Pennsylvania Trauma Systems Foundation Research Articles

An analysis of pediatric trauma center undertriage in a mature trauma system.

Improved mortality as a result of appropriate triage has been well established in adult trauma and may be generalizable to the pediatric trauma population as well. We sought to determine the overall undertriage rate (UTR) in the pediatric trauma population within Pennsylvania (PA). We hypothesized that a significant portion of pediatric trauma population would be undertriaged. All pediatric (age younger than 15) admissions meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database and the Pennsylvania Trauma Systems Foundation (PTSF) registry. Undertriage was defined as patients not admitted to PTSF-verified pediatric trauma centers (n = 6). The PHC4 contains inpatient admissions within PA, while PTSF only reports admissions to PA trauma centers. ArcGIS Desktop was used for geospatial mapping of undertriage. A total of 37,607 cases in PTSF and 63,954 cases in PHC4 met criteria, suggesting UTR of 45.8% across PA. Geospatial mapping reveals significant clusters of undertriage regions with high UTR in the eastern half of the state compared to low UTR in the western half. High UTR seems to be centered around nonpediatric facilities. The UTR for patients with a probability of death 1% or less was 39.2%. Undertriage is clustered in eastern PA, with most areas of high undertriage located around existing trauma centers in high-density population areas. This pattern may suggest pediatric undertriage is related to a system issue as opposed to inadequate access. Retrospective study, without negative criteria, Level III.

Long bone fractures of the lower extremity secondary to youth soccer

Abstract: Purpose The purpose of this study is to investigate the epidemiology, risk factors, and incidence of youth soccer related long bone lower extremity fractures treated in emergency departments in the state of Pennsylvania. Methods A retrospective review was conducted of soccer related long bone fractures in children under the age of 18 years from January 1, 2001 to December 31, 2015 with data from the Pennsylvania Trauma Systems Foundation, …

Undertriage in trauma: Does an organized trauma network capture the major trauma victim? A statewide analysis.

Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-TCs (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9, 800-959; Injury Severity Score [ISS], > 9 or > 15) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on ISSs throughout the state. For ISS > 9, 173,022 cases were identified from 2003 to 2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS > 15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to TCs comprise the highest proportion of undertriaged trauma patients. Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and health care system imperatives. Epidemiological study, level III; Therapeutic, level IV.

Development of a trauma system and optimal placement of trauma centers using geospatial mapping.

The care of patients at individual trauma centers (TCs) has been carefully optimized, but not the placement of TCs within the trauma systems. We sought to objectively determine the optimal placement of trauma centers in Pennsylvania using geospatial mapping. We used the Pennsylvania Trauma Systems Foundation (PTSF) and Pennsylvania Health Care Cost Containment Council (PHC4) registries for adult (age ≥15) trauma between 2003 and 2015 (n = 377,540 and n = 255,263). TCs and zip codes outside of PA were included to account for edge effects with trauma cases aggregated to the Zip Code Tabulation Area centroid of residence. Model assumptions included no previous TCs (clean slate); travel time intervals of 45, 60, 90, and 120 minutes; TC capacity based on trauma cases per bed size; and candidate hospitals ≥200 beds. We used Network Analyst Location-Allocation function in ArcGIS Desktop to generate models optimally placing 1 to 27 TCs (27 current PA TCs) and assessed model outcomes. At a travel time of 60 minutes and 27 sites, optimally placed models for PTSF and PHC4 covered 95.6% and 96.8% of trauma cases in comparison with the existing network reaching 92.3% or 90.6% of trauma cases based on PTSF or PHC4 inclusion. When controlled for existing coverage, the optimal numbers of TCs for PTSF and PHC4 were determined to be 22 and 16, respectively. The clean slate model clearly demonstrates that the optimal trauma system for the state of Pennsylvania differs significantly from the existing system. Geospatial mapping should be considered as a tool for informed decision-making when organizing a statewide trauma system. Epidemiological study/Care management, level III.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

BackgroundThe optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care. ObjectiveWe sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality. MethodsWe conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered. ResultsThere were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score−predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47–1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96–1.08). ConclusionsWe found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

A novel approach to optimal placement of new trauma centers within an existing trauma system using geospatial mapping.

Trauma system expansion is a complex process often governed by financial and health care system imperatives. We sought to propose a new, informed approach to trauma system expansion through the use of geospatial mapping. We hypothesized that geospatial mapping set to specific parameters could effectively identify optimal placement of new trauma centers (TC) within an existing trauma system. We used Pennsylvania Trauma Systems Foundation registry data of adult (age, ≥ 15 years) trauma for calendar years 2003 to 2015 (n = 408,432), hospital demographics, road networks, and US Census data files. We included TCs and zip codes outside of Pennsylvania to account for edge effects with trauma cases aggregated to the zip code centroid of residence. Our model assumptions included existing Pennsylvania Trauma Systems Foundation Level I and II TCs, a maximum travel time of 60 minutes to the TC, capacity based on mean statewide ratios of trauma cases per hospital bed size, Injury Severity Score, candidate hospitals with 200 or more licensed beds and 30 minutes or longer or 15 minutes or longer from an existing TC in nonurban/urban areas, respectively. We used the Network Analyst Location-Allocation function in ArcGIS Desktop to generate spatial models. Of the 130 candidate sites, only 14 met the bed size and travel time criteria from an existing TC. Approximately 70% of zip codes and 91% of cases were within 60 minutes of an existing TC. Adding one to six new optimally paced TCs increased to a maximum of 82% of zip codes and 96% of cases within 60 minutes of an existing TC. Changes to model assumptions had an impact on which candidate sites were selected. Intelligent trauma system design should include an objective process like geospatial to determine the optimum locations for new TCs within existing trauma networks. Epidemiological study, level III.

Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database

Objective The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively. Methods The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBP &lt; 90 mmHg was predictive of poor maternal outcome. Results Patients with severe blunt injury (ISS ≥ 9) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, p = 0.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and &lt;1% died; all other patients required discharge to a rehabilitation facility. Patients with penetrating trauma and SBP &lt; 90 mmHg on arrival were more likely to require delivery (35% vs. 5%, p &lt; 0.001) and were 14 times more likely to die (58% vs. 4%, p &lt; 0.001) when compared to the normotensive group. Conclusion ISS ≥ 9 and SBP &lt; 90 mmHg are predictors for poor outcomes after trauma during pregnancy. Severely injured blunt trauma patients often require surgery and delivery. Patients who present with SBP &lt; 90 after penetrating trauma are more likely to deliver and are 14 times more likely to die.

Where We Fail: Location and Timing of Failure to Rescue in Trauma

Failure to rescue (FTR) is an outcome metric that reflects a center's ability to prevent mortality after a major complication. Identifying the timing and location of FTR events could help target efforts to reduce FTR rates. We sought to characterize the timing and location of FTR occurrences at our center, hypothesizing that FTR rates would be highest early after injury and in settings of lower intensity of care. We used data, prospectively collected from 2009 to 2013, on patients ≥16 years old with minimum Abbreviated Injury Score ≥2 from a single institution. Major complications (per Pennsylvania Trauma Systems Foundation definitions), mortality, and FTR rates were examined by location [prehospital, emergency department, operating room, intensive care unit (ICU), and interventional radiology] and by day post admission. Kruskal-Wallis and chi-squared tests were used to compare variables (P = 0.05). Major complications occurred in 899/6150 (14.6%) of patients [median age: 42, interquartile range (IQR): 25-57; 56% African American, 73% male, 76% blunt; median Injury Severity Score: 10, IQR: 5-17]. Of 899, 111 died (FTR = 12.4%). Compared with non-FTR cases, FTR cases had earlier complications (median day 1 (IQR: 0-4) versus 5 (IQR: 2-8), P < 0.001). FTR rates were highest in the prehospital (55%), emergency department (38%), and operating room (36%) settings, but the greatest number of FTR cases occurred in the ICU (52/111, 47%). FTR rates were highest early after injury, but the majority of cases occurred in the ICU. Efforts to reduce institutional FTR rates should focus on complications that occur in the ICU setting.

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.

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

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

Trauma centers with higher rates of angiography have a lesser incidence of splenectomy in the management of blunt splenic injury

Nonoperative management (NOM) for blunt splenic injury (BSI) is well-established. Angiography (ANGIO) has been shown to improve success rates with NOM. Protocols for NOM are not standardized and vary widely between centers. We hypothesized that trauma centers that performed ANGIO at a greater rate would demonstrate decreased rates of splenectomy compared with trauma centers that used ANGIO less frequently. A large, multicenter, statewide database (Pennsylvania Trauma Systems Foundation) from 2007 to 2011 was used to generate the study cohort of patients with BSI (age ≥ 13). The cohort was divided into 2 populations based on admission to centers with high (≥13%) or low (<13%) rates of ANGIO. Patient demographics, grade of BSI, Injury Severity Score, level of trauma center designation, and patient volume were analyzed. Splenectomy rates were then compared between the 2 groups, and multivariable logistic regression for predictors of splenectomy (failed NOM) were also performed. The overall rate of splenectomy in the entire cohort was 21.0% (1,120 of 5,333 BSI patients). The high ANGIO group had a lesser rate of splenectoy compared with the low ANGIO group (19% vs 24%; P < .001). Treatment at high ANGIO centers was negatively associated with splenectomy compared with low ANGIO centers (odds ratio, 0.68; 95% CI 0.58-0.80; P < .001); this association was independent of the number of BSI admissions or level of trauma center designation. Treatment of BSI at trauma centers that performed ANGIO more frequently resulted in lesser splenectomy rates compared with centers with lesser rate of ANGIO. Inclusion of angiographic protocols for NOM of BSI should be considered strongly.

Magnet hospitals are a magnet for higher survival rates at adult trauma centers

Little is known about nursing care's impact on trauma outcomes. The Magnet Recognition Program recognizes hospitals for quality patient care and nursing excellence based on objective standards. We hypothesized that Magnet-designated trauma centers would have improved survival over their non-Magnet counterparts. All 2009 to 2011 admissions to Pennsylvania's Level I and II trauma centers with more than 500 admissions during the study period (10 Magnet and 17 non-Magnet hospitals) were extracted from the Pennsylvania Trauma Systems Foundation State Registry. A logistic regression model with mortality as the dependent variable included the following variables: Magnet status, age, sex, admitting temperature, logit transformation of mortality probability predicted by the Trauma Mortality Prediction Model (TMPM-ais), systolic blood pressure, mechanism of injury, paralytic drug use, and Glasgow Coma Scale motor (GCSm) score. A total of 73,830 patients from the Pennsylvania Trauma Outcome Study database met inclusion criteria for this study. The Magnet and non-Magnet hospital groups were statistically indistinguishable with respect to level of designation, medical school association, surgical residency programs, in-house surgeons, and urban locations. Patients admitted to a Magnet hospital had a significantly decreased odds of mortality when compared with their non-Magnet counterparts (odds ratio, 0.83; 95% confidence interval, 0.70-0.99; p = 0.033), when controlling for numerous factors. Overall, the model has outstanding discrimination with a receiver operating characteristic curve of 0.93. Admission to a Magnet-designated hospital is associated with a 20% reduction in mortality. We believe that the Magnet program's attention to nursing competence has important consequences for trauma patients, as reflected in the improved survival rates in trauma patients admitted to Magnet-designated hospitals. Epidemiologic/prognostic study, level III. Care management study, level IV.

Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database

BackgroundOptimal management of adolescent trauma patients with blunt abdominal solid organ injury (SOI) remains controversial. The purpose of this study was to identify management differences in adolescents with SOI treated at adult trauma centers (ATC) versus pediatric trauma centers (PTC). We hypothesized that adolescents with SOI would undergo different treatment at ATC and PTC. Materials and methodsRetrospective review of the Pennsylvania Trauma Systems Foundation database from 2005–2010 was performed. Adolescent patients (13–18 y old) with SOI (spleen, liver, and kidney injury) were included. Patient baseline characteristics and care processes for each injury were compared between ATC and PTC. ResultsA total of 1532 patients with at least one SOI were identified: 946 patients had a splenic injury, 505 had a liver injury, and 424 had a kidney injury. Spleen and liver procedures were performed more often at ATC than at PTC irrespective of injury grade (respectively, 16.1% versus 3.2%, 5.9% versus 0%; P < 0.01). Transarterial embolization for splenic injury was more frequently performed at ATC (2.8% versus 0.6%; P = 0.02). After adjusting for potential confounding factors, care at PTC was significantly associated with lower odds of splenic procedure for patients with splenic injury (OR: 0.16, 95% CI: 0.08–0.36, P < 0.001). In a subgroup analysis of nontransfer patients, care at PTC remained significantly associated with lower odds of splenic procedure (OR: 0.24, 95% CI: 0.10–0.59, P = 0.002) despite higher median injury severity score than ATC. ConclusionsSignificant differences in the management of adolescents with SOI were identified in Pennsylvania. Operative intervention for SOI was more often performed at ATC than at PTC. Further study will be needed to address the impact of these disparities on patient outcomes.

Injured Adolescents, Not Just Large Children: Difference in Care and Outcome between Adult and Pediatric Trauma Centers

Adolescent injury victims receive care at adult trauma centers (ATCs) and pediatric trauma centers (PTCs). The purpose of this study was to identify care variations and their impact on the outcome of adolescent trauma patients treated at PTC versus ATC. We queried the Pennsylvania Trauma Systems Foundation database for trauma patients between 13 and 18 years of age from 2005 to 2010. Mortality and hospital complication rates between ATC and PTC were compared in univariable and multivariable analysis. In addition, the differences in the delivery of care were also compared. Of 9033 total patients, 6027 (67%) received care at an ATC. Patients in the ATC group were older (16.7 vs. 14.9 years, P < 0.001) and more severely injured (Injury Severity Score: 14.5 vs. 12.2, P < 0.001). Admission diagnostic computed tomography (CT), emergent laparotomy and craniotomy, blood transfusion, and drug screening were more frequently performed at an ATC. After adjustment for potential confounders in multivariable regression models, treatment at a PTC was significantly associated with fewer CTs for transferred patients (odds ratio [OR], 0.28; P < 0.001) and with less frequent emergent laparotomy for all patients (OR, 0.65; P = 0.007). The ATC group had a significantly higher hospital mortality rate (2.9 vs. 0.9%, P < 0.001) and complication rate (9.7 vs. 4.8%, P < 0.001). However, these outcomes were not significantly different between PTC and ATC in multivariable regression models. In the state of Pennsylvania, there were no significant differences in risk-adjusted outcomes between PTC and ATC despite significant difference in use of CT scanning and emergent laparotomy.

Estimated additional hospital length of stay caused by 40 individual complications in injured patients

Complications are common in the care of trauma patients and increase hospital length of stay (LoS). Because many factors influence LoS and because patients may experience more than a single complication, it is difficult to estimate the effect of individual complications on LoS. We describe here a mathematically principled approach to estimating the additional LoS caused by complications and provide estimates for additional LoS caused by 40 common complications. The Pennsylvania Trauma Systems Foundation provided data on trauma patients hospitalized in one of 25 hospitals between 2002 and 2010. We estimated the attributable additional LoS in patients surviving to hospital discharge for 40 individual complications using a generalized linear model that controlled for anatomic injury and physiologic derangement at the time of admission, as well as patient factors (age, comorbidities, transfer status, type of insurance), discharge characteristics (day of week, destination), and year of admission. We also compared average risk-adjusted LoS among hospitals. Of 204,388 trauma patients surviving to discharge, 9.1% had one complication and 2.2% had multiple complications. Additional days LoS caused by individual complications ranged from less than 1 (bronchial intubation) to 16 days (wound dehiscence). Most complications added less than 1 week to LoS, but infectious complications added from 1 to 2 weeks; surgical complications added 2 to 3 weeks. If all complications could be eliminated, 24% of hospitalization days would be avoided. Individual hospitals' mean LoS differed from that predicted by our model by less than 1 day. Complications are common in the care of trauma patients and add moderately to LoS. Among all complications, surgical complications are associated with the greatest increases. Prognostic study, level III.

Preventability Classification in Mortality Cases: A Reliability Study

The Pennsylvania Trauma Systems Foundation ad hoc Outcomes Committee developed the Pennsylvania Outcomes and Performance Improvement Measurement System (POPIMS) software program that provided a consistent outcomes reporting template for trauma centers in the state. This study was performed to evaluate inter-rater reliability of POPIMS software for mortality classification. All trauma centers in the state were instructed to submit one preventable (P), one potentially preventable (PP), and one nonpreventable (NP) POPIMS mortality report to the Pennsylvania Trauma Systems Foundation office. The reports were blinded, an equal number of P, PP, and NP classified mortalities were randomly selected, and a meeting of trauma directors who submitted cases was convened. Institutional classification (IC) was compared with reviewing trauma directors (reviewer classification [RC]) to evaluate inter-rater reliability of software. Chi-square test was used to analyze differences. Inter-rater reliability among reviews was assessed using Cronbach's alpha coefficient. Twenty-eight trauma surgeons reviewed 34 cases (11 preventable, 12 PP, 11 nonpreventable), each having a minimum of 10 reviews. When compared with IC, RC was significantly different (p < 0.001). In addition, factors contributing to mortality were different when comparing IC and RC reviews of different mortality preventability classes. There was a moderate level of inter-rater reliability among reviewers as measured by Cronbach's alpha coefficient of 0.64. POPIMS is the first statewide PI reporting system to share outcomes information between trauma centers. Significant differences between IC of mortality and that provided by reviewers suggest that more objective criteria for mortality classification are needed. Realizing limitations of preventability classification, additional outcomes parameters should be pursued.

Intraventricular Endoscopy

INTRODUCTION: The timing of tracheostomy in the management of severely brain injured patients remains controversial. The purpose of this study was to examine the impact of tracheostomy timing on outcome in these patients. METHODS: Data were obtained from the Pennsylvania Trauma Systems Foundation (PTSF) prospective database over a 10-year period. Early tracheostomy (ET) was considered if it was performed by Day 7 of mechanical ventilation. Uni- and multivariate analyses were performed. RESULTS: Of 18,631 patients with severe head injury, 1577 and 1527 required early (ET) and late tracheostomy (LT), respectively. Age, sex, type of injury, admission physiological parameters, Injury Severity Score, GCS, and preexisting conditions were all similar in both groups. LT patients had significantly higher rates of pulmonary (odds ratio [OR], 2.068; 95% confidence interval [95% CI], 1.729–2.473), infectious (OR, 1.426; 95% CI, 1.160–1.753), cardiac (OR, 1.520; 95% CI, 1.265–1.827), and neurological (OR, 2.035; 95% CI, 1.329–3.116) adverse events. Patients with ET had significantly shorter intensive care unit (ICU) and hospital stays (8.86 and 10.94 fewer days, respectively; P < 0.0001). ET patients were also less likely to be functionally dependent at discharge (OR, 0.69; 95% CI, 0.55–0.86). Interestingly, however, LT patients did demonstrate a significant survival advantage (OR, 2.122; 95% CI, 1.599–2.815). CONCLUSION: Early tracheostomy in ventilated head trauma patients is associated with shorter ICU stay, shorter overall length of stay, fewer adverse occurrences, and functional independence at discharge. The survival advantage seen among late tracheostomy patients may be related to selection bias in this nonrandomized sample. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may improve outcome and reduce resource utilization.

Cervical Spine Injuries Associated With the Incorrect Use of Airbags in Motor Vehicle Collisions

Retrospective database review and analysis. The purpose of this study is to determine the rate of cervical spine injuries with correct and incorrect use of front driver and passenger-side airbags. Summary of Background Data. Although there are abundant literature showing reduced injury severity and fatalities from seatbelts and airbags, no recent studies have delineated the affect of incorrect use of airbags in cervical spine injuries. The database from the Pennsylvania Trauma Systems Foundation was searched for drivers and front-seat passenger injuries from 1990 to 2002. The resulting records were then grouped into those using both seatbelt and the airbag, airbag-only, seatbelt-only, and no restraints. The data were then analyzed for frequency of cervical spine fractures with or without spinal cord injury and injury severity indexes. The drivers using the airbag-only had significantly higher rate (54.1%) of cervical fractures than those using both airbag and a seatbelt (42.1%). Overall, drivers using the airbag-alone were 1.7 times more likely to suffer a cervical spine fracture than those using both protective devices. Likewise, passengers using the airbag-alone were 6.7 times more likely to suffer from a cervical spine fracture with spinal cord injury than those using both protective devices. In addition, the injury severity indexes (Glasgow coma scale, Injury Severity Score, Intensive Care Unit stays, and Total Hospital days) were significantly worse in patients who used an airbag-only. Airbag use without the concomitant use of a seatbelt is associated with a higher incidence of cervical spine fractures with or without spinal cord injuries. Airbag misuse is also associated with higher Injury Severity Score, lower Glasgow coma scale, and longer intensive care unit and total hospital stays, indicating that these patients suffer worse injury than those who use the airbag properly.

Increased Hospital Morbidity Among Trauma Patients With Diabetes Mellitus Compared With Age- and Injury Severity Score–Matched Control Subjects

We hypothesized that patients with diabetes mellitus (DM) have worse outcomes following trauma compared with patients without a history of DM. Retrospective data analysis of the Pennsylvania Trauma Systems Foundation database that compiles data from 27 accredited trauma centers in Pennsylvania. We used the Pennsylvania Trauma Systems Foundation database of 295 561 patients to compare outcomes in patients with DM vs those in patients who did not have DM. A total of 12 489 patients with DM from January 1984 to December 2002 were matched by sex, age, and Injury Severity Score with 12 489 patients who did not have DM. Differences in the length of hospital stay, intensive care unit stay, ventilatory assistance days, complications, and mortality rates. Patients with DM spent more days in the intensive care unit and receiving ventilator support. They were more likely to have a complication (23.0% in the DM group vs 14.0% in the non-DM group [odds ratio, 1.80; 95% confidence interval, 1.69-1.92]). No difference in mortality rates or length of hospital stay was noted. Patients with DM exposed to trauma have greater hospital morbidity resulting from longer intensive care unit stay, increased ventilator support, and more complications.

Nonoperative Management of Blunt Splenic Trauma in the Elderly: Does Age Play a Role?

Nonoperative management (NOM) of blunt splenic injury has become more frequent in the past several decades. Criteria that predict successful NOM remain poorly defined, and one factor that has been studied previously has been patient age. Previous studies have defined older patients as those greater than 55 years of age, but no studies have compared younger patients (55-75 years) with older patients (75+ years) within this age group. A total of 1008 patients > or =55 years of age who sustained blunt splenic injury between 1993 and 2001 were analyzed from the Pennsylvania Trauma Systems Foundation database. Statistical analysis was performed using regression analysis. Data was expressed as mean +/- SD, and a P value of < or = 0.05 was considered significant. Patients were classified as operative management (OM; 39.9%) or NOM (60.1%) according to their initial plan of treatment. Of the patients in the NOM group, 75.3 per cent were successfully managed nonoperatively (SNOM), whereas 24.7 per cent eventually required surgery. The Injury Severity Score of the OM group was highest (34) compared with the SNOM group (22) and failed NOM (FNOM; 27) groups. The mean splenic injury grade for OM, SNOM, and FNOM was 3.5, 2.4, and 3.3, respectively. The number of pre-existing conditions did not differ among the three groups. An upward trend in the failure rate of NOM was observed with increasing age (19.0%, 27.1%, and 28.3%, respectively) for three age groups, 55-64, 65-74, and 75+, but this trend was not statistically significant. Mortality rate was highest in the OM group (35.6%) compared with the successful (16.7%) and failed NOM (17.9%). Hospital length of stay (LOS) and intensive care unit (ICU) LOS were highest among patients who failed NOM (mean hospital LOS = 20.7 days, mean ICU LOS = 13.2 days) compared with OM (17.2 and 10.4, respectively) and successful NOM (12.4 and 6.9, respectively). The majority of patients > or = 55 years with blunt splenic injuries can be managed nonoperatively when carefully selected. In the subset of patients older than 55 years of age, increasing age is associated with a trend toward higher failure rates. Mortality was high regardless of management, and failure of NOM in older patients is associated with significantly longer hospital and ICU LOS.