Statewide variation in the treatment of patients hospitalized with spleen injury

Splenic injury admitted to a rural Level 3 trauma centre: a 10-year audit

OBJECTIVE

There is paucity of research documenting the management of splenic injury in rural Australia. No data exists for Rural, Remote and Metropolitan Area 4 locations.

DESIGN

A retrospective review of prospectively collected data. Records were additionally sought from transfer hospitals. A qualitative assessment of splenic trauma management in the Wimmera Region was also performed.

SETTING

Wimmera Health Care Group: Horsham Campus, a Level 3 trauma hospital between January 2000 and July 2011.

PARTICIPANTS

Patients coded with injury of spleen or excision procedure on spleen.

INTERVENTIONS

Nil

MAIN OUTCOME MEASURES

surgical vs. non-surgical management

RESULTS

Nineteen patients were included (mean age 27.8, range 8-54). Only 26% were from Horsham. Most injuries were due to sporting trauma/falls (53%) and motor vehicle accidents (37%). One patient died in theatre from massive trauma. Eleven patients were managed non-operatively. Seven patients had splenectomy performed. Four of these had delay in computed tomography scanning, delay to theatre and suffered major postoperative complication. The age (mean 39.9 versus 20.8) and Injury Severity Score (mean 21.9 versus 13.8) of patients requiring splenectomy was higher than those managed non-operatively. Six of the splenic injury admissions (32%) were transferred from surrounding general practitioner-run Rural, Remote and Metropolitan Area 5 hospitals. All of these patients had Victorian State Trauma Service-defined major trauma with an Injury Severity Score >15. There was an approximate 4-hour delay in transfer of these patients, with transfer occurring when clinical deterioration occurred.

CONCLUSIONS

Although splenic injury is uncommon in the Wimmera region, improved trauma triaging is required, with early transfer of unstable patients and high-energy trauma mechanisms. A lower threshold for computed tomography scanning is recommended.

National variation in outcomes and costs for splenic injury and the impact of trauma systems: a population-based cohort study

OBJECTIVE

To measure national variation in splenectomy rates, mortality, and costs for hospitalized patients with splenic injury and the impact of state trauma systems on these outcomes.

METHODS

Using the HCUP State Inpatient Database for 2001, 2004, and 2007, all patients hospitalized with splenic injury were identified from 19 participating states. Multivariate regression was performed to compare splenectomy rates, inpatient mortality, and costs between states. Inclusiveness of statewide trauma systems was categorized based on the proportion of hospitals designated as a trauma center.

RESULTS

Of 33,131 patients, 26.2% underwent splenectomy, 6.1% died, and median hospital costs were $14,317. After adjusting for patient, injury, and hospital characteristics, there was a 1.7-fold variation (RR 1.67; 95% CI, 1.39-2.01) among the 19 states in rates of splenectomy. Adjusted inpatient mortality varied more than 2-fold between the highest and lowest states (RR 2.43; 95% CI, 1.76-3.37). Adjusted hospital costs varied over 60% between the highest and lowest states (cost ratio 1.61; 95% CI, 1.41-1.83). States with the most inclusive trauma systems had significantly lower splenectomy rate (RR 0.79; 95% CI, 0.68-0.92) and lower mortality (RR 0.71; 95% CI, 0.58-0.87), but similar hospital costs (CR 1.05; 95% CI, 0.95-1.16) compared to states with exclusive or no trauma systems.

CONCLUSIONS

Significant geographic variation in the management, outcome, and costs for splenic injury exists in the United States, and may reflect differences in quality of care. Inclusive trauma systems seem to improve outcomes without increasing hospital costs.

Prior studies comparing outcomes from trauma care at children's hospitals versus adult hospitals

Current evidence suggests that the majority of injured children are not treated in a pediatric trauma center. This review failed to provide a definitive answer to the question of whether injured children treated at children's hospitals or adult hospitals with a dedicated pediatric unit have better outcomes than those treated at adult hospitals. However, it identified areas that have been addressed, and more importantly, uncovered others that are largely unanswered. In lieu of a prospective randomized trial, the next best way to address these unsolved issues would be a prospective collection of data with careful attention to assessing injury severity, physiologic response to the injury, associated injuries and comorbidities, along with resuscitation techniques, hospital resources, and manpower training.

Evaluation of a 15-year experience with splenic injuries in a state trauma system

BACKGROUND

The management of splenic injuries has evolved with a greater emphasis on nonoperative management. Although several institutions have demonstrated that nonoperative management of splenic injuries can be performed with an increasing degree of success, the impact of this treatment shift on outcome for all patients with splenic injuries remains unknown. We hypothesized that outcomes for patients with splenic injuries have improved as the paradigm for splenic injury treatment has shifted.

METHODS

Consecutive patients from 1987 to 2001 with splenic injuries who were entered into a state trauma registry were reviewed. Demographic variables, injury characteristics, and outcome data were collected.

RESULTS

The number of patients who were diagnosed with splenic injuries increased from 1987 through 2001, despite a stable number of institutions submitting data to the registry. The number of minor injuries and severe splenic injuries remained stable, and the number of moderately severe injuries significantly increased over time. Overall mortality rate improved but primarily reflected the decreased mortality rates of moderately severe injuries; the mortality rate for severe splenic injuries was unchanged.

CONCLUSION

Trauma centers are seeing increasing numbers of splenic injuries that are less severe in magnitude, although the number of the most severe splenic injuries is stable. The increased proportion of patients with less severe splenic injuries who are being admitted to trauma centers is a significant factor in the increased use and success rate of nonoperative management.

Is anything new in adult blunt splenic trauma?

Several decades ago, a shift occurred in the management of adult splenic injuries. Influenced by the experience in pediatric trauma patients, adult trauma surgeons began turning from mandatory operative treatment of all splenic injuries toward nonoperative management. Nonoperative treatment is now the most common method of management for patients with splenic injuries and is the most common method of splenic salvage. However, controversy exists about how to appropriately select patients for nonoperative treatment since bleeding from splenic injuries can incur significant morbidity and mortality. Recent refinements in the management of adult blunt splenic injuries will be reviewed.

Hospital Factors Associated with Splenectomy for Splenic Injury: A National Perspective

BACKGROUND

The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ.

METHODS

Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days.

RESULTS

Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals.

CONCLUSION

The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.

Resource utilization and its management in splenic trauma

BACKGROUND

This study compared resource utilization and its management for splenic injury at 2 level-I trauma centers and a pediatric referral center with other facilities in a state currently developing a trauma system.

METHODS

Management strategy, length of stay, and total charges for children were compared among the pediatric referral center, trauma centers, and other facilities. Adult management, length of stay, and total charges were compared between trauma centers and other facilities.

RESULTS

Nonoperative management was more frequent in children at the pediatric referral center than trauma centers or other facilities and was more common in adults at trauma centers than at other facilities. Mean length of stay and total charges for children were significantly greater at the pediatric referral center and trauma centers than at other facilities and for adults at trauma centers than at other facilities. Facility type was associated with length of stay and total charges when injury type and severity were controlled.

CONCLUSIONS

Nonoperative management of splenic injury is more common at trauma centers, and splenic trauma management may be more costly at trauma centers.

Variations in injury patterns, treatment, and outcome for spinal fracture and paralysis in adult versus geriatric patients

STUDY DESIGN

Retrospective cohort analysis of hospital discharge and mortality data for spinal fracture and spinal cord injury patients in a single state from 1990 to 1995.

OBJECTIVES

Population-based review of preinjury patient factors, injury and treatment patterns, and in-hospital versus 60-day mortality in adult and geriatric spinal injury patients.

SUMMARY OF BACKGROUND DATA

While population-based analyses of hospitalized injured patients indicate that geriatric patients are at higher risk for adverse outcome, less is known about the specific subset of patients with spinal fracture and spinal cord injury. A specific knowledge gap exists regarding factors that influence survival after hospital discharge of spine-injured patients.

METHODS

Patients with cervical, thoracic, or lumbar spinal fracture were identified by ICD-9-CM discharge diagnosis codes. Age, gender, preexisting conditions, and injury severity were determined, and patients were divided into adult (ages 16-64 years; n = 6,029) and geriatric (ages >or=65 years; n = 3,973) groups. In-hospital and 60-day mortality rates and odds ratios of 60-day mortality were calculated relative to patient and injury characteristics, level of treating hospital, and surgical treatment.

RESULTS

Increased 60-day mortality was associated with preexisting medical conditions, increased injury severity, and paralysis but reduced with surgical treatment. Geriatric patients had fewer cervical injures, lower force injuries, less severe overall injuries, decreased paralysis, increased preexisting conditions, decreased treatment at level 1 and 2 treatment centers, and decreased odds of surgical treatment. Geriatric patients also had increased 60-day versus in-hospital mortality and increased mortality associated with cervical spine injury.

DISCUSSION

Differences exist in preinjury patient factors, injury and treatment patterns, and mortality between adult and geriatric patients following spinal injuries. The increased 60-day versus in-hospital mortality for the geriatric population suggests that 60-day mortality may be a better measure of outcome for these patients. While the possibility of selection bias exists, both geriatricand adult patients had reduced 60-day mortality associated with surgical intervention.

Blunt thoraco-abdominal injury

Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.