Nontrauma Hospitals Research Articles

Rural Trauma Team Development Course decreases time to transfer for trauma patients.

The Rural Trauma Team Development Course (RTTDC) is designed to teach knowledge and skills for the initial assessment and stabilization of trauma patients in resource-limited environments. The effect of RTTDC training on transfers from nontrauma centers to definitive care has not been studied. We hypothesized that RTTDC training would decrease referring hospital emergency department (ED) length of stay (LOS), time to call for transfer, pretransfer computed tomography (CT) imaging rate, and mortality rate. We conducted a pre/post analysis of trauma patients who were transferred from rural, nontrauma hospitals from 2012 to 2014. Patients from six rural hospitals that participated in an RTTDC course were compared with a control group of similar centers that did not participate in the course. Primary outcome evaluated was referring hospital ED LOS, which was estimated using a difference-in-differences regression model. Secondary outcomes were time to transfer call, pretransfer CT imaging rates, and mortality. Two hundred fifty-three patients were available for study (RTTDC group, n = 130; control group, n = 123). Demographics, CT imaging, and mortality rates were similar between the two groups. In the primary outcome, the RTTDC group experienced an overall 61-minute reduction in referring hospital LOS (p = 0.02) compared with the control group. The RTTDC group also showed a 41-minute reduction (p = 0.03) in time to call for transfer compared with controls. There were no differences in the secondary outcomes of pretransfer CT scanning rates or mortality. Rural Trauma Team Development Course training shortens ED LOS at rural, nontrauma hospitals by more than 1 hour without increasing mortality. Future educational and research efforts should focus on decreasing unnecessary imaging prior to transfer as well as opportunities to improve mortality rates. This study suggests an important role for RTTDC training in the care of rural trauma patients and may allow trauma centers to recapture the "golden hour" for transferred trauma patients. Therapeutic/care management study, level III.

Perception of low-titer group A plasma and potential barriers to using this product: A blood center's experience serving community and academic hospitals

BackgroundTo alleviate the shortage of AB plasma, an alternative plasma product, low-titer group A plasma (LTGAP), is now available. The product is indicated for emergency transfusions when the patient's blood group has not been identified. The product's defining anti-B titers vary across institutions, and at our blood center we define <1:100 as low-titer. MethodsWe created two surveys and emailed them to hospital blood bank managers, supervisors, and medical directors who currently use LTGAP and those that have not ordered it. We calculated the amount of LTGAP that met our <1:100 cutoff. We searched our inventory database to obtain sales of LTGAP, AB, and all other types of plasma in 2014. ResultsWe learned from the surveys that the product is safe and being used as indicated for only life or limb-threatening emergencies until patient's blood group is known and specific products can be provided. Most common reasons for not using LTGAP were lack of need in non-trauma hospitals and limiting capabilities in blood bank software. Although sales of LTGAP increased by ~5% by end of the first year since introduction, sales of AB plasma remained relatively steady. ConclusionLTGAP appears to be a safe alternative to group AB plasma for emergency indications. By reviewing our percentage of group A plasma units that meet our low-titer cutoff and the current interest for the product, we can reduce the amount of units we titer each day by ~30% and can readjust that amount if there is increased interest. Besides lack of familiarity and limitations in computer software to incorporate LTGAP, the steady demand for AB plasma can potentially be attributed to trauma centers ordering more AB plasma than needed and potentially wasting it in nonurgent cases to avoid outdating the product and lack of institutional guidelines on when to switch from AB to type-specific plasma resulting in excess AB plasma being transfused.

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets. This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective. For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.

Association Between Hospital Trauma Designation and Maternal and Neonatal Outcomes after Injury among Pregnant Women in Washington State

Approximately 8% of all pregnant women experience a traumatic injury during pregnancy. There has been no evaluation of a state trauma system's effect on birth outcomes. This study examined the association of treatment in a designated trauma hospital vs a nontrauma hospital on maternal and neonatal outcomes among injured pregnant patients in Washington State. We conducted a population-based retrospective cohort study (1995 to 2012). The Washington State Birth Events Records Database and the Comprehensive Hospital Abstract Recording System were linked to ascertain all hospitalized injured pregnant patients. The cohort was dichotomized by exposure to trauma vs nontrauma hospitals. We analyzed the association between trauma hospital designation and risk of adverse birth outcomes using logistic regression to estimate odds ratios and 95% CI, adjusting for Injury Severity Score and other confounders. We ascertained 3,429 injured pregnant women. Patients treated in trauma hospitals had an adjusted odds ratio (aOR) of 0.60 (95% CI, 0.50-0.73) for preterm labor, aOR= 0.74 (95% CI, 0.57-0.96) for gestational age <37 weeks, aOR= 0.72 (95% CI, 0.54-0.97) for birth weight <2,500 g, and aOR= 0.54 (95% CI, 0.39-0.76) for meconium at delivery. No statistically significant associations were found for maternal death (aOR= 2.57; 95% CI, 0.32-20.38), fetal death (aOR= 1.60; 95% CI, 0.35-7.35), or neonatal death (aOR= 1.50; 95% CI, 0.50-4.49). Treatment of injured pregnant women at designated trauma hospitals was associated with several improved birth outcomes. Trauma hospital treatment, with a greater focus on maternal resuscitation and monitoring, might explain these findings.

Prospective Validation of the National Field Triage Guidelines for Identifying Seriously Injured Persons

The national field trauma triage guidelines have been widely implemented in US trauma systems, but never prospectively validated. We sought to prospectively validate the guidelines, as applied by out-of-hospital providers, for identifying high-risk trauma patients. This was an out-of-hospital prospective cohort study from January 1, 2011 through December 31, 2011 with 44 Emergency Medical Services agencies in 7 counties in 2 states. We enrolled injured patients transported to 28 acute care hospitals, including 7 major trauma centers (Level I and II trauma hospitals) and 21 nontrauma hospitals. The primary exposure term was Emergency Medical Services' use of one or more field triage criteria in the national field triage guidelines. Outcomes included Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary). We enrolled 53,487 injured children and adults transported by Emergency Medical Services to an acute care hospital, 17,633 of which were sampled for the primary analysis; 13.9% met field triage guidelines, 3.1% had Injury Severity Score ≥16, and 1.7% required early critical resources. The sensitivity and specificity of the field triage guidelines were 66.2% (95% CI, 60.2-71.7%) and 87.8% (95% CI, 87.7-88.0%) for Injury Severity Score ≥16 and 80.1% (95% CI, 65.8-89.4%) and 87.3% (95% CI 87.1-87.4%) for early critical resource use. Triage guideline sensitivity decreased with age, from 87.4% in children to 51.8% in older adults. The national field triage guidelines are relatively insensitive for identifying seriously injured patients and patients requiring early critical interventions, particularly among older adults.

A Statewide Analysis of the Incidence and Outcomes of Mesenteric Ischemia in Maryland, 2009-2013

Mesenteric ischemia is a surgical emergency that entails complex, multimodal management. Although associated with significant morbidity and mortality, the epidemiology and outcomes of this condition remain poorly defined. The aim of this study was to perform a population analysis of the contemporary incidence and outcomes of mesenteric ischemia. This was a retrospective analysis of mesenteric ischemia in the state of Maryland during 2009 to 2013 using a comprehensive statewide hospital admission database. Mesenteric ischemia was defined as an International Classification of Diseases, Ninth Revision code for intestinal ischemia plus the need for intra-abdominal surgery. Demographics, illness severity, comorbidities, and outcomes were studied. The primary outcome was inpatient mortality, and secondary outcomes were complications and inpatient lengths of stay. Survivors and nonsurvivors were analyzed by univariate analyses, with multivariable logistic regression analysis of risk factors for mortality. During the 5-year study period, there were 2,496,992 nontrauma hospital discharges in Maryland. Of these, 2402 patients (0.10%) had mesenteric ischemia and were primarily elderly and critically ill (Table). Inpatient mortality was high (24%), and on univariate analysis was associated with increasing age, colonic resection, and cardiovascular and renal comorbidities. Patients who died required more dialysis, mechanical ventilation, and transfusions than survivors. With multivariate analysis, independent risk factors (odds ratio [95% confidence interval]) for death were age >65 years (1.5 [1.2-1.9]), ischemic heart disease (1.5 [1.2-2.0]), renal insufficiency (1.8 [1.4-2.2]), dysrhythmia (1.4 [1.1-1.8]), hypercoagulability (2.6 [1.9-3.7]), and mechanical ventilation (3.2 [2.5-4.1]). Mesenteric ischemia occurs in ∼1/1000 admissions in Maryland. Patients with mesenteric ischemia have significant illness severity, substantial rates of organ dysfunction, and high mortality. Patients with chronic comorbidities and acute organ dysfunction are at increased risk of death, and recognition of these risk factors may enable prevention or earlier control of mesenteric ischemia in high-risk patients.TableMesenteric ischemia in MarylandVariablesAll patients (N = 2402)SurvivorsNonsurvivorsP valuen = 1825 (76%)n = 577 (24%)Age, ± SD years68 ± 1765 ± 1770 ± 15.0001Extreme APR severity of illness, No. (%)1603 (67)1045 (57)558 (97).0001Small bowel resection, No. (%)989 (41)842 (46)147 (25).01Colon resection, No. (%)1228 (51)907 (50)321 (56).0001Chronic ischemic heart disease, No. (%)431 (18)297 (16)134 (23).0001Chronic kidney disease, No. (%)910 (38)552 (30)358 (62).0001Mechanical ventilation, No. (%)938 (39)517 (28)421 (17).0001Inpatient dialysis, No. (%)194 (8)98 (5)96 (17).0001Hospital length of stay, days (IQR)11 (6-20)11 (7-20)8 (3-18).0001APR, All Patient Refined; IQR, interquartile range; SD, standard deviation. Open table in a new tab

A modified Kampala trauma score (KTS) effectively predicts mortality in trauma patients.

Mortality prediction in trauma patients has relied upon injury severity scoring tools focused on anatomical injury. This study sought to examine whether an injury severity scoring system which includes physiologic data performs as well as anatomic injury scores in mortality prediction. Using data collected from 18 Level I trauma centers and 51 non-trauma center hospitals in the US, anatomy based injury severity scores (ISS), new injury severity scores (NISS) were calculated as were scores based on a modified version of the physiology-based Kampala trauma score (KTS). Because pre-hospital intubation, when required, is standard of care in the US, a modified KTS was calculated excluding respiratory rate. The predictive ability of the modified KTS for mortality was compared with the ISS and NISS using receiver operating characteristic (ROC) curves. A total of 4716 individuals were eligible for study. Each of the three scores was a statistically significant predictor of mortality. In this sample, the modified KTS significantly outperformed the ISS (AUC=0.83, 95% CI 0.81-0.84 vs. 0.77, 95% CI 0.76-0.79, respectively) and demonstrated similar predictive ability compared to the NISS (AUC=0.83, 95% CI 0.81-0.84 vs. 0.82, 95% CI 0.80-0.83, respectively). The modified KTS may represent a useful tool for assessing trauma mortality risk in real time, as well as in administrative data where physiologic measures are available. Further research is warranted and these findings suggest that the collection of physiologic measures in large databases may improve outcome prediction.

Triage Patterns for Medicare Patients Presenting to Nontrauma Hospitals with Moderate to Severe Injuries: Mohan D, Barnato AE, Rosengart MR, et al. Ann Surg 2015;261:383–9.

Triage Patterns for Medicare Patients Presenting to Nontrauma Hospitals with Moderate to Severe Injuries: Mohan D, Barnato AE, Rosengart MR, et al. Ann Surg 2015;261:383–9.

Triage Patterns for Medicare Patients Presenting to Nontrauma Hospitals With Moderate or Severe Injuries

To understand hospital-level variation in triage practices for patients with moderate-to-severe injuries presenting initially to nontrauma centers. Many patients with moderate-to-severe traumatic injuries receive care at nontrauma hospitals, despite evidence of a survival benefit from treatment at trauma centers. We used claims from the Centers for Medicare and Medicaid Services to identify patients with moderate-to-severe injuries who presented initially to nontrauma centers. We determined whether or not they were transferred to a level I or II trauma center within 24 hours of presentation, and used multivariate regression to assess the influence of hospital-level factors on triage practices, after adjusting for differences in case mix. Transfer of patients with moderate-to-severe injuries to trauma centers occurred infrequently, with significant variation among hospitals (median 2%; interquartile range 1%-6%). Greater resource availability at nontrauma centers was associated with lower rates of successful triage, including the presence of neurosurgeons (relative reduction in transfer rate: 76%, P < 0.01), more than 20 intensive care unit beds (relative reduction 30%, P < 0.01) and a high resident-to-bed ratio (relative reduction 23%, P < 0.01). However, patients were more likely to survive if they presented to hospitals with higher triage rates (odds of death for patients cared for at hospitals with the highest tercile of triage rates, compared with lowest tercile: 0.92; 95% confidence interval: 0.85-0.99, P = 0.02). Injured Medicare beneficiaries presenting to nontrauma centers experience high rates of undertriage, determined in part by increasing availability of resources. Care at hospitals with low rates of successful triage is associated with worse outcomes.

Variability in Early Do Not Attempt Resuscitation Orders Among Patients With Serious Traumatic Brain Injury

The objective was describe the use of early do not attempt resuscitation (DNAR) orders in patients with serious traumatic brain injury (TBI) and its association with outcomes. This was a retrospective cohort study of all serious TBI patients admitted through the emergency department (ED) to acute care hospitals in California between 2002 and 2010 using ED International Classification of Diseases, 9th revision (ICD-9), admitting diagnosis codes specifying intracranial hemorrhage. DNAR placement within 24 hours of admission was the primary variable of interest. Outcomes included neurosurgical procedures and in-hospital mortality. Hospital and patient characteristics were analyzed using descriptive statistics and multivariable generalized estimation equation regression models to account for hospital-level clustering. Of all 76,962 patients with serious TBI, 71,275 were admitted at 141 hospitals that each cared for at least 10 serious TBI patients annually and formed the primary sample. Early DNAR orders were placed in 7.5% of patients (range = 0 to 36.1% by hospital). Early DNAR use varied by trauma designation: Level I, 4.0% (95% confidence interval [CI] = 3.8% to 4.4%); Level II, 6.7% (95% CI = 6.5% to 7.1%); Level III, 9.7% (95% CI = 8.4% to 11.3%); and nontrauma hospitals, 10.8% (95% CI = 10.6% to 11.3%). Early DNAR was also less likely in teaching hospitals (9.3% vs. 4.3%). These results persisted after accounting for age, year, and hospital-level clustering. In-hospital mortality (39.4% vs. 8.7%) and neurosurgical interventions (14.5% vs. 19.7%) also differed for patients with versus without early DNAR orders. Patients 65 years of age and older constituted 87.7% of those with early DNAR orders; our findings remained qualitatively unchanged when restricted to older adults. Use of early DNAR orders among patients with serious TBI is highly variable by individual hospital and hospital type, suggesting substantial practice variation. Associations with fewer surgical intervention and higher mortality suggest that such practice variation may be contributing to differences in TBI outcomes, particularly among older adults.

A critical analysis of secondary overtriage to a Level I trauma center.

Trauma centers often receive transfers from lower-level trauma centers or nontrauma hospitals. The aim of this study was to analyze the incidence and pattern of secondary overtriage to our Level I trauma center. We performed a 2-year retrospective analysis of all trauma patients transferred to our Level I trauma center and discharged within 24 hours of admission. Reason for referral, referring specialty, mode of transport, and intervention details were collected. Outcomes measures were incidence of secondary overtriage as well as requirement of major or minor procedure. Major procedure was defined as surgical intervention in the operating room. Minor procedures were defined as procedures performed in the emergency department. A total of 1,846 patients were transferred to our Level I trauma center, of whom 440 (24%) were discharged within 24 hours of admission. The mean (SD) age was 35 (21) years, 72% were male, and mean (SD) Injury Severity Score (ISS) 4 (4). The most common reasons for referral were extremity fractures (31%), followed by head injury (23%) and soft tissue injuries (13%).Of the 440 patients discharged within 24 hours, 380 (86%) required only observation (268 of 380) or minor procedure (112 of 380). Minor procedures were entirely consisted of fracture management (n = 47, 42%) and wound care (n = 65, 58%). The mean (SD) interfacility transfer distance was 45 (46) miles. Mean (SD) hospital charges per transfer were $12,549 ($5,863). A significant number of patients transferred to our trauma center were discharged within 24 hours; most of them required observation and/or minor procedures. Appropriately increasing primary hospital resources, in addition to interhospital outreach in the form of education or telemedicine, should be considered to decrease the number of avoidable transfers. Epidemiologic study, level III.

Variations in pediatric trauma transfer patterns in Northern California pediatric trauma centers (2001-2009).

Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles. A significant proportion of children with trauma is initially triaged to nontrauma hospitals and may require subsequent transfer to a specialty center. Trauma transfer patterns to a pediatric trauma center may provide insight into regional primary triage practices. Transfers from hospitals in close proximity to pediatric trauma centers might suggest that some children could have avoided transfer with minimal additional transport time. While pediatric trauma centers are scarce and serve as regional resources, transfers from beyond the regular catchment area of a trauma center could be an indication of clinical need. The objective of this study was to gain an understanding of patterns of pediatric trauma transfer to all pediatric trauma centers within the region as a first step in assessing the efficacy and efficiency of trauma triage. The authors examined three groups of transfer patients: transfers from within the same county as the pediatric trauma center (near transfers), transfers from counties adjacent to the pediatric trauma center (catchment transfers), and transfers from more distant counties (far transfers). The hypothesis was that catchment transfers would form the bulk of transfers, near transfers would compose < 10% of total transfers, and far transfers would be younger and more severely injured than catchment transfers. This was a retrospective analysis of institutional trauma registry data of children < 18years from all pediatric trauma centers in Northern California from 2001 through 2009. Transfers were characterized by the location of the transfer hospital relative to the location of the pediatric trauma center. Characteristics associated with near transfer compared to primary triage to a pediatric trauma center were identified, as well as characteristics associated with far transfer compared to catchment transfer. A total of 2,852 of 11,952 (23.9%) pediatric trauma patients were transfers. Near transfers comprised 24.5% of cases, catchment transfers were 37.4%, and far transfers were 38.2%. After controlling for demographic, clinical, and geographic factors, younger age, higher Injury Severity Score (ISS), public versus private insurance, and an injury mechanism of "fall" were associated with near transfer rather than direct triage. Older age, higher ISS, and mechanism of "motor vehicle crash" were associated with far rather than catchment transfer. This analysis of patterns of transfer to all pediatric trauma centers within Northern California gives the most comprehensive population view of pediatric trauma triage to date, to the authors' knowledge. Trauma transfers comprise an important minority of patients cared for at pediatric trauma centers. The number of near transfers documented indicates the potential to improve the primary triage process of patients to pediatric trauma centers. The frequency of far transfers substantiates the well-known shortage of pediatric trauma expertise. Development of regionwide standardized transfer protocols and agreements between hospitals, as well as standardized monitoring of the process and outcomes, could increase efficiency of care.

Complications and mortality in cervical spine surgery: racial differences.

Retrospective national database analysis. Our goal was to estimate racial and ethnic differences in in-hospital complication and mortality rates associated with cervical spine surgery. The impact of observed racial and ethnic disparities in orthopedic spine care use on morbidity and mortality is not well understood. On the basis of the Nationwide Inpatient Sample, there were 983,420 adult nontrauma hospital discharges from 2000 through 2009. In-hospital complications and mortality were the outcome variables. The primary independent variable was race/ethnicity (defined as non-Hispanic white [white], non-Hispanic black [black], and Hispanic). Covariates were age, sex, household income, insurance status, geographical location, hospital volume, and comorbidities. Multivariable regression models were used to determine the association between race/ethnicity and in-hospital complication and mortality. Significance was set at a P value less than 0.05. The overall rates of an in-hospital complication or mortality were 4.09% and 0.42%, respectively. There were no differences in the rates of in-hospital complications or mortality between Hispanics and Caucasians. Compared with Caucasians, African Americans had higher odds of experiencing an in-hospital complication (odds ratio, 1.37; 95% confidence interval, 1.27-1.48) and higher odds of dying during hospitalization (odds ratio, 1.59; 95% confidence interval, 1.30-1.96). Although there were no differences between Caucasians and Hispanics, African Americans had significantly higher rates of in-hospital complications and mortality associated with cervical spine surgery than did Caucasians. These differences persisted after adjusting for known risk factors for complications and mortality. 3.

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Objective. To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the undertriage of seriously injured elders to non-trauma hospitals. Methods. This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP ÷ heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was “serious injury,” defined as Injury Severity Score (ISS) ≥ 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria. Results. A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS ≥ 16. Nonlinear associations existed between all physiologic measures and ISS ≥ 16 (unadjusted and adjusted p ≤ 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score ≤ 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1–9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3–15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%. Conclusions. Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing overtriage to major trauma centers.

From 9-1-1 call to death

This study aimed to characterize initial clinical presentations of patients served by emergency medical services (EMS) who die following injury, with particular attention to patients with occult ("talk-and-die") presentations. This was a population-based, multiregion, mixed-methods retrospective cohort study of fatally injured children and adults evaluated by 94 EMS agencies transporting to 122 hospitals in seven Western US regions from 2006 to 2008. Fatalities were divided into two main groups: occult injuries (talk-and-die; Glasgow Coma Scale [GCS] score ≥ 13, no cardiopulmonary arrest, and no intubation) versus overt injuries (all other patients). These groups were further subdivided by timing of death: early (<48 hours) versus late (>48 hours). We then compared demographic, physiologic, procedural, and injury patterns using descriptive statistics. We also used qualitative methods to analyze available EMS chart narratives for contextual information from the out-of-hospital encounter. During the 3-year study period, 3,358 persons served by 9-1-1 EMS providers died, with 1,225 (37.1%) in the field, 1,016 (30.8%) early in the hospital, and 1,060 (32.1%) late in the hospital. Of the 2,133 patients transported to a hospital, there were 612 (28.7%) talk-and-die patients, of whom 114 (18.6%) died early. Talk-and-die patients were older (median age, 81 years; interquartile range, 67-87 years), normotensive (median systolic blood pressure, 138 mm Hg; interquartile range, 116-160 mm Hg), commonly injured by falls (71.3%), and frequently (52.4%) died in nontrauma hospitals. Compared with overtly injured patients, talk-and-die patients had relatively fewer serious head injuries (13.7%) but more frequent extremity injuries (20.3% vs. 10.6%) and orthopedic interventions (25.3% vs. 5.0%). EMS personnel often found talk-and-die patients lying on the ground with hip pain or extremity injuries. Patients served by EMS who "talk-and-die" are typically older adults with falls, transported to nontrauma hospitals, with subtle clinical indications of the severity of their injuries. Improving recognition of talk-and-die patients may avoid fatal outcomes in a portion of these patients. Epidemiologic study, level III.

Englsih

Air ambulance transport for injured patients is vitally important given increasing patient volumes, the limited number of trauma centres and inadequate subspecialty coverage in nontrauma hospitals. Air ambulance services have been shown to improve patient outcomes compared with ground transport in select circumstances. Our primary goal was to compare injuries, interventions and outcomes in patients transported by helicopter versus nonhelicopter transport. We performed a retrospective 10-year review of 14 440 patients transported to an urban Level 1 trauma centre by helicopter or by other means. We compared injury severity, interventions and mortality between the groups. Patients transported by helicopter had higher median injury severity scores (ISS), regardless of penetrating or blunt injury, and were more likely to have Glasgow Coma Scale scores less than 8, require airway control, receive blood transfusions and require admission to the intensive care unit or operating room than patients transported by other means. Helicopter transport was associated with reduced overall mortality (odds ratio 0.41, 95% confidence interval 0.33-0.39). Patients transported by other methods were more likely to die in the emergency department. The mean ISS, regardless of transport method, rose from 12.3 to 15.1 (p = 0.011) during our study period. Patients transported by helicopter to an urban trauma centre were more severely injured, required more interventions and had improved survival than those arriving by other means of transport.

Regional collaboration across hospital systems to develop and implement trauma protocols saves lives within 2 years

The Northern Ohio Trauma System (NOTS) was created with the expressed goal of improving trauma care through collaboration, system-wide protocol implementation, and evidence-based process improvement. The primary goal of this study was to evaluate the mortality of trauma patients seen across the region after 2 years of beginning NOTS. Regional data was compared with the 2 years pre-NOTS (2008 and 2009) to the 2 years post-NOTS (2010 and 2011). The regional system consisted of two large hospital systems, initially including one level 1 center, four level 2 centers, seven nontrauma hospitals, and local emergency medical services groups. Two level 2 trauma centers closed during the study period. Mortality was the primary outcome for this study. Multivariate logistic regression also was performed to evaluate for independent predictors of mortality. An odds ratio (OR) and 95% confidence interval (CI) of survival were determined after we adjusted for other factors associated with mortality. During the 4-year period 29,890 trauma patients were seen throughout NOTS. The mean age was 44 with a mean Injury Severity Score (ISS) of 8; 65% of the patients were male. Racial breakdown demonstrated that 64.0% were white, 31.9% were black, and 4.1% were other races. The hospital stay (mean ± SD) was 3.0 ± 5.2 days, and overall mortality was 3.4%. A separate analysis in which we used multivariate logistic regression demonstrated that patients treated in the post-NOTS period was an independent predictor for survival when we controlled for age, sex, ethnicity, mechanism, and ISS. The OR of survival of post NOTS was 0.81 (95% CI 0.70-0.94) when we evaluated all patients. The OR for admitted patients was 0.79 (95% CI 0.67-0.94) and 0.76 (0.62-0.95) in patients with ISS > 24. There was an increase in the percentage of patients seen at the level 1 center in the post-NOTS period, which was especially demonstrated in patients with greater ISS. NOTS appears to have contributed to the saving of lives within 2 years of its formation. Regionalized protocols, collaboration, and consolidation resulted in an improvement in mortality.

The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers

Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.

The mortality risk from motor vehicle injuries in California has increased during the last decade

Organized trauma systems and trauma centers are thought to improve trauma outcomes. It is clear that injured patients who receive care in trauma centers have survival advantages. However, large regions of California still do not have access to trauma centers. Many injured patients in California continue to receive their care in nontrauma center hospitals. The purpose of this study was to compare outcomes in California counties with and without trauma centers. In addition, we wished to query the efficacy of the current statewide trauma system by asking whether mortality after motor vehicle trauma in California has improved during the last decade. We performed a retrospective outcome study. The California highway patrol provided data from all motor vehicle crashes (MVCs) and mortality during the years 1999 to 2008 for the 58 counties in California. Percent fatality was calculated as the number of motor vehicle fatalities divided by the number of injuries. Data were analyzed to compare outcomes in counties with and without trauma centers. Furthermore, demographic data were studied to analyze the relationship of population and hospital density on mortality. Mortality was significantly lower in counties with trauma centers. Low population and hospital density independently correlated with increased mortality. Injury mortality rates after MVCs increased during the decade both in counties with and without trauma centers. Overall, the presence of a trauma center improved the chances of survival after an MVC in California counties. However, mortality rates after injuries increased during the decade both in counties with and without trauma centers. Future efforts to improve outcomes for injured patients in California will require new approaches, which must include improving both access to trauma centers and the care provided in nontrauma center hospitals. Epidemiologic study, level III.

Geographic distribution of severely injured patients

Despite decades of trauma system development, many severely injured patients fail to reach a trauma center for definitive care. The purpose of this study was to define the regions served by Florida's designated trauma centers and define the geographic distribution of severely injured patients who do not access the state's trauma system. Severely injured patients discharged from Florida hospitals were identified using the 2009 Florida Agency for Health Care Administration database. The home zip codes of patients discharged from trauma and nontrauma center hospitals were used as a surrogate for injury location and plotted on a map. A radial distance containing 75% of trauma center discharges defined trauma center catchment area. Only 52% of severely injured patients were discharged from trauma centers. The catchment areas varied from 204 square miles to 12,682 square miles and together encompassed 92% state's area. Although 93% of patients lived within a trauma center catchment area, the proportion treated at a trauma center in each catchment area varied from 13% to 58%. Mapping of patient residences identified regions of limited access to the trauma system despite proximity to trauma centers. The distribution of severely injured patients who do not reach trauma centers presents an opportunity for trauma system improvement. Those in proximity to trauma centers may benefit from improved and secondary triage guidelines and interfacility transfer agreements, whereas those distant from trauma centers may suggest a need for additional trauma system resources. Epidemiologic study, level III.