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Kwon J, Lee M, Jung K. National Assessment of Opportunities for Improvement in Preventable Trauma Deaths: A Mixed-Methods Study. Healthcare (Basel) 2023; 11:2291. [PMID: 37628489 PMCID: PMC10454732 DOI: 10.3390/healthcare11162291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Trauma is a significant public health issue worldwide, particularly affecting economically active age groups. Quality management of trauma care at the national level is crucial to improve outcomes of major trauma. In Korea, a biennial nationwide survey on preventable trauma death rate is conducted. Based on the survey results, we analyzed opportunities for improving the trauma treatment process. Expert panels reviewed records of 8282 and 8482 trauma-related deaths in 2017 and 2019, respectively, identifying 258 and 160 cases in each year as preventable deaths. Opportunities for improvement were categorized into prehospital, interhospital, and hospital stages. Hemorrhage was the primary cause of death, followed by sepsis/multiorgan failure and central nervous system injury. Delayed hemostatic procedures and transfusions were common areas for improvement in hospital stage. Interhospital transfers experienced significant delays in arrival time. This study emphasizes the need to enhance trauma care by refining treatment techniques, centralizing patients in specialized facilities, and implementing comprehensive reviews and performance improvements throughout the patient transfer system. The findings offer valuable insights for addressing trauma care improvement from both clinical and systemic perspectives.
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Affiliation(s)
- Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea;
| | - Myeonggyun Lee
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA;
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea;
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Bass GA, Stephen C, Forssten MP, Bailey JA, Mohseni S, Cao Y, Chreiman K, Duffy C, Seamon MJ, Cannon JW, Martin ND. Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury. J Surg Res 2022; 277:310-318. [DOI: 10.1016/j.jss.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/04/2022] [Accepted: 04/01/2022] [Indexed: 02/02/2023]
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Newsome K, Autrey C, Sen-Crowe B, Ang D, Elkbuli A. The Affordable Care Act and its Effects on Trauma Care Access, Short- and Long-term Outcomes and Financial Impact: A Review Article. ANNALS OF SURGERY OPEN 2022; 3:e145. [PMID: 37600113 PMCID: PMC10431310 DOI: 10.1097/as9.0000000000000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/07/2022] [Indexed: 11/26/2022] Open
Abstract
Objective The purpose of this study is to evaluate the current evidence regarding the impact of the ACA on trauma outcomes and the financial impact on trauma patients and trauma systems. Background Traumatic injuries are the leading cause of death and disability between the ages of 1 to 47 years. Uninsured status has been associated with worse outcomes and higher financial strain. The Affordable Care Act (ACA) was signed into law with the aim of increasing health insurance coverage. Despite improvements in insured status, it is unclear how the ACA has affected trauma. Methods We conducted a literature search using PubMed and Google Scholar for peer-reviewed studies investigating the impact of the ACA on trauma published between January 2017 and April 2021. Results Our search identified 20 studies that evaluated the impact of ACA implementation on trauma. The evidence suggests ACA implementation has been associated with increased postacute care access but not significant changes in trauma mortality. ACA implementation has been associated with a decreased likelihood of catastrophic health expenditures for trauma patients. ACA was also associated with an increase in overall reimbursement and amount billed for trauma visits, but a decrease in Medicaid reimbursement. Conclusions Some improvements on the financial impact of ACA implementation on trauma patients and trauma systems have been shown, but studies are limited by methods of calculating costs and by inconsistent pre-/post-ACA timeframes. Further studies on cost-effectiveness and cost-benefit analysis will need to be conducted to definitively determine the impact of ACA on trauma.
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Affiliation(s)
- Kevin Newsome
- From the Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Cody Autrey
- From the Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Brendon Sen-Crowe
- Dr. Kiran C. Patel College of Allopathic Medicine, NSU NOVA Southeastern University, Fort Lauderdale, FL
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, Ocala, FL
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL
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Magyar CTJ, Bednarski P, Jakob DA, Schnüriger B. Severe penetrating trauma in Switzerland: first analysis of the Swiss Trauma Registry (STR). Eur J Trauma Emerg Surg 2021; 48:3837-3846. [PMID: 34727193 DOI: 10.1007/s00068-021-01822-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to examine the epidemiology, demographics, injury characteristics and outcomes of patients who presented to Swiss trauma centers following severe penetrating trauma. METHODS Swiss Trauma Registry (STR)-cohort analysis including patients with severe (ISS ≥ 16 or AIS head ≥ 3) penetrating trauma between 2017 and 2019. Primary outcome was mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), and prehospital times. RESULTS During the 3-year study period, 134 (1.6% of entire STR) patients with severe penetrating trauma were identified [64 (48%) gunshot wounds (GSW), 70 (52%) stab wounds (SW)]. Median age was 40.5 (IQR 29.0-59.0) and 82.8% were male. Mortality rate was 50% for GSW; 9% for SW. Overall, prehospital time [incident to arrival emergency department (ED)] was 65 (IQR 45-94) minutes. The median number of patients admitted for a severe GSW/SW per center and year was 2 (range 0-14). Of 64 patients who sustained a GSW, 42 (65.6%) were self-inflicted. Mortality in self-inflicted GSW reached 66.7%, with the head being severely injured in 78.6%. The 67 patients with severe isolated torso GSW/SW had an ISS of 20 (IQR 16-26) and a mortality of 15%. Multivariable analysis identified severe chest trauma, ED Glasgow Coma Scale ≤ 8, age, self-infliction, massive blood transfusion and ISS as independent predictors for mortality. CONCLUSION Severe penetrating trauma is very rare in Switzerland. Mortality ranges from 9% in SW to 67% in self-inflicted GSW. Particularly in the setting of GSW/SW to the torso, reduction in prehospital time may further improve patient outcomes.
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Affiliation(s)
- Christian T J Magyar
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Piotr Bednarski
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Dominik A Jakob
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
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Hatchimonji JS, Kaufman EJ, Stoecker JB, Sharoky CE, Holena DN. Failure to Rescue in Emergency Surgery: Is Precedence a Problem? J Surg Res 2020; 250:172-178. [PMID: 32070836 DOI: 10.1016/j.jss.2019.12.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/04/2019] [Accepted: 12/26/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations. METHODS National Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (<48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations. RESULTS There was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P < 0.001) for laparotomy. CONCLUSIONS Precedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordan B Stoecker
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine E Sharoky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Naeem Z, McCormack JE, Huang EC, Vosswinkel JA, Shapiro MJ, Zarlasht F, Jawa RS. Impact of Type and Number of Complications on Mortality in Admitted Elderly Blunt Trauma Patients. J Surg Res 2019; 241:78-86. [PMID: 31015071 DOI: 10.1016/j.jss.2019.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/01/2019] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Advanced age and comorbidities are recognized risk factors for adverse outcomes in elderly trauma patients. However, the contribution of the number and type of complications to in-hospital mortality in elderly blunt trauma admissions has not been extensively studied. METHODS A retrospective review of the trauma registry at a level 1 trauma center for blunt trauma patients age ≥65 y hospitalized for at least 2 d between 2010 and 2015. RESULTS There were 2467 admissions, with a median age of 81 y and median injury severity score of 9. The most common mechanism of injury was a low-level fall. Approximately 19.6% of admissions had a complication: 11.1% major complications, 8.6% other complications. The in-hospital mortality rate was significantly different (P < 0.001) among the three groups at 16.1% of major complications group, 7.1% of other, and 2.1% of no complications (P < 0.001). On multivariate logistic regression, each major complication increased the odds for in-hospital mortality by 1.59-fold. CONCLUSIONS Complications are not infrequent in elderly blunt trauma admissions, despite a generally lower energy mechanism of injury. Each major complication is associated with increased odds of mortality. Multifaceted interventions for prevention and mitigation of complications are indicated.
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Affiliation(s)
- Zaina Naeem
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Jane E McCormack
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Marc J Shapiro
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Fnu Zarlasht
- Division of Geriatric Medicine, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University Renaissance School of Medicine, Stony Brook, New York.
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Characteristics and management of penetrating abdominal injuries in a German level I trauma center. Eur J Trauma Emerg Surg 2018; 45:315-321. [DOI: 10.1007/s00068-018-0911-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 01/13/2018] [Indexed: 10/18/2022]
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Abstract
PURPOSE OF REVIEW The geriatric population is the fastest growing segment of the population, and geriatric trauma patients are increasingly common. Caring for this population has unique challenges. The goal of the review is to identify factors that may help in the care of geriatric patients suffering from genitourinary trauma. RECENT FINDINGS Multiple factors lead to inferior outcomes in patients with geriatric trauma including failure to rescue, treatment in lower volume trauma centers, and undertriage of geriatric patients. Improvement in geriatric trauma outcomes occurs with the use of dedicated geriatric consult teams. The surgical management of genitourinary injuries in the geriatric population remains unchanged. SUMMARY Interventions for geriatric patients differ from younger populations. Direct changes in overall management of the geriatric population lead to improved outcomes. The treatment of geriatric trauma patients with genitourinary injuries is similar to a younger cohort. The lack of recent studies in clinical outcomes in this population has been identified as a gap in knowledge that will require future research to answer.
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Hildebrand F, Pape HC, Horst K, Andruszkow H, Kobbe P, Simon TP, Marx G, Schürholz T. Impact of age on the clinical outcomes of major trauma. Eur J Trauma Emerg Surg 2015; 42:317-32. [PMID: 26253883 DOI: 10.1007/s00068-015-0557-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/31/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients. METHODS Review of the literature. RESULTS Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality. CONCLUSION The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.
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Affiliation(s)
- F Hildebrand
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany. .,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany.
| | - H-C Pape
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - K Horst
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - H Andruszkow
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - P Kobbe
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - T-P Simon
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - G Marx
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - T Schürholz
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
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