Trauma Quality Improvement Program Research Articles

Obesity Does Not Increase Risk for Mortality in Severe Sepsis Trauma Patients.

The prevalence of obesity in the United States is up to 40% in adults. Obese patients with severe sepsis have a lower mortality rate compared with normal body mass index (BMI) patients. We hypothesized that trauma patients with severe sepsis and obese BMI will have a decreased mortality risk in comparison with normal BMI patients. The Trauma Quality Improvement Program (2017) was queried for adult trauma patients with documented BMI and severe sepsis. Patients were grouped based on BMI: non-obese trauma patients (nOTP) BMI <30kg/m2 and obese trauma patients (OTP) ≥30kg/m2. A multivariable logistic regression model was used for analysis of mortality. From 1246 trauma patients with severe sepsis, 566 (42.4%) were nOTP and 680 (57.6%) were OTP. OTP had increased length of stay (LOS) (19 vs 21 days, P < .001), intensive care unit (ICU) LOS (13 vs 18days, P < .001) and ventilator days (10 vs 11days, P < .001). After adjusting for covariates, when compared to normal BMI patients, patients who were overweight (OR 1.11 CI .875-1.41 P = .390), obese (OR .797 CI .59-1.06 P = .126), severely obese (OR .926 CI .63-1.36 P = .696) and morbidly obese (OR 1.448 CI 1.01-2.07 P = .04) all had a similar associated risk for mortality compared to patients with normal BMI. In adult trauma patients with severe sepsis, this national analysis demonstrated OTP had increased LOS, ICU LOS, and ventilator days compared to nOTP. However, patients with increasing degrees of obesity had similar associated risk of mortality compared to trauma patients with severe sepsis and a normal BMI.

Association Between Body Mass Index and Morbidity and Mortality During Hospitalization After Trauma.

Literature suggests that unhealthy body mass index is a risk factor for adverse clinical outcomes. To study the association between unhealthy body mass index and morbidity and mortality after trauma using the 2016 American College of Surgeons Trauma Quality Improvement Program database. A retrospective review was conducted comparing the normal weight control group to the underweight, overweight, obese, severely obese, and morbidly obese groups for differences in demographic factors, injury severity score, comorbidities, length of stay, and complications. Underweight, overweight, obese, severely obese, and morbidly obese body mass indexes, in comparison to normal weight body mass index, were associated with a higher probability of developing at least one complication after trauma. Additionally, we observed a J-shaped curve when analyzing body mass index and mortality, suggesting that both high and low body mass indexes are positively associated with mortality. In fact, morbidly obese patients had the highest mortality rate, followed by underweight patients (p < .001). Interestingly, however, multivariate logistic regression demonstrated that, compared with normal weight body mass index, overweight and obese body mass indexes were independently associated with 9.6% and 10.5% lower odds of mortality, respectively (p < .001 and p = .001). Irrespective of preexisting comorbidities, injury severity score, and mechanism of injury, underweight, overweight, obese, severely obese, and morbidly obese body mass indexes were independently associated with higher risks of morbidity, whereas overweight and obese body mass indexes were associated with lower mortality risks. These findings emphasize the complex relationship between body mass index and clinical outcomes for trauma patients.

Use of minimally invasive surgery for the management of hollow viscus traumatic injuries.

The objective of this study is to assess surgical outcomes following the initial use of laparoscopy versus laparotomy when managing patients with hollow viscus injuries due to trauma. Using the database from the American College of Surgeons Trauma Quality Improvement Program we identified all patients from 2015-2017 with ICD-10 Diagnosis codes for hollow viscus trauma. Types of procedures were identified by ICD-10 PCS codes. Patient outcomes were stratified by major trauma(ISS > 15) and minor trauma. Continuous variables were compared by ANOVA and categorical variables compared by Chi-Square. Analysis performed using STATA 16. We identified 16,284 patients that matched inclusion criteria within the study time frame. Of those, 1986 patients received a surgical intervention, 1911(96%) were open and 75(4%) were laparoscopic. In blunt trauma there were 106 diagnostic procedures, 87(82%) were open and 19(18%) were laparoscopic. There were 574 therapeutic procedures, 543(95%) were open and 31(5%) were laparoscopic. In penetrating trauma there were 223 diagnostic procedures, 215(96%) were open and 8(4%) were laparoscopic. There were 1039 therapeutic procedures for penetrating trauma, 1023(98%) were open and 16(2%) were laparoscopic. For minor trauma, mean length of stay(days) after open surgery was 5 while for laparoscopy it was 2 (p = 0.04). There were 203 complications noted in the open group and 7 in the laparoscopic group (p = 0.19). For major trauma, mean length of stay(days) after open surgery was 5 and 6 for laparoscopy p = 0.54). There were 242 complications in the open group and 1 in the laparoscopic group (p = 0.07). There was no noted significant difference noted in the disposition at discharge in either group in both major and minor trauma. For those that required surgery for hollow viscous injury, laparoscopy appeared to be safe, had less adverse outcomes and was underutilized, particularly when only a diagnostic procedure was required.

Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury.

Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI. Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality. Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02). SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.

Outcomes in Blunt vs Penetrating Pelvic Vascular Injuries.

The purpose of this study is to determine if there is a difference in outcomes for patients with blunt and penetrating vascular injuries of the pelvis. Data were abstracted from the Trauma Quality Improvement Program database from 2011 to 2015. Patients >18 years with hypogastric, iliac, uterine, or ovarian arterial or venous injuries were included. Individuals with an AIS head or chest score >3 were excluded. Of the 2559 patients included, the mean age was 43 years (±19), 75.25% were male, and 32.6% had a comorbidity. 64.9% presented with blunt injury (mean ISS of 23 (±12)). 74.9% experienced a complication. The median hospital length of stay (LOS) and ICU LOS were 10days and 4 days, respectively. 6.7% had an adverse discharge. Mortality occurred in 8.3%. On bivariate analysis, patients who sustained blunt trauma were older (51 vs 31years), female (32.7% vs 10.1%), had a higher ISS (25.71 vs 17.65), and had a longer hospital LOS (16.65 vs 13.88). Patients with penetrating trauma had an increased chance of complications (78.4% vs 73.0%) and mortality (10.7% vs 7.0%). Multivariate analysis revealed in patients with blunt injuries have more complications (OR: 1.950 CI: 0.886-4.291 P = .097), a lower ISS (OR: 0.919, CI: 0.908-0.930, P < .001, were more likely to have an adverse discharge (OR: 2.05, CI: 1.62-2.60, P = .000), and had a higher risk of mortality (OR: 4.08 CI: 2.78-6.41 P < .000). Patients with blunt pelvic vessel injuries are at risk for an increased number of complications and have a higher risk of mortality. Those who survive are more likely to have an adverse discharge.

Adolescent blunt solid organ injury: Differences in management strategies and outcomes between pediatric and adult trauma centers

BackgroundAdolescents with blunt solid organ injuries (BSOI) are cared for at both pediatric trauma centers (PTC) and adult trauma centers (ATC). Over the past decade, treatment strategies have shifted towards non-operative management with reported favorable outcomes. The aim of this study was to compare management strategies and outcomes between PTC and ATC. MethodsWe queried the 2016–2018 Trauma Quality Improvement Program (TQIP) datasets to identify adolescents between the ages of 16 and 19 with BSOI. Characteristics were stratified by center type (pediatric or adult) for comparative analyses. Separate logistic regressions were used to assess the association of hospital type, location of injury, age, gender, weight, Glascow Coma Score (GCS), Injury Severity Score (ISS), and intensive care unit (ICU) admissions for outcomes of interest. ResultsAmong the 3,011,310 patients enrolled in the 2016–2018 TQIP datasets, 106,892 (3.5%) had a BSOI ICD9/10 code. Of those, 9,193 (8.6%) were between 16 and 19 years of age and included in this analysis. Within this cohort, 6,073 (66.1%) were managed at an ATC and 3,120 (33.9%) were managed at a PTC. While statistically different, there were no clinically relevant differences for age, weight, and sex between groups. A significantly higher ISS and lower GCS score were observed among those admitted to ATC compared to PTC. ICU admissions were more frequent at ATC. Number of blood transfusions by 4 h after presentation were also higher among those admitted to an ATC. Despite a lower ISS and higher GCS at presentation, mortality was higher among those treated at a PTC with an odds ratio (95% confidence interval) of 2.42 (1.31–4.53). After excluding adolescents with a traumatic brain injury, a common cause of mortality among adolescent trauma patients, these differences in outcomes persisted. ConclusionsOur data suggest that adolescents with BSOI managed at a PTC are less likely to receive blood transfusions by 4 h of admission or be admitted to the ICU than those managed at an ATC. However, this more conservative approach may come at the expense of higher overall mortality. Further work is needed to understand these differences and determine if PTC need to be more aggressive in managing BSOI.

Marijuana Use Associated with Decreased Mortality in Trauma Patients.

The incidence of trauma patients with a positive marijuana screen (pMS) is increasing but the effects of marijuana on outcomes have varied in previous studies. A recent statewide analysis demonstrated decreased mortality for intensive care unit (ICU) trauma patients with pMS. Thus, we hypothesized a pMS to be associated with a decreased risk of mortality for all trauma patients. The 2017 Trauma Quality Improvement Program (TQIP) database was queried for adult (≥18years-old) pMS patients, who were compared to patients negative for all drugs and alcohol (nDS). Patients not drug tested or testing positive for drug(s)/alcohol other than marijuana were excluded. Multivariable logistic regression was used to evaluate risk of mortality after controlling for known predictors of mortality including age, sex, injury severity, vital signs, and comorbidities. Additional subgroup analyses were performed for ICU patients and younger adults (<40years-old). From 141737 tested patients, 23310 (16.4%) had an isolated pMS. Patients with pMS were younger (P < .001) but had a similar median injury severity score (ISS) (9, P = .42) compared to nDS patients. On multivariable analysis the associated risk of mortality was lower for pMS (OR .79, .71-.87, P < .001) compared to nDS patients. Subgroups analyses also demonstrated decreased associated risk of mortality for ICU and younger patients (both P < .05). Patients with a pMS had decreased associated risk of mortality compared to nDS patients, including subgroups of ICU and younger patients. These findings require corroboration with future prospective clinical study and basic science evaluation to ascertain the exact pathophysiologic basis and thereby target potential interventions.

Early pharmacologic thromboprophylaxis after splenectomy is associated with better outcomes: A matched cohort study

BackgroundThis study aimed to explore the timing of pharmacologic prophylaxis initiation after trauma splenectomy and the development of venous thromboembolism (VTE). MethodsRetrospective review of American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2013–2017. Adults (>16 years) with isolated splenic injuries who underwent splenectomy and received pharmacologic VTE prophylaxis were stratified based on timing of initiation of prophylaxis: ≤48 h (EARLY) or > 48 h (LATE) from admission. Patients were matched for demographic and clinical characteristics and outcomes compared. Results3631 patients were included. On logistic regression, LATE prophylaxis was associated with DVT (OR 2.317, p < 0.001) and VTE (OR 2.064, p < 0.001). Low molecular weight heparin (LMWH) was protective for DVT (OR 0.621, p = 0.014) and VTE (OR 0.667, p = 0.015). 1196 patients with EARLY prophylaxis were matched with 1196 patients with LATE prophylaxis. VTE and overall complications were significantly higher in the LATE group (7.4% vs. 4.3%, p = 0.001 and 25.8% vs 16.6%, p < 0.001). ConclusionsLate initiation of VTE prophylaxis is associated with DVT and VTE in post-splenectomy patients, while LMWH is protective.

Derivation and Validation of a Score Using Prehospital Data to Identify Adults With Trauma Requiring Early Laparotomy

A scoring tool to identify which adults with traumatic injury will require early laparotomy could help improve prehospital triage and system readiness. To develop and validate a prediction model using prehospital information for early laparotomy following trauma. This retrospective cohort study analyzed data from the 2017 version of the American College of Surgeons Trauma Quality Improvement Program database. All adult patients with traumatic injury aged 18 years or older who were admitted to a US trauma center in 2017 were included. Patients were randomly assigned to a derivation or validation cohort. Data were collected and analyzed between July 2020 and September 2020. The primary outcome was laparotomy within 2 hours of hospital arrival. A scoring system was developed to predict early laparotomy using a logistic regression model in the derivation cohort. This was validated in the validation cohort using the area under the receiver operating characteristic curve. A total of 379 890 US adults with traumatic injury were included; 190 264 patients were in the derivation cohort and 189 626 patients were in the validation cohort. The cohorts had the same proportion of laparotomy within 2 hours of hospital arrival (1.1%). The median (IQR) age was 32 (25-46) years in the early laparotomy group and 54 (33-72) years in the group with no early laparotomy. The early laparotomy group contained 113 776 of 188 211 (60.5%) male patients, while the group with no early laparotomy contained 1702 of 2053 (82.9%) male patients. The variable most strongly associated with early laparotomy was penetrating injury to the head, neck, torso, or extremities proximal to the elbow or knee (odds ratio, 13.47; 95% CI, 12.22-14.86) with a point value of 10 (maximum overall score 20). Other variables included in the scoring system were the male sex, a systolic blood pressure less than 90 mm Hg, a Glasgow Coma Scale of less than or equal to 13, having chest wall instability or deformity, pelvic fracture, and high-risk blunt mechanism. In the validation cohort, the C statistic of the scoring system was 0.78 (95% CI, 0.77-0.79). In this study, a novel scoring tool using prehospital information was derived and validated to identify which adults with traumatic injury will require laparotomy within 2 hours of hospital arrival. This tool may help trauma professionals allocate operative team resources before patient arrival.

A taxonomy of childhood pedal cyclist injuries from latent class analysis: associations with factors pertinent to prevention

BackgroundStudies of pedal cyclist injuries have largely focused on individual injury categories, but every region of the cyclist’s body is exposed to potential trauma. Real-world injury patterns can be complex, and isolated injuries to one body part are uncommon among casualties requiring hospitalization. Latent class analysis (LCA) may identify important patterns in heterogeneous samples of qualitative data.MethodsData were taken from the Trauma Quality Improvement Program of the American College of Surgeons for 2017. Inclusion criteria were age 18 years or less and an external cause of injury code for pedal cyclist. Injuries were characterized by Abbreviated Injury Scale codes. Injury categories and the total number of injuries served as covariates for LCA. A model was selected on the basis of the Akaike and Bayesian information criteria and the interpretability of the classes. Associations were analyzed between class membership and demographic factors, circumstantial factors, metrics of injury severity, and helmet wear. Within-class associations of helmet wear with injury severity were analyzed as well.ResultsThere were 6151 injured pediatric pedal cyclists in the study sample. The mortality rate was 0.5%. The rate of helmet wear was 18%. LCA yielded a model with 6 classes: ‘polytrauma’ (5.5%), ‘brain’ (9.0%), ‘abdomen’ (11.0%), ‘upper limb’ (20.9%), ‘lower limb’ (12.4%), and ‘head’ (41.2%). Class membership had highly significant univariate associations with all covariates except insurance payer. Helmet wear was most common in the ‘abdomen’ class and least common in the ‘polytrauma’ and ‘brain’ classes. Within classes, there was no association of helmet wear with severity of injury.ConclusionsLCA identified 6 clear and distinct patterns of injury with varying demographic and circumstantial associations that may be relevant for prevention. The rate of helmet wear was low, but it varied among classes in accordance with mechanistic expectations. LCA may be an underutilized tool in trauma epidemiology.

Development of a novel tool to predict pulmonary complications in trauma patients with and without chest injury

BackgroundExisting chest trauma scoring tools are often only applicable to patients with chest trauma. We sought to develop a novel Trauma Induced Pulmonary Event (TIPE) score to predict the risk of developing pulmonary complications in all adult trauma patients. MethodsMultiple logistic regression models were created using the 2017 Trauma Quality Improvement Program (TQIP) to identify independent predictors of pulmonary complications in trauma patients. The weighted average and relative impact of each independent predictor was used to derive a TIPE score. We then validated the score using area under the receiver operating curve (AROC). ResultsA total of 22 independent predictors of pulmonary complications were identified. The TIPE score was derived with scores ranging from 0 to 43. Injury accounted for 74% of the total score while comorbidities and demographics made up 21% and 5%, respectively. The most important individual predictors were injuries to the spinal cord and bile ducts (both 4 points). The AROC for this was 0.844. DiscussionTIPE is a novel scoring tool to help predict pulmonary complications in all trauma patients.

Laparoscopy in the Evaluation of Blunt Abdominal Injury in Level-I and II Pediatric Trauma Centers.

An American College of Surgeons (ACS) Level-I (L-I) pediatric trauma center demonstrated successful laparoscopy without conversion to laparotomy in ∼65% of trauma cases. Prior reports have demonstrated differences in outcomes based on ACS level of trauma center. We sought to compare laparoscopy use for blunt abdominal trauma at L-I compared to Level-II (L-II) centers. The Pediatric Trauma Quality Improvement Program was queried (2014-2016) for patients ≤16 years old who underwent any abdominal surgery. Bivariate analyses comparing patients undergoing abdominal surgery at ACS L-I and L-II centers were performed. 970 patients underwent abdominal surgery with 14% using laparoscopy. Level-I centers had an increased rate of laparoscopy (15.6% vs 9.7%, P = .019); however they had a lower mean Injury Severity Score (16.2 vs 18.5, P = .002) compared to L-II centers. Level-I and L-II centers had similar length of stay ventilator days, and SSIs (all P > .05). While use of laparoscopy for pediatric trauma remains low, there was increased use at L-I compared to L-II centers with no difference in LOS or SSIs. Future studies are needed to elucidate which pediatric trauma patients benefit from laparoscopic surgery.

Time to OR for patients with abdominal gunshot wounds: A potential process measure to assess the quality of trauma care?

Abdominal gunshot wounds (GSWs) require rapid assessment and operative intervention to reduce the risk of death and complications. We sought to determine if time to the operating room (OR) might be a useful process measure for the assessment of trauma care quality. We evaluated the facility benchmark time to OR for patients with serious injury and whether this was associated with lower rates of complications and mortality. We evaluated time to OR for adult patients with an abdominal GSW presenting in shock to American College of Surgeons Trauma Quality Improvement Program centers from 2015 to 2020. We calculated the 75th percentile time to the OR for each center and characterized centers as average, slow, or fast. We compared patient and facility characteristics across outlier status, as well as risk-adjusted complications and mortality using hierarchical multivariable logistic regression models. There were 4,027 patients in 230 centers that met the inclusion criteria. Mortality was 28%. There were 61 (27%) fast and 52 (23%) slow centers. The median time for slow centers was 83 minutes (68-94 minutes) compared with fast centers, 35 minutes (32-38 minutes). Injury Severity Score and emergency department vital signs were similar across centers. Fast hospitals had higher total case volumes, more cases per surgeon, and were more likely to be Level I centers. Patients cared for in these centers had similar risk-adjusted rates of complications and mortality. Time to OR for patients with abdominal GSWs and shock might be a useful process measure to evaluate rapid decision making and OR access. Surgeon and center experience as measured by annual case volumes, coupled with a rapid surgical response required through Level I trauma center standards might be contributory. There was no association between outlier status and complications or mortality suggesting other factors apart from time to the OR are of greater significance. Therapeutic/care management, Level IV.

Alcohol is not associated with increased mortality in adolescent traumatic brain injury patients

PurposeCompared to adults, there is a paucity of data regarding the association of a positive alcohol screen (PAS) and outcomes in adolescent patients with traumatic brain injury (TBI). We hypothesize adolescent TBI patients with a PAS on admission to have increased mortality compared to patients with a negative alcohol screen.MethodsThe 2017 Trauma Quality Improvement Program database was queried for patients aged 13–17 years presenting with a TBI and serum alcohol screen. Patients with missing information regarding midline shift on imaging and Glasgow Coma Scale (GCS) score were excluded. A multivariable logistic regression analysis for mortality was performed.ResultsFrom 2553 adolescent TBI patients with an alcohol screen, 220 (8.6%) had a PAS. Median injury severity scores and rates of penetrating trauma (all p > 0.05) were similar between alcohol positive and negative patients. Patients with a PAS had a similar mortality rate (13.2% vs. 12.1%, p = 0.64) compared to patients with a negative screen. Multivariate logistic regression controlling for risk factors associated with mortality revealed a PAS to confer a similar risk of mortality compared to alcohol negative patients (p = 0.40).ConclusionAdolescent TBI patients with a PAS had similar associated risk of mortality compared to patients with a negative alcohol screen.

Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury.

Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level. The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis. The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001). In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

Validation of the artificial intelligence–based trauma outcomes predictor (TOP) in patients 65 years and older

BackgroundThe Trauma Outcomes Predictor tool was recently derived using a machine learning methodology called optimal classification trees and validated for prediction of outcomes in trauma patients. The Trauma Outcomes Predictor is available as an interactive smartphone application. In this study, we sought to assess the performance of the Trauma Outcomes Predictor in the elderly trauma patient. MethodsAll patients aged 65 years and older in the American College of Surgeons–Trauma Quality Improvement Program 2017 database were included. The performance of the Trauma Outcomes Predictor in predicting in-hospital mortality and combined and specific morbidity based on incidence of 9 specific in-hospital complications was assessed using the c-statistic methodology, with planned subanalyses for patients 65 to 74, 75 to 84, and 85+ years. ResultsA total of 260,505 patients were included. Median age was 77 (71–84) years, 57% were women, and 98.8% had a blunt mechanism of injury. The Trauma Outcomes Predictor accurately predicted mortality in all patients, with excellent performance for penetrating trauma (c-statistic: 0.92) and good performance for blunt trauma (c-statistic: 0.83). Its best performance was in patients 65 to 74 years (c-statistic: blunt 0.86, penetrating 0.93). Among blunt trauma patients, the Trauma Outcomes Predictor had the best discrimination for predicting acute respiratory distress syndrome (c-statistic 0.75) and cardiac arrest requiring cardiopulmonary resuscitation (c-statistic 0.75). Among penetrating trauma patients, the Trauma Outcomes Predictor had the best discrimination for deep and organ space surgical site infections (c-statistics 0.95 and 0.84, respectively). ConclusionThe Trauma Outcomes Predictor is a novel, interpretable, and highly accurate predictor of in-hospital mortality in the elderly trauma patient up to age 85 years. The Trauma Outcomes Predictor could prove useful for bedside counseling of elderly patients and their families and for benchmarking the quality of geriatric trauma care.

Octogenarian Survival After Neurosurgical Procedures To Treat Severe Head Trauma

Falls are common for persons of advanced age and can result in severe traumatic brain injury (TBI). The purpose of the present study was to determine the survival benefit from aggressive operative intervention. The trauma quality improvement program database from 2013 to 2016 was accessed for the present study. All patients aged 80-89 years who had sustained a severe TBI with a Glasgow coma scale (GCS) score of ≤8 and brain abbreviated injury scale score of ≥3 and had undergone operative intervention (craniotomy or craniectomy) were included in the present study. The patients were divided into 2 groups, those who had survived and those who had died, and the characteristics, injury severity score (ISS), types of intracranial hemorrhage, and comorbidities were compared. Multivariable logistic regression analysis was performed to determine the factors associated with survival. A receiving operating characteristic curve was created to test the model, and the area under the curve was calculated. Of the 1266 patients who had met the inclusion criteria for the present study, only 477 (37.68%) had survived. A lower ISS, higher GCS score, and no history of coagulopathy were factors indicating a greater chance of survival. Operative intervention for epidural hematoma, brain contusion, and subdural hematoma was associated with 3.5, 2.25, and 1.86 odds of survival, respectively. Procedure type (craniectomy vs. craniotomy) did not affect the outcome. The area under the curve was 0.723 (95% confidence interval, 0.694-0.752). The octogenarians who had undergone craniotomy or craniectomy for severe TBI after a fall had very high mortality. A lower ISS, higher GCS score, no history of coagulopathy and evacuation of subdural hematoma, epidural hematoma, or brain contusion indicated a greater probability of survival.

Association of Venous Thromboembolism Prophylaxis After Neurosurgical Intervention for Traumatic Brain Injury With Thromboembolic Complications, Repeated Neurosurgery, and Mortality

There is a lack of evidence regarding the effectiveness and safety of pharmacologic venous thromboembolism (VTE) prophylaxis among patients who undergo neurosurgical interventions for traumatic brain injury (TBI). To measure the association between timing of VTE prophylaxis after urgent neurosurgical intervention for TBI and thromboembolic and intracranial complications. This retrospective cohort study included adult patients (aged ≥16 years) who underwent urgent neurosurgical interventions (craniotomy/craniectomy or intracranial monitor/drain insertion within 24 hours after admission) for TBI at level 1 and 2 trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program between January 1, 2012, and December 31, 2016. Data were analyzed from January to August 2020. Timing of pharmacologic VTE prophylaxis initiation after urgent neurosurgical intervention (prophylaxis delay) measured in days (24-hour periods). The primary outcome was VTE (deep vein thrombosis or pulmonary embolism). Secondary outcomes were repeated neurosurgery (neurosurgical reintervention after initiation of VTE prophylaxis) and mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis delay and each outcome at the patient level and were adjusted for patient baseline and injury characteristics. The study included 4951 patients (3676 [74%] male; median age, 50 years [IQR, 31-64 years]) who underwent urgent neurosurgical intervention for TBI at 304 trauma centers. The median prophylaxis delay was 3 days (IQR, 1-5 days). After adjustment for patient baseline and injury characteristics, prophylaxis delay was associated with increased odds of VTE (adjusted odds ratio [aOR], 1.08 per day; 95% CI, 1.04-1.12). Earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. During the first 3 days, each additional day of prophylaxis delay was associated with a 28% decrease in odds of repeated neurosurgery (aOR, 0.72 per day; 95% CI, 0.59-0.88). After 3 days, each additional day of prophylaxis delay was associated with an additional 15% decrease in odds of repeated neurosurgery (aOR, 0.85 per day; 95% CI, 0.80-0.90). Earlier prophylaxis was associated with greater mortality among patients who initially underwent intracranial monitor/drain procedures, such that each additional day of prophylaxis delay was associated with decreased odds of death (aOR, 0.94 per day; 95% CI, 0.89-0.99). In this cohort study of patients who underwent urgent neurosurgical interventions for TBI, early pharmacologic VTE prophylaxis was associated with reduced risk of thromboembolism. However, earlier initiation of prophylaxis was associated with increased risk of repeated neurosurgery. These findings suggest that although timely initiation of prophylaxis should be prioritized, caution should be used particularly during the first 3 days after the index procedure, when this risk appears to be highest.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States

Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

The impact of gender on clinical outcomes after sustaining a pelvic fracture.

In trauma care, pelvic fractures contribute to morbidity and mortality. Since men and women have different pelvic structures and hormonal milieu, we studied if these gender differences affect clinical outcomes after pelvic fractures. Using the 2016 American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) database, we stratified 24,425 patients with pelvic fractures by gender. Male and female patients were analyzed for differences in comorbidities, mechanism of injury,complications, and other clinical parameters. Female patients were older (p < 0.001) and had more comorbidities (p < 0.001), such as bleeding disorder, congestive heart failure, chronic obstructive pulmonary disorder, dementia, chronic renal failure, diabetes mellitus, and hypertension. Although female patients were sicker before sustaining pelvic fractures, male patients had higher rates of post-trauma complications (p < 0.001), such as acute kidney injury, deep vein thrombosis, unplanned admission to the intensive care unit (ICU), and unplanned return to the operating room (OR). Multivariate logistic regression further supports this asmalegender was independently associated with a 26.1% higher risk of developing at least one complication (p < 0.001), despite having a higher averageInjury Severity Score (ISS) (21.91 ± 0.09 versus 20.71 ± 0.11,p < 0.001). Interestingly, male patients also had a longer hospital length of stay than female patients (13.36 ± 0.12days versus 11.8 2± 0.14days,p < 0.001). Even though female patients were older and had more pre-existing comorbidities, male patients developed more complications and had longer hospital stays. Trial registration number Not a clinical trial.