Nontrauma Centers Research Articles

P151. Inspection of the global variability for the AO spine upper cervical injury classification

<h3>BACKGROUND CONTEXT</h3> Previous AO Spine classifications have demonstrated substantial accuracy, interobserver reliability and intraobserver reproducibility regardless of geographic region (as defined by the 6 AO regions of the world – North America, Latin/South America, Africa, Asia and Oceania, Middle East and Europe). However, upper cervical spine injuries are often quickly transferred to academic/tertiary care centers, and as such, may have much greater variability in regional classification ability. The AO Spine Upper Cervical Injury Classification is based on injury level (I. occipital condyle and craniocervical junction, II. C1 and C1-C2 joint, and III. C2 and C2-3 joint) and type of injury (A-bony injury, B-tension band injury, C-fracture dislocation). <h3>PURPOSE</h3> To determine the global variability of the intraobserver reproducibility, interobserver reliability and % agreement compared to the gold-standard (as determined by members of the AO Spine Knowledge Forum Trauma) for the AO Spine Upper Cervical Injury Classification. <h3>STUDY DESIGN/SETTING</h3> Global cross-sectional survey. <h3>PATIENT SAMPLE</h3> A total of 275 AO Spine members. <h3>OUTCOME MEASURES</h3> Precentage agreement with gold-standard, intraobserver reproducibility and interobserver reliability. <h3>METHODS</h3> A total of 275 AO Spine members responded to an open invitation to participate in the AO Spine Upper Cervical Injury Classification validation. A live, online assessment with all participants presenting simultaneously was performed twice at a three-week interval. A total of 25 consecutive upper cervical spine computed tomography (CT) videos, which included axial, sagittal and coronal videos, were played at a rate of 2 frames/second. A REDCap survey was used to capture all participants' classification grades. Pearson's chi square test was used to compare geographic region with significance set at P<0.05. Fleiss' kappa (ƙ) was used to identify the interobserver reliability and intraobserver reproducibility (ƙ=0-0.20 was categorized as slight, 0.21-0.4 was fair, 0.41-0.60 was moderate, 0.61-0.8 was substantial and 0.81-1.0 was excellent). <h3>RESULTS</h3> The majority of participants were from Europe (41.2%) and Asia (23.5%) with the remaining from Central/South America (13.6%), the Middle East (7%), North America (9.5%), and Africa (5.3%). Only 43.6% worked in an academic center and 69.8% worked at a level I trauma center. Participants from Europe, the Middle East, Asia and North America had the highest percentage agreement compared to the gold-standard (range: 75.1-82.9% on both assessments), while Africa and Central/South America (range: 68.9-71.2% on both assessments) had a significantly lower agreement percentage (p<0.001). The interobserver reliability was substantial (ƙ=0.61-0.682) for Asia, Europe, the Middle East, and North America, but it was only moderate for Africa and Central/South America (ƙ=0.487, 0.466, respectively). The intraobserver reproducibility was substantial for North America, Europe, and Asia (ƙ = 0.70, 0.71, 0.61), excellent for the Middle East (ƙ=0.81), and moderate for Africa and Central/South America (0.57 and 0.55, respectively). <h3>CONCLUSIONS</h3> Significant variation in the percentage agreement compared to the gold-standard was identified based on geographic regions. Participants in Africa and South/Latin America regions were less accurate compared to Asia, Europe, South/Latin America and the Middle East. The interobserver reliability and intraobserver reproducibility also showed significant variation between world regions. This may be partly due to less CT scan availability in these regions and the infrequency of these injuries presenting to non-trauma or academic centers, which may make these types of injuries more difficult to accurately identify for some participants. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Interfacility Emergency Department Transfer for Mandibular Fractures in the United States

Interfacility hospital transfer for isolated mandibular fractures is common but rarely clinically necessary. The purpose of this study was to generate nationally representative estimates regarding the incidence, risk factors, and cost of transfer for isolated mandibular fractures. This was a retrospective cohort study using the Nationwide Emergency Department Sample 2018 to identify patients with isolated mandibular fractures. The primary predictor variable was hospital trauma center designation (Level I, Level II, Level III, and nontrauma center). The primary outcome variablewas hospital transfer. Total emergency department (ED) charges were also assessed. Covariates were demographic, medical, injury-related, and hospital characteristics. Descriptive, bivariate, and multiplelogistic regression statistics were used to evaluate the incidence and predictors of interfacility transfer. A total of 28,357 encounters with mandibular fracture as the primary diagnosis were included. Within this cohort there were 2,893 hospital transfers (10.2%). In unadjusted analysis, evaluation at a nontraumacenter, level III trauma center, metropolitan nonteaching hospital, nonmetropolitan nonteaching hospital, micropolitan region, and history of cerebrovascular event was associated with hospitaltransfer (P≤.001). In the adjusted model, independent predictors (risk factors) for hospital transfer were evaluation at a nontrauma center (P≤.001, odds ratio [OR]=12.8, 95% confidence interval [CI]=6.43 to 25.4), level III trauma center (P≤.001, OR=10.7, 95% CI=5.25 to 21.7), nonmetropolitan nonteaching hospital (P≤.001, OR=2.45, 95% CI=1.73 to 3.46), metropolitan nonteaching hospital (P≤.001, OR=1.57, 95% CI=1.20 to 2.06), cervical spine injury (P=.002, OR=3.53, 95% CI=1.61 to 7.75), fractures of the mandibular body (P=.007, OR=1.33, 95% CI=1.08 to 1.64), and unspecified mandibular fractures (P=.006, OR=1.49, 95% CI=1.12 to 1.99). The average ED charge per encounter was $7,482±565 for a total nationwide charge of $212,172,264. Transferred subjects had total ED charges of $25,632,974, not including additional charges incurred at the recipient hospital. Isolated mandibular fractures are common injuries that are frequently transferred and cost the healthcare system millions of dollars annually. Hospital characteristics rather than medical or injury-related variables were the strongest predictors of transfer, suggesting that transfers are primarily driven by need to access maxillofacial surgical services. Programs evaluating necessity of transfer and facilitating specialist evaluation in the outpatient setting may reduce healthcare expenditures for this injury.

Accurate completion of tertiary trauma survey for inpatients at a non-trauma centre following significant trauma

IntroductionA tertiary trauma survey (TTS) is a structured, comprehensive top-to-toe examination following major trauma [1]. Literature suggests that the ideal time frame for the initial TTS should be completed within 24-hours of a patient's admission and repeated at important moments [2–4]. Evidence suggests that formal TTS reduces the rate of missed injuries by up to 38% [2]. AimsTo determine the rate of TTS being conducted in trauma patients in a tertiary hospital without an admitting trauma service. MethodsWe performed a retrospective analysis of adult trauma patients admitted to Middlemore Hospital (MMH) over six months. To be included, patients were either deemed to have a significant mechanism of injury or triggered a trauma call when arriving in the Emergency Department. ResultsWe identified 246 patients who met our criteria for requiring a TTS. 74 (30%) had a TTS completed. Of those completed, 22 (30%) were documented using a standardised form. 35 (47%) were done within the ideal timeframe (24 h); a further 21 (28%) were done within 48 h. House Officers (Junior Medical Officers) conducted the majority (80%), with the remainder being done by final-year medical students (12%), Registrars (Residents) (4%) and Consultants (Attendings) (4%). Of the 74 TTS that were completed, 21 (28%) detected a possible new injury, with 22% leading to further investigations being ordered. 14 (19%) were found to have a previously undetected, clinically significant injury on TTS (defined as ‘injuries requiring further clinical intervention’). Most patients (90%) were admitted to either General Surgery or Orthopaedics. Sixty-two (54%) of patients admitted to General Surgery received a TTS; compared to just 11 (10%) admitted under Orthopaedics and 1 of 24 (4%) admitted to other specialities (including Hands, Plastics, Maxillo-Facial, Gynaecology and Medicine). Conclusion30% of patients requiring a TTS received one. 19% of TTS conducted detected clinically significant injuries.

Blunt Trauma Mortality: Does Trauma Center Level Matter?

Trauma centers have improved outcomes compared to nontrauma centers when caring for injured patients. A multicenter report found blunt trauma patients treated at American College of Surgeons' Level I trauma centers have improved survival compared to Level II centers. In a subsequent multicenter study, Level II centers had improved survival in all trauma patients. We sought to provide a more granular analysis by stratifying blunt mechanisms-to determine if there was a difference in mortality between Level I and Level II centers. The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting to an American College of Surgeons' Level I or II trauma center after blunt trauma. A multivariable logistic regression analysis was performed controlling for comorbidities and Trauma and Injury Severity Score. From 734,473 patients with blunt trauma, 507,715 (69.1%) were treated at a Level I center and 226,758 (30.9%) at a Level II center. The Level I cohort was younger (median age, 53 versus 58, P=0.01), with a higher median injury severity score (13 versus 10, P<0.001) and with more patients presenting after a motor vehicle accident (MVA) (27.9% versus 22.4%, P<0.001) and lower rates of falls (46.6% versus 54.5%, P<0.001). After adjusting for covariates, there was no difference in mortality between Level I and Level II centers (P>0.05). When stratifying by mechanisms, Level I centers had a decreased associated mortality for MVA (odds ratio=0.94, CI: 0.88-0.99, P=0.04) and bicycle accidents (odds ratio=0.77, CI: 0.74-0.03, P=0.01) but no difference in falls or pedestrians struck (P>0.05). Overall, blunt trauma patients presenting to a Level I center have no difference in mortality compared to a Level II center. However, when stratified by mechanism, those involved in MVA or bicycle accidents have a decreased associated risk of mortality. Future prospective studies examining variations in practice to account for these differences are warranted.

Emergency Pancreatoduodenectomy: A Non-Trauma Center Case Series.

(1) Background: Emergency pancreatoduodenectomy (EPD) is a rare procedure, especially in non-trauma centers. Pancreatoduodenectomy is a challenging intervention, that has even higher risks in emergency settings. However, EPD can be a life-saving procedure in selected cases. (2) Methods: Our study is a single-center prospective consecutive case series, on patients that underwent emergency pancreatoduodenectomies in our surgical department between January 2014 to May 2021. (3) Results: In the 7-year period, 4 cases were operated in emergency settings, out of the 615 patients who underwent PD (0.65%). All patients were male, with ages between 44 and 65. Uncontrollable bleeding was the indication for surgery in 3 cases, while a complex postoperative complication was the reason for surgery in one other case. In three cases, a classical Whipple procedure was performed, and only one case had a pylorus-preserving pancreatoduodenectomy. The in-hospital mortality rate was 25% and the morbidity rate was 50%; the two patients that registered complications also needed reinterventions. The patients who were discharged had a good long-term survival. (4) Conclusion: EPD is a challenging procedure, rare encountered in non-traumatic cases, that can be a life-saving intervention in well-selected cases, offering good long-term survival.

Emergency Department Visits by Pediatric Patients for Snakebites.

Few studies have examined pediatric emergency department (ED) visits for snakebites. This study sought to examine characteristics of pediatric patients presenting to EDs nationally in the United States for snakebites. This retrospective cohort study obtained data from the Nationwide Emergency Department Sample for 2006 to 2014. Pediatric patients sustaining a snakebite were identified with International Classification of Diseases, Ninth Revision, E-codes E905.0 or E906.2. Data extracted included age, sex, insurance, disposition, hospital trauma designation, ED charges, and geographic region. Comparative analyses were performed for patients younger than 10 years and aged 10 to 17 years. There were 24,388 ED visits from 2006 to 2014 by pediatric patients for snakebites: 10,554 were younger than 10 years, and 13,834 were aged 10 to 17 years. Males comprised 62% and 67% of the respective age cohorts. Most patients (younger than 10 years, 68%; aged 10-17 years, 63%) experienced snakebites in the South. Only 14% of those younger than 10 years and 10% of those aged 10 to 17 years were treated at a level 1 trauma center, whereas 50% and 54%, respectively, were treated at hospitals with no trauma designation. The majority of patients were discharged from the ED (younger than 10 years, 72%; aged 10-17 years, 80%). The mean ED charges for snakebite victims younger than 10 years were $5363 and for those aged 10 to 17 years were $4618. Medicaid was the primary insurer of younger patients, whereas private insurance was more common in older patients. Most pediatric snakebites are seen in nontrauma centers and in the South region and are more commonly male. Most patients were discharged from the ED, with a small percentage being admitted or transferred to another facility.

Do All Isolated Traumatic Subarachnoid Hemorrhages Need to Be Transferred to a Level 1 Trauma Center?

The management of isolated traumatic subarachnoid hemorrhage (itSAH) in non-trauma centers usually results in transfer to a Level 1 trauma center with neurosurgical capabilities. Due to lack of trauma center resources, we sought to evaluate if patients with itSAH need transfer to a Level I trauma center. A retrospective review of the trauma registry was conducted from Jan 2015-Dec 2020. Patients with itSAH on initial computed tomographic imaging and a Glasgow Coma Scale score >13 were included. Patients with any other intracranial pathology, skull fractures, multi-system trauma or age less than 15 were excluded. 120 patients were identified with itSAH. Mean age was 63years, and 44% were male. Mean injury severity score was 4.7 with 48% on anticoagulation/antiplatelet therapy. Radiology Reports were reviewed and only 2 scans (1.7%) showed an increase in itSAH, 98.3% reports revealed no change, improvement, or resolution. No patients deteriorated and no patients underwent neurosurgical intervention. Once admitted, 27 (23%) were treated for acute medical conditions and 39 (33%) required subspecialty medical consultations. There was no difference in increased itSAH on repeat imaging between patients on anticoagulation/antiplatelet therapy and those without. The population taking anticoagulant/antiplatelet therapy was older, more likely to have suffered a fall, have more comorbid conditions, was more likely to be treated for a non-traumatic medical condition and have a subspecialty medical consultation. Patients with itSAH do not require transfer to a Level 1 trauma center for acute neurosurgical intervention.

Association of Trauma Center Designation With Postdischarge Survival Among Older Adults With Injuries

Trauma centers improve outcomes for young patients with serious injuries. However, most injury-related hospital admissions and deaths occur in older adults, and it is not clear whether trauma center care provides the same benefit in this population. To examine whether 30- and 365-day mortality of injured older adults is associated with the treating hospital's trauma center level. This prospective, population-based cohort study used Medicare claims data from January 1, 2013, to December 31, 2016, for all fee-for-service Medicare beneficiaries 66 years or older with inpatient admission for traumatic injury in 2014 to 2015. Data analysis was performed from January 1 to June 31, 2021. Preinjury health was measured using 2013 claims, and outcomes were measured through 2016. The population was stratified by anatomical injury pattern. Propensity scores for level I trauma center treatment were estimated using the Abbreviated Injury Scale, age, and residential proximity to trauma center and then used to match beneficiaries from each trauma level (I, II, III, and IV/non-trauma centers) by injury type. Admitting hospital's trauma center level. Case fatality rates (CFRs) at 30 and 365 days after injury, estimated in the matched sample using multivariable, hierarchical logistic regression models. A total of 433 169 Medicare beneficiaries (mean [SD] age, 82.9 [8.3] years; 68.4% female; 91.5% White) were included in the analysis. A total of 206 275 (47.6%) were admitted to non-trauma centers and 161 492 (37.3%) to level I or II trauma centers. Patients with isolated extremity fracture had the fewest deaths (365-day CFR ranged from 16.1% [95% CI, 11.2%-22.4%] to 17.4% [95% CI, 11.8%-24.6%] by trauma center status). Patients with both hip fracture and traumatic brain injury had the most deaths (365-day CFRs ranged from 33.4% [95% CI, 25.8%-42.1%] to 35.8% [95% CI, 28.9%-43.5%]). These findings suggest that older adults do not benefit from existing trauma center care, which is designed with younger patients in mind. There is a critical need to improve trauma care practices to address common injury mechanisms and types of injury in older adults.

The extent to which geography explains one of trauma's troubling trends: Insurance-based differences in appropriate interfacility transfer.

A growing body of literature suggests the persistence of a counterproductive triage pattern wherein uninsured adults with major injuries presenting to nontrauma centers (NTCs) are more likely than insured adults to be transferred. Geographic differences are frequently blamed. The objective of this study was to explore geography's influence on variations in insurance transfer patterns, asking whether differences in distance and travel time by road from NTCs to the nearest level 1 or 2 trauma center alter the effect. As a secondary objective, differences in neighborhood socioeconomic disadvantage were also assessed. Adults (16-64 years) with major injuries (Injury Severity Score, >15) presenting to NTC emergency departments (EDs) were abstracted from 2007 to 2014 state inpatient/ED claims. Differences in the risk-adjusted odds of admission versus transfer were compared using mixed-effect hierarchical logistic regression and spatial analysis. A total of 48,283 adults presenting to 492 NTC EDs were included. Among them, risk-adjusted admission differences based on insurance status exist (e.g., private vs. uninsured odds ratio [95% confidence interval], 1.60 [1.45-1.76]). Spatial analysis revealed significant geographic variation ( p < 0.001). However, in contrast to expectations, the largest insurance-based discrepancies were seen in less disadvantaged NTCs located closer to larger trauma centers. Stratified analyses comparing the closest versus furthest distance, shortest versus longest travel time, and least versus most deprived populations agreed, as did sensitivity analyses restricting uninsured transfer patients to those who remained uninsured versus subsequently became insured. Adults with major injuries presenting to NTCs were less likely to be transferred if insured. The trend persisted after accounting for differences in access to care, revealing that, while significant geographic variation in the phenomenon exists, geography alone does not explain the issue. Taken together, the findings suggest that additional and potentially subjective elements to insurance-based triage disparities at NTCs are likely to exist. Prognostic/Epidemiological, Level III.

Reporting acute trauma in a non-trauma centre: improving scan turnover time

Background: Non-trauma centres continue to receive trauma patients where the mechanism of injury is not severe enough to warrant transfer to a major trauma centre (MTC). In these cases, timely and appropriate cross-sectional imaging is essential to detect life-threatening injuries for appropriate management, including whether transfer to a MTC if necessary. While stringent guidelines exist for MTCs, there are no set standards for trauma reporting at non-major trauma centres, where facilities and pathways of a MTC may not exist. This could lead to a significant delay in management.

The significance of direct transportation to a trauma center on survival for severe traumatic brain injury

IntroductionWhile timely specialized care can contribute to improved outcomes following traumatic brain injury (TBI), this condition remains the most common cause of post-injury death worldwide. The purpose of this study was to investigate the difference in mortality between regional trauma centers in Sweden (which provide neurosurgical services round the clock) and non-trauma centers, hypothesizing that 1-day and 30-day mortality will be lower at regional trauma centers.Patients and methodsThis retrospective cohort study used data extracted from the Swedish national trauma registry and included adults admitted with severe TBI between January 2014 and December 2018. The cohort was divided into two subgroups based on whether they were treated at a trauma center or non-trauma center. Severe TBI was defined as a head injury with an AIS score of 3 or higher. Poisson regression analyses with both univariate and multivariate models were performed to determine the difference in mortality risk [Incidence Rate Ratio (IRR)] between the subgroups. As a sensitivity analysis, the inverse probability of treatment weighting (IPTW) method was used to adjust for the effects of confounding.ResultsA total of 3039 patients were included. Patients admitted to a trauma center had a lower crude 30-day mortality rate (21.7 vs. 26.4% days, p = 0.006). After adjusting for confounding variables, patients treated at regional trauma center had a 28% [adj. IRR (95% CI): 0.72 (0.55–0.94), p = 0.015] decreased risk of 1-day mortality and an 18% [adj. IRR (95% CI): 0.82 (0.69–0.98)] reduction in 30-day mortality, compared to patients treated at a non-trauma center. After adjusting for covariates in the Poisson regression analysis performed after IPTW, admission and treatment at a trauma center were associated with a 27% and 17% reduction in 1-day and 30-day mortality, respectively.ConclusionFor patients suffering a severe TBI, treatment at a regional trauma center confers a statistically significant 1-day and 30-day survival advantage over treatment at a non-trauma center.

Changes in the Deceased-Donor Trend in Korea: Establishment of Regional Trauma Centers and KODA.

South Korea utilizes living-donor liver transplantation to overcome a shortage of deceased donors. After the Korea Organ Donation Agency (KODA) was established, many hospitals were selected to be donor-managing hospital. A nationwide regional trauma center project was carried out separately in 2015. This study aims to analyze how the trend of deceased-donor recruitment and donation has changed based on policy factors such as independent organ-procurement organization (IOPO) activities and establishing regional trauma centers. KONOS data from 2010–2019 were used to analyze the impacts of these policy changes. The results showed that 62 centers had 4395 deceased donors, and 3863 recipients underwent deceased-donor liver transplantation. The two most common causes of donor death are cerebrovascular events and head trauma. When the rate of deceased donors was analyzed by the early period (2010–2014) and the late period (2015–2019), 53 non-trauma centers went from an average of 29.3 cases to 31.0 cases (6.2% increase) annually. Nine regional trauma centers showed a statistically significant increase from an average of 39.8 cases to 70.3 cases (75.9% increase) annually. Based on these policies, he locations where deceased donors are identified are changing. It is necessary to communicate with regional trauma center staff to recruit more deceased donors.

The public health burden of geriatric trauma: Analysis of 2,688,008 hospitalizations from Centers for Medicare and Medicaid Services inpatient claims.

Geriatric trauma care (GTC) represents an increasing proportion of injury care, but associated public health research on outcomes and expenditures is limited. The purpose of this study was to describe GTC characteristics, location, diagnoses, and expenditures. Patients at short-term nonfederal hospitals, 65 years or older, with ≥1 injury International Classification of Diseases, Tenth Revision, were selected from 2016 to 2019 Centers for Medicare and Medicaid Services Inpatient Standard Analytical Files. Trauma center levels were linked to Inpatient Standard Analytical Files data via American Hospital Association Hospital ID and fuzzy string matching. Demographics, care location, diagnoses, and expenditures were compared across groups. A total of 2,688,008 hospitalizations (62% female; 90% White; 71% falls; mean Injury Severity Score, 6.5) from 3,286 hospitals were included, comprising 8.5% of all Medicare inpatient hospitalizations. Level I centers encompassed 7.2% of the institutions (n = 236) but 21.2% of hospitalizations, while nontrauma centers represented 58.5% of institutions (n = 1,923) and 37.7% of hospitalizations. Compared with nontrauma centers, patients at Level I centers had higher Elixhauser scores (9.0 vs. 8.8) and Injury Severity Score (7.4 vs. 6.0; p < 0.0001). The most frequent primary diagnosis at all centers was hip/femur fracture (28.3%), followed by traumatic brain injury (10.1%). Expenditures totaled $32.9 billion for trauma-related hospitalizations, or 9.1% of total Medicare hospitalization expenditures and approximately 1.1% of the annual Medicare budget. The overall mortality rate was 3.5%. Geriatric trauma care accounts for 8.5% of all inpatient GTC and a similar percentage of expenditures, the most common injury being hip/femur fractures. The largest proportion of GTC occurs at nontrauma centers, emphasizing their vital role in trauma care. Public health prevention programs and GTC guidelines should be implemented by all hospitals, not just trauma centers. Further research is required to determine the optimal role of trauma systems in GTC, establish data-driven triage guidelines, and define the impact of trauma centers and nontrauma centers on GTC mortality. Therapeutic/care management, Level III.

Cost-effectiveness of field trauma triage among injured children transported by emergency medical services.

A pediatric field triage strategy that meets the national policy benchmark of ≥95% sensitivity would likely improve health outcomes but increase heath care costs. Our objective was to compare the cost-effectiveness of current pediatric field triage practices to an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity. We developed a decision-analysis Markov model to compare the outcomes and costs of the two strategies. We used a prospectively collected cohort of 3507 (probability weighted, unweighted n=2832) injured children transported by 44 emergency medical services (EMS) agencies to 28 trauma and non-trauma centers in the Northwestern United States from 1/1/2011 to 12/31/2011 to derive the alternative field triage strategy and to populate model probability and cost inputs for both strategies. We compared the two strategies by calculating quality adjusted life years (QALYs) and health care costs over a time horizon from the time of injury until death. We set an incremental cost-effectiveness ratio threshold of less than $100,000 per QALY for the alternative field triage to be a cost-effective strategy. Current pediatric field triage practices had a sensitivity of 87.4% (95% confidence interval [CI] 71.9 to 95.0%) and a specificity of 82.3% (95% CI 81.0 to 83.5%) and the alternative field triage strategy had a sensitivity of 97.3% (95% CI 82.6 to 99.6%) and a specificity of 46.1% (95% CI 43.8 to 48.4%). The alternative field triage strategy would cost $476,396 per QALY gained compared to current pediatric field triage practices and thus would not be a cost-effective strategy. Sensitivity analyses demonstrated similar findings. Current field triage practices do not meet national policy benchmarks for sensitivity. However, an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity is not a cost-effective strategy.

Evaluation of an Expedited Trauma Transfer Protocol: Right Place, Right Time

Trauma patients may initially be evaluated at non-trauma centers. This may cause a delay in treatment, which could affect their outcome. Additionally, advanced imaging may be performed which may be suboptimal or unnecessary, increase time to transfer, or unable to be viewed when the patient reaches a trauma center increasing the delays to treatment or need for repeat imaging. Rapid identification and transfer to definitive trauma care, minimizing unnecessary delays should be the priority. The trauma registry at a regional Level 1 Adult/Pediatric Trauma center was queried for transferred trauma patients over a 3-y period. A retrospective review was performed. Transferred trauma patients were compared prior to an expedited transfer protocol to after implementation. Demographics, mechanism of injury, injury severity score, computerized tomography scans performed prior to transfer, mortality, hospital and intensive care unit length of stay were compared using bivariate and multivariable regression statistics where appropriate. Transferred trauma patients were identified, 683 in the pre-protocol group and 821 in the post-protocol group, an increase of 16.8%. There were no differences in age, sex, injury severity score, mechanism of injury, mortality, hospital, or intensive care unit length of stay (LOS) throughout the study period. There was a significant decrease in time to transfer (263 min ± 222 versus 227 ± 189, P < 0.001) and computerized tomography scans performed prior to transfer (Head 47% versus 32%, C-spine 36% versus 23%, Thorax 22% versus 16%, Abdomen/Pelvis 24% versus 14%, all P values <0.001 except CT Thorax). Interestingly, the rate of underinsured patients did not increase (21% versus 25%, P=0.05). Risk-adjusted mortality and hospital LOS also did not change during the study period. After implementation of an expedited trauma transfer protocol to a regional Level 1 trauma center there was an associated reduced time of arrival to definitive care and decreased advanced imaging done prior to transfer. However, there was noassociated decrease inmortality or LOS among transferred patients. Further studies examining prehospital transport or hospital choice decisions and subsequent care provided at non-trauma facilities regarding imaging obtained, care rendered, and transfer decisions can be explored.

Outcomes after a Digital Behavior Change Intervention to Improve Trauma Triage: An Analysis of Medicare Claims

Under-triage in trauma remains prevalent, in part because of decisions made by physicians at non-trauma centers. We developed two digital behavior change interventions to recalibrate physician heuristics (pattern recognition), and randomized 688 emergency medicine physicians to use the interventions or to a control. In this observational follow-up, we evaluated whether exposure to the interventions changed physician performance in practice. We obtained 2016 - 2018 Medicare claims for severely injured patients, linked the names of trial participants to National Provider Identifiers (NPIs), and identified claims filed by trial participants for injured patients presenting to non-trauma centers in the year before and after their trial. The primary outcome measure was the triage status of severely injured patients. We linked 670 (97%) participants to NPIs, identified claims filed for severely injured patients by 520 (76%) participants, and claims filed at non-trauma centers by 228 (33%). Most participants were white (64%), male (67%), and had more than three years of experience (91%). Patients had a median Injury Severity Score of 16 (IQR 16 - 17), and primarily sustained neuro-trauma. After adjustment, patients treated by physicians randomized to the interventions experienced less under-triage in the year after the trial than before (41% versus 58% [-17%], P=0.015); patients treated by physicians randomized to the control experienced no difference in under-triage (49% versus 56% [-7%], P=0.35). The difference-in-the-difference was non-significant (10%, P=0.18). It was feasible to track trial participants' performance in national claims. Sample size limitations constrained causal inference about the effect of the interventions.

The Financial and Radiation Burden of Early Reimaging in Neurosurgical Patients: An Original Study and Review of the Literature.

The computed tomographic (CT) scanner has become ubiquitous in healthcare. When trauma patients are imaged at facilities not equipped to care for them, imaging is often repeated at the receiving institution. CTs have clinical, financial, and resource costs, and eliminating unnecessary imaging will benefit patients, providers, and institutions. This paper reviews patterns of repetition of CT scans for transferred trauma patients and motivations underlying such behaviors via analysis of our Trauma Registry database and literature published in this area.Neurosurgeons are fundamentally impactful in this decision-making process. The most commonly repeated scan is a CT head (CTH). More than ¼ of our patients receiving a clinically indicated repeat CTH also had a repeat scan of their cervical spine with no reason given for the cervical scan. Herein, we discuss our findings that both non-trauma center practitioners and non-neurosurgical staff at trauma centers cite a lower level of comfort with neuroradiology and fear of litigation as motivators in overzealous neuroimaging. As a result, inappropriate neurosurgical imaging is routinely ordered prior to transfer and again upon arrival at trauma centers. Education of non-neurosurgical staff is essential to prevent inappropriate neuroaxis imaging.

Disaster preparedness should represent an augmentation of the everyday trauma system, but are we prepared?

BackgroundThe increased frequency, geographical spread and the heterogenicity in mass casualty incidents (MCIs) challenge healthcare systems worldwide. Trauma systems constitute the base for disaster preparedness. Norway is sparsely populated, with...

Grade IV blunt hepatic injury treated conservatively and successfully in a non-trauma centre: a case report

Management of blunt hepatic injury changed over the past three decades as a non-operative treatment is nowadays advocated by most in haemodynamically stable patients. We present the case of a young female patient with a high-grade blunt liver injury successfully treated in a non-trauma centre. She developed several complications secondary to the injury like a delayed bleeding, two different bilomas and a reactive pleural effusion requiring surgical expertise, interventional radiology, upper gastro-intestinal endoscopy and intensive care facilities. In the literature, the mortality and the morbidity rates for grade IV liver injuries respectively reach 16% and 39%. Because of potential delayed symptoms or signs and high complication rate, we think it should be appropriate to manage such a complex patient in a centre where at least above-mentioned specialities are available. Otherwise, a referral to a trauma centre should be a better option.

Factors associated with potentially avoidable interhospital transfers in emergency general surgery–A call for quality improvement efforts

BackgroundEmergency general surgery conditions are common, require urgent surgical evaluation, and are associated with high mortality and costs. Although appropriate interhospital transfers are critical to successful emergency general surgery care, the performance of emergency general surgery transfer systems remains unclear. We aimed to describe emergency general surgery transfer patterns and identify factors associated with potentially avoidable transfers. MethodsWe performed a retrospective cohort study of emergency general surgery episodes in 8 US states using the 2016 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases and the American Hospital Association Annual Surveys. We identified Emergency Department-to-Inpatient and Inpatient-to-Inpatient interhospital emergency general surgery transfers. Potentially avoidable transfers were defined as discharge within 72 hours after transfer without undergoing any procedure or operation at the destination hospital. We examined transfer incidence and characteristics. We performed multilevel regression examining patient-level and hospital-level factors associated with potentially avoidable transfers. ResultsOf 514,410 adult emergency general surgery episodes, 26,281 (5.1%) involved interhospital transfers (Emergency Department-to-Inpatient: 65.0%, Inpatient-to-Inpatient: 35.1%). Over 1 in 4 transfers were potentially avoidable (7,188, 27.4%), with the majority occurring from the emergency department. Factors associated with increased odds of potentially avoidable transfers included self-pay (versus government insurance, odds ratio: 1.26, 95% confidence interval: 1.09–1.45, P = .002), level 1 trauma centers (versus non-trauma centers, odds ratio: 1.24, 95% confidence interval: 1.05–1.47, P = .01), and critical access hospitals (versus non-critical access, odds ratio: 1.30, 95% confidence interval: 1.15–1.47, P < .001). Hospital-level factors (size, trauma center, ownership, critical access, location) accounted for 36.1% of potentially avoidable transfers variability. ConclusionOver 1 in 4 emergency general surgery transfers are potentially avoidable. Understanding factors associated with potentially avoidable transfers can guide research, quality improvement, and infrastructure development to optimize emergency general surgery care.