Hoeft, Christopher J; Buick, Jason; Karanicolas, Paul; Rizoli, Sandro; Hunt, John P; Nathens, Avery B

2016-04-01

Emergency medical service (EMS) prehospital times vary between regions, yet the impact of local prehospital times on trauma center (TC) performance is unknown. To inform external benchmarking efforts, we explored the impact of EMS prehospital times on the risk-adjusted rate of emergency department (ED) death and overall hospital mortality at urban TCs across the United States. We used a novel ecologic study design, linking EMS data from the National EMS Information System to TCs participating in the American College of Surgeons' Trauma Quality Improvement Program (TQIP) by destination zip code. This approach provided EMS times for populations of injured patients transported to TQIP centers. We defined the exposure of interest as the 90th percentile total prehospital time (PHT) for each TC. TCs were then stratified by PHT quartile. Analyses were limited to adult patients with severe blunt or penetrating trauma, transported directly by land to urban TQIP centers. Random-intercept multilevel modeling was used to evaluate the risk-adjusted relationship between PHT quartile and the outcomes of ED death and overall hospital mortality. During the study period, 119,740 patients met inclusion criteria at 113 TCs. ED death occurred in 1% of patients, and overall mortality was 7.2%. Across all centers, the median PHT was 61 minutes (interquartile range, 53-71 minutes). After risk adjustment, TCs in regions with the shortest quartile of PHTs (<53 minutes) had significantly greater odds of ED death compared with those with the longest PHTs (odds ratio, 2.00; 95% confidence interval, 1.43-2.78). However, there was no association between PHT and overall TC mortality. At urban TCs, local EMS prehospital times are a significant predictor of ED death. However, no relationship exists between prehospital time and overall TC risk-adjusted mortality. Therefore, there is no evidence for the inclusion of EMS prehospital time in external benchmarking analyses.

American Association for the Surgery of Trauma Prevention Committee topical overview: National Trauma Data Bank, geographic information systems, and teaching injury prevention.

PubMed

Crandall, Marie; Zarzaur, Ben; Tinkoff, Glen

2013-11-01

Injury is the leading cause of death for all Americans aged 1 to 35 years, and injury-related costs exceed $100 billion per year in the United States. Trauma centers can be important resources for risk identification and prevention strategies. The authors review 3 important resources for injury prevention education and research: the National Trauma Data Bank, geographic information systems, and an overview of injury prevention education. The National Trauma Data Bank and the Trauma Quality Improvement Program are available through the Web site of the American College of Surgeons. Links to research examples using geographic information systems software and the National Trauma Data Bank are provided in the text. Finally, resources for surgical educators in the area of injury prevention are summarized and examples provided. Database research, geographic information systems, and injury prevention education are important tools in the field of injury prevention. This article provides an overview of current research and education strategies and resources. Copyright © 2013 Elsevier Inc. All rights reserved.

Experience of two trauma-centers with pancreatic injuries requiring immediate surgery.

PubMed

Ouaïssi, Mehdi; Sielezneff, Igor; Chaix, Jean Baptiste; Mardion, Remi Bon; Pirrò, Nicolas; Berdah, Stéphane; Emungania, Olivier; Consentino, Bernard; Cresti, Silvia; Dahan, Laetitia; Orsoni, Pierre; Moutardier, Vincent; Brunet, C; Sastre, Bernard

2008-01-01

Pancreatic injury from blunt trauma is infrequent. The aim of the present study was to evaluate a simplified approach of management of pancreatic trauma injuries requiring immediate surgery consisting of either drainage in complex situation or pancreatectomy in the other cases. From January 1986 to December 2006, 40 pancreatic traumas requiring immediate surgery were performed. Mechanism of trauma, clinical and laboratories findings were noted upon admission, classification of pancreatic injury according to Lucas' classification were considered. Fifteen (100%) drainages were performed for stage I (n=15), 60% splenopancreatectomies and 40% drainage was achieved for stage II (n=18), 3 Pancreaticoduonectomies and 2 exclusion of duodenum with drainage and 2 packing were performed for stage IV (n=7). There were 30 men and 10 women with mean age of 29+/-13 years (15-65). Thirty-eight patients had multiple trauma. Overall, mortality and global morbidity rate were 17% and 65% respectively, and the rates increased with Lucas' pancreatic trauma stage. Distal pancreatectomy is indicated for distal injuries with duct involvement, and complex procedures such as pancreaticoduodenectomy should be performed in hemodynamically stable patients.

Can we improve the clinical utility of respiratory rate as a monitored vital sign?

PubMed

Chen, Liangyou; Reisner, Andrew T; Gribok, Andrei; McKenna, Thomas M; Reifman, Jaques

2009-06-01

Respiratory rate (RR) is a basic vital sign, measured and monitored throughout a wide spectrum of health care settings, although RR is historically difficult to measure in a reliable fashion. We explore an automated method that computes RR only during intervals of clean, regular, and consistent respiration and investigate its diagnostic use in a retrospective analysis of prehospital trauma casualties. At least 5 s of basic vital signs, including heart rate, RR, and systolic, diastolic, and mean arterial blood pressures, were continuously collected from 326 spontaneously breathing trauma casualties during helicopter transport to a level I trauma center. "Reliable" RR data were identified retrospectively using automated algorithms. The diagnostic performances of reliable versus standard RR were evaluated by calculation of the receiver operating characteristic curves using the maximum-likelihood method and comparison of the summary areas under the receiver operating characteristic curves (AUCs). Respiratory rate shows significant data-reliability differences. For identifying prehospital casualties who subsequently receive a respiratory intervention (hospital intubation or tube thoracotomy), standard RR yields an AUC of 0.59 (95% confidence interval, 0.48-0.69), whereas reliable RR yields an AUC of 0.67 (0.57-0.77), P < 0.05. For identifying casualties subsequently diagnosed with a major hemorrhagic injury and requiring blood transfusion, standard RR yields an AUC of 0.60 (0.49-0.70), whereas reliable RR yields 0.77 (0.67-0.85), P < 0.001. Reliable RR, as determined by an automated algorithm, is a useful parameter for the diagnosis of respiratory pathology and major hemorrhage in a trauma population. It may be a useful input to a wide variety of clinical scores and automated decision-support algorithms.

eFAST for Pneumothorax: Real-Life Application in an Urban Level 1 Center by Trauma Team Members.

PubMed

Maximus, Steven; Figueroa, Cesar; Whealon, Matthew; Pham, Jacqueline; Kuncir, Eric; Barrios, Cristobal

2018-02-01

The focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultrasonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical "real-life" application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFAST was either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.

Barriers to implementing the World Health Organization's Trauma Care Checklist: A Canadian single-center experience.

PubMed

Nolan, Brodie; Zakirova, Rimma; Bridge, Jennifer; Nathens, Avery B

2014-11-01

Management of trauma patients is difficult because of their complexity and acuity. In an effort to improve patient care and reduce morbidity and mortality, the World Health Organization developed a trauma care checklist. Local stakeholder input led to a modified 16-item version that was subsequently piloted. Our study highlights the barriers and challenges associated with implementing this checklist at our hospital. The checklist was piloted over a 6-month period at St. Michael's Hospital, a Level 1 trauma center in Toronto, Canada. At the end of the pilot phase, individual, semistructured interviews were held with trauma team leaders and nursing staff regarding their experiences with the checklist. Axial coding was used to create a typology of attitudes and barriers toward the checklist, and then, vertical coding was used to further explore each identified barrier. Checklist compliance was assessed for the first 7 months. Checklist compliance throughout the pilot phase was 78%. Eight key barriers to implementing the checklist were identified as follows: perceived lack of time for the use of the checklist in critically ill patients, unclear roles, no memory trigger, no one to enforce completion, not understanding its importance or purpose, difficulty finding physicians at the end of resuscitation, staff/trainee changes, and professional hierarchy. The World Health Organization Trauma Care Checklist was a well-received tool; however, consideration of barriers to the implementation and staff adoption must be done for successful integration, with special attention to its use in critically ill patients. Therapeutic/care management, level V.

Pulmonary Contusion in Mechanically Ventilated Subjects After Severe Trauma.

PubMed

Dhar, Sakshi Mathur; Breite, Matthew D; Barnes, Stephen L; Quick, Jacob A

2018-03-13

Pulmonary contusions are thought to worsen outcomes. We aimed to evaluate the effects of pulmonary contusion on mechanically ventilated trauma subjects with severe thoracic injuries and hypothesized that contusion would not increase morbidity. We conducted a single-center, retrospective review of 163 severely injured trauma subjects (injury severity score ≥ 15) with severe thoracic injury (chest abbreviated injury score ≥ 3), who required mechanical ventilation for >24 h at a verified Level 1 trauma center. Subject data were analyzed for those with radiographic documentation of pulmonary contusion and those without. Statistical analysis was performed to determine the effects of coexisting pulmonary contusion in severe thoracic trauma. Pulmonary contusion was present in 91 subjects (55.8%), whereas 72 (44.2%) did not have pulmonary contusions. Mean chest abbreviated injury score (3.54 vs 3.47, P = .53) and mean injury severity score (32.6 vs 30.2, P = .12) were similar. There was no difference in mortality (11 [12.1%] vs 9 [12.5%], P > .99) or length of stay (16.29 d vs 17.29 d, P = .60). Frequency of ventilator-associated pneumonia was comparable (43 [47.3%] vs 32 [44.4%], P = .75). Subjects with contusions were more likely to grow methicillin-sensitive Staphylococcus aureus in culture (33 vs 10, P = .004) as opposed to Pseudomonas aeruginosa in culture (6 vs 13, P = .003). Overall, no significant differences were noted in mortality, length of stay, or pneumonia rates between severely injured trauma subjects with and without pulmonary contusions. Copyright © 2018 by Daedalus Enterprises.

The utility of a "trauma 1 OP" activation at a level 1 pediatric trauma center.

PubMed

Hunt, Madison M; Stevens, Austin M; Hansen, Kristine W; Fenton, Stephen J

2017-02-01

To expedite flow of injured children suspected to require operative intervention, a "trauma 1 OP" (T1OP) activation classification was created. The purpose of this study was to review this strategy at a level 1 pediatric trauma center. A retrospective review of T1OP activations between 2003 and 2015 was performed. Children suspected of requiring neurosurgical intervention were classified as trauma 1 OP neuro (T1OP(N)). Comparisons were made to trauma 1 (T1) patients who required emergent operative intervention, excluding orthopedic injuries. Overall, 461 T1OP activations occurred (72% T1OP(N)) compared to 129 T1 activations requiring emergent surgery. Demographics were not significantly different between groups, although T1OP patients were slightly younger and more often experienced falls or were victims of abuse. Compared to T1 activations, T1OP activations had a significantly higher mortality rate (21% vs. 7%, p<0.001). Repeat head imaging was more common in the T1OP(N) group compared to imaged children in the T1 group (20% vs. 37%, p=0.05). T1OP(N) patients more often went directly to the OR (45% vs. 33%, p=0.02) and did so in a significantly faster period of time (32min vs. 53min, p<0.001). Use of the T1OP activations appropriately triaged surgical patients, resulting in significantly faster transport times to the OR. II, prognosis study. Copyright © 2017 Elsevier Inc. All rights reserved.

Cumulative childhood trauma and psychological maladjustment of sexually abused children in Korea: mediating effects of emotion regulation.

PubMed

Choi, Ji Young; Oh, Kyung Ja

2014-02-01

The purpose of the present study was to identify the mediating effects of emotion regulation on the association between cumulative childhood trauma and behavior problems in sexually abused children in Korea, using structural equation modeling (SEM). Data were collected on 171 children (ages 6-13 years) referred to a public counseling center for sexual abuse in Seoul, Korea. Cumulative childhood traumas were defined on the basis of number of traumas (physical abuse, witnessing domestic violence, neglect, traumatic separation from parent, and sexual abuse) and the severity and duration of traumas. Children were evaluated by their parents on emotion regulation using the Emotion Regulation Checklist and internalizing and externalizing behavior problems using the Korean-Child Behavior Checklist. SEM analyses confirmed the complete mediation model, in which emotion dysregulation fully mediates the relationship between cumulative childhood traumas and internalizing/externalizing behavior problems. These findings indicate that emotion regulation is an important mechanism that can explain the negative effects of cumulative childhood traumas and that there is a need to focus on emotion regulation in sexually abused children exposed to cumulative trauma. Copyright © 2013 Elsevier Ltd. All rights reserved.

The epidemiology and injury patterns of acetabular fractures: are the USA and China comparable?

PubMed

Mauffrey, Cyril; Hao, Jiandong; Cuellar, Derly O; Herbert, Benoit; Chen, Xiao; Liu, Bo; Zhang, Yingze; Smith, Wade

2014-11-01

Acetabular fractures are rare injuries in heterogeneous patient groups, making it difficult to develop adequately powered prospective single-center clinical trials in the USA or Europe. Chinese trauma centers treat a high volume of these injuries, and if the patient population and injury patterns are comparable to those in the USA, this might support development of multicenter studies in Level I trauma centers in the two countries. We determined whether the following parameters were similar between operative acetabular fractures treated at Chinese and US trauma centers: (1) epidemiology of injured patients, (2) mechanism of injuries and fracture types, and (3) hospital stay parameters, including symptomatic postoperative deep vein thrombosis (DVT) rate. We extracted data from trauma databases for patients admitted with acetabular fractures managed surgically from 2005 to 2012 for one Chinese center and from 2008 to 2012 for one US center. Sex, age, mechanism of injury, fracture classification, Injury Severity Score (ISS), time from injury to surgery, length of hospital stay, and symptomatic DVT rate were analyzed. We included 661 Chinese patients (539 men, 122 women) and 212 US patients (163 men, 49 women). Mean age at time of injury was different between China and the USA, at 40 years with a unimodal distribution and 44 years with a bimodal distribution (p<0.001), respectively. Incidence of surgically treated acetabular fractures has been increasing in China but decreasing in the USA. Mean ISSs were comparable. Although the distribution of mechanisms of injury was different (p=0.004), high-energy injuries (motor vehicle accidents, falls>10 feet) still accounted for most fractures in both centers. Fracture classifications (per Letournel) were comparable, with posterior wall fractures most common. Mean time from injury to surgery and mean hospital stay were longer in China than in the USA (9 versus 3 days [p<0.001] and 26 versus 11 days [p<0.001], respectively). Symptomatic DVT rates were comparable. Although we identified differences between the two centers, we also noted important similarities. Multicenter clinical studies involving these locations should be performed with caution and focus on similar end points, taking into account the populations' baseline differences. Because of the potential for such differences, this kind of validation study should be performed before embarking on resource-intensive multicenter trials. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Geriatric trauma.

PubMed

Adams, Sasha D; Holcomb, John B

2015-12-01

The landscape of trauma is changing due to an aging population. Geriatric patients represent an increasing number and proportion of trauma admissions and deaths. This review explores recent literature on geriatric trauma, including triage criteria, assessment of frailty, fall-related injury, treatment of head injury complicated by coagulopathy, goals of care, and the need for ongoing education of all surgeons in the care of the elderly. Early identification of high-risk geriatric patients is imperative to initiate early resuscitative efforts. Geriatric patients are typically undertriaged because of their baseline frailty being underappreciated; however, centers that see more geriatric patients do better. Rapid reversal of anticoagulation is important in preventing progression of brain injury. Anticipation of difficult disposition necessitates early involvement of physical therapy for rehabilitation and case management for appropriate placement. Optimal care of geriatric trauma patients will be based on the well established tenets of trauma resuscitation and injury repair, but with distinct elements that address the physiological and anatomical challenges presented by geriatric patients.

Positive FAST without hemoperitoneum due to fluid resuscitation in blunt trauma.

PubMed

Slutzman, Jonathan E; Arvold, Lisa A; Rempell, Joshua S; Stone, Michael B; Kimberly, Heidi H

2014-10-01

The focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients. To describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma. We describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination. This case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination. Copyright © 2014 Elsevier Inc. All rights reserved.

A National Coordinating Center for Trauma Research

DTIC Science & Technology

2016-10-01

of ketamine during the first three days following injury has a sustained effect on reducing the incidence or severity of Post -Traumatic Stress... design , medical modeling, physical modeling, engineering and system integration. Progress Reported: The subcontract was fully executed on 05...were posted on the NTI website (www.nationaltraumainstitute.org). The goal is to comprehensively disseminate published works to the wider trauma

National Trauma Institute: A National Coordinating Center for Trauma Research Funding

DTIC Science & Technology

2016-12-01

comparing the effectiveness of modern ventilator modalities upon patients with ARDS/ALI does not exist. Low-tidal volume ventilation (ARDSNet...associated with better oxygenation , less sedative usage, and less ventilator -associated pneumonia compared with other ventilator modes. However, questions...hypercoagulable at baseline, and that further investigations into the effects of platelet activation and obesity, time-to-enoxaparin administration, and

Clinical outcomes of traumatized youth in adolescent substance abuse treatment: a longitudinal multisite study.

PubMed

Williams, Julie K; Smith, Douglas C; An, Hyonggin; Hall, James A

2008-03-01

The purpose of this study was to evaluate the effectiveness of outpatient substance abuse treatment for youth with high traumatic stress compared to youth without high traumatic stress in substance abuse treatment centers across the United States. The data for this study were gathered using a longitudinal survey design with purposive sampling from nine drug treatment delivery systems across the United States participating in the cooperative grant Strengthening Communities for Youth (SCY) awarded by SAMHSA's Center for Substance Abuse Treatment (CSAT) between September 2002 and June 2006. Follow-up assessments were conducted with the youth at three,six, and 12 months following intake. Traumatized youth responded to outpatient treatment in a similar pattern when compared to nontraumatized youth, although the traumatized youth had consistently higher scores on substance use frequency and substance problems scales than nontraumatized youth throughout the study. Current empirically validated treatments for adolescent substance abuse do not prepare the practitioner for trauma-informed practice or specifically address trauma-informed recovery. Based on our results, we advocate for the development and integration of trauma-informed practice within substance abuse treatment for adolescents to help them recover from trauma and substance abuse issues.

Methodological Considerations for Research With Black Male Victims of Violent Injury in an Urban Trauma Unit.

PubMed

St Vil, Christopher; Richardson, Joseph; Cooper, Carnell

2018-04-01

There is a body of research over the last three decades that has focused on the etiology of violence among victims of violent injury. This body of literature indicates that Black men are disproportionately represented among victims of violent injury seen in emergency departments and trauma centers across the country. Despite the disproportionate number of low-income young Black men treated for violent injury in urban trauma units and the growing body of literature accompanying it, little is known about the unique methodological challenges violent injury researchers face when conducting research on this vulnerable population in a clinical setting. This article describes the unique and often nuanced methodological difficulties a research team encountered while conducting a longitudinal qualitative study on risk factors for repeat violent injury among low-income young Black male victims of violent injury treated at a Level II trauma center in the Eastern United States. Four methodological challenges are identified: (a) the identification and screening of participants, (b) recruitment and interviewing, (c) understanding hospital culture, policies, and procedures, and (d) retention and attrition of sample. Recommendations to overcome these challenges are offered.

Topical Application of Tranexamic Acid to Reduce Blood Loss during Complex Combat-Related Spine Trauma Surgery

DTIC Science & Technology

2016-10-01

UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) Washington University St . Louis, MO 63110-1010 Columbia University Medical Center...the Thomas Jefferson University Medical Center and Washington University in St . Louis Medical Center IRB for review and approval, to be completed by

78 FR 52605 - Announcing the Twenty First Public Meeting of the Crash Injury Research and Engineering Network...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-23

... First Public Meeting of the Crash Injury Research and Engineering Network (CIREN) AGENCY: National... announces the Twenty First Public Meeting of members of the Crash Injury Research and Engineering Network... of centers, medical and engineering. Medical centers are based at Level I Trauma Centers that admit...

76 FR 46359 - Announcing the Nineteenth Public Meeting of the Crash Injury Research and Engineering Network...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-02

... Nineteenth Public Meeting of the Crash Injury Research and Engineering Network (CIREN) AGENCY: National... announces the Nineteenth Public Meeting of members of the Crash Injury Research and Engineering Network... of centers, medical and engineering. Medical centers are based at Level I Trauma Centers that admit...

77 FR 46154 - Announcing the Twentieth Public Meeting of the Crash Injury Research and Engineering Network (CIREN)

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-02

... Twentieth Public Meeting of the Crash Injury Research and Engineering Network (CIREN) AGENCY: National... announces the Twentieth Public Meeting of members of the Crash Injury Research and Engineering Network... of centers, medical and engineering. Medical centers are based at Level I Trauma Centers that admit...

An unusual case of foreign body pulmonary embolus: case report and review of penetrating trauma at a pediatric trauma center.

PubMed

Boomer, Laura A; Watkins, Daniel J; O'Donovan, Julie; Kenney, Brian D; Yates, Andrew R; Besner, Gail E

2015-03-01

Penetrating thoracic trauma is relatively rare in the pediatric population. Embolization of foreign bodies from penetrating trauma is very uncommon. We present a case of a 6-year-old boy with a penetrating foreign body from a projectile dislodged from a lawn mower. Imaging demonstrated a foreign body that embolized to the left pulmonary artery, which was successfully treated non-operatively. We reviewed the penetrating thoracic trauma patients in the trauma registry at our institution between 1/1/03 and 12/31/12. Data collected included demographic data, procedures performed, complications and outcome. Sixty-five patients were identified with a diagnosis of penetrating thoracic trauma. Fourteen of the patients had low velocity penetrating trauma and 51 had high velocity injuries. Patients with high velocity injuries were more likely to be older and less likely to be Caucasian. There were no statistically significant differences between patients with low vs. high velocity injuries regarding severity scores or length of stay. There were no statistically significant differences in procedures required between patients with low and high velocity injuries. Penetrating thoracic trauma is rare in children. The case presented here represents the only report of cardiac foreign body embolus we could identify in a pediatric patient.

Vertebra identification using template matching modelmp and K-means clustering.

PubMed

Larhmam, Mohamed Amine; Benjelloun, Mohammed; Mahmoudi, Saïd

2014-03-01

Accurate vertebra detection and segmentation are essential steps for automating the diagnosis of spinal disorders. This study is dedicated to vertebra alignment measurement, the first step in a computer-aided diagnosis tool for cervical spine trauma. Automated vertebral segment alignment determination is a challenging task due to low contrast imaging and noise. A software tool for segmenting vertebrae and detecting subluxations has clinical significance. A robust method was developed and tested for cervical vertebra identification and segmentation that extracts parameters used for vertebra alignment measurement. Our contribution involves a novel combination of a template matching method and an unsupervised clustering algorithm. In this method, we build a geometric vertebra mean model. To achieve vertebra detection, manual selection of the region of interest is performed initially on the input image. Subsequent preprocessing is done to enhance image contrast and detect edges. Candidate vertebra localization is then carried out by using a modified generalized Hough transform (GHT). Next, an adapted cost function is used to compute local voted centers and filter boundary data. Thereafter, a K-means clustering algorithm is applied to obtain clusters distribution corresponding to the targeted vertebrae. These clusters are combined with the vote parameters to detect vertebra centers. Rigid segmentation is then carried out by using GHT parameters. Finally, cervical spine curves are extracted to measure vertebra alignment. The proposed approach was successfully applied to a set of 66 high-resolution X-ray images. Robust detection was achieved in 97.5 % of the 330 tested cervical vertebrae. An automated vertebral identification method was developed and demonstrated to be robust to noise and occlusion. This work presents a first step toward an automated computer-aided diagnosis system for cervical spine trauma detection.

Epidemiological Study of Patients of Road Traffic Injuries Attending Emergency Department of a Trauma Center in New Delhi

PubMed Central

Misra, Puneet; Majumdar, Anindo; Misra, Mahesh Chandra; Kant, Shashi; Gupta, Sanjeev Kumar; Gupta, Amit; Kumar, Subodh

2017-01-01

Background and Aims: There is paucity of data regarding some of the lesser known contextual and epidemiological factors with respect to road traffic injuries (RTIs). The objective was to study the epidemiological profile of RTI victims attending an emergency department of a tertiary care trauma center. Methods: The present study was a hospital-based cross-sectional study conducted in the emergency department of a tertiary care trauma center in New Delhi. All patients of RTI attending the emergency department during the designated data collection days were included in the study. Patients brought dead were excluded from the study. A semi-structured interview schedule was developed for collecting data on various domains such as sociodemographic characteristics, vehicle-related factors, accident site-related factors, personal protection measures, contextual factors, and prehospital care-related factors. Results: A total of 984 patients and informants were approached and finally data of 900 participants were analyzed after excluding those who refused participation and those for whom incomplete data were available. Out of 900 RTI victims, 756 were male (84.0%) and 144 (16.0%) were female. Mean age of the victims was 32.7 years. Most of the victims, i.e., 377 out of 900 (41.9%) were occupants rather than drivers. Majority of victim's vehicle meeting accidents were motorized two-wheelers (53.4%), and majority of the colliding vehicle was a four-wheeler (39.3*). Helmet use was found to be low (63.3%), but seat belt use was particularly low (32.4%). Most accidents (28%) happened between midnight and 6 A.M. More than half of the victims were in a hurry on the day of the accident. An ambulance was used to transport the victims in only 14.6% cases. Conclusion: In road traffic accidents some lesser known epidemiological data were generated that may be useful in defining preventive measures. PMID:29142380

OPEN PELVIC FRACTURES: THE UNIVERSITY OF TENNESSEE MEDICAL CENTER AT KNOXVILLE EXPERIENCE OVER TEN YEARS

PubMed Central

Black, Emily Anne; Lawson, Christy M; Smith, Scott; Daley, Brian J

2011-01-01

Introduction Open fractures of the pelvis remain a devastating injury with a high mortality and morbidity. Such injuries require an aggressive treatment plan and the coordination of trauma and orthopaedic surgeons to achieve the best outcomes. We report our experience at the University of Tennessee Medical Center at Knoxville with open pelvic fractures over the last ten years. Methods After IRB and institutional approval, we reviewed patients admitted with a diagnosis of open fracture of the pelvis from 1999 to 2009. Demographic and admission data were recorded in the trauma registry (TRACS) of the Level I Trauma Center, serving the 1.2 million people living in the regions of east Tennessee, western North Carolina and southeastern Kentucky. Data on fractures were obtained from review of the medical records and radiographs within the chart Results There were 3053 pelvic fractures from January 1999 to December 2009. There were 231 deaths in this group (6%) and ages ranged from 18 to 89 years old and Injury Severity Scores ranged from 4 to 75, with a mean of 18.3. Seventy five percent of patients were able to be discharged home. Fifty-two fractures were open. There were 43 men and the mean age was 39 years old. Average ISS was 23 and ranged from 5 to 50. There were 10 deaths (19%) and eight patients underwent an-gioembolization for control of bleeding (3 deaths). Motorcycle crashes were the most frequent cause of an open fracture, with lateral compression injuries representing 71%. A defined algorithm for fracture management has been in place and employed to assure adequate resuscitation and fracture care and is presented. Discussion Open pelvic fractures are usually the result of a high energy transfer, and convey a high morbidity and mortality. A defined resuscitation and fixation strategy improves outcome from historical reports. Injuries from penetrating mechanisms are associated with less morbidity and lower mortality. PMID:22096441

Differences in Access to Services in Rural Emergency Departments of Quebec and Ontario

PubMed Central

Archambault, Patrick; Audette, Louis David; Plant, Jeff; Bégin, François; Poitras, Julien

2015-01-01

Introduction Rural emergency departments (EDs) are important safety nets for the 20% of Canadians who live there. A serious problem in access to health care services in these regions has emerged. However, there are considerable geographic disparities in access to trauma center in Canada. The main objective of this project was to compare access to local 24/7 support services in rural EDs in Quebec and Ontario as well as distances to Levels 1 and 2 trauma centers. Materials and Methods Rural EDs were identified through the Canadian Healthcare Association's Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities. There were 26 rural EDs in Quebec and 62 in Ontario meeting these criteria. Data were collected from ministries of health, local health authorities, and ED statistics. Fisher’s exact test, the t-test or Wilcoxon-Mann-Whitney test, were performed to compare rural EDs of Quebec and Ontario. Results All selected EDs of Quebec and Ontario agreed to participate in the study. The number of EDs visits was higher in Quebec than in Ontario (19 322 ± 6 275 vs 13 446 ± 8 056, p = 0.0013). There were no significant differences between Quebec and Ontario’s local population and small town population density. Quebec’s EDs have better access to advance imaging services such as CT scanner (77% vs 15%, p < .0001) and most the consultant support and ICU (92% vs 31%, p < .0001). Finally, more than 40% of rural EDs in Quebec and Ontario are more than 300 km away from Levels 1 and 2 trauma centers. Conclusions Considering that Canada has a Universal health care system, the discrepancies between Quebec and Ontario in access to support services are intriguing. A nationwide study is justified to address this issue. PMID:25874948

Education and prevention for teens: using Trauma Nurses Talk Tough presentation with pretest and posttest evaluation of knowledge and behavior changes.

PubMed

Allabaugh, Chianti Terri; Maltz, Sheldon; Carlson, Glenn; Watcharotone, Kuanwong

2008-01-01

Injury prevention is an essential part of any trauma program. Trauma Nurses Talk Tough (TNTT) is an injury prevention program utilized at many trauma centers targeting school-aged children from kindergarten through 12th grade. We hypothesized that TNTT would increase knowledge of safety strategies and change behavior with a prospective, correlational study using TNTT for 6th- to 8th-grade (n = 372) and 9th- to 12th-grade (n = 158) students, respectively. The TNTT injury prevention program had an effect on all students of 6th to 12th grades; however, the effect was more pronounced in the 6th- to 8th-grade group.

Ethnoracial Variations in Acute PTSD Symptoms Among Hospitalized Survivors of Traumatic Injury

PubMed Central

Stephens, Kari A.; Sue, Stanley; Roy-Byrne, Peter; Unützer, Jürgen; Wang, Jin; Rivara, Frederick P.; Jurkovich, Gregory J.; Zatzick, Douglas F.

2011-01-01

Ethnoracial minority status contributes to an increased risk for posttraumatic stress disorder (PTSD) after trauma exposure, beyond other risk factors. A population-based sampling frame was used to examine the associations between ethnoracial groups and early PTSD symptoms while adjusting for relevant clinical and demographic characteristics. Acutely injured trauma center inpatients (N = 623) were screened with the PTSD Checklist. American Indian and African American patients reported the highest levels of posttraumatic stress and preinjury cumulative trauma burden. African American heritage was independently associated with an increased risk of higher acute PTSD symptom levels. Disparities in trauma history, PTSD symptoms, and event related factors emphasize the need for acute care services to incorporate culturally competent approaches for treating these diverse populations. PMID:20564368