York State Trauma Registry Research Articles

Blunt Adrenal Injury: Results of a State Trauma Registry Review

In the past, injuries to the adrenal glands due to blunt trauma were considered rare, and were reported to be associated with high Injury Severity Scores (ISSs) and high mortality. Recent reports have reported a much high incidence associated with lower ISS and lower mortality. The purpose of this study was to assess the incidence of adrenal gland injuries due to blunt trauma in a large state trauma registry and determine whether these injuries are associated with a higher ISS and increased risk for mortality. A retrospective review was performed on the New York State Trauma Registry comparing blunt injured adults with adrenal injuries to those who did not. Concurrent organ injuries, ISS, and inhospital mortality were compared. Three hundred thirty-nine patients with adrenal gland injuries were identified. Concurrent liver and kidney injuries were more prevalent in the adrenal injured group, and concurrent injuries to the small and large intestine and spleen were more prevalent in the nonadrenal injured group. There was no difference in ISS or mortality between the adrenal injured and nonadrenal injured populations. The results of this study are consistent with recent smaller studies which identified incidence rates which were higher than previously reported and that ISS and mortality risk were unchanged by the presence of blunt adrenal gland injuries. Adrenal gland injuries due to blunt trauma are not uncommon, with an incidence rate of 0.61 per cent. Adrenal gland injuries are not associated with higher ISS or an increased risk of mortality.

Patient Characteristics Associated with Comfort Care among Trauma Patients at a Level I Trauma Center

Trauma patients admitted to the intensive care unit are a unique population with high mortality. This study aims to identify characteristics predicting the likelihood of progressing to palliative management often referred to as comfort care measures, thus enabling the trauma team to broach end-of-life decisions earlier in these patients' care. This is a retrospective analysis of the prospectively collected New York State Trauma Registry database for a single Level I trauma center for patients admitted from 2008 to 2015. During this time, a total of 13,662 patients were admitted to the trauma service and there were 827 deaths, resulting in a crude annual mortality rate of approximately 6 per cent. Approximately one-half of the total mortalities, 404 of 827 (48.9%), were ultimately designated as comfort care. Univariate analysis identified the following risk factors for comfort care designation: advanced age, multiple comorbidities, blunt trauma mechanism, traumatic brain injury, and admission location. Multivariate analysis confirmed advanced age and traumatic brain injury. Subgroup analysis also identified advanced directives, pre-existing dementia, and bleeding disorders as significant associations with comfort care designation. The identification of factors predicting comfort care will result in improved care planning and resource utilization.

Elderly trauma inpatients in New York state: 1994-1998.

The aging of the population in the United States has led to an increase in geriatric trauma. This study aimed to examine the characteristics and outcomes of geriatric trauma patients in New York State. Four groups of elderly trauma patients (ages 40-64, 65-74, 75-84, and 85+ years) were contrasted with younger adults ages 13 to 39 years with respect to mechanism of injury, discharge disposition, hospital length of stay, comorbidities, and type of hospital in which they were treated. Also, the independent association of each group with in-hospital mortality was investigated for patients with blunt injuries using logistic regression. There was a 17.6% increase between 1994 and 1998 in the number of traumatic injuries qualifying for the New York State Trauma Registry in the 75- to 84-year-old group and a 16.4% increase in the group ages 85 years or older, despite a decrease in traumatic injuries in other age groups. The majority of these injuries among the patients 75 years of age or older resulted from low falls (from the same level). The mortality rate rose substantially with age, from 5.1% to 5.9% to 9.4% to 12.3% to 15.8%, respectively, for the groups ages 13 to 39, 40 to 64, 65 to 74, 75 to 84, and 85 or more years. Also, fewer than 20% of the patients older than 75 years died within 1 day after admission to the hospital, as compared with 44% of the patients younger than 65 years. The groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older were all independent (increasingly) significant predictors of mortality for all three mechanisms of injury investigated. The adjusted odds ratios for mortality relative to patients who were 13 to 39 years of age were 2.67, 8.41, 17.40, and 34.98, respectively, for the groups ages 40 to 64, 65 to 74, 75 to 84, and 85 years or older. Trauma is a serious and escalating problem for the elderly, and increasing age is a significant risk factor for patient mortality.

Mortality risk after head injury increases at 30 years.

Age has long been recognized as a critical factor in predicting outcomes after head injury, with individuals older than 60 years predicted to have a worse outcome than those younger than 60. The object of this study was to determine the effect of age by decade of life beginning at birth in patients with head injuries of all levels of severity. The New York State Trauma Registry was searched for head injuries from January 1, 1994 to December 31, 1995; the 13,908 cases found were placed into age groups by decade. Data were sought for each patient on demographics, Glasgow Coma Score, ICD-9 injury code, New Injury Severity Score (NISS), and mechanism of injury. These data were analyzed with chi-square and one-way ANOVA tests, with significance set at p < 0.05. The risk of dying was significantly increased in patients beginning at 30 years of age compared with those in the younger age groups, with the greatest increases occurring after age 60 (p < 0.001). For the population with available Glasgow Coma Score data (n = 12,844), the mortality rate for patients ages 0 to 30 was 10.9%, and for patients ages 31 to 50 was 12.4%. The mean Glasgow Coma Score for nonsurvivors ages 0 to 20 (3.9) and for nonsurvivors ages 31 to 50 (5.1) were significantly different, with a risk ratio of 1.3 (p < 0.001). The risk of dying for patients suffering head injuries increases as early as 30 years of age, making it necessary for health-care providers to consider increased monitoring and treatment for patients in this younger age group.

Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity.

The purpose of this study was to compare data obtained from a statewide data set for elderly patients (age > 64 years) that presented with traumatic brain injury with data from nonelderly patients (age > 15 and < 65 years) with similar injuries. The New York State Trauma Registry from January 1994 through December 1995, from trauma centers and community hospitals excluding New York City (45,982 patients), was examined. Head-injured patients were identified by International Classification of Diseases, Ninth Revision diagnosis codes. A relative head injury severity scale (RHISS) was constructed on the basis of groups of these codes (range, 0 = none to 3 = severe). Comparisons were made with nonelderly patients for mortality, Glasgow Coma Scale (GCS) score at admission and discharge, Injury Severity Score, New Injury Severity Score, and RHISS. Outcome was assessed by a Functional Independence Measure score in three major domains: expression, locomotion, and feeding. Data were analyzed by the chi2 test and Mann-Whitney U test, with p < 0.05 considered significant. There were 11,772 patients with International Classification of Diseases, Ninth Revision diagnosis of head injury, of which 3,244 (27%) were elderly. There were more male subjects in the nonelderly population (78% male subjects) compared with the elderly population (50% men). Mortality was 24.0% in the elderly population compared with 12.8% in the nonelderly population (risk ratio, 2.2; 95% confidence interval, 1.99-2.43). The elderly nonsurvivors were statistically older, and mortality rate increased with age. Stratified by GCS score, there was a higher percentage of nonsurvivors in the elderly population, even in the group with only moderately depressed GCS score (GCS score of 13-15; risk ratio, 7.8; 95% confidence interval, 6.1-9.9 for elderly vs. nonelderly). Functional outcome in all three domains was significantly worse in the elderly survivors compared with the nonelderly survivors. Elderly traumatic brain injury patients have a worse mortality and functional outcome than nonelderly patients who present with head injury even though their head injury and overall injuries are seemingly less severe.

Paramedic versus nurse crews in the helicopter transport of trauma patients

Introduction: A wide variety of opinions exist about using paramedics on flight teams, most of which have not been substantiated by research findings. This study was conducted to explore the outcomes of patients transported by helicopter crews that consisted of either two nurses or a nurse and a paramedic. Methods: Using data from the New York State Trauma Registry and prehospital care reports, a retrospective comparison was made between the outcomes of 1193 air medical patients transported either by crews consisting of two nurses (N/N) or a nurse and a paramedic (N/P). The sample included blunt and penetrating trauma patients with an Injury Severity Score greater than or equal to 9 and who were older than 16 years. Results: The findings indicate the percentages of patients who lived, died, or were discharged home or to rehabilitation were similar for N/P and N/N groups. Using TRISS methodology and the Z statistic, no statistically significant difference was found in observed versus predicted mortality for both groups (P<0.5). Conclusion: No significant diffeerence existed in patient outcomes between N/P and N/N crews.

Motor vehicle crashes in New York State: importance of accounting for emergency department deaths when assessing differences in in-hospital mortality by level of care.

Motor vehicle crashes (MVCs) are one of the leading causes of death in the nation and in New York State, particularly among younger adult males. It is important to study how to reduce mortality from MVCs. Hospitalized victims of motor vehicle crashes in the 1994-1995 New York State Trauma Registry were identified for the study. A statistical model was used to calculate risk-adjusted mortality rates for groups of hospitals constituting each level of care (regional trauma center, area trauma center, noncenter). Levels of care were also compared with respect to the location of deaths in the hospital (emergency department, inpatient), and the time between emergency department admission and death for patients dying in the hospital. The risk-adjusted mortality rate for MVCs in patients in regional centers was higher, although not significantly higher (6.91%; 95% confidence interval [CI], 6.18%-7.70%) than for area centers (5.53%; 95% CI, 4.43%-6.82%) or for noncenters (5.83%; 95% CI, 4.70%-7.15%). However, regional centers admitted seriously injured trauma patients from the emergency department much more quickly than other levels of care. Whereas only 18% of all in-hospital deaths occurred in emergency departments of regional centers, the comparable percentages for area centers and noncenters were 39% and 46%, respectively. Also, 43% of all deaths in regional centers occurred within 24 hours of presentation to the emergency department, compared with 15% in area centers and 21% in noncenters. Risk-adjusted inpatient mortality rates for victims of MVCs may not yield a fair comparison of performance for different levels of care or for different hospitals because of differences in how quickly emergency department patients are admitted to the hospital. A more equitable way to assess hospital mortality rates may be to include emergency department deaths in addition to inpatient deaths.

An artificial neural network as a model for prediction of survival in trauma patients: validation for a regional trauma area.

To develop and validate an artificial neural network (ANN) for predicting survival of trauma patients based on standard prehospital variables, emergency room admission variables, and Injury Severity Score (ISS) using data derived from a regional area trauma system, and to compare this model with known trauma scoring systems. The study was composed of 10,609 patients admitted to 24 hospitals comprising a seven-county suburban/rural trauma region adjacent to a major metropolitan area. The data was generated as part of the New York State trauma registry. Study period was from January 1993 through December 1996 (1993-1994: 5,168 patients; 1995: 2,768 patients; 1996: 2,673 patients). A standard feed-forward back-propagation neural network was developed using Glasgow Coma Scale, systolic blood pressure, heart rate, respiratory rate, temperature, hematocrit, age, sex, intubation status, ICD-9-CM Injury E-code, and ISS as input variables. The network had a single layer of hidden nodes. Initial network development of the model was performed on the 1993-1994 data. Subsequent models were generated using the 1993, 1994, and 1995 data. The model was tested first on the 1995 and then on the 1996 data. The ANN model was tested against Trauma and Injury Severity Score (TRISS) and ISS using the receiver operator characteristic (ROC) area under the curve [ROC-A(z)], Lemeshow-Hosmer C-statistic, and calibration curves. The ANN showed good clustering of the data, with good separation of nonsurvivors and survivors. The ROCA(z) was 0.912 for the ANN, 0.895 for TRISS, and 0.766 for ISS. The ANN exceeded TRISS with respect to calibration (Lemeshow-Hosmer C-statistic: 7.4 for ANN; 17.1 for TRISS). The prediction of survivors was good for both models. The ANN exceeded TRISS in nonsurvivor prediction. An ANN developed for trauma patients using prehospital, emergency room admission data, and ISS gave good prediction of survival. It was accurate and had excellent calibration. This study expands our previous results developed at a single Level I trauma center and shows that an ANN model for predicting trauma deaths can be applied across hospitals with good results

Predicting inpatient mortality for pediatric trauma patients with blunt injuries: A better alternative

Purpose: The aim of this study was to identify significant independent predictors of inpatient mortality rates for pediatric victims of blunt trauma and to develop a formula for predicting the probability of inpatient mortality for these patients.Methods: Emergency department and inpatient data from 2,923 pediatric victims of blunt injury in the New York State Trauma Registry in 1994 and 1995 were used to explore the relationship between patient risk factors and mortality rate. A stepwise logistic regression model with P < .05 was developed using survival status as the dependent variable. Independent variables included are elements of the Pediatric Trauma Score (PTS), additional elements from the Revised Trauma Score (RTS), the motor response and eye opening components of the Glasgow Coma Scale (GCS), age-specific systolic blood pressure, the AVPU score, and 2 measures of anatomic injury severity (the Injury Severity Score [ISS] and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]).Results: The only significant independent predictors of severity that emerged were the ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component from the AVPU score. The statistical model exhibited an excellent fit (C statistic = .964). The specificity associated with the prediction of inpatient mortality rate based on the presence of 1 or more of these risk factors was .926, and the sensitivity was.944.Conclusion: The best independent predictors of inpatient mortality rate for pediatric trauma patients with blunt injuries include variables not specifically contained in the PTS or the RTS: ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component of the AVPU score.

An examination of the volume-mortality relationship for New York State trauma centers.

New York State Trauma Registry data were analyzed to determine whether there is a significant relationship between the volume of trauma patients treated by a trauma center and its risk-adjusted inpatient mortality rate. Stepwise logistic regression was used to identify significant independent predictors of mortality, their weights, and the probability of in-hospital mortality for each patient. These data were then used to calculate risk-adjusted mortality rates for various ranges of hospital volume. Ranges were identified on the basis of homogeneity of mortality rates, the number of hospitals in each range, and the number of patients in each range. Three volume measures were used: (1) total annual volume of trauma cases > or = 1200 and total annual volume > or = 240 for patients with Injury Severity Score (ISS) > or = 15 (equivalent to American College of Surgeons [ACS] criteria), (2) total annual volume of patients with ISS > or = 15, and (3) total annual volume of cases in the Registry (approximately, inpatients with ISS > or = 9). Results show that the 35 New York State trauma centers not meeting the ACS criteria had lower, but not significantly lower, observed and risk-adjusted mortality rates (7.62% and 8.25%, respectively) than the corresponding rates for the 8 New York State trauma centers that met the ACS criteria (9.36% and 8.83%, respectively). Regarding the other two criteria, hospital ranges representing lower annual volumes tended to have somewhat lower, although not significantly lower, observed and risk-adjusted mortality rates. For example, using a total annual volume for patients with ISS > or = 15, the risk-adjusted mortality rates for the volume ranges 1-150, 151-250, and 251+ were 7.78%, 9.23%, and 8.70%, respectively. We were unable to document an inverse relationship between hospital volume and inpatient mortality rate for trauma centers in New York State. Volume criteria should not be considered indicators of the quality of trauma care.