Pennsylvania Trauma Systems Foundation Research Articles

436 Use of Ventriculostomy for Severe Traumatic Brain Injury Is Associated With Reduced Mortality Compared to Intraparenchymal Monitor Use: A Propensity Score-Matched Analysis

INTRODUCTION: There is a lack of data on whether intracranial pressure (ICP)-guided therapy with an intraparenchymal fiberoptic monitor (IPM) or an external ventricular drain (EVD) leads to superior mortality outcomes. METHODS: Retrospective analysis of patients with severe TBI that required IPM or EVD placement for ICP-guided therapy from 1/1/2010-12/31/2020. The data was obtained from the Pennsylvania Trauma Systems Foundation (PTSF) registry. RESULTS: A total of 2,305 patients met the inclusion criteria with 1,048 (45.5%) IPM and 1,257 (54.5%) EVD placed. A craniectomy was performed in 47.0% of the patients in the IPM cohort and 66.0% of the EVD cohort (p < 0.001). Multivariable logistic regression analysis showed that older age (OR 1.03, p < 0.001), decreasing GCS score (OR 1.16, p < 0.001), requiring craniectomy (OR 1.22, p = 0.049), and an IPM (OR 1.40, p = 0.001) were significant predictors of mortality. A propensity score-matched analysis was performed, adjusting the cohorts for age, gender, race, GCS, ISS, and craniotomy. EVD use is associated with a significant 28% decrease in inpatient mortality when compared to IPM (OR 0.72, p < 0.001). Hospital length of stay was also significantly shorter in the EVD cohort (OR 0.86, p = 0.03). CONCLUSIONS: A significant decrease in mortality was associated with the use of EVD in comparison to IPM based on our propensity score-matched analysis. Further investigation.

Intoxication and Glasgow coma scale scores in patients with head trauma

IntroductionThe Glasgow Coma Scale (GCS) is an assessment tool commonly used by emergency department (ED) clinicians to objectively describe level of consciousness, especially in trauma patients. This study aims to assess the effect of drug and alcohol intoxication on GCS scores in cases of traumatic head injury. MethodsIn this retrospective chart review study, data were extracted from The Pennsylvania Trauma Systems Foundation Data Base Collection System. Eligible subjects included trauma patients aged 18 years and older, with head trauma, who presented between January 2019 and August 2023. Subjects were matched to controls who did not test positive for drugs or alcohol, matched by Injury Severity Score (ISS) category. ResultsAmong 1088 subjects, the mean age was 63 (95% CI 62–64). The mean Injury Severity Score was 21 (95% CI 21–22). The median GCS among all subjects was 14 (IQR 6–15). Cases with alcohol or drug use were matched to controls without alcohol or drug use, and were matched by categories of Injury Severity Score. Cases with alcohol or drug use had lower GCS (median 13; IQR 3–15), compared to cases without alcohol or drug use (median 15; IQR 13–15) (p < 0.0001, Wilcoxon Rank Sum Test). ConclusionsAmong patients with head trauma, intoxicated patients had statistically significant lower GCS scores as compared to matched patients with similar Injury Severity Scores.

Age-Adjusted Modified Frailty Index: Association With Hip Fracture Discharge Functional Dependence

IntroductionHip fractures are a common traumatic injury that carry significant morbidity and mortality, and prognostication of functional outcome is becoming increasingly salient. Across multiple surgical specialties, the five-item and 11-item Modified Frailty Index (mFI-5 and mFI-11) have been found to be convenient, quick, and sensitive tools for identifying patients at risk for perioperative complications. A prior study described the superiority of an Age-Adjusted Modified Frailty Index (aamFI) for predicting perioperative complications compared to the mFI-5 in an elective hip surgery. We sought to externally validate the aamFI in a multicenter hip fracture cohort and hypothesize that these risk scores would not only predict functional dependence (FD) at discharge, but that the aamFI would outperform the mFI-5 and mFI-11. MethodsThe Pennsylvania Trauma Systems Foundation registry was queried from 2010 to 2020 for CPT codes, ICD-9 and ICD-10 codes pertaining to hip fracture patients. Patients with missing locomotion and transfer mobility data were excluded. FD status was determined by discharge locomotion and transfer mobility scores per existing methodology. Univariable and Multivariable analysis as well as receiver operator characteristic curves were used to evaluate and compare the three indices for prediction of functional status at discharge. P value < 0.05 was considered significant. ResultsTwelve thousand seven hundred and forty patients met inclusion criteria (FD: 8183; functional independent 4557). On univariable logistic regression analysis, the mFI-11 (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.47-1.58, P < 0.05), mFI-5 (OR 1.57, 95% CI 1.51-1.63), and aamFI (OR 1.57, 95% CI 1.52-1.62, P < 0.05) were associated with FD. On multivariable logistic regression analysis for predictors of FD, when controlling for age (for the mFI-11 and mFI-5), sex, injury severity score, and admission vitals (systolic blood pressure and respiratory rate), higher mFI-11 and mFI-5 scores independently predicted FD at discharge (OR 1.23, 95% CI 1.18-1.28, P < 0.05 and OR 1.23, 95% CI 1.18-1.29P < 0.05 respectively). Higher aaMFI scores had superior association with functional dependence (OR 1.59, 95% CI 1.54-1.64, P < 0.05). Receiver operator characteristic curves for the mFI-11, mFI-5, and aaMFI showed comparable diagnostic strength (area under curve [AUC] = 0.63 95% CI 0.62-0.64, P < 0.05; AUC = 0.63 95% CI 0.62-0.64, P < 0.05; and AUC = 0.67 95% CI 0.65-0.67, P < 0.05 respectively). ConclusionsThe mFI-11, mFI-5, and aamFI are predictive of functional outcome following hip fracture. By including age, the aamFI retains the ease of use of the mFI-5 while improving its prognostic utility for functional outcome.

Comparison of 5-Item and 11-Item Modified Frailty Index as Predictors of Functional Independence in Patients With Spinal Cord Injury.

Retrospective Cohort Study. The 11-item modified Frailty index (mFI-11) by the ACS-NSQIP database was used to predict which patients are high risk for complications and inpatient mortality. ACS-NSQIP now has switched to the 5-item MFI. However, there are no studies on how these frailty indices fare against each other and their prognostic value of functional independence in patients with spinal cord injury (SCI). To compare the mFI-5 and mFI-11 in order to standardize frailty assessment in the SCI population. Retrospective analysis of 272,174 patients with SCI from 2010 to 2020 from the Pennsylvania Trauma Systems Foundation (PTSF) registry. Multivariable logistic regression was used to determine the predictive value of mFI for functional independence as determined by locomotion and transfer mobility. A total of 1907 patients were included with a mean age of 46.9 ± 15.1years. The 3 most common MFI factors were hypertension (32.2%), diabetes mellitus (13.7%) and chronic obstructive pulmonary disease (8.5%). Multivariable logistic regression analyses using MFI-5 and MFI-11 showed that a higher frailty score in MFI-5 (OR 1.375, P < .001) and in MFI-11 (OR 1.366, P < .001) were each predictive of poor functional status at discharge. ROC curves for the MFI-5 (AUC = .818, P < .001) and MFI-11 (AUC = .819, P < .001) demonstrated excellent diagnostic accuracy. The new MFI-5 is equivalent to its predecessor, the MFI-11, and predictive of functional outcomes in patients with SCI. MFI-5 can serve as the preferred frailty index at the point of care and in research contexts.

Ventriculostomy Associated with Reduced Mortality in Severe Traumatic Brain Injury Compared to Parenchymal ICP Monitoring: A Propensity Score–Adjusted Analysis

There is a lack of data on whether intracranial pressure (ICP)-guided therapy with an intraparenchymal fiberoptic monitor (IPM) or an external ventricular drain (EVD) leads to superior outcomes. Our goal is to determine the relationship between ICP-guided therapy with an EVD or IPM and mortality. Retrospective analysis of severe traumatic brain injury cases that required IPM or EVD placement for ICP-guided therapy from January 1, 2010 to December 31, 2020. The data were obtained from the Pennsylvania Trauma Systems Foundation registry. A total of 2305 patients met the inclusion criteria, with 1048 (45.5%) IPM and 1257 (54.5%) EVD placed. Inpatient mortality occurred in 337 (32.2%) and 334 (26.6%) patients in the IPM and EVD cohorts, respectively (P= 0.003). Even among those treated medically only, inpatient mortality occurred in 171 (30.8%) of those with an IPM and in 100 (23.4%) of those with an EVD (P= 0.010). Multivariable logistic regression analysis showed that older age (odds ratio [OR] 1.03, P < 0.001), lower Glasgow Coma Scale (GCS) score (OR 1.16, P < 0.001), requiring surgery (OR 1.22, P= 0.049), and an IPM (OR 1.40, P= 0.001) were significant predictors of mortality. Propensity score-adjusted analysis using inverse probability of treatment weighted method revealed a 28% decrease in mortality and a 14% decrease in length of hospital stay with EVD use when adjusting for age, sex, GCS, Injury Severity Score, surgery, and Hispanic ethnicity. A significant mortality benefit was associated with the use of EVD compared to IPM. This mortality benefit was observed regardless of whether patients required surgery or not.

Association of Prehospital Transfusion With Mortality in Pediatric Trauma

Optimal hemostatic resuscitation in pediatric trauma is not well defined. To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children. This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023. Receipt of a blood product transfusion in the prehospital setting compared with the emergency department. The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications. Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10). In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.

Time Passages.

In 1978, singer–songwriter Al Stewart produced the song Time Passages (Stewart, 1978). The single spent 10 weeks at number one on the U.S. Billboard Easy Listening chart, the longest song to hold the title for the entire decade (Stewart, 1978). The lyrics are about the power of memory. It allows the listener to identify with the concept of enjoying recollections of the past, while remaining excited about the present and future. As pleasant and comforting as memories may be, the promise of future-focused vision drives one forward. The Society of Trauma Nurses (STN) applied the Time Passages song meaning during the development of the 2022–2024 strategic plan, which was approved at TraumaCon in Denver, CO, during the annual membership meeting. STN finds comfort in recalling amazing memories and accomplishments that built the foundation for our success, and we are able, with excitement, to be future-focused and plan for goals to continue to advance our organization. I can apply the message of Time Passages to my tenure as STN's 26th President. This time was the most exciting time of my professional career. I have made eternal and heartfelt memories, and, yet, I am extremely enthusiastic about STN's future. As honored as I was to be the President, I am as thrilled by passing the role and responsibilities onto Linda Reinehart, STN's 27th President. The 2022 TraumaCon Presidential Address was titled “It's About Time.” In this message, I discussed the concepts of the past, the present, and the future. Referencing the song Seasons of Love from Jonathan Larson's musical Rent, I asked the audience “How do you measure a year in your life?” (Larson, 2008). The song repeats the lyrics of 525,600 min, alluding to the number of minutes in a year (Larson, 2008). It encourages the listener to make the most of the minutes we are given. I promised STN, as President, I would do my best to apply this principle and challenged the membership to do the same. As I am writing my last Journal of Trauma Nursing's Presidential Message, I wonder if I made the most of my minutes. There were many personal STN Presidential highlights, including attending TraumaCon22 and 23, Board Meetings, Committee Meetings, Special Interest Groups (SIGs), the Pan American Trauma Congress, the All Levels Trauma Conference, and collaborating with other professional organizations. Ironically, as important as these more formal events were, some of the other moments that stick out in my mind were sitting with a colleague, in sincere appreciation, as she shared her experience of providing nursing services in Ukraine, and another time when I communicated with an STN friend to let him know I was proud of the work he was doing. Things such as this, although on a much smaller stage, seem to weigh equally on my memory evaluation scale. When reviewing the accomplishments of STN's year, we can quickly determine that the members also made the most of their minutes. Highlights include the publication of the diversity, equity and inclusion (DEI) statement, the first STN/EAST monthly literature review takeover, the evolution of the geriatric SIG to a full committee, the launching of the Pediatric Trauma Across the Care Continuum (PTACC) Course, the revision of the TOPIC and Rural TOPIC curriculums, the position statement on gun violence, and the past presidents' statement regarding the role and qualifications of a Trauma Program Manager, which represent just some of the amazing work. When I think about all of these accomplishments for a volunteer organization, I wonder how we ever found the time to get it all done, and, yet, knowing the dedication of the volunteers, it is comprehensible. The final lyric in the song Time Passages is “buy me a ticket on the last train home tonight” (Stewart, 1978). This translates into not only trying to prolong the act of leaving the warmth of fond memories but also finding comfort in knowing the destination is home. It is time for me to get my ticket home and end this Presidential term. I would like to take every moment of time to savor these past few minutes and then be on the last train home. I must thank the Pennsylvania Trauma Systems Foundation, my employer, for their amazing support this year, allowing me to be present in my STN minutes. Thank you to the STN Board, staff, Committee Chairs, SIG Chairs, and the entire membership for allowing me to grow with the organization and for the honor to represent our professional home, filled with dedicated people. Thank you all for rising to the challenge of making your minutes count. Thank you for reminiscing about the past, working hard in the present, and being future-focused. Here is to getting a ticket home and riding into the sunset of time passages. After all, it's about time.

766 Use of Ventriculostomy for Severe Traumatic Brain Injury Significantly Reduces Mortality Compared to Intraparenchymal Monitor Use

INTRODUCTION: There is a lack of data on whether intracranial pressure (ICP)-guided therapy with an intraparenchymal fiberoptic monitor (IPM) or an external ventricular drain (EVD) leads to superior outcomes. Given the lack of consensus on whether an EVD or an IPM monitor should be preferentially used if both are feasible options, there is a pressing need to determine which modality leads to more effective ICP-guided therapy while also minimizing the procedure-related complications. METHODS: Retrospective analysis of severe TBI that required IPM or EVD placement for ICP-guided therapy from 1/1/2010-12/31/2020. The data was obtained from the Pennsylvania Trauma Systems Foundation (PTSF) registry. RESULTS: A total of 2,305 patients met the inclusion criteria with 1,048 (45.5%) IPM and 1,257 (54.5%) EVD placed. A craniectomy was performed in 47.0% of the patients in the IPM cohort and 66.0% of the EVD cohort (p &lt; 0.001). Multivariable logistic regression analysis showed that older age (OR 1.03, p &lt; 0.001), decreasing GCS score (OR 1.16, p &lt; 0.001), requiring craniectomy (OR 1.22, p = 0.049), and an IPM (OR 1.40, p = 0.001) were significant predictors of mortality. Among those treated medically only, inpatient mortality occurred in 171 (30.8%) of those with an IPM and in 100 (23.4%) of those with an EVD (p = 0.010); the EVD conferred significant mortality benefit (30% decrease, p = 0.005) when controlling for age and admission GCS. CONCLUSIONS: The lack of consensus on whether IPM monitor or EVD is more effective leads to ambiguity in the treatment of patients with severe TBI. Our study demonstrates a significant improvement in mortality was associated with the use of EVD in comparison to IPM. This mortality benefit was seen in patients who underwent decompressive hemicraniectomy as well as those who did not.

Falls from Tree Stands Have Become the Leading Cause of Deer Hunting Accidents in Pennsylvania.

This study aimed to describe, using a statewide trauma registry, the incidence, trends, and injuries for tree stand falls while deer hunting in Pennsylvania. Falls from tree stands were abstracted from the Pennsylvania Trauma Systems Foundation registry (1990-2017) and combined with the number of licensed deer hunters, deer hunting days, and deer hunting-related shooting incidents (HRSIs) provided by the Pennsylvania Game Commission to calculate tree stand fall and HRSI rates (per 1 million deer hunting days) and age-group specific fall rates (per 100,000 licensed deer hunters). Poisson regression was used to assess the significance of the annual and age group rate trends (significance P < 0.05). Case fatality rate (percentage of number of deaths per number of injured hunters) also was calculated. There were 1229 victims of tree stand falls and 560 victims of HRSIs between 1990 and 2017. Fall rates increased from 1.5 to 10.4 (P < 0.0001), and HRSI rates decreased from 4.9 to 1.2 (P = 0.001). Fall rates surpassed HRSI rates in 1999 and increased with advancing age (P = 0.007), peaking at 7.2 for hunters aged 50 to 59 years. Most (77%) injured hunters sustained multiple injuries. The case fatality rate was only 0.8%, but 26% of the injured hunters had a dependent functional limitation at hospital discharge. Tree stand falls are now the leading cause of Pennsylvania deer hunting accidents. Fall victims usually sustain multiple nonfatal but often disabling injuries. Study findings support the need for surveillance of these accidents and additional tree stand safety education.

Coming in hot: Police transport and prehospital time after firearm injury.

In Philadelphia, PA, police and emergency medical services (EMS) transport patients with firearm injuries. Prior studies evaluating this system have lacked reliable prehospital times. By linking police and hospital data sets, we established a complete timeline from firearm injury to outcome. We hypothesized that police-transported patients have shorter prehospital times that, in turn, are associated with improved survival and increased unexpected survivorship at 6 and 24 hours. This retrospective study linked patient-level data from OpenDataPhilly Shooting Victims and the Pennsylvania Trauma Systems Foundation. All adults transported to a Level I or II trauma center after firearm injury in Philadelphia from 2015 to 2018 were included. Patient-level characteristics were compared between cohorts; unexpected survivors were identified using Trauma Score-Injury Severity Score. Multiple regression estimated risk-adjusted associations between transport method, prehospital time, and outcomes. Police-transported patients (n = 977) had significantly shorter prehospital times than EMS-transported patients (n = 320) (median, 9 minutes [interquartile range, 7-12 minutes] vs. 21 minutes [interquartile range, 16-29 minutes], respectively; p < 0.001). Police-transported patients were more often severely injured than those transported by EMS (60% vs. 50%, p = 0.002). After adjusting for confounders, police-transported patients had improved survival relative to EMS on hospital arrival (87% vs. 84%, respectively, p = 0.035), but not at 6 hours (79% vs. 78%, respectively, p = 0.126) or 24 hours after arrival (76% vs. 76%, respectively, p = 0.224). Compared with EMS, police-transported patients were significantly more likely to be unexpected survivors at 6 hours (6% vs. 2%, respectively, p < 0.001) and 24 hours (3% vs. 1%, respectively, p = 0.021). Police-transported patients had more severe injuries, shorter prehospital times, and increased likelihood of unexpected survival compared with EMS-transported patients. After controlling for confounders, patient physiology and injury severity represent meaningful determinants of mortality in our mature trauma system, indicating an ongoing opportunity to optimize in-hospital care. Future studies should investigate causes of death among unexpected early survivors to mitigate preventable mortality. Prognostic/Epidemiological, Level III.

The effect of COVID-19 on adult traumatic orthopedic injuries: a database study.

PurposeThis study compares orthopedic injuries, procedures, and hospital outcomes of patients presenting to trauma centers in Pennsylvania before and during the COVID-19 pandemic.MethodsA retrospective review of adult patients presenting to hospitals with Pennsylvania Trauma Systems Foundation (PTSF) designations was performed. All patients 18 years of age and older who presented with orthopedic injuries were included. Demographic information, injury and hospital stay details, and mortality were reviewed. Data were compared between the cohorts of patients presenting during April 2020 (COVID cohort) and April 2017, April 2018, and April 2019 (pre-COVID cohort).ResultsOverall, 14,858 patients were reviewed, and 9427 patients were included in this study. There were fewer orthopedic injuries (4868 vs. 6603 yearly mean) in the COVID cohort which led to fewer procedures (1763 vs. 2329 yearly mean). The COVID cohort had a significantly shorter mean hospital length of stay compared to the pre-COVID cohort (4.7 days versus 5.2 days, p = 0.01). A higher mortality rate was seen in the COVID cohort (n = 115, 6.1%) compared to the pre-COVID cohort (n = 305, 4.0%; p < 0.01).ConclusionThe characteristics of orthopedic injuries sustained by patients presenting to trauma centers during the COVID pandemic were not different from prior to the pandemic. However, there were decreases in the number of orthopedic injuries and procedures accompanied by a 50% increase in mortality seen in these patients during the pandemic. Resources should be appropriately marshalled to prevent rises in-hospital mortality for patients with orthopedic trauma treated during a pandemic.Level of evidenceLevel III.

Virtual Trauma Center Surveys, Are They Virtually the Same?

The coronavirus pandemic forced regulatory agencies to develop innovative methods for achieving regulatory compliance. The accrediting body for trauma centers in Pennsylvania, the Pennsylvania Trauma Systems Foundation (PTSF), was one of the many agencies forced to find creative and safe ways to maintain prepandemic processes of evaluating trauma centers for compliance with trauma standards. With the uncertainty of government and hospital regulations prohibiting on-site participation and precautionary efforts to protect the health and well-being of survey participants, a virtual site visit survey process was developed to facilitate trauma center accreditation within the Commonwealth of Pennsylvania. The purpose of this article is to describe an accrediting body's experience with implementing a virtual accreditation site visit survey process for Level I and II trauma centers. In 2021, the PTSF piloted the virtual survey process and completed two virtual accreditation surveys. Feedback from participants included both positive and negative responses. The virtual format was effective in maintaining a high-quality accreditation process. However, multiple downsides were identified, including loss of interactive participation, loss of collaboration, limited educational opportunities, and increased presurvey workload for all participants. The in-person and virtual formats can accomplish the goal of the accreditation survey. The negative implications identified suggest that a traditional on-site accreditation process is preferred, with the virtual format reserved for extenuating circumstances.

The Effect of COVID-19 on Pediatric Traumatic Orthopaedic Injuries: A Database Study.

Introduction:Stay-at-home orders and other social distancing restrictions had a profound effect on the lives of children during the pandemic. This study characterizes pediatric orthopaedic injuries and in-hospital outcomes during the COVID-19 pandemic and compares them with pre-COVID patterns.Methods:A retrospective review of pediatric patients presenting to hospitals with Pennsylvania Trauma Systems Foundation designations was performed. All patients younger than 18 years who presented with orthopaedic injuries were included. Patient demographics, injuries, hospital stays, and mortality were compared between the COVID and pre-COVID cohorts.Results:Overall, 1112 patients were included. During the pandemic, more injuries occurred at home (44.7% versus 54.9%, P = 0.01) and fewer at sporting areas, parks, and pools (7.8% versus 1.6%, P < 0.01) as well as at schools (3.4% versus 0.5%, P = 0.03). Injuries caused by child abuse were more prevalent during the pandemic (5.6% versus 11.0%, P < 0.01). Finally, the COVID cohort had a longer mean hospital length of stay (3.1 versus 2.4 days, P = 0.01), higher mean number of ICU days (1.0 versus 0.7 days, P = 0.02), and higher mortality rate (3.8% versus 1.3%, P = 0.02).Discussion:Pediatric patients sustained injuries in differing patterns during the pandemic, but these led to worse hospital outcomes, including higher mortality rates.

Impact of Coronavirus Disease 2019 Shutdown on Neurotrauma Volume in Pennsylvania

ObjectiveThe 2020 coronavirus disease 2019 (COVID-19) pandemic resulted in state-specific quarantine protocols and introduced the concept of social distancing into modern parlance. We assess the impact of the COVID-19 pandemic on neurotrauma presentations in the first 3 months after shutdown throughout Pennsylvania.MethodsThe Pennsylvania Trauma Systems Foundation was queried for registry data from the Pennsylvania Trauma Outcomes Study between March 12 and June 5 in each year from 2017 to 2020.ResultsAfter the COVID-19 shutdown, there was a 27% reduction in neurotrauma volume, from 2680 cases in 2017 to 2018 cases in 2020, and a 28.8% reduction in traumatic brain injury volume. There was no significant difference in neurotrauma phenotype incurred relative to total cases. Injury mechanism was less likely to be motor vehicle collision and more likely caused by falls, gunshot wound, and recreational vehicle accidents (P < 0.05). Location of injury was less likely on roads and public locations and more likely at indoor private locations (P < 0.05). The proportion of patients with neurotrauma with blood alcohol concentration >0.08 g/dL was reduced in 2020 (11.4% vs. 9.0%; P < 0.05). Mortality was higher during 2020 compared with pre-COVID years (7.7% vs. 6.4%; P < 0.05).ConclusionsDuring statewide shutdown, neurotrauma volume and alcohol-related trauma decreased and low-impact traumas and gunshot wounds increased, with a shift toward injuries occurring in private, indoor locations. These changes increased mortality. However, there was not a change in the types of injuries sustained.

A comprehensive analysis of undertriage in a mature trauma system using geospatial mapping.

The correct triage of trauma patients to trauma centers (TCs) is essential. We sought to determine the percentage of patients who were undertriaged within the Pennsylvania (PA) trauma system and spatially analyze areas of undertriage (UTR) in PA for all age groups: pediatric, adult, and geriatric. We hypothesized that there would be certain areas that had high UTR for all age groups. From 2003 to 2015, all admissions from the Pennsylvania Trauma Systems Foundation registry and those meeting trauma criteria (International Classification of Diseases, Ninth Diseases: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Admissions were divided into age groups: pediatric (<15 years), adult (15-64 years), and geriatric (≥65 years). All pediatric trauma cases were included from the Pennsylvania Trauma Systems Foundation and PHC4 registry, while only cases with Injury Severity Score of >9 were included in adult and geriatric age groups. Undertriage was defined as patients not admitted to level I/II adult TCs (n = 24), pediatric (n = 3), or adult and pediatric combined facility (n = 3) divided by the total number of patients from the PHC4 database. ArcGIS Desktop (version 10.7; ESRI, Redlands, CA) and GeoDa (version 1.14.0; CSDS, Chicago, IL) open source license were used for geospatial mapping of UTR with a spatial empirical Bayesian smoothed UTR by zip code tabulation area (ZCTA) and Stata (version 16.1; Stata Corp., College Station, TX) for statistical analyses. There were significant percentages of UTR for all age groups. One area of high UTR for all age groups had TCs and large nontrauma centers in close proximity. There were high rates of UTR for all ages in rural areas, specifically in the upper central regions of PA, with limited access to TCs. It appears there are two patterns leading to UTR. The first is in areas where TCs are in close proximity to large competing nontrauma centers, which may lead to inappropriate triage. The second has to do with lack of access to TCs. Geospatial mapping is a valuable tool that can be used to ascertain where trauma systems should focus scarce resources to decrease UTR. Epidemiological, level III; Care management, level III.

Disparities in rural versus urban field triage: Risk and mitigating factors for undertriage.

There are well-known disparities for patients injured in rural setting versus urban setting. Many cite access to care; however, the mechanisms are not defined. One potential factor is differences in field triage. Our objective was to evaluate differences in prehospital undertriage (UT) in rural setting versus urban settings. Adult patients in the Pennsylvania Trauma Outcomes Study (PTOS) registry 2000 to 2017 were included. Rural/urban setting was defined by county according to the Pennsylvania Trauma Systems Foundation. Rural/urban classification was performed for patients and centers. Undertriage was defined as patients meeting physiologic or anatomic triage criteria from the National Field Triage Guidelines who were not initially transported to a Level I or Level II trauma center. Logistic regression determined the association between UT and rural/urban setting, adjusting for transport distance and prehospital time. Models were expanded to evaluate the effect of individual triage criteria, trauma center setting, and transport mode on UT. There were 453,112 patients included (26% rural). Undertriage was higher in rural patients (8.6% vs. 3.4%, p < 0.01). Rural setting was associated with UT after adjusting for distance and prehospital time (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.82-6.78; p < 0.01). Different triage criteria were associated with UT in rural/urban settings. Rural setting was associated with UT for patients transferred to an urban center (OR, 3.32; 95% CI, 1.75-6.25; p < 0.01), but not a rural center (OR, 0.68; 95% CI, 0.08-5.53; p = 0.72). Rural setting was associated with UT for ground (OR, 5.01; 95% CI, 2.65-9.46; p < 0.01) but not air transport (OR, 1.18; 95% CI, 0.54-2.55; p = 0.68). Undertriage is more common in rural settings. Specific triage criteria are associated with UT in rural settings. Lack of a rural trauma center requiring transfer to an urban center is a risk factor for UT of rural patients. Air medical transport mitigated the risk of UT in rural patients. Provider and system interventions may help reduce UT in rural settings. Care Management, Level IV.

Femur, Tibia, and Fibula Fractures Secondary to Youth Soccer: A Descriptive Study and Review of the Literature.

ObjectivesSoccer is the most popular sport in the world and is one of the top sports with increased participation. Despite the vast and increasing numbers of soccer players, limited data are available on pediatric lower extremity injuries. In particular, the purpose of the study is to describe the epidemiology of femur, tibia, and fibula fractures secondary to youth soccer.MethodsA retrospective review concerning soccer-related femur, tibia, and fibula fractures was conducted in children under the age of 18 years from January 1, 2000 to December 31, 2015 with statewide data from the Pennsylvania Trauma Systems Foundation (PTSF), Mechanicsburg, PA.ResultsA total of 258 youth soccer players were admitted for femur, tibia, and fibula fractures from 2000 to 2015. These fractures constituted 33% of soccer-related injuries in youth admitted at trauma centers. Sixty-five percent of the fractures involved the tibia and 34% involved the femur. Body contact injury resulted in 54% of the fractures and non-body contact injury resulted in 46% of the fractures. Athletes the age of 13 and older sustained 67% of the fractures and were more likely to incur contact injuries (p-value=0.000041) than those less than 13. Males sustained 67% of the fractures, and gender was not associated with the mechanism of injury (p-value=0.43). Open fractures included 10% of tibia fractures and did not occur in femur fractures. The growth plate was involved in 24% of the femur fractures and 17% of the tibia fractures.ConclusionYouth soccer has the potential for serious femur, tibia, and fibula fractures. Intervention programs should aim at reducing non-body contact mechanism in children < 13 years of age and body contact mechanism in children ≥ 13 years of age. Further research should investigate injury prevention methods such as potentially reducing body contact mechanism by improving the effectiveness of shin guards.

The geriatric trauma patient: A neglected individual in a mature trauma system.

Those older than 65 years represent the fastest growing demographic in the United States. As such, their care has been emphasized by trauma entities such as the American College of Surgeons Committee on Trauma. Unfortunately, much of that focus has been of their care once they reach the hospital with little attention on the access of geriatric trauma patients to trauma centers (TCs). We sought to determine the rate of geriatric undertriage (UT) to TCs within a mature trauma system and hypothesized that there would be variation and clustering of the geriatric undertriage rate (UTR) within a mature trauma system because of the admission of geriatric trauma patient to nontrauma centers (NTCs). From 2003 to 2015, all geriatric (age >65 years) admissions with an Injury Severity Score of greater than 9 from the Pennsylvania Trauma Systems Foundation (PTSF) registry and those meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Undertriage rate was defined as patients not admitted to TCs (n = 27) divided by the total number of patients as from the PHC4 database. The PHC4 contains all inpatient admissions within Pennsylvania (PA), while PTSF reports admissions to PA TCs. The zip code of residence was used to aggregate calculations of UTR as well as other aggregate patient and census demographics, and UTR was categorized into lower, middle box, and upper quartiles. ArcGIS Desktop: Version 10.7, ESRI, Redlands, CA and GeoDa: Version 1.14.0, Open source license were used for geospatial mapping of UT with a spatial empirical Bayesian smoothed UTR, and Stata: Version 16.1, Stata Corp., College Station TX was used for statistical analyses. Pennsylvania Trauma Systems Foundation had 58,336 cases, while PHC4 had 111,626 that met the inclusion criteria, resulting in a median (Q1-Q3) smoothed UTR of 50.5% (38.2-60.1%) across PA zip code tabulation areas. Geospatial mapping reveals significant clusters of UT regions with high UTR in some of the rural regions with limited access to a TC. The lowest quartile UTR regions tended to have higher population density relative to the middle or upper quartile UTR regions. At the patient level, the lowest UTR regions had more racial and ethnic diversity, a higher injury severity, and higher rates of treatment at a TC. Undertriage rate regions that were closer to NTCs had a higher odds of being in the upper UTR quartile; 4.48 (2.52-7.99) for NTC with less than 200 beds and 8.53 (4.70-15.47) for NTC with 200 beds or greater compared with zip code tabulation areas with a TC as the closest hospital. There are significant clusters of geriatric UT within a mature trauma system. Increased emphasis needs to focus prehospital on identifying the severely injured geriatric patient including specific geriatric triage protocols. Epidemiological, Level III.

Statewide Trends in Intracranial Pressure Monitor Use in 36,915 Patients with Severe Traumatic Brain Injury in a Mature Trauma System over the Past 18 Years

Intracranial pressure (ICP)-guided therapy has been the mainstay of treatment of patients with severe traumatic brain injury (TBI), but recent data have questioned its efficacy. The aim of this study was to demonstrate trends in compliance to TBI guidelines and use of ICP-guided care in a mature trauma system. A retrospective analysis was conducted of 36,915 patients with severe TBI collected by the Pennsylvania Trauma Systems Foundation. The registry includes all patients >18 years old with a diagnosis of TBI with a Glasgow Coma Scale score ≤8 who were admitted from January 2000 to December2017. Of 36,915 patients, 73.6% were men with a median age of 43.0 ± 21.3 years. An ICP monitor was placed in 16.3% of all patients. The rate of ICP monitoring ranged from 17.8% of patients in 2000-2004 to 16.7% in 2005-2009, 16.4% in 2010-2014, and 12.8% in 2015-2017 (P< 0.001). The most statistically significant decrease was noted from 2014 (16.4%) to 2015 (14.1%, P= 0.042). The percent decrease in ICP monitoring from 2000-2014 to 2015-2017 was equivalent for patients with Glasgow Coma Scale scores of 3-5 (-4.0%) and 6-8 (-4.5%). As studies emerged that demonstrated unclear benefit of ICP monitoring in improving care in patients with severe TBI, there was a significant statewide decline in the use of ICP monitoring after 2014 among all TBI subpopulations despite noteworthy limitations in the aforementioned studies and clear recommendations from the Brain Trauma Foundation guidelines.

A preliminary analysis of Level IV trauma centers within an organized trauma system.

The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared preaccreditation to postaccreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. The Pennsylvania Trauma Systems Foundation collects predesignation and postdesignation data from hospitals pursuing accreditation. Data from Pennsylvania Trauma Systems Foundation between 2012 and 2017 were analyzed. Variables of interest included patient demographics, injury severity, mortality, and incidence of surgical interventions precredentialingto postcredentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania. Five hospitals underwent Level IV credentialing from 2012 to 2017, providing data on 5,076 cases (pre, 2,395 [47.2%]; post, 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed preaccreditation to postaccreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p < 0.014) and adjusted analyses (adjusted odds ratios, 1.13, p = 0.389). There was a trend toward reduced odds of mortality postcredentialing (adjusted odds ratios, 0.59, p = 0.261). Major surgical intervention decreased (Pre, 0.42%; Post, 0.04%; p = 0.004). Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. Prognostic and epidemiological, level III.