Trauma Service Research Articles

How Many Trauma Admissions Require Acute Trauma Team Interventions?

Introduction. The purpose of this study was to determine the percentage of trauma patients who have been admitted and received intervention and, of these, which were performed by non-trauma specialists. Methods. A retrospective chart review was performed on all adult patients presenting through the trauma service between January 2019 and June 2019. The information collected included: demographics, trauma activation level, total interventions performed, interventions by the trauma team, interventions by the subspecialty teams, and isolated injuries (orthopedic, neurosurgery, and other). Results. A total of 287 patients were reviewed. One hundred eleven of these patients (38.7%) underwent operative intervention. Seventy-five patients (26.1%) underwent operative intervention by the orthopedic surgery team. Sixteen patients (5.6%) underwent operative intervention by the neurosurgery team. Fourteen patients (4.9%) underwent operative intervention by other subspecialties. Only 6 patients (2.1%) underwent operative intervention by the trauma team. Conclusions. The collected data suggests that less than half of the patient population underwent intervention by a surgical team. This data demonstrates the need to re-evaluate admission criteria for trauma patients.

Value in acute care surgery, part 4: The economic value of an acute care surgery service to a hospital system

ABSTRACT The Healthcare Economics Committee of the American Association for the Surgery of Trauma has published a series of three articles on the topic of value in acute care surgery (ACS). In this series, the key elements of value, cost and outcomes, and the impact of stakeholder perspective on what constitutes high-value care are discussed. The fourth article in this series continues the discussion by focusing on the unique economic value that an ACS service brings to a hospital system and its patients. Characterized by the immediate 24-hour availability of surgeons trained in trauma management, emergency general surgery, and surgical critical care, acute care surgeons extend the benefits of surgical rescue and critical care to all hospitalized patients. As such, an ACS service acts as a vital part of a hospital's infrastructure to successfully care for complex and seriously ill patients, in addition to enabling the establishment of other, high revenue-generating services such as vascular, transplant, and complex oncologic surgery programs. The trauma service acts as intake for patients that lead to downstream revenue creation by other disciplines such as orthopedic and neurological surgery, while trauma center designation itself results in dedicated state funding to ensure trauma readiness in many states in the United States. The traditional “value equation” in health care of outcomes achieved per dollar spent is ill-suited to capture many of these unique aspects and benefits of ACS. This article provides the background to understand the economic value of an ACS service and future directions toward improving overall value of care. LEVEL OF EVIDENCE Economic & Value-based Evaluations: Level IV.

Health related outcomes of patients with serious traumatic injury: Results of a longitudinal follow-up program delivered by trauma clinicians

IntroductionThe routine collection of long-term patient health outcomes after serious traumatic injury at the health service level is uncommon. In 2019, we implemented the longitudinal Trauma Service Follow Up (TSFU) program at a level I trauma centre. Delivered by the trauma service clinicians involved in inpatient care, it assesses quality of life and disability. This study reports the 6- and 12-month outcomes of the first two years of operation of the TSFU program. MethodsThis is a prospective cohort study of seriously injured adult trauma patients admitted to a level I trauma centre with 6- and 12-months post-discharge outcome assessments. Outcomes were quality of life and function/disability as measured using the EQ-5D-5L and WHODAS 2.0 validated instruments. Changes from 6 to 12 months were assessed using generalised estimating equations methods. Logistic regression models were used to identify factors associated with ongoing problems at each time point. ResultsFive-hundred and eight seriously injured patients were eligible for the TSFU program with follow-up rates over 80 % at both 6- and 12-month timepoints. At six months, ongoing problems with pain (69.9 %), anxiety and depression (49 %) and carrying out usual activities (57.5 %) were highly prevalent; at 12 months problems with pain (61.4 %) and anxiety and depression (43.8 %) persisted. Lower extremity and/or pelvic surgery was associated with ongoing pain, odds ratio (OR) = 3.77 (95 % CI 1.54–9.21, p=0.01), anxiety and depression (OR 1.95, 95 % CI 1.09–3.48, p=0.02) and problems carrying out their usual activities (OR 3.19, 95 % CI 0.75–13.5, p=0.11) at six months. These patterns mostly persisted at 12 months. Similar associations between surgical intervention and high levels of disability were evident at both time points. ConclusionPersistent impairments in physical and emotional health continues to affect many people following serious traumatic injury. The collection of longitudinal health outcomes by trauma clinicians enables identification of factors that contribute to disability and a reduction in quality of life. This in turn can drive quality improvement initiatives within the hospital trauma system. Longitudinal follow-up programs may provide a platform to provide ongoing specialist trauma-informed care after hospital discharge.

SIMULTANEOUS VERSUS STAGED TOTAL HIP ARTHROPLASTY FOLLOWING ACETABULAR FRACTURE FIXATION: A COMPARISON OF OUTCOMES

Acetabular fractures present a challenge. Anatomical reduction can be achieved by open reduction and internal fixation (ORIF). However, in elderly patients with complex fracture patterns and osteoporotic bone stock, “fix and replace” has become an option in the management of these injuries. This involves ORIF of the acetabulum to enable insertion of a press fit cup and subsequent cemented femoral stem at the index surgery.A Retrospective analysis of all operatively managed acetabular fractures by a regional Pelvic and Acetabular Trauma service (01/01/2018-30/05/2023) STATA used for analysis. 34 patients undergoing “fix and replace” surgery. Of the 133 patients managed with ORIF, 21 subsequently required Total Hip Arthroplasty (THA). Mean follow up was 2.7 years versus 5.1. There was no statistical significance between the two groups with regards to BMI or sex. Mean age in the “fix and replace” group was 68 compared to 48 in the ORIF and subsequent THA group. This reached statistical significance between the two groups (p=0.001).ASA and Charlson Comorbidity Index (3 and 3 in “fix and replace” and 2 and 1.2 in ORIF to THA group) and Charlson Comorbidity Index both were statistically significantly different (p=0.006 and p=0.027, respectively). High energy mechanism of injury accounted for 56% of the “fix and replace” group compared to 48% in the ORIF to THA. 74% of “fix and replace” were associated fractures compared to 53% of ORIF to THA. Wait to surgery was 3 days for “fix and replace” while 186 days was the mean wait time from listing to THA for the ORIF to THA group. Complication rate was 41% versus 43% in the two groups. 14% in the ORIF to THA group developed PJI versus 6% in “fix and replace”.Fix and replace allows early mobilisation in frailer, elderly patients. Our results show fewer returns to theatre and less PJI in patients having arthroplasty as part of “fix and replace” than subsequent to Open reduction internal fixation.

Prehospital Delta Shock Index Predicts Mortality and Need for Life Saving Interventions in Trauma Patients

Objectives The delta shock index (ΔSI), defined as the change in shock index (SI) over time, is associated with hospital morbidity and mortality, but prehospital studies about ΔSI are limited. We investigate the association of prehospital ΔSI with mortality and resource utilization, hypothesizing that increases in SI among field trauma patients are associated with increased mortality and blood product transfusion. Methods We performed a multicenter, retrospective, observational study from the Linking Investigators in Trauma and Emergency Services (LITES) network. We obtained data from January 2017 to June 2021. We fit logistic regression models to evaluate the association between an increase ΔSI > 0.1 and 28-day mortality and blood product transfusion within 4 h of emergency department (ED) arrival. We used negative binomial models to evaluate the association between ΔSI > 0.1 and days in hospital, intensive care unit (ICU), and on ventilator (up to 28 days). Results We identified 33,219 prehospital patients. We excluded burn patients and those without documented prehospital or ED heart rate or blood pressure, resulting in 30,511 cases for analysis. In adjusted analysis for the primary outcome of 28-day mortality, patients who had a ΔSI > 0.1 based on initial vital signs were 31% more likely to die (adjusted odds ratio (AOR) of 1.31, 95% CI 1.21-1.41) compared to those patients who had a ΔSI ≤0.1. These patients also spent 16% more days in hospital (adjusted incident rate ratio (AIRR) 1.16, 95% CI 1.14-1.19), 34% more days in ICU (AIRR 1.34, 95% CI 1.28-1.41), and 61% more days on ventilator (ARR 1.61, 95% CI 1.47-1.75). Additionally, patients with a ΔSI > 0.1 had higher odds of receiving blood products (AOR 2.00, 95% CI 1.88-2.12) within 4 h of ED arrival. Models fit excluding hypotensive patients performed similarly. Conclusions An increase of greater than 0.1 in the ΔSI was associated with increased 28-day mortality; increased days in hospital, in ICU, and on ventilator; and increased need for blood product transfusion within 4 h of ED arrival. This association held true for initially normotensive patients. Validation and implementation are needed to incorporate ΔSI into prehospital and ED triage.

Comparison of the epidemiology of elderly trauma between major trauma centres in Riyadh, Saudi Arabia and Melbourne, Australia.

To review the epidemiology of elderly trauma at the Kind Saud Medical City (KSMC), Riyadh, Saudi Arabia, and carry out risk-adjusted analyses to benchmark outcomes with the Alfred Hospital, Melbourne, Australia, the largest Australasian trauma service. This retrospective study included records of injured patients (≥65 years) from the hospital trauma registries during 2022. Demographic and injury data were extracted. Risk-adjusted endpoints were: inpatient mortality and length of stay, analysed using logistic and median regression. A total of 193 elderly patients were registered on the KSMC registry and 1233 elderly patients were registered on the Alfred Hospital registry. Kind Saud Medical City saw proportionally less major trauma (injury severity score of >12, 24.4% vs. 44.2%, p<0.001) and less females (31.1% vs 44.4%, p<0.001). The modal injury group was low level falls in both centres (≈60%). Discharge destination was different, particularly for patients discharged home (86.5% vs. 56%) or to a rehabilitation facility (0.5% vs. 28.2%). The risk-adjusted length of stay was 4.5 days less at the Alfred Hospital (95% CI: [3.25-5.77] days, p<0.001). The odds of in-hospital death were not significantly different (OR=0.72, 95% CI: [0.36-1.47], p=0.37). Despite the different settings, low level falls were the major cause of injury in older patients. A longer length of stay in the acute hospital was identified for KSMC, however, this may be partly explained by discharge destination practices in the 2 countries.

“For the Care of the Underserved” A Descriptive Analysis of MTOA Admitted Under the Non-Trauma Specialties in a MTC

Abstract Background The recent NOCA report highlights a significant portion of major trauma cases resulting from falls among older adults, who often face limited access to trauma centres and age-related biases in treatment. Existing protocols and services for older trauma patients are lacking. This study aimed to audit the incidence and outcomes of MTOA admitted under the non-trauma specialties at a Major Trauma Centre. Methods Data from handover documents between January 2019 and December 2023 were screened for cases of “older trauma” (patients &amp;gt;65 with new trauma injuries) and analysed using Microsoft Excel. Results Between 2019 and 2023, 992 older patients were admitted under non-trauma specialties, with a mean age of 83 years and a majority being female 73% (N=170). The mean length of stay was 14 days, with pelvis injuries being most common 31% (N=307). Falls from standing height accounted for 83% (N=823) of injuries. Only 28% (N=217) of patients at immediate risk of further fragility fractures received bone protection. Most patients were discharged home 49% (N=456), while 6% (N=55) were institutionalized. The total mortality rate in hospital was 7% (N=66). The total mortality at one year was 17% (N=121). The injury with the highest mortality in hospital 24% (N=21) and at one year 40% (N=35) was traumatic brain injuries. Conclusion This audit reveals disparities in trauma care for older patients, despite advances in the field. While initiatives like the hip fracture database have improved care for specific injuries, pathways for older trauma patients not requiring surgery are lacking. Given the excess morbidity and mortality among this population, establishing a Geriatric Trauma Service is imperative. This is in line with literature supporting the idea that older trauma patients demand specialist attention; they are not just older adults.

Evaluating chemical venous thromboembolism prophylaxis in trauma patients at a single Australian center.

Trauma patients are at an elevated risk of developing venous thromboembolism (VTE), with the subsequent mortality in patients requiring intensive care unit admission ranging from 25% to 38%. There remains significant variability in clinical practice related to VTE prophylaxis in trauma patients due to the frequent presence of contraindications impacting the timing and consistency of application. This study aimed to assess the effectiveness of the current practice of chemical VTE prophylaxis in trauma patients at a single Australian center. A prospective review was conducted on patients admitted to the ACT Trauma Service (Canberra, Australia) from July to November 2022. The included patients were 18 years or older, without a direct contraindication to anticoagulation, who received chemical VTE prophylaxis with low-molecular-weight heparin (enoxaparin) for at least three doses and underwent subsequent testing of anti-factor Xa (aFXa) levels. During the study period, 187 patients were admitted, of whom 63 were included in the study. Of these, 47 patients achieved therapeutic levels of anticoagulation as determined by their aFXa levels, while 16 were subtherapeutic. The only statistically significant difference between the two groups was in weight, with patients in the subtherapeutic group weighing an average of 91.9 kg compared to 79.1 kg in the therapeutic group (P<0.05). A fixed-dose enoxaparin regimen was utilized, with limited individualization based on patient factors, such as injuries, comorbidities, and other biological factors. Sixteen patients (25%) had subtherapeutic VTE prophylaxis, as measured by aFXa levels. Higher weight was significantly correlated with inadequate VTE prophylaxis dosing. While age, sex, and smoking status might play important roles in clinical decision-making, weight-based dosing of low-molecular-weight heparin may be more effective in achieving adequate VTE prophylaxis.

Forensic Pathologists and Clinical Trauma Reviews: Performance Improvement, Public Health, and a Concise Autopsy Documentation Guide.

As a powerful tool for discovering and documenting injury, the forensic autopsy has been incorporated into trauma care quality improvement. Autopsy findings are used to determine the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) to assess a patient's trauma severity. Clinical trauma services use autopsy reports to educate, improve patient care, and strengthen the information used in epidemiological and injury prevention studies. However, there is sometimes a disconnect between the forensic pathologist's injury descriptions and the information needed by the trauma service and for AIS/ISS coding.We formed a collaboration between forensic pathologists and trauma teams to improve this communication. Accordingly, we describe injuries that are commonly overlooked or poorly described in autopsy reports, useful injury terminology, opportunities for trauma care improvement revealed by autopsies, and which medical examiner/coroner cases will most benefit from attention to specific injury details. We demonstrate how differences in injury description impact AIS/ISS results, and distill the detailed AIS manual into a pragmatic, concise, "quick reference" autopsy-directed guide for the forensic pathologist. Collaborations between trauma teams and forensic pathologists benefit each other and help communicate autopsy findings in a more clinically useful way to stakeholders to further benefit the living.

Qualitative focus group study of interprofessional healthcare providers to inform the development of a virtual psychoeducational training program for the treatment of childhood interpersonal trauma

ABSTRACT The shortage of adequately trained healthcare providers (HCPs) able to treat adults who have experienced childhood interpersonal trauma (CIT) is a pressing concern. This study explored HCPs’ training needs for a trauma-focused psychoeducational group intervention and the potential barriers and facilitators to accessing such training. Three 1-hour focus group sessions were conducted with HCPs (n = 17) from two urban and one rural community healthcare organization serving diverse populations in Ontario, Canada, including under-housed people, women struggling with mental health and addiction, and LGBTQ+ populations. On average, participants had 2.4 years in their current role and 18.1 years of mental health field experience. Thematic analysis revealed key findings: a strong clinical need for trauma services, accessible training programs, and broadly applicable interventions relevant for diverse populations. Notably, participants emphasized the clinical advantages and increased accessibility of a virtual training programs focused on psychoeducational treatment interventions, particularly within community-based healthcare settings. This study highlights the potential of a virtual psychoeducational training programs for HCPs to address this critical gap in healthcare provision for individual with CIT. It also underscores the need to move beyond training program development and focus on implementation and sustainability of interventions in clinical practice.

Implementation of a Speech-Language Pathologist–Led Tracheostomy Team in a Level 1 Trauma Hospital

Purpose: Cited benefits of a tracheostomy team include reduction in adverse events, length of stay (LOS), and hospital costs. However, there is a lack of research regarding the implementation and benefits of a speech-language pathologist (SLP)-led tracheostomy team. Our goal is to evaluate the effect of an SLP-led tracheostomy team in trauma patients. Method: An SLP-led tracheostomy team was implemented in the trauma service at Hospital Corporations of America Florida Kendall Hospital as a quality improvement project. Data were collected from January 1, 2021, to August 31, 2022. Patients were divided into a pre-tracheostomy team cohort, which served as a historical control, and a post-tracheostomy team cohort. SLP consult, days to SLP consult, Passy-Muir Valve (PMV) use, days to PMV, oral diet, days to start oral diet, downsizing the tracheostomy tube, days to downsize, decannulation, days to decannulation, and LOS were the outcome measures of interest. Pearson's chi-square and Mann–Whitney tests were used to evaluate for a significant difference ( p &lt; .05) between the pre-tracheostomy team cohort and the post-tracheostomy team cohort. Results: Ninety-one patients were included in the final analysis (36 pre-tracheostomy team cohort, 55 post-tracheostomy team cohort). Pre-tracheostomy team and post-tracheostomy team cohorts were grossly similar ( p &gt; .05) in age, sex, and primary admission diagnosis. We found an increase in SLP consultation (58.3%–89.1%, p &lt; .001), PMV utilization (44.4%–67.3%, p = .031), and decannulation (8.3%–30.9%, p = .011). Days to SLP consult decreased when comparing pre-tracheostomy team to post-tracheostomy team cohorts from 6 to 2, respectively ( p &lt; .001). Conclusions: Our approach of placing the SLP in the leading role is novel. After implementation of an SLP-led tracheostomy team, we saw improved outcomes of tracheostomy patients in the trauma population. SLPs should be included as integral members and potential leaders of tracheostomy teams based on their experience and expertise in tracheostomized patient care.

Correlation between alcohol consumption and facial trauma in patients from Dr. João Lúcio Pereira Machado Emergency Hospital in Manaus/AM

Alcohol consumption is a significant health issue in Brazil, contributing to a high incidence of trauma. Recent research indicates that 67% of the population consumes alcohol, with a growing number of alcohol-related facial traumas. This study aims to gather recent data on patients treated for trauma at a Brazilian emergency hospital and assess the relationship between alcohol abuse and facial trauma. Patients arriving at the emergency room were evaluated and categorized by gender, alcohol influence, and subsequent medical interventions. All data were then analyzed. The study found that 528 patients were treated for trauma at Dr. João Lúcio Pereira Emergency Hospital. Of these, 206 had consumed alcohol, with 166 males and 40 females. Among the males, 68 were discharged, 28 required immediate hospital treatment, and 35 were referred to specialized services. Of the females, 18 were discharged, 6 were admitted, and 16 were referred to specialists. The findings indicate that males have a higher incidence of alcohol-related facial trauma compared to females, representing 39% of trauma service visits. These results highlight the need for stricter evaluation of alcohol distribution and enforcement of laws against driving under the influence.

Whole Blood Program: Implementation in a Rural Trauma Center

BACKGROUND: The balanced transfusion of blood components plays a leading role in traumatic hemostatic resuscitation. Yet, previous whole blood studies have only focused on urban trauma center settings. OBJECTIVE: To compare component vs whole blood therapy on wastage rates and mortality in the rural setting. METHODS: This study was a nonrandomized, retrospective, observational, single-center study on a cold-stored whole blood program implementation for adult massive transfusions from 2020 to 2022 at a Level II trauma center. Trauma registry data determined the facility’s whole blood needs and facilitated sustainable blood supplies. Whole blood use protocols were established, and utilization and laboratory compliance for incompatible ABO antibody hemolysis was monitored and reviewed monthly at stakeholder and trauma services meetings. RESULTS: From 2018 to 2019, the facility initiated component therapy massive transfusions every 9 days (n = 41). Therefore, four units of low-titer, O-positive whole blood delivered fortnightly was determined to provide patient coverage and minimize wastage. Across the study time frame (2020–2022), there were n = 68 hemodynamically unstable patients, consisting of those receiving whole blood, n = 37, and patients receiving component therapy, n = 31. Mortality rates were significantly lower (p = .030) in the whole blood population (n = 3, 8%) compared to those solely receiving component therapy (n = 9, 29%). Wastage rates were constantly evaluated; in 2021, 43.4% was not utilized, and in 2022, this was reduced to 38.7%. Anecdotally, nurses appreciated the ease of administration and documentation of transfusing whole blood, as it negated ratio compliance. CONCLUSION: This evidence-based whole blood program provides vital care to severely injured trauma patients in a vast, rural region.

Suicide ideation and intentional self-harm as a risk factor for readmission within one year following a trauma alert: A 10 year retrospective analysis

The objective of this analysis is to study physical traumatic injury as a risk factor for suicide ideation and attempts. The analysis is retrospective, focusing on inpatient readmission with suicide ideation or intentional self-harm within one year of hospitalization as a trauma alert (TA). Injured patients were divided into TA and emergencies without activation (EMWA) of trauma services. We estimated the probability of readmission with suicide ideation or intentional self-harm using a logistic regression. Rates of readmission with intentional self-harm and suicide ideation were on average 60 and 45% higher for the TA group (p < 0.01). Over 80% of patients readmitted with intentional self-harm or suicide ideation had a preexisting mental health condition, compared to approximately 45% in the overall sample. Logistic regression results indicate these patients had an odds-ratio of near six, predicting the readmission. When patients with a preexisting mental health condition were excluded from the analysis, TA patients were significantly more likely to experience a readmission with intentional self-harm and suicide ideation. Demographic and socioeconomic characteristics (gender, age, race, insurance status, and median incomes) as well as injury type (traumatic brain injury or TBI) also help predict readmission with suicide ideation and intentional self-harm. The main risk factors for reengagement with self-harm and suicidal ideation/attempt include preexisting mental health conditions, TA status, and socioeconomic status. Targeted, sustained, and prolonged rehabilitation and trauma-informed therapy for this high-risk group of severely injured patients may yield significant health and social benefits.

Characteristics of Trauma Patients Who Died at UGM Academic Hospital (RSA UGM)

BACKGROUND : Trauma becomes the main health problem worldwide due to its high mortality rate. Traffic accidents are a trauma with a high incidence and death rate in Indonesia, specifically in Yogyakarta. Factors causing trauma-related death are the lack of hospital infrastructure, the lack of quality human resources, the lack of standardization of trauma management, and the limited number of hospitals providing comprehensive trauma services. This research aims to identify the characteristics of trauma patients who died while receiving medical treatment at UGM Academic Hospital and to analyze the mortality of patients according to the trimodal distribution to prepare this hospital to become a trauma center hospital.METHOD : This quantitative descriptive research used a cross-sectional method. Data were taken from medical records of patients admitted to the ER of UGM Academic Hospital in 2018-2023 based on predetermined inclusion and exclusion criteria. The research was conducted from March to November 2023.RESULT : This research involved 58 patients consisting of 42 (72.4%) male and 16 (27.6%) female patients. The most common cause of death was brain injury (63%), followed by spinal cord injury (13.7%), multi-organ failure and sepsis (8.6%), cardiac and respiratory arrest (6.8%), and comorbidities patients (6.8%).CONCLUSION : The majority of trauma patients who died at the UGM Academic Hospital are male and aged 60-80 years with the main cause of death of brain injury. The patient dies at the late death stage based on trimodal distribution of death time.

The relationship between social environmental stressors and depressive symptoms among Chinese young adults: Above and beyond the effects of childhood trauma

Childhood trauma has been identified as an important etiological risk factor for depressive symptoms, but there are other modifiable social environmental factors that may be equally, if not more, important. This study aimed to improve our understanding of the social determinants of depressive symptoms among young people while taking childhood trauma into account. We analyzed survey data from a convenience sample of Chinese young adults aged between 18 to 24 (N = 205). Participants completed standardized assessments of childhood trauma (the Brief Betrayal Trauma Survey), depressive symptoms (the PHQ-9), and social environmental stressors (the Social Environmental Stress Questionnaire). Social environmental stressors had the strongest relationship with depressive symptoms (β = .416, p < .001), above and beyond the effects of childhood trauma. We also identified some specific modifiable and targetable social environmental stressors (e.g., school work and occupation issues, high expectations from others, sleep environment) that were positively correlated with depressive symptoms, even when the Bonferroni correction was applied. Although childhood trauma is a well-documented risk factor for mental health problems, there are modifiable factors associated with depressive symptoms, above and beyond the effects of childhood trauma. Educators, healthcare practitioners, social service providers, and policymakers can play a vital role in changing the trajectory of depression in the community.

Optimizing Orthogeriatric Hip Fracture Care: Why Fracture Type Matters

Hip fractures significantly impact morbidity and mortality among frail older adults, posing ongoing challenges in orthogeriatric care despite significant advancements. Established in the 1960s by Devas and Irvine, this field integrates orthopedics, trauma services, and geriatric medicine to address the complex needs of this population comprehensively. A critical and underexplored aspect is the precise identification and tailored treatment of various fracture types, each linked to unique clinical challenges and outcomes. This special article emphasizes the complex interplay between specific fracture types, their management options, and the roles of comorbidity and polypharmacy, highlighting the essential role of orthogeriatricians. Orthogeriatricians navigate the complexities posed by comorbidities, frailty, and polypharmacy, significantly influencing treatment outcomes. Their roles have expanded to include decision making about both operative and nonoperative strategies, emphasizing patient-centered care and moving beyond simplistic categorizations of “hip fractures.” As future experts on the nuances of fracture types and their broader health implications, orthogeriatricians are also crucial in advancing treatment protocols that address preoperative and postoperative needs. Their comprehensive knowledge ensures effective in-hospital management and postdischarge planning, aligning treatment strategies with the holistic needs of frail older adults. The ongoing evolution of orthogeriatric practices promises to enhance decision-making and patient outcomes through a more informed and integrated care approach.

Traumatic Brain Injury Patients Admitted on High-Census Days Receive Less Critical Care and Have an Increased Risk for Delirium.

The utilization of healthcare services in a growing population has raised concerns about its impact on clinical outcomes. Studies have shown that increased hospital census is associated with higher admission rates and unnecessary consults, tests, and procedures in various areas of healthcare. Traumatic brain injuries (TBIs), a significant concern due to their potential for long-term disabilities, are commonly encountered in intensive care units (ICUs) and are a leading cause of patient mortality. Despite extensive research on various aspects of TBI, the effect of the patient census on TBI outcomes remains unexplored. This study aims to investigate the relationship between healthcare provider patient census and clinical outcomes in TBI patients at a level I trauma center. A retrospective review was conducted from 2017 to 2022. The mean number of patients per day in the trauma service was determined, with patients below this average considered to be present on low-census days and those above it on high-census days. Patient demographics, mechanisms of injury, vital signs, TBI severity, and associated injuries were analyzed. Adjusted regression analyses were conducted. Over the study period, 1,527 TBI patients were identified. Demographics were similar between patients admitted on high- and low-census days. Patients with moderate TBI were 30% less likely to be admitted to the ICU on high-census days, whereas there was no difference in ICU admission for patients with mild or severe TBI. Delirium was significantly higher in patients admitted on high-census days compared to those on low-census days. This was further identified to be predominantly driven by patients with mild TBI admitted on high-census days. While most outcomes remained consistent, significant rates of delirium were found in our mild TBI patients admitted on high-census days suggesting the need for additional factors in the evaluation of these patients on admission. This study also reveals potential under-triage in moderate TBI patientson high-census days as they had significantly lower rates of ICU admission. These findings emphasize the need for further investigations to optimize patient care strategies within the context of fluctuating healthcare system demands.

Treating wartime injuries amidst attack: insights from a medical facility on the edge of combat

BackgroundProviding emergency care during conflict poses unique challenges for frontline hospitals. Barzilai Medical Center (BUMCA) in Ashkelon, Israel is a Level I trauma center located close to the Gaza border. During the November 2023 escalation of conflict, BUMCA experienced surging numbers of civilian and military trauma patients while also coming under rocket fire.MethodsWe conducted a retrospective review of BUMCA operational records and 827 de-identified patient records from October 7–14, 2023. Records provided data on daily patient volumes, injury patterns, resource constraints, and impacts of rocket attacks on hospital function. Basic demographic data was obtained including age, gender, injury severity scores, and disposition.ResultsOf the 827 patients brought to BUMCA, most (n = 812, 98.2%) presented through the emergency department. Tragically, 99 individuals were pronounced dead on arrival. Injury severity assessments found nearly half (47%) had minor injuries such as lacerations, contusions and sprains, while 25% exhibited moderate injuries like deep lacerations and fractures. 15% sustained severe or critical injuries including severe head injuries. The largest age group consisted of adults aged 19–60 years. No pediatric patients were admitted despite proximity to residential neighborhoods. The majority of cases (61%) involved complex polytrauma affecting multiple body regions. BUMCA served as both the primary treatment facility and a triage hub, coordinating secondary transports to other trauma centers as needed. Patient volumes fluctuated unpredictably from 30 to an overwhelming 125 daily, straining emergency services. Resources faced shortages of beds, medical staff, supplies and disruptions to power from nearby missile impacts further challenging care delivery.ConclusionDespite facing surging demand, unpredictable conditions and external threats, BUMCA demonstrated resilience in maintaining emergency trauma services through an adaptive triage approach and rapid surges in capacity. Their experience provides insights for improving frontline hospital preparedness and continuity of care during conflict through advance contingency planning and surge protocols. Analysis of patient outcomes found a mortality rate of 15% given the complex, multi-region injuries sustained by many patients. This study highlights the challenges faced and strengths exhibited by medical professionals operating under hazardous conditions in minimizing loss of life.Patient and public involvement in researchGiven that the study analyzed patient data from a hospital treating casualties of an ongoing armed conflict, directly engaging patients or the public during the sensitive research process could have posed risks. The volatile security situation and restrictions and protections in place amidst the crisis made it not feasible or appropriate to involve them in the study’s design, methods, reporting of results, or dissemination plans. Our aim was to conduct this retrospective analysis in a way that did not endanger those affected or compromise the hospital’s emergency response operations.

FIXING THE PERIPROSTHETIC FEMUR FRACTURE PROBLEM: ARE WE ABLE TO PROVIDE SAFE, EFFECTIVE, AND TIMELY CARE IN NORTH WALES? A PAN BETSI COLLABORATIVE STUDY

The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years.We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential cost savings compared to transfer to tertiary centre for PPFF management was £2.31 million. Thus, it is possible to successfully provide adequate care for PPFFs at DGHs and efforts should be made to appropriately equip and adequately staff DGHs, to provide service for local PPFF care.