Interhospital transfer of blunt multiply injured patients to a level 1 trauma center does not adversely affect outcome

Pediatric TBI: Direct admissions vs. secondary referrals to a hospital: A single‑center, retrospective study

The present retrospective study was conducted in an aim to examine the differences between pediatric traumatic brain injury (TBI) cases referred to and those admitted directly to the hospital. For this purpose, pediatric patients who presented to a main trauma center with TBI between January, 2015 and December, 2019 were reviewed retrospectively, emphasizing whether they were admitted directly or referred from another center. Data collected included the demographic characteristics of the patients, as well as their presenting complaints and the cause of TBI. A total of 981 cases of pediatric TBI were admitted over the 5-year period. The average age of the patients was 58.1 months for the referred cases and almost 50 months for the patients directly admitted. The male sex accounted for 63.6% of all cases. The most common cause of injury was falling (63.5%). Nausea and vomiting were the most typical presenting symptoms, occurring more among the directly admitted cases (P-value ≤0.05). Mild TBI accounted for 85.3% of the cases, and the most common radiological diagnosis was skull fracture (37.4%) (P-value ≤0.004). The referred patients had a more extended hospital stay (P-value ≤0.001). On the whole, the present study identified 981 cases; the majority of these were direct admissions, and the majority of the severe cases were referred from other healthcare facilities. Further research is required on this topic as only a single hospital was covered herein, and patients were not followed-up after discharge. A multi-center analysis would cover a greater number of patients and would thus provide more substantial data on the topic.

Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study

BACKGROUND

Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking.

METHOD

This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT.

RESULTS

A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (- 40.5%). Patients were younger (median age, 63 [45-77] vs. 61[44-74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158-480] vs. 263[180-674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025).

CONCLUSION

We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

Correlation between trauma and injury severity score and prognosis in patients with trauma

Objectives

This study aims to determine the correlation between Trauma and Injury Severity Score (TRISS) and prognosis in patients with trauma.

Methods

We retrospectively analysed 187 medical records of patients with trauma who presented to the emergency department of a level II trauma centre in East Java, Indonesia, between August and December 2018. We analysed the data, which included demographic characteristics, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and injury scores of six parts of the body. Spearman's rank correlation was used to determine the correlation among variables.

Results

A total of 181 medical records of patients with trauma were reviewed in this study. Two-third of the patients were male (n = 113, 62.4%). Approximately half of the trauma injuries were caused by road traffic accidents (n = 89, 49.2%); the majority of these injuries resulted from blunt trauma (n = 167, 92.3%). The TRISSes of most of the patients (n = 178, 98.3%) with a good prognosis ranged from 77.1% to 99.7%. There was a statistically significant correlation between trauma, TRISS, and prognosis (p = 0.002 < 0.05), with a positive correlation among variables (r = 0.225).

Conclusion

There was a significant correlation between TRISS and prognosis in patients with trauma.

Emergency trauma care in rural and remote settings: Challenges and patient outcomes

INTRODUCTION

Trauma is a global public health concern, with higher mortality rates acknowledged in rural and remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary objective of this integrative literature review was to examine the challenges associated with providing emergency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective was to explore strategies to improve trauma patient outcomes.

METHODS

An integrative review approach was used to inform the methods of this study. A systematic search of databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other search methods included hand searching journal references.

RESULTS

2157 articles were identified for screening and 87 additional papers were located by hand searching. Of these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique challenges in the provision of emergency trauma care such as large distances, delays transferring patients to definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors, weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural and remote populations often experience higher mortality rates in comparison to urban populations although this may be different for specific mechanisms of injury or population subsets. While an increased risk of death was associated with an increase in remoteness, research also found it costs substantially less to provide care to rural patients in their rural environment than their urban counterparts. Other factors found to influence mortality rates were severity of injury and differences in characteristics between rural and urban populations. Trauma systems vary around the world and must address local issues that may be affected by distance, geography, seasonal population variations, specific population risk factors, trauma network operationalisation, referral and retrieval and involvement of hospitals and services which have no trauma designation.

CONCLUSIONS

The challenges acknowledged for rural and remote trauma patients may be lessened and mortality rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma systems that are responsive to local needs and resources. Additional research to determine which of these challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve this.

Direct transport vs secondary transfer to level I trauma centers in a French exclusive trauma system: Impact on mortality and determinants of triage on road-traffic victims

Background

Transporting a severely injured patient directly to a trauma center (TC) is consensually considered optimal. Nevertheless, disagreement persists regarding the association between secondary transfer status and outcome. The aim of the study was to compare adjusted mortality between road traffic trauma patients directly or secondarily transported to a level 1 trauma center (TC) in an exclusive French trauma system with a physician staffed prehospital emergency medical system (EMS).

Methods

A retrospective cohort study was performed using 2015–2017 data from a regional trauma registry (Traumabase®), an administrative database on road-traffic accidents and prehospital-EMS records.

Multivariate logistic regression models were computed to determine the role of the modality of admission on mortality and to identify factors associated with secondary transfer. The primary outcome was day-30 mortality.

Results: During the study period, 121.955 victims of road-traffic accident were recorded among which 4412 trauma patients were admitted in the level 1 regional TCs, 4031 directly and 381 secondarily transferred from lower levels facilities. No significant association between all-cause 30-day mortality and the type of transport was observed (Odds ratio 0.80, 95% confidence interval (CI) [0.3–1.9]) when adjusted for potential confounders. Patients secondarily transferred were older, with low-energy mechanism and presented higher head and abdominal injury scores. Among all 947 death, 43 (4.5%) occurred in lower-level facilities. The population-based undertriage leading to death was 0.15%, 95%CI [0.12–0.19].

Conclusion

In an exclusive trauma system with physician staffed prehospital care, road-traffic victims secondarily transferred to a TC do not have an increased mortality when compared to directly transported patients.

Impact of Referring Hospital Imaging on Mortality at a Level I Trauma Center

BACKGROUND

Computed tomography (CT) has become a standard adjunct in the evaluation of patients with trauma. However, utility of imaging at the referring hospital remains controversial. We study the effect of CT scans at referring hospitals on in-hospital mortality at a receiving trauma center.

MATERIALS AND METHODS

A retrospective cohort study was performed with adult patients with severe trauma transferred to a level I trauma center from regional nontrauma hospitals between 2012 and 2017. Baseline characteristics were compared with Student's t-test and Pearson's chi-squared testing. The primary endpoint was in-hospital mortality. Cox regression, controlling for transfer time, was used to evaluate the effect of imaging on mortality.

RESULTS

Three thousand four hundred and fifteen adult patients with trauma were included: 1135 (33.2%) received a pretransfer CT scan, whereas 2280 (66.8%) did not. Patients who received a pretransfer CT scan were more likely to be older, female, white, have a higher Charlson Comorbidity Index, less severely injured, have a blunt mechanism, and be transferred by ground. There was no difference in distance (58.3 miles versus 57.0 miles, P = 0.34), but transfer times were significantly increased for those who received pretransfer scans (288 versus 213 min, P < 0.005). The adjusted model controlling for multiple variables has a hazard ratio of 0.533 (95% confidence interval 0.42-0.68, P < 0.005).

CONCLUSIONS

There is a survival advantage for patients who receive pretransfer CT scans despite having significantly longer transport times. We suggest that this decreased mortality associated with pretransfer imaging may reflect improving trends in referring physician transfer decisions.

A Comparison of Pediatric Traumatic Injuries on Farms and Residences from 2009 to 2014

PURPOSE

Children injured on farms in the United States are hospitalized at 14 times the rate of children with injuries unrelated to farming. This study characterizes pediatric injuries occurring on farms compared to injuries in homes.

METHODS

We examined the National Trauma Data Bank from 2009 to 2014 to identify children ages 0-17 with ICD-9 E-codes reflecting a farm or residential place of injury occurrence. Appropriate nonparametric tests were used to compare patient, injury, and hospitalization characteristics by injury locale. Mixed effects models for binary responses were used to examine the odds of an injury occurring on a farm versus at home, and we controlled for random effects of trauma center after adjustment for potential confounding variables including age, sex, and categorical injury severity.

FINDINGS

There were 2,776 injuries on farms, and 133,119 injuries at homes. Children injured on farms had a median age of 10 years compared to 4 years at homes (P < .001). Machinery injuries were 19 times more frequent on farms (P < .001), and injuries to multiple anatomic locations were twice as frequent on farms (P < .001). Children injured on farms required helicopter transport 4 times as often as those injured at home. Additionally, children injured on farms were nearly 2.5 times more likely to have a length of stay greater than 7 days.

CONCLUSION

Injuries occur during the course of childhood; however, injuries sustained in a farming environment are more severe and require greater clinical management than injuries which occur in the home.

Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

PURPOSE

Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients.

METHODS

A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant.

RESULTS

There were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3-12 that including 6351 (72%) patients with GCS of 3-8 and 2380 (28%) patient with GCS of 9-12. In these 8731 patients with GCS of 3-12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12, 1256 (89%) patients with GCS 3-8, 148 (11%) patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI.

CONCLUSION

The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.

The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system

INTRODUCTION

Florida serves as a model for the study of trauma system performance. Between 2010 and 2104, 5 new trauma centers were opened alongside 20 existing centers. The purpose of this study was to explore the impact of trauma system expansion on system triage performance and trauma center patients' profiles.

METHODS

A statewide data set was queried for all injury-related discharges from adult acute care hospitals using International Classification of Diseases, Ninth Revision (ICD-9) codes for 2010 and 2014. The data set, inclusion criteria, and definitions of high-risk injury were chosen to match those used by the Florida Department of Health in its trauma registry. Hospitals were classified as existing Level I (E1) or Level II (E2) trauma centers and new E2 (N2) centers.

RESULTS

Five N2 centers were established 11.6 to 85.3 miles from existing centers. Field and overall trauma system triage of high-risk patients was less accurate with increased overtriage and no change in undertriage. Annual volume at N2 centers increased but did not change at E1 and E2 centers. In 2014, Patients at E1 and E2 centers were slightly older and less severely injured, while those at N2 centers were substantially younger and more severely injured than in 2010. The injured patient-payer mix changed with a decrease in self-pay and commercial patients and an increase in government-sponsored patients at E1 and E2 centers and an increase in self-pay and commercial patients with a decrease in government-sponsored patients at N2 centers.

CONCLUSION

Designation of new trauma centers in a mature system was associated with a change in established trauma center demographics and economics without an improvement in trauma system triage performance. These findings suggest that the health of an entire trauma system network must be considered in the design and implementation of a regional trauma system.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV; epidemiological, level IV.

Rural Trauma Team Development Course decreases time to transfer for trauma patients

BACKGROUND

The Rural Trauma Team Development Course (RTTDC) is designed to teach knowledge and skills for the initial assessment and stabilization of trauma patients in resource-limited environments. The effect of RTTDC training on transfers from nontrauma centers to definitive care has not been studied. We hypothesized that RTTDC training would decrease referring hospital emergency department (ED) length of stay (LOS), time to call for transfer, pretransfer computed tomography (CT) imaging rate, and mortality rate.

METHODS

We conducted a pre/post analysis of trauma patients who were transferred from rural, nontrauma hospitals from 2012 to 2014. Patients from six rural hospitals that participated in an RTTDC course were compared with a control group of similar centers that did not participate in the course. Primary outcome evaluated was referring hospital ED LOS, which was estimated using a difference-in-differences regression model. Secondary outcomes were time to transfer call, pretransfer CT imaging rates, and mortality.

RESULTS

Two hundred fifty-three patients were available for study (RTTDC group, n = 130; control group, n = 123). Demographics, CT imaging, and mortality rates were similar between the two groups. In the primary outcome, the RTTDC group experienced an overall 61-minute reduction in referring hospital LOS (p = 0.02) compared with the control group. The RTTDC group also showed a 41-minute reduction (p = 0.03) in time to call for transfer compared with controls. There were no differences in the secondary outcomes of pretransfer CT scanning rates or mortality.

CONCLUSIONS

Rural Trauma Team Development Course training shortens ED LOS at rural, nontrauma hospitals by more than 1 hour without increasing mortality. Future educational and research efforts should focus on decreasing unnecessary imaging prior to transfer as well as opportunities to improve mortality rates. This study suggests an important role for RTTDC training in the care of rural trauma patients and may allow trauma centers to recapture the "golden hour" for transferred trauma patients.

LEVEL OF EVIDENCE

Therapeutic/care management study, level III.

What factor within the Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) criteria is most strongly correlated with trauma induced DIC? A retrospective study using thromboelastometry in a single center in Japan

Purpose

The diagnostic criteria for disseminated intravascular coagulation (DIC) established by the Japanese Association for Acute Medicine (JAAM) is able to diagnose DIC accurately and promptly. The aim of this retrospective study is to evaluate the degree of association between each parameter of JAAM DIC criteria and the diagnosis of trauma induced DIC (T-DIC) utilizing thromboelastometry (ROTEM).

Methods

Trauma patients transported to our hospital with ROTEM performed in the emergency department between January 2013 and December 2015 were enrolled in this study. We evaluated (1) the characteristics of T-DIC, (2) the relationships between T-DIC and each parameter of the JAAM DIC criteria and (3) the diagnostic accuracies of each parameter for T-DIC by statistical measurement.

Results

All 72 patients (21 T-DIC and 51 control) were included in primary analysis. T-DIC was significantly related to younger age, more severe trauma scores, more cases of massive transfusions, and remarkable coagulation abnormality detected by standard coagulation tests. In the cases of T-DIC, ROTEM showed longer clotting time, lower acceleration, lower clot firmness, and inhibited fibrinolysis in EXTEM/INTEM. Within the JAAM DIC score, PT-INR ≥1.2 was the most accurate factor for T-DIC diagnosis; sensitivity 60.0%, specificity 100.0%, and accuracy 88.7%. PT-INR ≥1.2 was statistically correlated with the JAAM DIC score (p < 0.001, r = 0.709). The univariate analysis based on 1.2 of PT-INR indicated statistical differences in most categories of ROTEM, which is similar to analysis performed for the presence and absence of T-DIC.

Conclusions

Among JAAM DIC criteria, the PT-INR ≥1.2 was the most accurate factor for both the diagnosis of T-DIC and the evaluation of its severity.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.

MATERIAL AND METHODS

In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.

RESULTS

Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation.

CONCLUSION

This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

Understanding an inclusive trauma system through characterization of admissions at level IV centers

BACKGROUND

Level IV trauma centers are an integral part of inclusive trauma systems, although sparse data exists for these facilities.

METHODS

An observational study was conducted using a Midwestern state's inpatient data files to characterize level IV center patients. Injury and severity levels, injury mechanism and/or intent, and distances to nearest tertiary centers were determined.

RESULTS

During the study year, 3,346 injured patients were admitted at level IV centers. The median distance to nearest tertiary center was 43 miles. Median patient age was 81 years, and primary injury mechanism was falls. Overall, 22% of patients had an isolated hip fracture. Of moderately injured patients, 64% had an isolated hip fracture, 8% nonisolated hip fractures, and 9% rib fractures without hip fracture. Overall, 30% of patients had a high severity of injury.

CONCLUSIONS

A large number of patients were admitted to level IV trauma centers. Patients admitted tended to be elderly and have orthopedic fall injuries. Study results provide important implications for provider education, prevention efforts, need for orthopedic surgical capabilities, and necessity of capturing these data in registries.

Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study

OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIS_head) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIS_head score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.