Trauma Level Designation Research Articles

Incidence and characteristics of vascular trauma at a level 2 trauma center

ObjectiveDespite the significant number of trauma patients treated at level 2 trauma centers (L2TCs) in the United States, most of the literature describing vascular trauma is from level 1 trauma centers (L1TCs). Currently, trauma center designation criteria do not require vascular surgery as a necessary component service. MethodsA retrospective chart review was performed for all trauma patients with a vascular surgery consultation seen at our L2TC between 2013 and 2018. Patient demographics, injury characteristics, and outcomes were collected and analyzed with descriptive statistics. ResultsOf the 3062 trauma patients evaluated at our L2TC, 110 (3.6%) had a vascular surgery consultation. Operative intervention was performed in 35.2% of consults, and 1.0% of all trauma patients had a vascular intervention. Average age was 57 years, and the majority were male (n = 75; 68.2%). Mean Injury Severity Score was 12.0 ± 9.6, and blunt injury (n = 77; 87.5%) was more common than penetrating (n = 11; 12.5%). The most common location of injury was the lower extremity (n = 23; 74.2%), followed by upper extremity (n = 3; 9.7%), chest (n = 2; 6.5%), neck (n = 2; 6.5%), and pelvis (n = 1; 3.2%). Endovascular interventions were performed by the vascular surgery service in 67.7% (n = 21) of all injuries. There was one amputation (3.2%) and one postoperative mortality (3.2%). ConclusionsAt our L2TC, postoperative morbidity and mortality rates at 30 days were substantially lower compared with previously reported data. However, mean injury severity score and the incidence of penetrating and polytrauma were also lower at our institution. Most patients were managed nonoperatively, but when they did require an operation, endovascular therapies were more commonly implemented. Vascular surgery should be considered an integral service in trauma level designation, and there is a need for further investigation of these outcomes in L2TCs.

Operations Factors Associated with Emergency Department Length of Stay: Analysis of a National Operations Database.

Prolonged emergency department (ED) length of stay (LOS) has been shown to adversely affect patient care. We sought to determine factors associated with ED LOS via analysis of a large, national, ED operations database. We performed retrospective, multivariable, linear regression modeling using the 2019 Emergency Department Benchmarking Alliance survey results to identify associated factors of ED LOS for admitted and discharged patients. A total of 1,052 general and adult-only EDs responded to the survey. Median annual volume was 40,946. The median admit and discharge LOS were 289 minutes and 147 minutes, respectively. R-squared values for the admit and discharge models were 0.63 and 0.56 with out-of-sample R-squared values of 0.54 and 0.59, respectively. Both admit and discharge LOS were associated with academic designation, trauma level designation, annual volume, proportion of ED arrivals occurring via emergency medical services, median boarding, and use of a fast track. Additionally, admit LOS was associated with transfer-out percentage, and discharge LOS was associated with percentage of high Current Procedural Terminology, percentage of patients <18 years old, use of radiographs and computed tomography, and use of an intake physician. Models derived from a large, nationally representative cohort identified diverse associated factors of ED length of stay, several of which were not previously reported. Dominant within the LOS modeling were patient population characteristics and other factors extrinsic to ED operations, including boarding of admitted patients, which was associated with both admitted and discharged LOS. The results of the modeling have significant implications for ED process improvement and appropriate benchmarking.

Level II trauma centers have highest charges for hip fractures

Objectives: To evaluate the charges for pertrochanteric hip fracture care in Texas. Design: Database review. Setting: Texas Hospital Inpatient Public Use Data File (PUDF) Intervention: Charges reported by hospitals to the Texas Department of State Health Services for pertrochanteric hip fractures. Main outcome measurement: Charges associated with pertrochanteric hip fracture stratified by implant type and according to facility trauma level designation, urban versus rural, teaching versus non-teaching, and border versus inland status. Results and conclusions: There were a total of 44,853 pertrochanteric hip fracture surgeries performed over the three-year period in the state of Texas. The vast majority were treated at urban (93.4%), inland (non-border) (92.3%), non-teaching (74.2%) facilities with intramedullary fixation (56.9%). A significant increase in charges was associated with treatment at an urban ($32,412), border ($44,919), or teaching ($10,501) facility. Mean inpatient charges at Level II facilities was $113,700. Further study is warranted to determine what drives the differences in charges associated with hip fracture treatment. Level of Evidence: IV; Economic Database Analysis Keywords: hip fracture, access to care, charge analysis, value-based care, Texas. (J Ortho Business 2022; 1:4-6)

Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States

Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police. Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police. Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13–15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321–2.333); p = 0.776). Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.

Recalibrating the Glasgow Coma Score as an Age-Adjusted Risk Metric for Neurosurgical Intervention

The Glasgow Coma Scale (GCS) score is the most frequently used neurologic assessment in traumatic brain injury (TBI). The risk for neurosurgical intervention based on GCS is heavily modified by age. The objective is to create a recalibrated Glasgow Coma Scale (GCS) score that accounts for an interaction by age and determine the predictive performance of the recalibrated GCS (rGCS) compared to the standard GCS for predicting neurosurgical intervention. This retrospective cohort study utilized the National Trauma Data Bank and included all patients admitted from 2010-2015 with TBI (ICD9 diagnosis code 850-854.19). The study population was divided into 2 subsets: a model development dataset (75% of patients) and a model validation dataset (remaining 25%). In the development dataset, logistic regression models were used to calculate conditional probabilities of having a neurosurgical intervention for each combination of age and GCS score, to develop a point-based risk score termed the rGCS. Model performance was examined in the validation dataset using area under the receiver operating characteristic (AUROC) curves and calibration plots. There were 472,824 patients with TBI. The rGCS ranged from 1-15, where rGCS 15 denotes the baseline risk for neurosurgical intervention (4.4%) and rGCS 1 represents the greatest risk (62.6%). In the validation dataset there was a statistically significant improvement in predictive performance for neurosurgical intervention for the rGCS compared to the standard GCS (AUROC: 0.71 versus 0.67, difference, -0.04, P<0.001), overall and by trauma level designation. The rGCS was better calibrated than the standard GCS score. The relationship between GCS score and neurosurgical intervention is significantly modified by age. A revision to the GCS that incorporates age, the rGCS, provides risk of neurosurgical intervention that has better predictive performance than the standard ED GCS score.

Delay in Hip Fracture Repair in the Elderly: A Missed Opportunity Towards Achieving Better Outcomes

BackgroundHip fractures are a major cause of morbidity and mortality in the elderly. The American Academy of Orthopedic Surgeons (AAOS) recommends surgical repair within 48 hours of admission, as this is associated with lower postoperative mortality and complications. This study demonstrates the association between patient demographics, level of care, and hospital region to delay in hip fracture repair in the elderly. MethodsThe National Trauma Data Bank (NTDB) was queried for elderly patients (age >65 years) who underwent proximal femoral fracture repair. Identified patients were subcategorized into two groups: hip fracture repair in <48 hours, and hip fracture repair > 48 hours after admission. Patient and hospital characteristics were collected. Outcome variables were timed from the day of admission to surgery and inpatient mortality. ResultsOut of 69,532 patients, 28,031 were included after inclusion criteria were applied. 23,470 (83.7%) patients underwent surgical repair within 48 hours. The overall median time to procedure was 21 (interquartile range [IQR] 7-38) hours. Females were less likely to undergo a delay in hip fracture repair (odds ratio [OR; 95% confidence interval {CI}]: 0.82 [0.76-0.88], P< 0.05), and patients with higher Injury Severity Score (ISS ≥25) had higher odds of delay in surgical repair (OR; 95% CI: 1.56 [1.07-2.29], P< 0.05). Patients treated at hospitals in the Western regions of the United States had lower odds of delay, and those treated in the Northeast and the South had higher odds of delay compared to the hospitals in the Midwest (taken as standard). There was no association between trauma level designation and odds of undergoing delay in hip fracture repair. ConclusionVariables related to patient demographic and hospital characteristics are associated with delay in hip fracture repair in the elderly. This study delineates key determinants of delay in hip fracture repair in the elderly patients.

Impact of trauma center designation in pediatric renal trauma: National Trauma Data Bank analysis

The pediatric kidney is the most common urinary tract organ injured in blunt abdominal trauma. Trauma care in the United States has been established into a hierarchical system verified by the American College of Surgeons (ACS). Literature evaluating management of pediatric renal trauma across trauma tier designations is scarce. To examine the differences in the management and outcomes of renal trauma in the pediatric population based on trauma level designation across the United States. We performed a review of the ACS - National Trauma Data Bank database. Pediatric patients (age 0-18 years) who were treated for renal injury between years 2011-2016 were identified. Our primary outcome was the difference in any complication rate amongst Level I versus Non-Level I trauma centers. Management strategies were evaluated as secondary outcomes. Propensity score matching (PSM) was utilized to adjust for baseline differences between cohorts. Multivariable regression analysis was performed to determine the independent effects of individual factors on complications, operative intervention, minimally invasive procedure, and blood transfusions. Overall, 12,097 pediatric patients were diagnosed with renal trauma between 2011 and 2016 using target ICD-9 and AAST codes. After PSM, there was a total of 1623 subjects withing each group. No difference was identified between groups for occurrence on any complication [105 (6.5%) vs 114 (7.0%), p=0.576. There were no differences in the rate of minimally invasive interventions [67 (4.1%) vs 48 (3.0%), p=0.087], operative intervention [58 (3.6%) vs 68 (4.2%), p=0.413], or nephrectomy [42 (2.6%) vs 47 (2.9%), p=0.667] between Level I and Non-Level I trauma designations, respectively. Length of stay was longer in the Level I cohort compared to Non-Level I (days (SD)) [6.9 (8.8) vs 6.2 (7.9), p=0.024. When specifically looking at risk factors associated with operative intervention, higher renal injury grade and injury severity score were highly correlated, whereas, trauma level designation was not found to be predictive for more aggressive management. Our results corroborate with previous literature that renal injury grade and injury severity score are strong predictors of morbidity, invasive management, and complications. Pediatric renal trauma was managed similarly across trauma center designations, with the rate of complication and intervention more prevalent in patients with high grade renal injuries and concomitant injuries. Further studies are necessary to identify patients who will benefit most from transfer to a level I center.

Impact of trauma level designation on survival of patients arriving with no signs of life to US trauma centers

BackgroundTrauma level designation and verification are examples of healthcare regionalization aiming at improving patient outcomes. This study examines impact of Trauma Levels on survival of patients arriving with “no signs of life” to US trauma centers. MethodsThis retrospective study used the US National Trauma Data Bank (NTDB) 2015 dataset. A descriptive followed by a bivariate analysis was done comparing variables by the trauma designation levels. A multivariate analysis assessed the effect of the trauma designation on survival to hospital discharge after controlling for potential confounding factors. Results6160 patients without signs of life were included. The average age was 40.66 years (±19.96) with male predominance (77.3%). Most patients were transported using ground ambulance (83.5%) and were taken to Level I (57%) and Level II (32.4%) centers. Blunt injuries were the most common (56.9%). Motor Vehicle Collision (MVC) (38.5%) and firearm (33.8%) were the most common mechanisms of injury. Survival to hospital discharge among patients with no signs of life ranged from 13.7% at Level I to 27.9% at Level III. After adjusting for confounders, including Injury Severity Score (ISS), higher survival was noted at Level II trauma centers compared to Level I. ConclusionsPatients presenting without signs of life to Level II trauma centers had higher survival to hospital discharge compared to Level I and Level III centers. These findings can guide future prehospital triage criteria of trauma patients in organized Emergency Medical Services (EMS) systems and highlight the need for more outcome research on trauma systems.

Morbidity and Mortality Among Critically Injured Children With Acute Respiratory Distress Syndrome.

To evaluate morbidity and mortality among critically injured children with acute respiratory distress syndrome. Retrospective cohort study. Four-hundred sixty Level I/II adult or pediatric trauma centers contributing to the National Trauma Data Bank. One hundred forty-six thousand fifty-eight patients less than 18 years old admitted to an ICU with traumatic injury from 2007 to 2016. None. We assessed in-hospital mortality and need for postdischarge care among patients with and without acute respiratory distress syndrome and hospital resource utilization and discharge disposition among survivors. Analyses were adjusted for underlying mortality risk (age, Injury Severity Score, serious brain or chest injury, and admission heart rate and hypotension) and year, transfer status, and facility trauma level designation. Acute respiratory distress syndrome occurred in 2,590 patients (1.8%). Mortality was 20.0% among acute respiratory distress syndrome patients versus 4.3% among nonacute respiratory distress syndrome patients, with an adjusted relative risk of 1.76 (95% CI, 1.52-2.04). Postdischarge care was required in an additional 44.8% of acute respiratory distress syndrome patients versus 16.0% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.59; 2.87-4.49), with only 35.1% of acute respiratory distress syndrome patients discharging to home versus 79.8% of patients without acute respiratory distress syndrome. Acute respiratory distress syndrome mortality did not change over the 10-year study period (adjusted relative risk, 1.01/yr; 0.96-1.06) nor did the proportion of acute respiratory distress syndrome patients requiring postdischarge care (adjusted relative risk, 1.04/yr; 0.97-1.11). Duration of ventilation, ICU stay, and hospital stay were all significantly longer among acute respiratory distress syndrome survivors. Tracheostomy placement occurred in 18.4% of acute respiratory distress syndrome survivors versus 2.1% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.10; 2.59-3.70). Acute respiratory distress syndrome development following traumatic injury in children is associated with significantly increased risk of morbidity and mortality, even after adjustment for injury severity and hemodynamic abnormalities. Outcomes have not improved over the past decade, emphasizing the need for new therapeutic interventions, and prevention strategies for acute respiratory distress syndrome among severely injured children.

Back to Basics: Mass Casualty Incidents.

Terrorist attacks, mass shootings, violent crimes, and other disasters may leave those affected feeling afraid and overwhelmed with emotion. It has been more than 17 years since the attacks on the World Trade Center in New York City killed almost 3,000 people. Since that time, the world has experienced a profuse number of mass casualty events; they are becoming commonplace and a risk that everyone recognizes as part of daily life. When disasters occur, health care providers may be required to mobilize and should be prepared for anything. Regardless of the size of the facility or the trauma level designation, perioperative nurses need to be aware of how they may be affected by traumatic events. This Back to Basics article reviews some significant mass casualty incidents and explores strategies for perioperative staff members to execute a successful response.

Effect of Patient Volume and American College of Surgeons Trauma Level Designation on Mortality: A National Trauma Data Bank Study

Effect of Patient Volume and American College of Surgeons Trauma Level Designation on Mortality: A National Trauma Data Bank Study

Impact of Trauma Center Designation and Interfacility Transfer on Renal Trauma Outcomes: Evidence for Universal Management

BackgroundRenal trauma may be managed differently in tiered trauma systems and among those who requireinterfaculty transfer. ObjectiveTo evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation and interfacility transfer status, and analyze management trends over time. Design, setting, and participantsRetrospective cohort study of renal trauma from the National Trauma Data Bank 2010–2015. InterventionNephrectomy, angioembolization, or nonoperative management. Outcomes measurements and statistical analysisWe used generalized estimating equations to compare odds of each management outcome in patients transferred and directly admitted to a level I center, versus those directly admitted to a non–level I center, adjusting for vital signs, injury, demographic, and facility characteristics. We also used generalized estimating equations to examine linear time trends in management outcome, adjusting for injury characteristics. Results and limitationsA total of 51798 renal trauma records were included: 44 838 low-grade (American Association for the Surgery of Trauma I–III) and 6359 high grade (IV–V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred or directly admitted to a level I center compared with those treated at a non–level I center. Changes in management over time demonstrated a decreased rate of nephrectomy (p=0.007) in high-grade injuries, while the rate of angioembolization remained constant (p=0.33). Study limitations include mortality prior to hospital transfer or arrival, and its retrospective nature. ConclusionsIn this contemporary trauma analysis, outcomes of both low- and high-grade renal trauma are similar across patients managed in tiered trauma centers and those undergoing transfer, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high-grade renal injury over our study period, suggesting new adoption of kidney-sparing management. Patient summaryRenal trauma is now managed similarly in tiered trauma centers and in patients requiring interfacility transfer. The rate of nephrectomy for high-grade renal injuries has decreased over time.

PD02-01 IMPACT OF TRAUMA CENTER DESIGNATION ON RENAL TRAUMA OUTCOMES: EVIDENCE FOR UNIVERSAL MANAGEMENT

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2018PD02-01 IMPACT OF TRAUMA CENTER DESIGNATION ON RENAL TRAUMA OUTCOMES: EVIDENCE FOR UNIVERSAL MANAGEMENT Marc Bjurlin, Audrey Renson, Richard Jacob Fantus, and Richard Joseph Fantus Marc BjurlinMarc Bjurlin More articles by this author , Audrey RensonAudrey Renson More articles by this author , Richard Jacob FantusRichard Jacob Fantus More articles by this author , and Richard Joseph FantusRichard Joseph Fantus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.226AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tiered delivery of trauma care has resulted in improved trauma outcomes at level I trauma centers compared to non-level I centers. In the era of conservative management of kidney injuries, comparison of outcomes of renal trauma by hospital designation is not well studied. Our study objective was to evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation, and analyze management trends over time. METHODS This retrospective cohort study included renal trauma from the National Trauma Data Bank 2010-2015. We examined the association between hospital trauma level designation (level I vs transferred to level I vs non-level I), and renal trauma management including nephrectomy, angioembolization, and nonoperative management, along with presence of any annual linear time trends in management. RESULTS We analyzed 51,798 renal trauma records; 44,838 low grade (AAST I-III) and 6,359 high grade (IV-V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred to a level I and directly admitted to level I centers, compared to those treated at non-level I for both high and low grade injuries (Table 1), although mortality was lower in those transferred to level I centers (OR 0.70, 95% Cl 0.61-0.80, p<0.001). Change over time of management of high grade renal injuries demonstrated a decrease in the use of nephrectomy (p=0.007) while rates of angioembolization remained constant (p=0.33) (Figure 1). CONCLUSIONS In this contemporary trauma analysis, outcomes of both low and high grade renal trauma are similar across those patients managed in tiered trauma centers, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high grade renal injury over our study period suggesting new adoption of kidney sparing management. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e64-e65 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Marc Bjurlin More articles by this author Audrey Renson More articles by this author Richard Jacob Fantus More articles by this author Richard Joseph Fantus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Change in Care Transition Practice for Patients With Nonspecific Chest Pain After Emergency Department Evaluation 2006 to 2012.

From 2005 to 2010 health care financing shifts in the United States may have affected care transition practices for emergency department (ED) patients with nonspecific chest pain (CP) after ED evaluation. Despite being less acutely ill than those with myocardial infarction, these patients' management can be challenging. The risk of missing acute coronary syndrome is considerable enough to often warrant admission. Diagnostic advances and reimbursement limitations on the use of inpatient admission are encouraging the use of alternative ED care transition practices. In the setting of these health care changes, we hypothesized that there is a decline in inpatient admission rates for patients with nonspecific CP after ED evaluation. We retrospectively used the Nationwide ED Sample to quantify total and annual inpatient hospital admission rates from 2006 to 2012 for patients with a final ED diagnosis of nonspecific CP. We assessed the change in admission rates over time and stratified by facility characteristics including safety-net hospital status, U.S. geographic region, urban/teaching status, trauma-level designation, and hospital funding status. The admission rate for all patients with a final ED diagnosis of nonspecific CP declined from 19.2% in 2006 to 11.3% in 2012. Variability across regions was observed, while metropolitan teaching hospitals and trauma centers reflected lower admission rates. There was a 41.1% decline in inpatient hospital admission for patients with nonspecific CP after ED evaluation. This reduction is temporally associated with national policy changes affecting reimbursement for inpatient admissions.

Unexpected High Rates of Angiography and Angioembolization for Isolated Low-grade Renal Trauma: Results From a Large, Statewide, Trauma Database

To evaluate usage of diagnostic angiography (DA) and renal angioembolization (RAE) for isolated renal injuries while assessing differences in utilization based on trauma-level designation. Isolated renal injuries from 2000 to 2013 were identified in the prospectively maintained Pennsylvania Trauma Outcome Study database and stratified by the American Association for the Surgery of Trauma kidney injury grade. Therapeutic intervention and International Classification of Diseases-9 codes identified DA and/or RAE performance, whereas renal injury was designated through Abbreviated Injury Scale codes. Univariate and multivariate models identified factors associated with utilization of DA or RAE. Of 449,422 patients entered into the Pennsylvania Trauma Outcome Study from 2000 to 2013, 1628 (0.4%) isolated kidney injuries were identified. The majority of patients (1190/1628, 73.1%) experienced low-grade (American Association for the Surgery of Trauma I-III) renal trauma. Although isolated grade IV (41/350, 11.7%) or grade V (10/88, 11.4%) renal trauma patients underwent DA or RAE at a greater rate (P < .001), low-grade patients still underwent DA or RAE 4.3% (51/1190) of the time. Patients with grade I injuries were significantly more likely to undergo DA or RAE at level 1 trauma centers (odds ratio 5.4, 95% confidence interval 1.2-23.8, P = .03). Despite overwhelming evidence supporting conservative management for patients with isolated, low-grade traumatic renal injuries, contemporary utilization of DA and RAE in such patients treated at trauma centers is surprisingly high. Factors accounting for a significant increase in utilization at Level 1 trauma centers need to be further elucidated.

A National Study of Trauma Level Designation and Renal Trauma Outcomes: Hotaling JM, Voelzke BB, Wang J, et al. J Urol 2012; 187:536–41.

A National Study of Trauma Level Designation and Renal Trauma Outcomes: Hotaling JM, Voelzke BB, Wang J, et al. J Urol 2012; 187:536–41.

A National Study of Trauma Level Designation and Renal Trauma Outcomes

A National Study of Trauma Level Designation and Renal Trauma Outcomes

A National Study of Trauma Level Designation and Renal Trauma Outcomes

We examined the initial management of renal trauma and assessed patterns of management based on hospital trauma level designation. The National Trauma Data Bank is a comprehensive trauma registry with records from hospitals in the United States and Puerto Rico. Renal injuries treated at a member hospital from 2002 to 2007 were identified. We classified initial management as expectant, minimally invasive (angiography, embolization, ureteral stent or nephrostomy) or open surgical management based on ICD-9 procedure codes. The primary outcome was use of secondary therapies. Of 3,247,955 trauma injuries in the National Trauma Data Bank 9,002 were renal injuries (0.3%). High grade injuries demonstrated significantly higher rates of definitive success with the first urological intervention at level I trauma centers vs other trauma centers (minimally invasive 52% vs 26%, p <0.001), and were more likely treated successfully with conservative management (89% vs 82%, p <0.001). When adjusting for other known indices of injury severity, and examining low and high grade injuries, level I trauma centers were 90% more likely to offer an initial trial of conservative management (OR 1.90; 95% CI 1.19, 3.05) and had a 30% lower chance of patients requiring multiple procedures (OR 0.70; 95% CI 0.52, 0.95). Following multivariate analysis conservative therapy was more common at level I trauma centers despite the patient population being more severely injured. Initial intervention strategies were also more definitive at level I trauma centers, providing additional support for tiered delivery of trauma care.

Do Trauma Safety-Net Hospitals Deliver Truly Safe Trauma Care? A Multilevel Analysis of the National Trauma Data Bank

Patients treated at "safety-net hospitals," facilities that care for a high percentage of uninsured patients, are known to have worse outcomes. This study seeks to analyze whether care at "trauma safety-net hospitals" (TSNH) accounts for the known mortality disparity between uninsured and insured trauma patients. A retrospective analysis of trauma patients (age, 18-64 years) in the National Trauma Data Bank (6.2; 2001-2005) with moderate to severe injury (Injury Severity Score ≥9) was performed. TSNH were defined as facilities treating ≥47% uninsured trauma patients. The main outcome measure was adjusted mortality of patients treated at TSNH versus non-TSNH. A multilevel analysis using multiple logistic regression and generalized estimating equations was performed to control for both hospital and patient-level characteristics (age, gender, insurance, injury severity, shock, and type and mechanism of injury). Subset analyses by hospital trauma level designation and patient injury severity and type were also performed. Collectively 343,053 trauma patients were treated at 46 TSNH and 413 non-TSNH. TSNH patients (n = 36,774) were more likely to be minorities (55% vs. 27%; p < 0.05) compared with non-TSNH patients (n = 306,279). Unadjusted mortality was greater in TSNH versus non-TSNH patients (6.8% vs. 4.6%; *p < 0.05). After controlling for patient- and hospital-level factors, patients at TSNH and non-TSNH facilities had equivalent odds ratio of death = 0.93 (95% confidence interval = 0.65-1.32). Similar results were obtained in all subset analyses. Patients treated at TSNH have equivalent mortality compared with those treated at non-TSNH. Disparate trauma outcomes due to insurance status are not explained by differences between trauma treating institutions.

Use and Determinants of the Methylprednisolone Protocol for Traumatic Spinal Cord Injury in South Carolina Acute Care Hospitals

The use of methylprednisolone sodium succinate (MPSS) in the treatment of traumatic spinal cord injury was initially reported to enhance recovery in the National Acute Spinal Cord Injury Studies (NASCIS), 1990 and 1997. Controversy led to subsequent research and a 2002 report citing insufficient evidence for MPSS treatment standards or guidelines. Our purpose was to explore emergency department (ED) response to this shifting information by assessing the impact of NASCIS and the 2002 report on MPSS protocols and to study factors associated with MPSS administration. Availability of protocols and hospital characteristics were determined by survey of all hospitals with EDs in South Carolina. Protocol copies were obtained and reviewed for accuracy based on NASCIS. Patient hospital discharge information was collected through the state Office of Research and Statistics, and factors associated with receiving MPSS were evaluated using multivariable techniques. Having a protocol was associated with trauma level designation and volume of traumatic spinal cord injury patients per annum, with 100% of Level I trauma facilities having a protocol. Across all trauma levels, 40% of reporting EDs had an MPSS protocol, with 86% of these accurate, and none withdrawn during the study. Patient factors associated with being less likely to receive MPSS were female gender, injury below thoracic level, and treatment in an undesignated trauma center. Shifting information on the benefit of MPSS did not lead to withdrawal of protocols over the study time period. However, within those hospitals having a protocol, only 32% of eligible patients received MPSS treatment.