Pennsylvania Trauma Outcome Study Database Research Articles

Initial Heart Rate Predicts Functional Independence in Patients With Spinal Cord Injury Requiring Surgery: A Registry-Based Study in a Mature Trauma System Over the Past 10Years.

Retrospective Cohort Study. To determine the ability of early vital sign abnormalities to predict functional independence in patients with SCI that required surgery. A retrospective analysis of data extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients >18years with a diagnosis of SCI who required urgent spine surgery in Pennsylvania from 1/1/2010-12/31/2020 and had complete records available. A total of 644 patients met the inclusion criteria. The mean age was 47.1 ± 14.9years old and the mean injury severity score (ISS) was 22.3 ± 12.7 with the SCI occurring in the cervical, thoracic, and lumbar spine in 61.8%, 19.6% and 18.0%, respectively. Multivariable logistic regression analyses for predictors of functional independence at discharge showed that higher HR at the scene (OR 1.016, 95% CI 1.006-1.027, P = .002) and lower ISS score (OR .894, 95% CI .870-.920, P < .001) were significant predictors of functional independence. Similarly, higher admission HR (OR 1.015, 95% CI 1.004-1.027, P = .008) and lower ISS score (OR .880, 95% CI 0.864-.914, P < .001) were significant predictors of functional independence. Peak Youden indices showed that patients with HR at scene >70 and admission HR ≥83 were more likely to achieve functional independence. Early heart rate is a strong predictor of functional independence in patients with SCI. HR at scene >70 and admission HR ≥83 is associated with improved outcomes, suggesting lack of neurogenic shock.

The Homeless Population: Medical Refugees in a Mature Trauma System.

On any given day, there are >550,000 homeless persons in the United States. Little research has examined the relationship between the homeless population and traumatic injuries. We hypothesized that homeless trauma patients have a higher mortality compared to those who are not homeless. The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2018 for all adult (age ≥15) patients admitted to trauma centers in Pennsylvania. Homelessness was defined as homeless on admission or homeless as their discharge status. Patient demographics, comorbidities, and clinical variables were compared between homeless and non-homeless patients. Logistic regression was used to control for age, gender, injury severity, injury type, admission Glasgow Coma Scale, and systolic blood pressure to assess morbidity and mortality. 773 patients were identified upon query. Homeless trauma patients were more likely to be male, younger, black, and of Hispanic ethnicity. Compared to non-homeless, they were more likely to have a positive drug screen or mental illness at the time of injury. They were not more significantly injured than their counterparts; however, in adjusted analysis, the homeless had significantly higher odds of both complications (Adjusted Odds Ratio [AOR]: 3.11; 95%CI: 2.64-3.66, P < .001) and mortality (AOR: 1.79; 95%CI: 1.29-2.50, P = .001). Although homeless patients were not more severely injured than the general trauma population, they had significantly higher odds of both complications and mortality. This population represents a very vulnerable community in need of medical intervention and injury prevention programs.

A Statewide Analysis of Pediatric Liver Injuries Treated at Adult Versus Pediatric Trauma Centers.

Hemodynamically normal pediatric trauma patients with solid organ injury receive nonoperative management. Prior research supports that pediatric patients have higher rates of nonoperative management at pediatric trauma centers (PTCs). We sought to evaluate differences in outcomes of pediatric trauma patients with liver injuries. We hypothesized that the type of trauma center (PTC versus adult trauma center [ATC]) would not be associated with any difference in mortality. The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all patients (<15 y) with liver injuries by International Classification of Disease 9 and 10 codes. Patients were categorized based on admission to the PTC or ATC. The primary endpoint was mortality with secondary endpoints being operative intervention and length of stay. Multivariate logistic regressions assessed the adjusted impact on mortality and surgical intervention. Of the 1600 patients with liver trauma, 607 met inclusion criteria. A total of 78.4% were treated at PTCs. Patients underwent hepatobiliary surgery more frequently at ATCs (11.5% [n=15] versus 2.74% [n=13], P<0.001). Adjusted analysis showed lower odds of surgical intervention for hepatobiliary injuries at PTCs (adjusted odds ratio: 0.17, P=0.001). There was a decrease in mortality at PTCs versus ATCs (adjusted odds ratio: 0.38, P=0.032). Our statewide analysis showed that pediatric trauma patients with liver injuries treated at ATCs were associated with having higher odds of mortality and higher incidence of operative management for hepatobiliary injuries than those treated at PTCs. In addition, between centers, patients had similar functional status at discharge.

Location of Injury and Other Factors Associated With Increased Survival Among Severely Injured Geriatric Trauma Patients.

Patients with a Trauma Injury Severity Score (TRISS) < .5 are termed "unexpected survivors." There is scarce information published on this subset of geriatric patients whose survival is an anomaly. This is a retrospective case-control study examining all geriatric patients (age ≥65) not expected to survive (TRISS<.5) in the Pennsylvania Trauma Outcome Study (PTOS) database from 2013 to 2017. Primary outcome was survival to discharge. We selected 10 clinically important variables for logistic regression analysis as possible factors that may improve survival. 1336 patients were included, 395 (29.6%) were unexpected survivors. Factors that improved survival odds are the following: Place of injury: street/highway (AOR:0.51; 95% CI: .36-.73, P < .001) and residential institution (AOR:0.46; 95% CI: .21-.98, P = .043); and presence of Benzodiazepines (AOR:0.49; 95% CI: .31-.77, P = .002) or ethanol (AOR:0.57; 95% CI: .34-.97, P = .040). Factors that decreased survival odds are the following: Hypotension (AOR: 8.59; 95% CI: 4.33-17.01, P < .001) and hypothermia (AOR: 1.58; 95% CI: 1.10-2.28, P = .014). Gender, race/ethnicity, blood transfusion in first 24hours, shift of presentation to Emergency Department, place of injury (farm, industrial, recreational, or public building), use of Tetrahydrocannabinol, amphetamines or opioids, and level of trauma activation did not impact survival. Location of injury (street/highway and residential institution) and ethanol or benzodiazepine use led to a significant increased survival in severely injured geriatric patients. Hypotension and hypothermia led to decreased survival. Future studies should determine possible reasons these factors lead to survival (and identify additional factors) to focus efforts in these areas to improve outcomes in geriatric trauma.

Trampoline Injuries in a Statewide Trauma System.

It is well known that trampolines can be a particular source of danger, especially in children. We sought to examine the profile of those patients with trampoline injuries. We hypothesized there would be certain injury patterns predicative of trampoline injuries. All patients submitted to Pennsylvania Trauma Outcome Study database from 2016 to 2018 were analyzed. Trampoline injury was determined by ICD-10 activity code. Injury patterns in the form of abbreviated injury scale body regions were examined. Patient demographics and clinical variables were compared between those with trampoline injury vs those without. There were 107 patients with a trampoline injury. All of these patients were discharged alive and had a blunt mechanism of injury. The most common injury type was injury to the extremities (n=90,[84.1%]) with 54(50.5%) upper extremity injuries and 36(33.6%) lower extremity injuries. Ten (9.35%) patients had injury to the spine and five (4.67%) had head injury. Those with trampoline injuries were significantly younger (13y vs. 48.6y) and more likely to be white or of Hispanic ethnicity. Almost half of the patients injured (49.5%) were under 10 years. Patients with trampoline injuries had significantly lower Injury Severity Scores and significantly higher shock index. The majority of patients with trampoline injuries had injury to an extremity. These results help better understand the demographic, physiologic, and anatomic patterns surrounding trampoline injuries. Current government standards recommend that no child under age six should use a full-sized trampoline; however, based of this study, we advise that this age be increased to ten.

Unplanned Readmissions to the Intensive Care Unit Among Geriatric Trauma Patients.

Unplanned readmission/bounceback to the intensive care unit (ICUBB) is a prevalent issue in the medical community. The geriatric population is incompletely studied in regard to ICUBB. We sought to determine if ICUBB in older patients was associated with higher risk of mortality. We hypothesized that, of those who were older, those with ICUBB would have higher mortality compared to those with no ICUBB. Further, we hypothesized that of those with ICUBB, older age would lead to higher mortality. The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all trauma patients of age ≥40years. Those with advance directives were excluded. Adjusted analysis in the form of logistic regressions controlling for demographic and injury covariates and clustering by facility were used to assess the adjusted impact of ICUBB and age on mortality. 363,778 patients were aged ≥40 years. When comparing mortalities between the age 40 and 49 years group and those in older groups, a dramatic increase in mortality was observed between those in each respective age category with ICUBB vs non-ICUBB. This trend was most prominent in those in the 90+ years age group (ICUBB: AOR: 34.78, P < .001; non-ICUBB: AOR: 9.08, P < .001). A second model only including patients who had ICUBB found that patients of age ≥65 years had significantly higher odds of mortality (AOR: 4.10, P < .001) when compared to their younger counterparts (age <65years). An ICUBB seems to exacerbate mortality rates as age increases. This profound increase in mortality calls for strategies to be developed, especially in the older population, to attempt to mitigate the factors leading to ICUBB.

Benzodiazepines increase the likelihood of both infectious and thrombotic complications.

Benzodiazepines (BZDs) modulate peripheral γ-amino-butyric acid type A on macrophages causing immunomodulation. They inhibit proinflammatory cytokines increasing infections. Prior studies have also shown that infections can increase thrombotic complications. We sought to examine this relationship in trauma patients. We hypothesized that the presence of BZDs on admission urine drug screen (UDS) would increase rates of both complications. All patients submitted to the Pennsylvania Trauma Outcome Study database from 2003 to 2018 were queried. Those with a positive UDS for BZDs were analyzed. Infectious complications were defined as pneumonia, urinary tract infection, sepsis, wound, and soft tissue infection, and thrombotic complications were defined as presence of pulmonary embolism or deep vein thrombosis. Logistic regressions controlling for demographic and injury covariates assessed the adjusted impact of BZDs on infectious and thrombotic complications. A total of 3,393 patients (2.08%) had infectious complications, and 3,048 (1.87%) had thrombotic complications. Furthermore, 33,260 patients (20.4%) had a positive UDS for BZDs on admission. Univariate analysis showed that those positive for BZDs had higher rates of infectious (3.33% vs. 1.76%, p < 0.001) and thrombotic (2.84% vs. 1.62%, p < 0.001) complications. Multivariate analysis revealed that BZDs significantly increased the odds of infectious and thrombotic complications. Patients who tested positive for BZDs and subsequently developed infection had increased odds (adjusted odds ratio, 1.65; p < 0.001) of developing thrombotic complications. Trauma patients with a positive UDS for BZDs had higher odds of both infectious and thrombotic complications. Moreover, odds of thrombotic complications were higher in those with infections. Epidemiological, level III.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System

BackgroundWe sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC. Materials and methodsThe Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge. ResultsA total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT. ConclusionsPOT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT.Level of Evidence: Epidemiologic study, level III.

The Pediatric Open Supracondylar Fracture: Associated Injuries and Surgical Management.

While supracondylar (SC) fractures are relatively common in children, the incidence of open injuries is believed to be only 1%. Two prior studies on open SC fractures in children reported an increased incidence of vascular injuries. The purposes of our study were to clarify the incidence, associated conditions, and current treatment for open SC fractures. The Pennsylvania Trauma Outcome Study database was queried. Subjects age 25 to 156 months old admitted to trauma centers between January 2000 and December 2015 with a SC fracture were included. Controls were those with closed fractures and the study group, those with open injuries. Study variables were age, sex, weight, injury severity score, length of stay (LOS), nerve injury, ipsilateral forearm fracture, compartment syndrome/fasciotomy, requirement for a vascular procedure. Other variables were mode of treatment, provisional reduction, repeat reduction, time interval between referring facility admission and operation, and time from emergency department admission to operation. A total of 4308 subjects were included, 104 (2.4%) of whom had an open SC fracture. LOS was 2 days for the study group versus 1 day for controls (P<0.001). Open SC fractures were more likely than closed to be associated with a nerve injury (13.5% vs. 3.7%), ipsilateral forearm fracture (18.3% vs. 6.4%) and/or a vascular procedure (6.7% vs. 0.3%) (P<0.001). 5.9% of those in the study group required repeat surgery compared with 0.4% for controls (P<0.001). Time from emergency department admission to operation was 3.2 versus 10.3 hours (P<0.001). We report the largest series to date of open SC fractures in children. Surgeons caring for such patients should be aware of their increased risks for both associated injuries and potential requirement for vascular reconstruction. The majority of children with an open SC fracture are managed with 1 operation and in the absence of vascular injury, seldom require an extended LOS. Level III-retrospective cohort study.

Geriatric Trauma Mortality: Does Trauma Center Level Matter?

Given their mostly rural/suburban locations, level II trauma centers (TCs) may offer greater exposure to and experience in managing geriatric trauma patients. We hypothesized that geriatric patients would have improved outcomes at level II TCs compared to level I TCs. The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for geriatric (age ≥65years) trauma patients admitted to level I and II TCs in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in care between level I and II TCs. A multivariate logistic regression model assessed the adjusted impact of care at level I vs II TCs on mortality, complications, and functional status at discharge (FSD). The National Trauma Data Bank (NTDB) was retrospectively queried for geriatric (age ≥65years) trauma admissions to state-accredited level I or level II TCs in 2013. 112648 patients met inclusion criteria. The proportion of geriatric trauma patients across level I and level II TCs were determined to be 29.1% and 36.2% (P <.001), respectively. In adjusted analysis, there was no difference in mortality (adjusted odds ratio [AOR]: 1.13; P = .375), complications (AOR: 1.25; P = .080) or FSD (AOR: 1.09; P = .493) when comparing level I to level II TCs. Adjusted analysis from the NTDB (n = 144622) also found that mortality was not associated with TC level (AOR: 1.04; P = .182). Level I and level II TCs had similar rates of mortality, complications, and functional outcomes despite a higher proportion (but lower absolute number) of geriatric patients being admitted to level II TCs. Future consideration for location of centers of excellence in geriatric trauma should include both level I and II TCs.

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

Massive transfusion protocols (MTP) are a routine component of any major trauma center's armamentarium in the management of exsanguinating hemorrhages. Little is known about the potential complications of those that survive a MTP. We sought to determine the incidence of venous thromboembolism (VTE) following MTP. We hypothesized that MTP would be associated with a higher risk of VTE when compared with a risk-adjusted control population without MTP. The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2015 to 2018 for trauma patients who developed VTE and survived until discharge at accredited trauma centers in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in VTE development between MTP and non-MTP patients. A multivariate logistic regression model assessed the adjusted impact of MTP on VTE development. 176 010 patients survived until discharge, meeting inclusion criteria. Of those, 1667 developed a VTE (pulmonary embolism [PE]: 662 [0.4%]; deep vein thrombosis [DVT]: 1142 [0.6%]; PE and DVT: 137 [0.1%]). 1268 patients (0.7%) received MTP and, of this subset of patients, 171 (13.5%) developed a VTE during admission. In adjusted analysis, patients who had a MTP and survived until discharge had a higher odds of developing a VTE (adjusted odds ratio: 2.62; 95% CI: 2.13-3.24; P < .001). MTP is a harbinger for higher risk of VTE in those patients who survive. This may, in part, be related to the overcorrection of coagulation deficits encountered in the hemorrhagic event. A high index of suspicion for the development of VTE as well as aggressive VTE prophylaxis is warranted in those patients who survive MTP.

Predictors of Trauma High Resource Consumers in a Mature Trauma System.

Extended hospital length of stay (LOS) is widely associated with significant healthcare costs. Since LOS is a known surrogate for cost, we sought to evaluate outliers. We hypothesized that particular characteristics are likely predictive of trauma high resource consumers (THRC) and can be used to more effectively manage care of this population. The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2017 for all adult (age ≥15) trauma patients admitted to accredited trauma centers in Pennsylvania. THRC were defined as patients with hospital LOS two standard deviations above the population mean or ≥22 days (p<0.05). Patient demographics, comorbid conditions and clinical variables were compared between THRC and non-THRC to identify potential predictor variables. A multilevel mixed-effects logistic regression model controlling for age, gender, injury severity, admission Glasgow coma score, systolic blood pressure, and injury year assessed the adjusted impact of clinical factors in predicting THRC status. The National Trauma Data Bank (NTDB) was retrospectively queried from 2014-2016 for all adult (age ≥15) trauma patients admitted to state-accredited trauma centers and likewise were assessed for factors associated with THRC. A total of 465,601 patients met inclusion criteria [THRC: 16,818 (3.6%); non-THRC 448,783 (96.4%)]. Compared to non-THRC counterparts, THRC patients were significantly more severely injured (median ISS: 9 vs. 22, p<0.001). In adjusted analysis, gunshot wound (GSW) to the abdomen, undergoing major surgery and reintubation along with injury to the spine, upper or lower extremities were significantly associated with THRC. From the NTDB, 2 323 945 patients met inclusion criteria. In adjusted analysis, GSW to the abdomen was significantly associated with THRC. Penetrating injury overall was associated with decreased risk of being a THRC in the NTDB dataset. Those who had either GSW to abdomen, surgery, or reintubation required significantly longer LOS (p<0.001). Reintubation, major surgery, gunshot wound to abdomen, along with injury to the spine, upper or lower extremities are all strongly predictive of THRC. Understanding the profile of the THRC will allow clinicians and case management to proactively put processes in place to streamline care and potentially reduce costs and LOS.

A comparison of adolescent penetrating trauma patients managed at pediatric versus adult trauma centers in a mature trauma system

While there is little debate that pediatric trauma centers (PTC) are uniquely equipped to manage pediatric trauma patients, the extent to which adolescents benefit from treatment there remains controversial. We sought to elucidate differences in management approach and outcome between PTC and adult trauma centers (ATC) for the adolescent penetrating trauma population. We hypothesized that improved mortality would be observed at ATC for this subset of patients. Adolescent patients (age, 15-18 years), presenting to Pennsylvania-accredited trauma centers between 2003 and 2017 with penetrating injury, were queried from the Pennsylvania Trauma Outcome Study database. Dead on arrival, transfer patients, and those admitted to a Level III or Level IV trauma center were excluded from analysis. Patient length of stay, number of complications, surgical intervention, and mortality were compared between ATC and PTC. Multilevel mixed effects logistic regression models with trauma center as the clustering variable were used to assess the impact of center type (ATC/PTC) on management approach and mortality adjusted for appropriate covariates. A total of 2,630 adolescent patients met inclusion criteria (PTC: n = 428 [16.3%]; ATC: n = 2,202 [83.7%]). Pediatric trauma centers had a lower adjusted odds of mortality (adjusted odds ratio [AOR], 0.35; 95% confidence interval [CI], 0.17-0.74; p = 0.006) and a lower adjusted odds of surgery (AOR, 0.67; 95% CI, 0.0.48-0.93; p = 0.016) than their ATC counterparts. There were no differences in complication rates (AOR, 0.94; 95% CI, 0.57-1.55; p = 0.793) or length of stay longer than 4 days (AOR, 0.95; 95% CI, 0.61-1.48; p = 0.812) between the PTCs and ATCs. There were also differences in penetrating injury type between PTC and ATC. The adolescent penetrating trauma patient population treated at PTC had less surgery performed with improved mortality compared with ATC. Therapeutic, Level IV.

The effect of the Affordable Care Act on rates on inpatient rehabilitation hospital admission in a mature trauma system.

The beneficial effects of acute rehabilitation for trauma patients are well documented but can be limited because of insurance coverage. The Patient Protection and Affordable Care Act (ACA) went into effect on March 23, 2010. The ACA allowed patients who previously did not have insurance to be fully incorporated into the health system. We sought to analyze the likelihood of discharge to rehab for trauma patients before and after the implementation of the ACA. We hypothesized that there would be a higher rate of inpatient rehabilitation hospital (IRH) admission after the ACA was put into effect. The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for all trauma patients admitted to accredited trauma centers in Pennsylvania, who also had a functional status at discharge (FSD). Admission to an IRH was determined using discharge destination. Two categories were created to represent periods before and after ACA was implemented, 2003 to 2009 (pre-ACA) and 2010-2017 (post-ACA). A multilevel mixed-effects logistic regression model controlling for demographics, injury severity, and FSD assessed the adjusted impact of ACA implementation on IRH admissions. From the Pennsylvania Trauma Outcome Study query, 341,252 patients had FSD scores and of these patients, 47,522 (13.9%) were admitted to IRH. Patients who were severely injured were more likely to be admitted to IRH. Compared with FSD scores signifying complete independence at discharge, those with lower FSD had significantly increased odds of IRH admission. The odds of IRH admission post-ACA implementation significantly increased when compared with pre-ACA years (adjusted odds ratio, 1.14; 95% confidence interval, 1.12-1.17; p < 0.001; area under the receiver operating curve, 0.818). The implementation of the ACA significantly increased the likelihood of discharge to IRH for trauma patients. Care management, level III.

An analysis of outcomes and predictors of intensive care unit bouncebacks in a mature trauma system.

With the recent birth of the Pennsylvania TQIP Collaborative, statewide data identified unplanned admissions to the intensive care unit (ICU) as an overarching issue plaguing the state trauma community. To better understand the impact of this unique population, we sought to determine the effect of unplanned ICU admission/readmission on mortality to identify potential predictors of this population. We hypothesized that ICU bounceback (ICUBB) patients would experience increased mortality compared with non-ICUBB controls and would likely be associated with specific patterns of complications. The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2012 to 2015 for all ICU admissions. Unadjusted mortality rates were compared between ICUBB and non-ICUBB counterparts. Multilevel mixed-effects logistic regression models assessed the adjusted impact of ICUBB on mortality and the adjusted predictive impact of 8 complications on ICUBB. A total of 58,013 ICU admissions were identified from 2012 to 2015. From these, 53,715 survived their ICU index admission. The ICUBB rate was determined to be 3.82% (2,054/53,715). Compared with the non-ICUBB population, ICUBB patients had a significantly higher mortality rate (12% vs. 8%; p < 0.001). In adjusted analysis, ICUBB was associated with a 70% increased odds ratio for mortality (adjusted odds ratio, 1.70; 95% confidence interval, 1.44-2.00; p < 0.001). Adjusted analysis of predictive variables revealed unplanned intubation, sepsis, and pulmonary embolism as the strongest predictors of ICUBB. Intensive care unit bouncebacks are associated with worse outcomes and are disproportionately burdened by respiratory complications. These findings emphasize the importance of the TQIP Collaborative in identifying statewide issues in need of performance improvement within mature trauma systems. Epidemiological study, level III.

Assessing the role of urologists and general surgeons in the open repair of bladder injuries: Analysis of a large, statewide trauma database

Bladder injuries often occur in the setting of polytrauma, and if severe, may require open surgical repairs. We assess the role of urologists and general surgeons (GS) in the open surgical management of bladder injuries and their outcomes in a traumatic setting. Patients who underwent open bladder injury repair secondary to trauma from 2000 to 2017 by urology or GS were identified in the Pennsylvania Trauma Outcome Study database by International Classification of Diseases-9th Rev.-Clinical Modification procedure codes (57.19-57.93). Patient demographics, initial trauma assessment, length of hospital stay, associated complications, and mortality were evaluated. Urology management of a bladder injury was defined by documentation of a urologist in the operating room or urological consultation during the hospital stay. GS management was defined by documented bladder repair without urology involvement as described previously. Of 624,504 patients in the database, 701 met inclusion criteria (419 managed by urology, 282 by GS). The most commonly performed procedure was suturing of bladder lacerations (80.5%). On univariate analysis, GS was more likely to manage patients with penetrating injuries and those who required exploratory laparotomy less than 2 hours upon arrival. Urology was more likely to manage patients with concomitant pelvic fractures and higher Injury Severity Score (ISS). On multivariate analysis, higher ISS was predictive of urology management (odds ratio, 1.83; 95% confidence interval, 1.17-2.87, p = 0.008), while patients who required urgent exploratory laparotomy was predictive of GS management (odds ratio, 0.34; 95% confidence interval, 0.21-0.55, p < 0.001). Patients with concomitant pelvic fractures (n = 318) were also more likely to have higher ISS (p < 0.001) and were more likely to be managed by urology (odds ratio, 1.52; 95% confidence interval, 1.01-2.30, p = 0.046). Mortality, length of hospital stay, and complication rates were not significantly different between the two specialties and among individual procedures. Our study describes the landscape of traumatic bladder repairs between urology and GS. GS may maintain similar patient outcomes when managing select cases of traumatic bladder injuries in the absence of urologists. Therapeutic, level IV.

Development of clinical tracheostomy score to identify cervical spinal cord injury patients requiring prolonged ventilator support.

Cervical spinal cord injuries often necessitate ventilator support (VS). Prolonged endotracheal tube use has conveyed substantial morbidity in prospective study. Tracheostomy is recommended if VS is anticipated to be 7 days or longer, which defines prolonged ventilation (PV). Identifying these patients on arrival and before tracheostomy need is readily evident could prevent morbidity while lowering hospital costs. We aimed to create a tracheostomy score (trach score) to identify patients requiring PV and who could benefit from immediate tracheostomy. A review of patients with cervical spine fractures and cervical spinal cord injuries from 2005 to 2017 from the Pennsylvania Trauma Outcome Study database was performed. Patients were excluded for missing data, no use of VS or death in less than 7 days. Patients were selected for a training set or validation set by state identification number. We used automated forward stepwise selection to select a logistic model. Significant continuous variables were dichotomized to create a simplified screening score (trach score) and this was applied to the validation set. Needing ventilation for 7 or more days was positively associated with higher Injury Severity Scores having a complete or anterior injury, and having a motor cord injury from C1 to C4. Application of the logistic model to the validation data produced a receiver operating characteristic curve with area under the curve of 0.7712, with 95% confidence limit (CL) of 0.6943 to 0.8481. The validation receiver operating characteristic curve was statistically better than chance using a contrast test with χ with p value less than 0.01. In the validation set, a trach score of 0 correlated to 33% needing PV, a score of 1 with 67% needing PV, 2 with 85%, and 3 with 98%. Use of the trach score identified the majority of patients requiring prolonged VS in our study. An early tracheostomy protocol using predictive modeling could aid in reduction of intensive care unit length of stay and improving ventilator weaning in these patients. External verification of this predictive tool and of an early tracheostomy protocol is needed. This work is a retrospective prognostic cohort study and meets evidence Level III criteria.

The magic number: Are improved outcomes observed at trauma centers with undertriage rates below 5%?

The American College of Surgeons Committee on Trauma (ACSCOT) advises trauma centers maintain <5% undertriage rate (UTR), but provides limited rationale for this figure. We sought to determine whether patients managed at Level I/II trauma centers with a UTR less than 5% had improved outcomes compared with centers with greater than 5% UTR. We hypothesized that similar overall adjusted outcomes would be observed at trauma centers in Pennsylvania regardless of their compliance with ACSCOT undertriage recommendation. The Pennsylvania Trauma Outcome Study database was retrospectively queried for all trauma patients managed at accredited adult Level I/II trauma centers (n = 27) from 2003 to 2015. Patients with missing data on Injury Severity Score and/or Trauma Activation Status were excluded from the analysis. Institutional UTR were calculated for all trauma centers based on ACSCOT criteria (Injury Severity Score >15; no trauma activation) and were categorized into less than 5% or greater than 5% subgroups. A multilevel mixed-effects logistic regression model assessed the adjusted impact of management at centers with less than 5% undertriage. Statistical significance was set at p less than 0.05. A total of 404,315 patients from 27 trauma centers met inclusion criteria. Institutional UTRs ranged from 0% to 20.5%, with 15 centers exhibiting UTR less than 5% and 12 centers with UTR greater than 5%. No clinically meaningful difference in unadjusted mortality rate was observed between subgroups (<5% UTR: 5.19%; >5% UTR: 5.20%; p < 0.001). In adjusted analysis, no difference in mortality was found for patients managed at centers with less than 5% UTR compared to those with greater than 5% UTR (adjusted odds ratio, 1.06; 95% confidence interval, 0.85-1.33; p = 0.608). Achieving ACSCOT less than 5% undertriage standards appears to have limited impact on institutional mortality. Further research should seek to identify new triage criteria that can be uniformly applied to all trauma centers. Epidemiological study, level III.

An epidemiologic overview of 13 years of firearm hospitalizations in Pennsylvania

BackgroundGun violence is a controversial public health issue plagued by a lack of recent research. We sought to provide a 13-y overview of firearm hospitalizations in Pennsylvania, analyzing trends in mode, intent, and outcome. We hypothesized that no adjusted change in mortality or functional status at discharge (FSD) would be observed for gunshot wound (GSW) victims over the study period. MethodsAll admissions to the Pennsylvania Trauma Outcome Study database from 2003 to 2015 were queried. GSWs were identified by external cause-of-injury codes. Collected variables included patient demographics, firearm type, intent (assault and attempted suicide), FSD, and mortality. Multilevel mixed-effects logistic regression models and ordinal regression analyses using generalized linear mixed models assessed the impact of admission year (continuous) on adjusted mortality and FSD score, respectively. Significance was set at P < 0.05. ResultsOf the 462,081 patients presenting to Pennsylvania trauma centers from 2003 to 2015, 19,342 were GSWs (4.2%). Handguns were the most common weapon of injury (n = 7007; 86.7%) among cases with specified firearm type. Most GSWs were coded as assaults (n = 15,415; 79.7%), with suicide attempts accounting 1866 hospitalizations (9.2%). Suicide attempts were most prevalent among young and middle-aged white males, whereas assaults were more common in young black males. Rates of firearm hospitalizations decreased over time (test of trend P = 0.001); however, admission year was not associated with improved adjusted survival (adjusted odds ratio: 0.99, 95% confidence interval: 0.97-1.01; P = 0.353) or FSD (adjusted odds ratio: 0.99, 95% confidence interval: 0.98-1.00; P = 0.089) while controlling for demographic and injury severity covariates. ConclusionsTemporal trends in outcomes suggest rates of firearm hospitalizations are declining in Pennsylvania; however, outcomes remain unchanged. To combat this epidemic, a multidisciplinary, demographic-specific approach to prevention should be the focus of future scientific pursuits.

Lawnmowers Versus Children: The Devastation Continues.

Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children. We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved? This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old. The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type. The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children. Level IV, therapeutic study.