Background

Our aim is to assess state variation in renal trauma outcomes. We hypothesize that states with more hospitals participating in a trauma system will have lower nephrectomy and mortality rates.

Methods

The Heathcare Cost and Utilization Project State Inpatient Database was utilized to conduct a retrospective cohort study of all patients hospitalized with renal injury from partnering states during 2001, 2004, and 2007. State trauma systems were categorized based on the proportion of all acute care hospitals designated as a trauma center (level I-V), with higher proportions correlating to a more inclusive system. Poisson regression for relative risks of inpatient nephrectomy and case fatality were performed adjusting for patient and state level factors.

Results

Patients in states with the “most inclusive” trauma systems had a 30% lower risk of nephrectomy (RR 0.70 95% CI 0.56, 0.88) and a 2.06% lower unadjusted inpatient case fatality rate compared to states with “exclusive” trauma systems. Inpatient case fatality risk varied significantly by trauma system inclusiveness. Patients treated in states with either a “more inclusive” (RR 0.85, 95% CI 0.74, 0.97) or “most inclusive” (0.74, 95% CI 0.64, 0.85) trauma system were independently associated with a lower inpatient case fatality risk compared to states with “exclusive” systems.

Conclusions

A reduced risk of nephrectomy and inpatient case fatality are more common among states that have a higher proportion of acute care hospitals participating as a trauma center (level I-V). Standardization of care may correlate with improved patient outcomes following renal trauma.

Objective

To survey US Level I trauma centers in order to assess the characteristics of child and adolescent psychosocial service delivery.

Study design

Trauma program staff at US Level I trauma centers were asked to complete a survey regarding the characteristics and quality of service delivery for youth. The presence of pediatric services and screening of injured youth for alcohol use problems and posttraumatic stress disorder (PTSD) symptoms were assessed.

Results

150 of 202 (74%) of trauma centers responded to the survey. Substantial variability was observed in trauma center age cutoffs for pediatric and adolescent patients. Although the majority of sites endorsed having specialized pediatric, intensive care unit, and surgical services, marked differences were found in the reported percentage of youth receiving psychosocial services. Even though the majority of sites screened injured youth for alcohol use problems, variability was observed in the actual percentage of children and adolescents screened. Only 20% of sites endorsed specialized PTSD services.

Conclusions

Our investigation observed marked variability across trauma centers in the delivery of child and adolescent services. Future research could develop high quality pediatric psychosocial services in order to inform trauma center standards nationwide.

Objective

To determine the accuracy of EMS provider assessments of motor vehicle damage, when compared to measurements made by a professional crash reconstructionist.

Methods

EMS providers caring for adult patients injured during a motor vehicle crash and transported to the regional trauma center in a midsized community were interviewed upon ED arrival. The interview collected provider estimates of crash mechanism of injury. For crashes that met a preset severity threshold, the vehicle’s owner was asked to consent to having a crash reconstructionist assess their vehicle. The assessment included measuring intrusion and external auto deformity. Vehicle damage was used to calculate change in velocity. Paired t-test and correlation were used to compare EMS estimates and investigator derived values.

Results

91 vehicles were enrolled; of these 58 were inspected and 33 were excluded because the vehicle was not accessible. 6 vehicles had multiple patients. Therefore, a total of 68 EMS estimates were compared to the inspection findings. Patients were 46% male, 28% admitted to hospital, and 1% died. Mean EMS estimated deformity was 18” and mean measured was 14”. Mean EMS estimated intrusion was 5” and mean measured was 4”. EMS providers and the reconstructionist had 67% agreement for determination of external auto deformity (kappa 0.26), and 88% agreement for determination of intrusion (kappa 0.27) when the 1999 Field Triage Decision Scheme Criteria were applied. Mean EMS estimated speed prior to the crash was 48 mph±13 and mean reconstructionist estimated change in velocity was 18 mph±12 (correlation -0.45). EMS determined that 19 vehicles had rolled over while the investigator identified 18 (kappa 0.96). In 55 cases EMS and the investigator agreed on seatbelt use, for the remaining 13 cases there was disagreement (5) or the investigator was unable to make a determination (8) (kappa 0.40).

Conclusions

This study found that EMS providers are good at estimating rollover. Vehicle intrusion, deformity, and seatbelt use appear to be more difficult to estimate with only fair agreement with the crash reconstructionist. As expected, the EMS provider estimated speed prior to the crash does not appear to be a reasonable proxy for change in velocity.

Objective

To determine the predictive value of the Mechanism of Injury step of the American College of Surgeon’s Field Triage Decision Scheme for determining trauma center need.

Methods

EMS providers caring for injured adult patients transported to the regional trauma center in 3 midsized communities over two years were interviewed upon ED arrival. Included was any injured patient, regardless of injury severity. The interview collected patient physiologic condition, apparent anatomic injury, and mechanism of injury. Using the 1999 Scheme, patients who met the physiologic or anatomic steps were excluded. Patients were considered to need a trauma center if they had non-orthopedic surgery within 24 hours, intensive care unit admission, or died prior to hospital discharge. Data were analyzed by calculating positive likelihood ratios (+LR) and 95% confidence intervals (CI) for each mechanism of injury criteria.

Results

11,892 provider interviews were conducted. Of those, 1was excluded because outcome data were not available and 2,408 were excluded because they met the other steps of the Field Triage Decision Scheme. Of the remaining 9,483 cases, 2,363 met one of the mechanism of injury criteria, 204 (9%) of which needed the resources of a trauma center. Criteria with a +LR ≥5 were death of another occupant in the same vehicle (6.8; CI:2.7–16.7), fall >20 ft.(5.2; CI:2.4–11.3), and motor vehicle crash (MVC) extrication >20 minutes (5.0; CI:3.2–8.0). Criteria with a +LR between 2 and <5 were intrusion >12 inches (3.7; CI:2.6–5.3), ejection (3.2; CI:1.3–8.2), and deformity >20 inches (2.3; CI:1.7–3.0). The criteria with a +LR <2 were MVC speed >40 mph (1.9; CI:1.5–2.2), pedestrian/bicyclist struck >5mph (1.2; CI:1.0–1.5), bicyclist/pedestrian thrown or run over (1.2; CI:0.9–1.6), motorcycle crash >20mph (1.1; CI:0.96–1.3), rider separated from motorcycle (1.0; CI:0.9–1.2), and MVC rollover (1.0; CI:0.7–1.5).

Conclusion

Death of another occupant, fall distance, and extrication time were good predictors of trauma center need when a patient did not meet the anatomic or physiologic conditions. Intrusion, ejection, and vehicle deformity were moderate predictors.

Objective

To develop and implement a stepped collaborative care intervention targeting PTSD and related co-morbidities to enhance the population impact of early trauma-focused interventions.

Method

We describe the design and implementation of the Trauma Survivors Outcomes & Support Study (TSOS II). An interdisciplinary treatment development team was comprised of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between front-line trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures.

Results

Two-hundred and seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing, and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by front-line acute care MSW and ARNP providers.

Conclusions

Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other non-specialty posttraumatic contexts.

In 2006, the CDC released a revised Field Triage Decision Scheme. It is unknown how this modified scheme will affect the number of patients identified by EMS for transport to a trauma center.

Objective

To determine the change in the number of patients transported by EMS who meet the 2006 scheme, compared to the 1999 scheme, and to determine how the scheme change would affect under- and over-triage rates.

Methods

EMS providers in charge of care for injured adult patients transported to a regional trauma center in three mid-sized cities were interviewed immediately after completing transport. All injured patients were included, regardless of severity. The interview included patient demographics, vital signs, apparent anatomic injury, and the mechanism of injury. Included patients were then followed through hospital discharge. The 1999 and 2006 scheme criteria were each retrospectively applied to the collected data. The number of patients identified by the two schemes was determined. Patients were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics including 95% confidence intervals.

Results

EMS interviews were conducted for 11,892 patients and outcome data was unavailable for one patient. Average patient age was 48 years; 51% were men. Providers reported bringing 54% of the enrolled patients to the trauma center based on their local trauma protocol. 12% of enrolled patients were identified as needing a trauma center based on medical record review. Use of the 2006 scheme would have resulted in 1,423 fewer patients (12%; 95% CI:11-13%) being identified as needing a trauma center by EMS providers (40%; 95%CI:39-41% versus 28%; 95%CI:27-29%). 1,344 of those patients did not actually need the resources of a trauma center (94%). 78 (6%) of those patients actually needed the resources of a trauma center and would have been under-triaged.

Conclusion

Use of the 2006 Field Triage Decision Scheme would have resulted in a significant decrease in the number of patients identified as needing the resources of a trauma center. These changes reduced over-triage while causing a small increase in the number of patients who would have been under-triaged.

Objective

The aim of this study was to develop and validate a comorbidity index to predict the risk of mortality associated with chronic health conditions following a traumatic injury.

Summary Background Data

Currently available comorbidity adjustment tools do not account for certain chronic conditions, which may influence outcome following traumatic injury or they have not been fully validated for trauma. Controlling for comorbidity in trauma patients is becoming increasingly important as the population ages and elderly patients are more active, as well as to adjust for bias in trauma mortality studies.

Methods

Cohort study using data from the National Study on the Costs and Outcome of Trauma. Subject pool (N = 4644/Weighted Number = 14,069) was randomly divided in half; the first half of subjects was used to derive the risk scale, the second to validate the instrument. To construct the Mortality Risk Score for Trauma (MoRT), univariate analysis and odds ratios were performed to determine relative risk of mortality at hospital discharge comparing those persons with a comorbid condition to those without. Conditions significantly associated with mortality (P < 0.05) were included in the multivariate model. The variables in the final model were used to build the MoRT. The predictive ability of the MoRT and the Charlson Comorbid-ity Index (CCI) for discharge and 1-year mortality were estimated using the c-statistic in the validation sample.

Results

Six comorbidity factors were independently associated with the risk of mortality and formed the basis for the MoRT: severe liver disease, myocardial infarction, cerebrovascular disease, cardiac arrhythmias, dementia, and depression. The MoRT had a similar overall discrimination as the CCI for mortality at hospital discharge in injured adults (c-statistic: 0.56 vs. 0.56) although neither by itself performed well. The addition of age and gender improved the predictive ability of the MoRT (0.59; 95% CI: 0.56, 0.62) and the CCI (0.59; 0.56, 0.62). Similar results were seen at 1-year postinjury. The further addition of Injury Severity Score significantly improved the predictive ability of the MoRT (0.77, 95% CI: 0.74, 0.79) and the CCI (0.77, 95% CI: 0.75, 0.80).

Conclusions

The MoRTs primary advantage over current instruments is its parsimony, containing only 6 items. In the present study, the comorbid conditions found to be predictive of mortality had some overlap with the CCI, but this study identified 2 novel predictors: cardiac arrhythmias and depression. Inclusion and reporting of these items within trauma registries would therefore be an important step to allow further validation and use of the MoRT.

BACKGROUND

In 2007, the American College of Surgeons (ACS) Committee on Trauma implemented a requirement that Level I trauma centers must have a mechanism to identify patients who are problem drinkers and the capacity to provide an intervention for patients who screen positive. Although the landmark alcohol screening and brief intervention (SBI) mandate is anticipated to impact trauma practice nationwide, a literature review revealed no studies that have systematically documented SBI practice pre-ACS requirement.

STUDY DESIGN

Trauma programs at all US Level I trauma centers were contacted and asked to complete a survey about pre-ACS requirement trauma center SBI practice.

RESULTS

One hundred forty-eight of 204 (73%) Level I trauma centers responded to the survey. More than 70% of responding centers routinely used laboratory tests (eg, blood alcohol concentration) to screen patients for alcohol and 39% routinely used a screening question or standardized screening instrument. Screen-positive patients received a formal alcohol consult or had an informal alcohol discussion with staff members approximately 25% of the time.

CONCLUSIONS

The investigation observed marked variability across Level I centers in the percentage of patients screened and in the nature and extent of intervention delivery in screen-positive patients. In the wake of the ACS Committee on Trauma requirement, future research could systematically implement and evaluate training in the delivery of evidence-based alcohol interventions and training in development of trauma center organizational capacity for sustained delivery of SBI.

Context

Few large-scale, multisite investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms and health outcomes across the spectrum of patients with mild, moderate, and severe traumatic brain injury (TBI).

Objectives

To understand the risk of developing PTSD symptoms and to assess the impact of PTSD on the development of health and cognitive impairments across the full spectrum of TBI severity.

Design

Multisite US prospective cohort study.

Setting

Eighteen level I trauma centers and 51 non–trauma center hospitals.

Patients

A total of 3047 (weighted n=10 372) survivors of multiple traumatic injuries between the ages of 18 and 84 years.

Main Outcome Measures

Severity of TBI was categorized from chart-abstracted International Classification of Diseases, Ninth Revision, Clinical Modification codes. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist 12 months after injury. Self-reported outcome assessment included the 8 Medical Outcomes Study 36-Item Short Form Health Survey health status domains and a 4-item assessment of cognitive function at telephone interviews 3 and 12 months after injury.

Results

At the time of injury hospitalization, 20.5% of patients had severe TBI, 11.7% moderate TBI, 12.9% mild TBI, and 54.9% no TBI. Patients with severe (relative risk, 0.72; 95% confidence interval, 0.58-0.90) and moderate (0.63; 0.44-0.89) TBI, but not mild TBI (0.83; 0.61-1.13), demonstrated a significantly diminished risk of PTSD symptoms relative to patients without TBI. Across TBI categories, in adjusted analyses patients with PTSD demonstrated an increased risk of health status and cognitive impairments when compared with patients without PTSD.

Conclusions

More severe TBI was associated with a diminished risk of PTSD. Regardless of TBI severity, injured patients with PTSD demonstrated the greatest impairments in self-reported health and cognitive function. Treatment programs for patients with the full spectrum of TBI severity should integrate intervention approaches targeting PTSD.

Necrotizing soft-tissue infections (NSTI) are often life-threatening illnesses that may be best treated at specialty care facilities such as burn centers. However, little is known about current treatment patterns nationwide. The purpose of this study was to describe the referral patterns for treatment of NSTI using a multistate discharge database and to investigate the differences in patients with NSTIs treated at burn centers and nonburn centers. The National Inpatient Sample is an all-payer inpatient database from 37 states containing data from 14 million hospital stays each year. We identified all patients with NSTI using International Classification of Disease version 9 codes for necrotizing fasciitis (728.86), gas gangrene (040.0), and Fournier’s gangrene (608.83) for the years 2001 and 2004. Patients were dichotomized by location of definitive treatment—either burn centers or nonburn centers. Burn center status was ascertained from the current American Burn Association burn center directory. Patient characteristics, payer status, hospital course, mortality rates, and disposition were compared between patients treated at burn centers and nonburn centers. In 2001 and 2004, a total of 10,940 patients were identified as having a NSTI. The majority (87.1%) of these patients received definitive care at nonburn centers. Patients treated at burn centers were more likely to be transferred from another hospital (OR 2.0, CI 1.8–2.2) and were more likely to have Medicaid (22.6% vs 16.3%, OR 1.39) or be uninsured (18.8% vs 13.7%, OR 1.38). Patients treated at burn centers had more surgical procedures (4.6 vs 4.3, P <.01), and higher hospital charges ($101,800 vs $68,500, P <.01). Total length of stay was also longer at burn centers (22.1 vs 16.0 days, P <.01). Based on a national discharge database, the majority of patients with NSTI are treated at nonburn centers. However, patients treated at burn centers were more likely to be transferred from non-burn centers, had longer lengths of stay, and underwent more operations, all of which are likely attributable to a greater severity of infection.

Purpose

To provide guidance for managing the problem of missing data in clinical studies of trauma in order to decrease bias and increase the validity of findings for subsequent use.

Organizing Construct

A thoughtful approach to missing data is an essential component of analysis to promote the clear interpretation of study findings.

Methods

Integrative review of relevant biostatistics, medical and nursing literature, and case exemplars of missing data analyses using multiple linear regression based upon data from the National Study on the Costs and Outcomes of Trauma (NSCOT) was used as an example.

Findings and Conclusions

In studies of traumatically injured people, multiple imputed values are often superior to complete case analyses that might have significant bias. Multiple imputation can improve accuracy of the assessment and might also improve precision of estimates. Sensitivity analyses which implements repeated analyses using various scenarios may also be useful in providing information supportive of further inquiry. This stepwise approach of missing data could also be valid in studies with similar types or patterns of missing data.

Clinical Relevance

In interpreting and applying findings of studies with missing data, clinicians need to ensure that researchers have used appropriate methods for handling this issue. If suitable methods were not employed, nurse clinicians need to be aware that the findings may be biased.

Background

To examine the association between patient complications and admission to level 1 trauma centers (TC) compared to non-trauma centers (NTC).

Study Design

A retrospective cohort study of data derived from the National Study on the Costs and Outcomes of Trauma (NSCOT). Patients were recruited from 18 level 1 TC and 51 NTC in 15 regions encompassing 14 states. Trained study nurses, using standardized forms, abstracted the medical records of the patients. The overall number of complications per patient was identified as well as the presence or absence of 13 specific complications.

Results

Patients treated in TC were more likely to have any complication compared to NTC with an adjusted relative risk (RR) of 1.34 (95% CI 1.03, 1.74). For individual complications, only urinary tract infection RR 1.94 (95% CI 1.07, 3.17) was significantly higher in TC. TC patients were more likely to have three or more complications, RR 1.83 (95% CI 1.16, 2.90). Treatment variables that are surrogates for markers of injury severity, such as use of pulmonary artery catheters, multiple operations, massive transfusions (> 2,500mL packed red blood cells), and invasive brain catheters, occurred significantly more often in TC.

Conclusions

Trauma centers have a slightly higher incidence rate of complications even after adjusting for patient case mix. Aggressive treatment may account for a significant portion of TC-associated complications. PA catheter use and intubation had the most influence on overall TC complication rates. Further study is needed to provide accurate benchmark measures of complication rates and to determine their causes.

Objective

To assess intensive care unit (ICU)/acute care service-delivery characteristics and pre-ICU factors as predictors of posttraumatic stress disorder (PTSD) and return to usual major activity after ICU admission for trauma.

Method

Data from the National Study on the Costs and Outcomes of Trauma was used to evaluate a prospective cohort of 1,906 ICU survivors. We assessed PTSD with the PTSD Checklist. Regression analyses ascertained associations between ICU/acute care service-delivery characteristics, pre-ICU factors, early post-ICU distress, and 12-month PTSD and return to usual activity, while controlling for clinical and demographic characteristics.

Results

Approximately 25% of ICU survivors had symptoms suggestive of PTSD. Increased early post-ICU distress predicted both PTSD and diminished usual major activity. Pulmonary artery catheter insertion (Risk Ratio (RR) 1.28, 95% Confidence Interval (95%CI) (1.05-1.57), p=0.01) and pre-ICU depression (RR 1.23, 95%CI (1.02-1.49), p=0.03) were associated with PTSD. Longer ICU lengths of stay (RR 1.21, 95%CI (1.03-1.44), p=0.02) and tracheostomy (RR 1.29, 95%CI (1.05-1.59), p=0.01) were associated with diminished usual activity. Greater pre-existing medical co-morbidities were associated with PTSD and limited return to usual activity.

Conclusions

Easily identifiable risk factors including ICU/acute care service-delivery characteristics and early post-ICU distress were associated with increased risk of PTSD and limitations in return to usual major activity. Future investigations could develop early screening interventions in acute care settings targeting these risk factors, facilitating appropriate treatments.

BACKGROUND:

Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies.

OBJECTIVE:

To determine whether residual hemothorax detected by chest x-ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema.

METHODS:

A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score.

RESULTS:

A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4±26) versus those who did not (22.6±13; P=0.03).

CONCLUSIONS:

The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach.

Objectives

To evaluate the effect of age on intensity of care provided to traumatically brain-injured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity.

Design

Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients.

Setting and Patients

A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25−84 yrs with a diagnosis of traumatic brain injury.

Measurements

Injury severity was determined by the motor component of the Glasgow Coma Scale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy.

Main Results

Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75−84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a do-not-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0).

Conclusions

There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, their consultation was associated with decreased risk of in-hospital death and death within 12 months. It is important that careproviders have an increased awareness of the potential contribution of multidisciplinary clinical decision making to patient outcomes in older traumatically brain-injured patients.