Trauma center care is associated with reduced readmissions after injury

Substantial heterogeneity in trauma triage tool characteristic operationalization for identification of major trauma: a hybrid systematic review

PURPOSE

Trauma Triage Tools (TTTs) support pre-hospital staff to identify major trauma patients based on prehospital characteristics and bring them to appropriate trauma centres. However, while triaging trauma has been examined extensively, there appears to be little consensus on how variables within TTTs are applied. We therefore aimed to examine the prehospital characteristics and their operationalization applied in the international literature in TTTs.

METHODS

We applied a hybrid systematic review approach. Searches were conducted in multiple databases. We initially searched for systematic reviews that analyse prehospital characteristics applied in TTTs, then supplemented this with an updated search of original TTT papers from November 2019.

RESULTS

We identified 92 papers which identified 52 adult general population TTTs. Results indicate considerable heterogeneity in prehospital characteristics included in TTTs internationally. There was similarity in the higher-level categories included in the tools: tools often included measurements of a patient's physiological characteristics, injury characteristics, mechanism of injury and any modifiers for high-risk groups. However, the prehospital characteristics that made up those groups, how they were applied and interpreted were found to vary considerably.

CONCLUSION

While there is agreement in the higher-level categories used in TTTs, the thresholds adopted in specific variables vary widely, which may reflect statistical rather than clinical considerations. This may contribute to considerable variation in standards of major trauma triaging internationally. An agreed taxonomy of operationalization of prehospital characteristics used in TTTs is required to prevent sub-optimal clinical decision-making in major trauma triaging.

REGISTRATION

PROSPERO CRD42023393094.

Changes in payer mix of new and established trauma centers: the new trauma center money grab?

Background

Although timely access to trauma center (TC) care for injured patients is essential, the proliferation of new TCs does not always improve outcomes. Hospitals may seek TC accreditation for financial reasons, rather than to address community or geographic need. Introducing new TCs risks degrading case and payer mix at established TCs. We hypothesized that newly accredited TCs would see a disproportionate share of commercially insured patients.

Study design

We collected data from all accredited adult TCs in Pennsylvania using the state trauma registry from 1999 to 2018. As state policy regarding supplemental reimbursement for underinsured patients changed in 2004, we compared patient characteristics and payer mix between TCs established before and after 2004. We used multivariable logistic regression to assess the relationship between payer and presentation to a new versus established TC in recent years.

Results

Over time, there was a 40% increase in the number of TCs from 23 to 38. Of 326 204 patients from 2010 to 2018, a total of 43 621 (13.4%) were treated at 15 new TCs. New TCs treated more blunt trauma and less severely injured patients (p<0.001). In multivariable analysis, patients presenting to new TCs were more likely to have Medicare (OR 2.0, 95% CI 1.9 to 2.1) and commercial insurance (OR 1.6, 95% CI 1.5 to 1.6) compared with Medicaid. Over time, fewer patients at established TCs and more patients at new TCs had private insurance.

Conclusions

With the opening of new centers, payer mix changed unfavorably at established TCs. Trauma system development should consider community and regional needs, as well as impact on existing centers to ensure financial sustainability of TCs caring for vulnerable patients.

Level of evidence

Level III, prognostic/epidemiological.

Comparison of age-adjusted shock indices as predictors of injury severity in paediatric trauma patients immediately after emergency department triage: A report from the Korean multicentre registry

INTRODUCTION

Shock index paediatric-adjusted (SIPA) was presented for early prediction of mortality and trauma team activation in paediatric trauma patients. However, the derived cut-offs of normal vital signs were based on old references. We established alternative SIPAs based on the other commonly used references and compared their predictive values.

METHODS

We performed a retrospective review of all paediatric trauma patients aged 1-15 years in the Emergency Department (ED)-based Injury In-depth Surveillance (EDIIS) database from January 1, 2011 to December 31, 2019. A total of 4 types of SIPA values were obtained based on the references as follows: uSIPA based on the Nelson textbook of paediatrics 21st ed., SIATLS based on the ATLS 10th guideline, SIPALS based on the PALS 2020 guideline, and SIPA. In each SIPA group, the cut-off was established by dividing the group into 4 subgroups: toddler (age 1-3), preschooler (age 4-6), schooler (age 7-12), and teenager (age 13-15). We performed an ROC analysis and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to compare the predicted values of each SIPA in mortality, ICU admission, and emergent surgery or intervention.

RESULTS

A total of 332,271 patients were included. The proportion of patients with an elevated shock index was 14.9 % (n = 49,347) in SIPA, 22.8 % (n = 75,850) in uSIPA, 0.3 % (n = 1058) in SIATLS, and 4.3 % (n = 14,168) in SIPALS. For mortality, uSIPA achieved the highest sensitivity (57.0 %; 95 % confidence interval 56.9 %-57.2 %) compared to SIPA (49.4 %, 95 % CI 49.2 %-49.5 %), SIATLS (25.5 %, 95 % CI 25.4 %-25.7 %), and SIPALS (43.8 %, 95 % CI 43.7 %-44.0 %), but there were no significant differences in the negative predictive value (NPV) or area under the curve (AUC). The positive predictive value (PPV) was highest in SIATLS (5.7 %, 95 % CI 5.6 %-5.8 %) compared to SIPA (0.2 %, 95 % CI 0.2 %-0.3 %), uSIPA (0.2 %, 95 % CI 0.2 %-0.2 %), and SIPALS (0.7 %, 95 % CI 0.7 %-0.8 %). The same findings were presented in ICU admission and emergent operation or intervention.

CONCLUSION

The ATLS-based shock index achieved the highest PPV and specificity compared to SIPA, uSIPA, and SIPALS for adverse outcomes in paediatric trauma.

Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery

ABSTRACT

This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study

PURPOSE

To assess the incidence of undertriage in major trauma, its determinant, and association with mortality.

METHODS

A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011-2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage.

RESULTS

A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51-65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36).

CONCLUSIONS

In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.

Challenges to the development of the trauma system in Egypt

Trauma is a hidden disease in Egypt, and its significance on public health has been underestimated for decades. Road traffic accidents are the leading cause of injuries presented to hospitals in Egypt. Trauma systems in developed countries effectively reduced the morbidity and mortality associated with injuries in crowded cities. Developing a trauma system in Egypt is mandatory with the exploding population growth, increasing incidence of injuries, and the vast expansion of the infrastructures in the road network. However, the implementation of the trauma system in Egypt will not be devoid of challenges, including a lack of mandatory healthcare infrastructures such as adequate pre-hospital care, poor quality of data, and a shortage of adequately trained emergency physicians across the country.

Predictors of hospital readmission after trauma: A retrospective cohort study in New Zealand

INTRODUCTION

Understanding predictors of hospital readmission following major trauma is important as readmissions are costly and some are potentially avoidable. This study describes the incidence of, and sociodemographic, injury-related and treatment-related factors predictive of, hospital readmission related to: a) all-causes, b) the index trauma injury, and c) subsequent injury events in the 30 days and 12 months following discharge for major trauma patients nationally in New Zealand.

METHODS

Data from the New Zealand Trauma Registry (NZTR) was linked with Ministry of Health hospital discharge data. Hospital readmissions were examined for all patients entered into the NZTR for an injury event between 1 January and 31 December 2018. Readmissions were examined for the 12-months following the discharge date for participant's index trauma injury.

RESULTS

Of 1986 people, 42% had ≥1 readmission in the 12 months following discharge; 15% within 30 days. Seven percent had ≥1 readmission related to the index trauma within 30 days of discharge; readmission was 3.43 (95% CI 1.87, 6.29) times as likely if the index trauma was self-inflicted compared to unintentional, and 1.64 (95% CI 1.15, 2.34) times as likely if the index trauma involved intensive care unit admission. Those admitted to hospital for longer for their index trauma were less likely to be readmitted due to their index trauma injury within 30 days compared to those admitted for 0-1 day. Seventeen percent were readmitted for a subsequent injury event within 12 months, with readmission more likely for older people (>65 years), those with comorbidities, Māori compared with non-Māori and those with higher trauma injury severity.

CONCLUSION

A substantial proportion of people are readmitted after discharge for major trauma. Factors identified in this study will be useful to consider when developing interventions to reduce preventable readmissions including those related to the index trauma injury, readmissions from other causes and subsequent injury-related readmissions. Further research specifically examining planned and unplanned readmissions is warranted.

The influence of inter-hospital transfers on mortality in severely injured patients

PURPOSE

The importance of treating severely injured patients in higher-level trauma centers is undisputable. However, it is uncertain whether severely injured patients that were initially transported to a lower-level trauma center (i.e., undertriage) benefit from being transferred to a higher-level trauma center.

METHODS

This observational study included all severely injured patients (i.e., Injury Severity Score ≥ 16) that were initially transported to a lower-level trauma center within eight ambulance regions. The exposure of interest was whether a patient was transferred to a higher-level trauma center. Primary outcomes were 24-h and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed to evaluate the association between transfer status and mortality.

RESULTS

We included 165,404 trauma patients that were transported with high priority to a trauma center, of which 3932 patients were severely injured. 1065 (27.1%) patients were transported to a lower-level trauma center of which 322 (30.2%) were transferred to a higher-level trauma center. Transferring undertriaged patients to a higher-level trauma center was significantly associated with reduced 24-h (relative risk [RR] 0.26, 95%-CI 0.10-0.68) and 30-day mortality (RR 0.65, 0.46-0.92). Similar results were observed in patients with critical injuries (24-h: RR 0.35, 0.16-0.77; 30-day: RR 0.55, 0.37-0.80) and patients with traumatic brain injury (24-h: RR 0.31, 0.11-0.83; 30-day: RR 0.66, 0.46-0.96).

CONCLUSIONS

A minority of the undertriaged patients are transferred to a higher-level trauma center. An inter-hospital transfer appears to be safe and may improve the survival of severely injured patients initially transported to a lower-level trauma center.

Temporal Changes in Serum S100B Levels From Prehospital to Early In-Hospital Sampling in Patients Suffering Traumatic Brain Injury

Background

The biomarker S100B is used for the rule-out of intracranial lesions in patients with mild traumatic brain injury (TBI) and is suggested for prehospital use in Europe. Early kinetics of S100B are not exhaustively investigated in human TBI. This post hoc descriptive study of the data from the PreTBI studies aimed to characterize the early temporal changes of S100B using two-sample timepoints.

Materials and Methods

Two consecutive blood samples were taken prehospital and in-hospital after injury and assayed for S100B. The endpoint adjudication of the outcome intracranial lesion was done by the evaluation of electronic medical patient journals. The data were analyzed using descriptive statistics, scatterplots, and temporal changes estimated by the locally weighted scatterplot smoothing (LOWESS) regression line.

Results

A total of 592 adult patients with TBI were included; 566 with Glasgow Coma Scale (GCS) 14-15, 20 with GCS 9-13, and 6 with GCS 3-8. Intracranial lesions were diagnosed in 44/566 (7.4%) of patients. In 90% of patients, S100B concentrations decreased from prehospital to in-hospital sampling. The mean decrease was−0.34 μg/L. S100B concentrations seem to decline already within 60 min. Patients sampled very close to trauma and patients suffering intracranial lesions may express a slight incline before this decline. Temporal changes of S100B did not differ in patients >65 years of age, in antiplatelet/-coagulant treatment, alcohol intoxicated, or suffering extra-cranial injuries.

Conclusion

S100B concentrations may peak earlier than expected from previous studies of temporal changes in human TBI. Patterns of S100B stand robust to parameters stated as limiting factors to the use for early rule-out of intracranial lesions in the current guidelines. Further studies are needed to investigate the ultra-early temporal profiles of other novel TBI biomarkers to assess prehospital applicability and optimal diagnostic performance in TBI.

Decreased ER visits and readmissions after implementation of a standardized perioperative toolkit for children with IBD

BACKGROUND

Pediatric inflammatory bowel disease (IBD) carries significant morbidity and requires extensive medical and often surgical intervention. The aim of this study was to evaluate the impact of a dedicated Multidisciplinary clinic on the outcomes of children with IBD.

METHODS

A retrospective review of a prospective database, established to track quality and outcomes of children undergoing an abdominal operation for IBD, was performed. Children who were managed before (09/2017-03/2019) and after (04/2019-06/2020) establishment of the multidisciplinary clinic were examined. The clinic instituted several care process protocols including early recovery (ERAS) and garnered additional resources for patients (wound ostomy, nutrition, social work, etc.) Primary outcomes were unanticipated return to the operating room, length of stay, ER visits within 30 days of surgery and hospital readmissions within 30 days of surgery.

RESULTS

We identified 41 children who underwent a total of 80 major abdominal operations; 46.3% of procedures occurred before and 53.7% occurred after instituting our clinic. There were no notable changes in disease distribution (e.g., ulcerative colitis vs. Crohn's), disease severity, medication exposure, or case urgency (elective vs. emergent). ER visits within 30 days of surgery decreased (4 (9.3%) vs. 10 (27%), p = 0.04) as did readmissions within 30 days of surgery (1 (2.3%) vs. 9 (24.3%), p = 0.005).

CONCLUSIONS

Implementation of a dedicated multidisciplinary clinic for IBD and its attendant focus on protocols and appropriate use of adjunctive resources was associated with decreased emergency department visits and hospital readmissions in the post-operative setting.

LEVEL OF EVIDENCE

III.

The impact of prehospital time intervals on mortality in moderately and severely injured patients

BACKGROUND

Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality.

METHODS

All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association.

RESULTS

We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality.

CONCLUSION

A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; level III.

The Feedback Form and Its Role in Improving the Quality of Trauma Care

Background: One of the tasks of a level I trauma center is quality improvement of level II and level III regional hospitals and emergency medical services by means of continuous education and learning processes. One of the tools for this, which provides constant monitoring of the quality of treatment, is feedback. The purpose of the study was to evaluate the effect of feedback on the quality of trauma care. Methods: Retrospective cohort study comprising two periods of time, 2012-2013 and 2017-2018. The study group included physicians and pre-hospital staff who treated patients prior to referral to the level I center. Upon arrival when the trauma teams identified issues requiring improvement, they were asked to fill in feedback forms. Data on patients treated in the trauma shock room for whom feedback forms were filled out were also extracted. Results: A total of 662 feedback forms were completed, showing a significant improvement (p ˂ 0.0001). The majority of the medical personnel who received the most negative feedback were the pre-hospital staff. A significant increase was revealed in the number of feedbacks with reference to mismanagement of backboard spinal fixation, of the pre-hospital staff, in 2012-2013 compared to 2017-2018 (p < 0.001). Improvement in reducing the time of treatment in the field was also revealed, from 15.2 ± 8.3 min in 2012-2013 to 13.4 ± 7.9 min in 2017-2018. Conclusion: The findings show that feedback improves the treatment of injured patients. Furthermore, constantly monitoring the quality of treatment provided by the trauma team is vital for improvement.

Association of traumatic brain injury severity and time to definitive care in three low-middle-income European countries

BACKGROUND

Low-middle-income countries experience among the highest rates of traumatic brain injury in the world. Much of this burden may be preventable with faster intervention, including reducing the time to definitive care. This study examines the relationship between traumatic brain injury severity and time to definitive care in major trauma hospitals in three low-middle-income countries.

METHODS

A prospective traumatic brain injury registry was implemented in six trauma hospitals in Armenia, Georgia and the Republic of Moldova for 6 months in 2019. Brain injury severity was measured using the Glasgow Coma Scale (GCS) at admission. Time to definitive care was the time from injury until arrival at the hospital. Cox proportionate hazards models predicted time to care by severity, controlling for age, sex, mechanism, mode of transportation, location of injury and country.

RESULTS

Among 1135 patients, 749 (66.0%) were paediatric and 386 (34.0%) were adults. Falls and road traffic were the most common mechanisms. A higher proportion of adult (23.6%) than paediatric (5.4%) patients had GCS scores indicating moderate (GCS 9-11) or severe injury (GCS 0-8) (p<0.001). Less severe injury was associated with shorter times to care, while more severe injury was associated with longer times to care (HR=1.05, 95% CI 1.01 to 1.09). Age interacted with time to care, with paediatric cases receiving faster care.

CONCLUSIONS

Implementation of standard triage and transport protocols may reduce mortality and improve outcomes from traumatic brain injury, and trauma systems should focus on the most severe injuries.

Patient and clinician perceptions of the trauma and acute care surgery hospitalization discharge transition of care: a qualitative study

OBJECTIVES

Trauma and acute care surgery (TACS) patients face complex barriers associated with hospitalization discharge that hinder successful recovery. We sought to better understand the challenges in the discharge transition of care, which might suggest interventions that would optimize it.

METHODS

We conducted a qualitative study of patient and clinician perceptions about the hospital discharge process at an urban level 1 trauma center. We performed semi-structured interviews that we recorded, transcribed, coded both deductively and inductively, and analyzed thematically. We enrolled patients and clinicians until we achieved data saturation.

RESULTS

We interviewed 10 patients and 10 clinicians. Most patients (70%) were male, and the mean age was 57±16 years. Clinicians included attending surgeons, residents, nurse practitioners, nurses, and case managers. Three themes emerged. (1) Communication (patient-clinician and clinician-clinician): clinicians understood that the discharge process malfunctions when communication with patients is not clear. Many patients discussed confusion about their discharge plan. Clinicians lamented that poorly written discharge summaries are an inadequate means of communication between inpatient and outpatient clinicians. (2) Discharge teaching and written instructions: patients appreciated discharge teaching but found written discharge instructions to be overwhelming and unhelpful. Clinicians preferred spending more time teaching patients and understood that written instructions contain too much jargon. (3) Outpatient care coordination: patients and clinicians identified difficulties with coordinating ongoing outpatient care. Both identified the patient's primary care physician and insurance coverage as important determinants of the outpatient experience.

CONCLUSION

TACS patients face numerous challenges at hospitalization discharge. Clinicians struggle to effectively help their patients with this stressful transition. Future interventions should focus on improving communication with patients, active communication with a patient's primary care physician, repurposing, and standardizing the discharge summary to serve primarily as a means of care coordination, and assisting the patient with navigating the transition.

LEVEL OF EVIDENCE

III-descriptive, exploratory study.

Evaluating the effect of driving distance to the nearest higher level trauma centre on undertriage: a cohort study

BACKGROUND

It is of great importance that emergency medical services professionals transport trauma patients in need of specialised care to higher level trauma centres to achieve optimal patient outcomes. Possibly, undertriage is more likely to occur in patients with a longer distance to the nearest higher level trauma centre. This study aims to determine the association between driving distance and undertriage.

METHOD

This prospective cohort study was conducted from January 2015 to December 2017. All trauma patients in need of specialised care that were transported to a trauma centre by emergency medical services professionals from eight ambulance regions in the Netherlands were included. Patients with critical resource use or an Injury Severity Score ≥16 were defined as in need of specialised care. Driving distance was calculated between the scene of injury and the nearest higher level trauma centre. Undertriage was defined as transporting a patient in need of specialised care to a lower level trauma centre. Generalised linear models adjusting for confounders were constructed to determine the association between driving distance to the nearest higher level trauma centre per 1 and 10 km and undertriage. A sensitivity analysis was conducted with a generalised linear model including inverse probability weights.

RESULTS

6101 patients, of which 4404 patients with critical resource use and 3760 patients with an Injury Severity Score ≥16, were included. The adjusted generalised linear model demonstrated a significant association between a 1 km (OR 1.04; 95% CI 1.04 to 1.05) and 10 kilometre (OR 1.50; 95% CI 1.42 to 1.58) increase in driving distance and undertriage in patients with critical resource use. Also in patients with an Injury Severity Score ≥16, a significant association between driving distance (1 km (OR 1.06; 95% CI 1.06 to 1.07), 10 km (OR 1.83; 95% CI 1.71 to 1.95)) and undertriage was observed.

CONCLUSION

Patients in need of specialised care are less likely to be transported to the appropriate trauma centre with increasing driving distance. Our results suggest that emergency medical services professionals incorporate driving distance into their decision making regarding transport destinations, although distance is not included in the triage protocol.

The advanced machine learner XGBoost did not reduce prehospital trauma mistriage compared with logistic regression: a simulation study

Background

Accurate prehospital trauma triage is crucial for identifying critically injured patients and determining the level of care. In the prehospital setting, time and data are often scarce, limiting the complexity of triage models. The aim of this study was to assess whether, compared with logistic regression, the advanced machine learner XGBoost (eXtreme Gradient Boosting) is associated with reduced prehospital trauma mistriage.

Methods

We conducted a simulation study based on data from the US National Trauma Data Bank (NTDB) and the Swedish Trauma Registry (SweTrau). We used categorized systolic blood pressure, respiratory rate, Glasgow Coma Scale and age as our predictors. The outcome was the difference in under- and overtriage rates between the models for different training dataset sizes.

Results

We used data from 813,567 patients in the NTDB and 30,577 patients in SweTrau. In SweTrau, the smallest training set of 10 events per free parameter was sufficient for model development. XGBoost achieved undertriage rates in the range of 0.314–0.324 with corresponding overtriage rates of 0.319–0.322. Logistic regression achieved undertriage rates ranging from 0.312 to 0.321 with associated overtriage rates ranging from 0.321 to 0.323. In NTDB, XGBoost required the largest training set size of 1000 events per free parameter to achieve robust results, whereas logistic regression achieved stable performance from a training set size of 25 events per free parameter. For the training set size of 1000 events per free parameter, XGBoost obtained an undertriage rate of 0.406 with an overtriage of 0.463. For logistic regression, the corresponding undertriage was 0.395 with an overtriage of 0.468.

Conclusion

The under- and overtriage rates associated with the advanced machine learner XGBoost were similar to the rates associated with logistic regression regardless of sample size, but XGBoost required larger training sets to obtain robust results. We do not recommend using XGBoost over logistic regression in this context when predictors are few and categorical.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01558-y.

Inter-hospital transfer of polytrauma and severe traumatic brain injury patients: Retrospective nationwide cohort study using data from the Swiss Trauma Register

Introduction

Polytrauma and traumatic brain injury (TBI) patients are among the most vulnerable patients in trauma care and exhibit increased morbidity and mortality. Timely care is essential for their outcome. Severe TBI with initially high scores on the Glasgow Coma (GCS) scores is difficult to recognise on scene and referral to a Major Trauma Center (MTC) might be delayed. Therefore, we examined current referral practice, injury patterns and mortality in these patients.

Materials and methods

Retrospective, nationwide cohort study with Swiss Trauma Register (STR) data between 01/012015 and 31/12/2018. STR includes patients ≥16 years with an Injury Severity Score (ISS) >15 and/or an Abbreviated Injury Scale (AIS) for head >2. We performed Cox proportional hazard models with injury type as the primary outcome and mortality as the dependent variable. Secondary outcomes were inter-hospital transfer and age.

Results

9,595 patients were included. Mortality was 12%. 2,800 patients suffered from isolated TBI. 69% were men. Median age was 61 years and median ISS 21. Two thirds of TBI patients had a GCS of 13–15 on admission to the Emergency Department (ED). 26% of patients were secondarily transferred to an MTC. Patients with isolated TBI and those aged ≥65 years were transferred more often. Crude analysis showed a significantly elevated hazard for death of 1.48 (95%CI 1.28–1.70) for polytrauma patients with severe TBI and a hazard ratio (HR) of 1.82 (95%CI 1.58–2.09) for isolated severe TBI, compared to polytrauma patients without TBI. Patients directly admitted to the MTC had a significantly elevated HR for death of 1.63 (95%CI 1.40–1.89), compared to those with secondary transfer.

Conclusions

A high initial GCS does not exclude the presence of severe TBI and triage to an MTC should be seriously considered for elderly TBI patients.

Readmission Following Hospitalization for Traumatic Brain Injury: A Nationwide Study

OBJECTIVE

To determine whether sociodemographic and clinical factors were associated with nonelective readmission within 30 days of hospitalization for traumatic brain injury (TBI). Secondary objectives were to examine the effects of TBI severity on readmission and characterize primary reasons for readmission.

SETTING

Hospitalized patients in the United States, using the 2014 Nationwide Readmission Database.

PARTICIPANTS

All patients hospitalized with a primary diagnosis of TBI between January 1, 2014, and November 30, 2014. We excluded patients (1) with a missing or invalid length of stay or admission date, (2) who were nonresidents, and 3) who died during their index hospitalization.

DESIGN

Observational study; cohort study.

MAIN MEASURES

Survey weighting was used to compute national estimates of TBI hospitalization and nonelective 30-day readmission. Associations between sociodemographic and clinical factors with readmission were assessed using unconditional logistic regression with and without adjustment for suspected confounders.

RESULTS

There were 135 542 individuals who were hospitalized for TBI; 8.9% of patients were readmitted within 30 days of discharge. Age (strongest association for 65-74 years vs 18-24 years: adjusted odds ratio [AOR], 2.57; 95% CI: 2.02-3.27), documentation of a fall (AOR, 1.24; 95% CI: 1.13-1.35), and intentional self-injury (AOR, 3.13; 95% CI: 1.88-5.21) at the index admission were positively associated with readmission. Conversely, history of a motor vehicle (AOR, 0.69; 95% CI: 0.62-0.78) or cycling (AOR, 0.56; 95% CI: 0.40-0.77) accident was negatively associated with readmission. Females were also less likely to be readmitted following hospitalization for a TBI (AOR, 0.87; 95% CI: 0.82-0.92).

CONCLUSIONS

Many sociodemographic and clinical factors were found to be associated with acute readmission following hospitalizations for TBI. Future studies are needed to determine the extent to which readmissions following TBI hospitalizations are preventable.

Accuracy of pre-hospital triage tools for major trauma: a systematic review with meta-analysis and net clinical benefit

BACKGROUND

We conducted a systematic review to evaluate and compare the accuracy of pre-hospital triage tools for major trauma in the context of the development of the Italian National Institute of Health guidelines on major trauma integrated management.

METHODS

PubMed, Embase, and CENTRAL were searched up to November 2019 for studies investigating pre-hospital triage tools. The ROC (receiver operating characteristics) curve and net clinical benefit for all selected triage tools were performed. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2. Certainty of the evidence was judged with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We found 15 observational studies of 13 triage tools for adults and 11 for children. In adults, according to the ROC curve and the net clinical benefit, the most reliable tool was the Northern French Alps Trauma System (TRENAU), adopting injury severity score (ISS) > 15 as reference (sensitivity (Sn), 0.92; specificity (Sp), 0.41; 1 study; sample size, 2572; high certainty of the evidence). When mortality as reference was considered, the pre-hospital triage tool with the best net clinical benefit trajectory was the New Trauma Score (NTS) < 18 (Sn, 0.82; Sp, 0.86; 1 study; sample size, 1001; moderate certainty of the evidence). In children, high variability among all triage tools for sensitivity and specificity was found.

CONCLUSION

Sensitivity and specificity varied across all available pre-hospital trauma triage tools. TRENAU and NTS are the best accurate triage tools for adults, whereas in the pediatric area a large variability prevents any firm conclusion.

Priority accuracy by dispatch centers and Emergency Medical Services professionals in trauma patients: a cohort study

Purpose

Priority-setting by dispatch centers and Emergency Medical Services professionals has a major impact on pre-hospital triage and times of trauma patients. Patients requiring specialized care benefit from expedited transport to higher-level trauma centers, while transportation of these patients to lower-level trauma centers is associated with higher mortality rates. This study aims to evaluate the accuracy of priority-setting by dispatch centers and Emergency Medical Services professionals.

Methods

This observational study included trauma patients transported from the scene of injury to a trauma center. Priority-setting was evaluated in terms of the proportion of patients requiring specialized trauma care assigned with the highest priority (i.e., sensitivity), undertriage, and overtriage. Patients in need of specialized care were defined by a composite resource-based endpoint. An Injury Severity Score ≥ 16 served as a secondary reference standard.

Results

Between January 2015 and December 2017, records of 114,459 trauma patients were collected, of which 3327 (2.9%) patients were in need of specialized care according to the primary reference standard. Dispatch centers and Emergency Medical Services professionals assigned 83.8% and 74.5% of these patients with the highest priority, respectively. Undertriage rates ranged between 22.7 and 65.5% in the different prioritization subgroups. There were differences between dispatch and transport priorities in 17.7% of the patients.

Conclusion

The majority of patients that required specialized care were assigned with the highest priority by the dispatch centers and Emergency Medical Services professionals. Highly accurate priority criteria could improve the quality of pre-hospital triage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01685-1.

Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma

BACKGROUND

Unplanned hospital readmissions are associated with morbidity and high cost. Existing literature on readmission after trauma has focused on how injury characteristics are associated with readmission. We aimed to evaluate how psychosocial determinants of health and complications of hospitalization combined with injury characteristics affect risk of readmission after trauma.

MATERIALS AND METHODS

We conducted a retrospective cohort study of adult trauma admissions from July 2015 to September 2017 to Harborview Medical Center in Seattle, Washington. We assessed patient, injury, and hospitalization characteristics and estimated associations between risk factors and unplanned 30-d readmission using multivariable generalized linear Poisson regression models.

RESULTS

Of 8916 discharged trauma patients, 330 (3.7%) had an unplanned 30-d readmission. Patients were most commonly readmitted with infection (41.5%). Independent risk factors for readmission among postoperative patients included public insurance (adjusted Relative Risk (aRR) 1.34, 95% CI 1.02-1.76), mental illness (aRR 1.39, 1.04-1.85), and chronic renal failure (aRR 2.17, 1.39-3.39); undergoing abdominal, thoracic, or neurosurgical procedures; experiencing an index hospitalization surgical site infection (aRR 4.74, 3.00-7.50), pulmonary embolism (aRR 3.38, 2.04-5.60), or unplanned ICU readmission (aRR 1.74, 1.16-2.62); shorter hospital stay (aRR 0.98/d, 0.97-0.99), and discharge to jail (aRR 4.68, 2.63-8.35) or a shelter (aRR 4.32, 2.58-7.21). Risk factors varied by reason for readmission. Injury severity, trauma mechanism, and body region were not independently associated with readmission risk.

CONCLUSIONS

Psychosocial factors and hospital complications were more strongly associated with readmission after trauma than injury characteristics. Improved social support and follow-up after discharge for high-risk patients may facilitate earlier identification of postdischarge complications.

ISS is not an appropriate tool to estimate overtriage

PURPOSE

The aim of this work is to study a cohort of patients of ISS < 15 admitted to a TC, and to determine the number of patients that ultimately benefited from the skills and resources specific of a level 1 trauma center.

METHODS

Retrospective study from a prospective cohort of patients admitted to TC (Beaujon Hospital, APHP) for suspected severe trauma from January 2011 to December 2017. The main outcome criterion was the use of surgery or interventional radiology within the first 24 h after admission of patients with ISS < 15. The secondary outcomes were stratified into severe (mortality, resuscitation care, length of stay in intensive care units) and non-severe criteria (mild head injury, hospital discharge or transfer within 24 h).

RESULTS

Of 3035 patients admitted during the study period, 1409 with an ISS < 15 were included, corresponding to a theoretical overtriage rate of 46.4%. Among these, 611 patients (43.4%) underwent emergency intervention within the first 24 h (586 surgical interventions, 19 direct transfers to the operating theater and 6 acts of interventional radiology), 238 (16.9%) of patients presented with severe and 531 (38%) with non-severe outcome criteria.

CONCLUSION

This work demonstrates that in a cohort of patients classified as ISS < 15 admitted to a TC, a considerable amount of TC-specific resources are required, and patients present with severe outcome criteria despite being classified as overtriaged. These results suggest that triage of trauma patients should be based on resource use and clinical outcome rather than anatomic criteria.

Musculoskeletal injury survivors' resiliency: A systematic review

BACKGROUND

Musculoskeletal traumas are on the rise in the United States; however, limited studies are available to help trauma providers assess and treat concerns beyond the physical impact. Little is understood about the psychological, social, and spiritual factors that protect patients from adverse effects after a physical trauma or their experiences with each factor afterward.

OBJECTIVE

This systematic review was conducted to investigate and review advancements in research related to risk and resiliency factors experienced by survivors of traumatic musculoskeletal injuries. The use of biopsychosocial-spiritual (BPS-S) framework and resiliency theory guided the analysis.

METHODS

Researchers reviewed 1003 articles, but only seven met the search criteria. Due to the complexity and uniqueness of traumatic brain injuries, studies on that target population were excluded.

RESULTS

Of the seven articles reviewed, three identified psychological protective factors that protect against negative health outcomes; three identified negative psychological, social, or spiritual outcomes; and none investigated social or spiritual health.

CONCLUSIONS

There are significant gaps in the literature surrounding risk and resiliency factors related to the BPS-S health of musculoskeletal injury survivors.

Emergency care systems in Africa: A focus on quality

Emergency care systems (ECS) are undergoing a period of rapid development on the African continent. What were formerly large intake zones are now being shaped into dedicated emergency units. Emergency care providers are being trained via certificate and even residency programs. However, significant challenges still exist. Resource limitations, staffing, and other system inputs are often the easiest issues to identify, but they only account for part of the problem. There are other prominent barriers to the delivery of high quality emergency care including lack of governmental leadership, poor system and facility organization, lack of provider training, and community misunderstanding of ECS functions. Released in May 2019, World Health Assembly (WHA) 72 resolution 12.9 "Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured" has squarely placed ECS strengthening as a priority item to member state governments. Moving forward, it will be important to ensure that these systems are set up for success, as high-quality emergency care systems have the potential to avert half of all deaths in low- and middle-income countries (LMIC). With momentum building from the recent WHA amendment and the health systems community more focused than ever on the consideration of quality in health systems design, it is of the utmost importance that ECS planners dovetail these interests such that these nascent systems are designed while 1) applying a systems thinking lens and 2) maintaining a focus on quality. This article helps to accomplish this by breaking down ECS into five major categories for evaluation as defined by the WHO Emergency Care Systems Assessment tool, providing an understanding of the functions of each, and identifying which indicators might be used to gauge performance. We also reinforce the notion that these indicators must dive deeper than system inputs and health outcomes, they must be patient centered in order to truly be reflective of success.

Development and Validation of a Prediction Model for Prehospital Triage of Trauma Patients

Importance

Prehospital trauma triage protocols are used worldwide to get the right patient to the right hospital and thereby improve the chance of survival and avert lifelong disabilities. The American College of Surgeons Committee on Trauma set target levels for undertriage rates of less than 5%. None of the existing triage protocols has been able to achieve this target in isolation.

Objective

To develop and validate a new prehospital trauma triage protocol to improve current triage rates.

Design, Setting, and Participants

In this multicenter cohort study, all patients with trauma who were 16 years and older and transported to a trauma center in 2 different regions of the Netherlands were included in the analysis. Data were collected from January 1, 2012, through June 30, 2014, in the Central Netherlands region for the design data cohort and from January 1 through December 31, 2015, in the Brabant region for the validation cohort. Data were analyzed from May 3, 2017, through July 19, 2018.

Main Outcomes and Measures

A new prediction model was developed in the Central Netherlands region based on prehospital predictors associated with severe injury. Severe injury was defined as an Injury Severity Score greater than 15. A full-model strategy with penalized maximum likelihood estimation was used to construct a model with 8 predictors that were chosen based on clinical reasoning. Accuracy of the developed prediction model was assessed in terms of discrimination and calibration. The model was externally validated in the Brabant region.

Results

Using data from 4950 patients with trauma from the Central Netherlands region for the design data set (58.3% male; mean [SD] age, 47 [21] years) and 6859 patients for the validation Brabant region (52.2% male; mean [SD] age, 51 [22] years), the following 8 significant predictors were selected for the prediction model: age; systolic blood pressure; Glasgow Coma Scale score; mechanism criteria; penetrating injury to the head, thorax, or abdomen; signs and/or symptoms of head or neck injury; expected injury in the Abbreviated Injury Scale thorax region; and expected injury in 2 or more Abbreviated Injury Scale regions. The prediction model showed a C statistic of 0.823 (95% CI, 0.813-0.832) and good calibration. The cutoff point with a minimum specificity of 50.0% (95% CI, 49.3%-50.7%) led to a sensitivity of 88.8% (95% CI, 87.5%-90.0%). External validation showed a C statistic of 0.831 (95% CI, 0.814-0.848) and adequate calibration.

Conclusions and Relevance

The new prehospital trauma triage prediction model may lower undertriage rates to approximately 10% with an overtriage rate of 50%. The next step should be to implement this prediction model with the use of a mobile app for emergency medical services professionals.

Readmissions after nonoperative trauma: Increased mortality and costs with delayed intervention

BACKGROUND

We sought to examine patterns of readmission after nonoperative trauma, including rates of delayed operative intervention and mortality.

METHODS

The Nationwide Readmissions Database (2013-2014) was queried for all adult trauma admissions and 30-day readmissions. Index admissions were classified as operative (OI) or nonoperative (NOI), and readmissions examined for major operative intervention (MOR). Multivariable regression modeling was used to evaluate risk for readmission requiring MOR and in-hospital mortality.

RESULTS

Of 2,244,570 trauma admissions, there were 59,573 readmissions: 66% after NOI, and 35% after OI. Readmission rate was higher after NOI compared with OI (3.6% vs. 1.7% p < 0.001). Readmitted NOI patients were older, with a higher proportion of Injury Severity Score ≥15 and were readmitted earlier (NOI median 8 days vs. OI 11 days). Thirty-one percent of readmitted NOI patients required MOR and experienced higher overall mortality compared with OI patients with operative readmission (NOI 2.9% vs. OI 2%, p = 0.02). Intracranial hemorrhage was an independent risk factor for NOI readmission requiring MOR in both the overall (hazard ratio, 1.11; 95% confidence interval [CI], 1.01-1.22) and Injury Severity Score of 15 or greater cohorts (hazard ratio, 1.46; 95% CI, 1.24-1.7), with a predominance of nonspine neurosurgical procedures (20.3% and 55.1%, respectively). Operative readmission after NOI cost a median of $17,364 (interquartile range, US $11,481 to US $27,816) and carried a total annual cost of US $147 million (95% CI, US $141 million to $154 million).

CONCLUSIONS

Nonoperative trauma patients have a higher readmission rate than operative index patients and nearly one third require operative intervention during readmission. Operative readmission carries a higher overall mortality rate in NOI patients and together accounts for nearly US $150 million in annual costs.

LEVEL OF EVIDENCE

Epidemiological, level III.

Unplanned readmission after traumatic injury: A long-term nationwide analysis

BACKGROUND

Long-term outcomes after trauma admissions remain understudied. We analyzed the characteristics of inpatient readmissions within 6 months of an index hospitalization for traumatic injury.

METHODS

Using the 2010 to 2015 Nationwide Readmissions Database, which captures data from up to 27 US states, we identified patients at least 15 years old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within 1 month, 3 months, and 6 months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors.

RESULTS

Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within 1 month, 21.6% within 6 months, and 29.8% within 6 months, with limited variability by year. After adjustment, the following were associated with all-cause 6 months inpatient readmissions: male sex (adjusted odds ratio [aOR], 1.10; 95% confidence interval [95% CI], 1.09-1.10), comorbidities (aOR, 1.21; 95% CI, 1.21-1.22), low-income quartiles (first and second) (aOR, 1.08; 95% CI, 1.07-1.10 and aOR, 1.04; 95% CI, 1.03-1.06, respectively), Medicare (aOR, 1.65; 95% CI, 1.62-1.69), Medicaid (aOR, 1.51; 95% CI, 1.48-1.53), being treated at private, investor-owned hospitals (aOR, 1.15; 95% CI, 1.12-1.18), longer hospital length of stay (aOR, 1.01; 95% CI, 1.01-1.01) and patient disposition to short-term hospital (aOR, 1.55; 95% CI, 1.49-1.62), skilled nursing facility (aOR, 1.43; 95% CI, 1.42-1.45), home health care (aOR, 1.27; 95% CI, 1.25-1.28), or leaving against medical advice (aOR, 1.85; 95% CI, 1.78-1.92).

CONCLUSION

Unplanned readmission after trauma is high and remains this way 6 months after discharge. Understanding the factors that increase the odds of readmissions within 1 month, 3 months, and 6 months offer a focus for quality improvement and have important implications for hospital benchmarking.

LEVEL OF EVIDENCE

Epidemiological study, level III.

[Analysis of causes and factors associated with hospital readmission in mild and moderate polythraumatism: An observational study]

BACKGROUND

Early readmissions (ER) occur during the 30 days after discharge, ER are common and expensive, associated with a decrease in the quality of care. The rate of ER in polytraumatic patients (PTP) is estimated between 4.3-15%. Our objective was to identify those factors associated with ER and its characteristics after suffering mild-moderate trauma in our area.

MATERIAL AND METHOD

This is a retrospective observational study, including data of patients with (PTP) mild or moderate admitted between July 2012 and June 2017 in our institution and their ER in public hospitals and/or outpatient centers. Demographic variables, diagnoses, procedures and characteristics of readmissions were collected. After a bivariant analysis was done, a Logistic regression had benn performed to determine risk factors for ER.

RESULTS

1013 patients were included, with median age of 38 years, ISS of 3 points and initial hospital stay of 1 day. 185 patients were readmitted (18.3%). Independent factors associated with ER were: injury mechanism, especially bicycle accident (OR 2.26), comorbidities highlighting HBP (OR 1.83) and COPD (OR 1.98), fracture immobilization (OR 1.99) and hospital admission in the initial care (OR 0.56). The causes of ER were: pain 61.6%, wound infection 15.1%, scheduled cures and deferred interventions 12.97%, medical 6.4% and psychiatric decompensation. 2.7% CONCLUSION: The ERs in mild-moderate PTP are multifactorial, our results show an association between factors such as injury mechanism, the presence of comorbidities and the procedures performed in the sentinel episode and the rate of ER. The implementation of simple interventions at discharge could reduce its incidence clearly.

Trauma transitional care coordination: A mature system at work

BACKGROUND

We have previously demonstrated effectiveness of a Trauma Transitional Care Coordination (TTCC) Program in reducing 30-day readmission rates for trauma patients most at risk. With program maturation, we achieved improved readmission rates for specific patient populations.

METHODS

TTCC is a nursing driven program that supports patients at high risk for 30-day readmission. The TTCC interventions include calls to patients within 72 hours of discharge, complete medication reconciliation, coordination of medical appointments, and individualized problem solving. Account IDs were used to link TTCC patients with the Health Services Cost Review Commission database to collect data on statewide unplanned 30-day readmissions.

RESULTS

Four hundred seventy-five patients were enrolled in the TTCC program from January 2014 to September 2016. Only 10.5% (n = 50) of TTCC enrollees were privately insured, 54.5% had Medicaid (n = 259), and 13.5% had Medicare (n = 64). Seventy-three percent had Health Services Cost Review Commission severity of injury ratings of 3 or 4 (maximum severity of injury = 4). The most common All Patient Refined Diagnosis Related Groups for participants were: lower-extremity procedures (n = 67, 14%); extensive abdominal/thoracic procedures (n = 40, 8.4%); musculoskeletal procedures (n = 37, 7.8%); complicated tracheostomy and upper extremity procedures (n = 29 each, 6.1%); infectious disease complications (n = 14, 2.9%); major chest/respiratory trauma, major small and large bowel procedures and vascular procedures (n = 13 each, 2.7%). The TTCC participants with lower-extremity injury, complicated tracheostomy, and bowel procedures had 6-point reduction (10% vs. 16%, p = 0.05), 11-point reduction (13% vs. 24%, p = 0.05), and 16-point reduction (11% vs. 27%, p = 0.05) in 30-day readmission rates, respectively, compared to those without TTCC.

CONCLUSION

Targeted outpatient support for high-risk patients can decrease 30-day readmission rates. As our TTCC program matured, we reduced 30-day readmission in patients with lower-extremity injury, complicated tracheostomy and bowel procedures. This represents over one million-dollar savings for the hospital per year through quality-based reimbursement.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Development and validation of a novel prediction model to identify patients in need of specialized trauma care during field triage: design and rationale of the GOAT study

BACKGROUND

Adequate field triage of trauma patients is crucial to transport patients to the right hospital. Mistriage and subsequent interhospital transfers should be minimized to reduce avoidable mortality, life-long disabilities, and costs. Availability of a prehospital triage tool may help to identify patients in need of specialized trauma care and to determine the optimal transportation destination.

METHODS

The GOAT (Gradient Boosted Trauma Triage) study is a prospective, multi-site, cross-sectional diagnostic study. Patients transported by at least five ground Emergency Medical Services to any receiving hospital within the Netherlands are eligible for inclusion. The reference standards for the need of specialized trauma care are an Injury Severity Score ≥ 16 and early critical resource use, which will both be assessed by trauma registrars after the final diagnosis is made. Variable selection will be based on ease of use in practice and clinical expertise. A gradient boosting decision tree algorithm will be used to develop the prediction model. Model accuracy will be assessed in terms of discrimination (c-statistic) and calibration (intercept, slope, and plot) on individual participant's data from each participating cluster (i.e., Emergency Medical Service) through internal-external cross-validation. A reference model will be externally validated on each cluster as well. The resulting model statistics will be investigated, compared, and summarized through an individual participant's data meta-analysis.

DISCUSSION

The GOAT study protocol describes the development of a new prediction model for identifying patients in need of specialized trauma care. The aim is to attain acceptable undertriage rates and to minimize mortality rates and life-long disabilities.

Ten-year trends in traumatic brain injury: a retrospective cohort study of California emergency department and hospital revisits and readmissions

OBJECTIVE

To describe visits and visit rates of adults presenting to emergency departments (EDs) with a diagnosis of traumatic brain injury (TBI). TBI is a major cause of death and disability in the USA; yet, current literature is limited because few studies examine longer-term ED revisits and hospital readmission patterns of TBI patients across a broad spectrum of injury severity, which can help inform potential unmet healthcare needs.

DESIGN

We performed a retrospective cohort study.

SETTING

We analysed non-public patient-level data from California's Office of Statewide Health Planning and Development for years 2005 to 2014.

PARTICIPANTS

We identified 1.2 million adult patients aged ≥18 years presenting to California EDs and hospitals with an index diagnosis of TBI.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our main outcomes included revisits, readmissions and mortality over time. We also examined demographics, mechanism and severity of injury and disposition at discharge.

RESULTS

We found a 57.7% increase in the number of TBI ED visits, representing a 40.5% increase in TBI visit rates over the 10-year period (346-487 per 100 000 residents). During this time, there was also a 33.8% decrease in the proportion of patients admitted to the hospital. Older, publicly insured and black populations had the highest visit rates, and falls were the most common mechanism of injury (45.5% of visits). Of all patients with an index TBI visit, 40.5% of them had a revisit during the first year, with 46.7% of them seeking care at a different hospital from their initial hospital or ED visit. Additionally, of revisits within the first year, 13.4% of them resulted in hospital readmission.

CONCLUSIONS

The large proportion of patients with TBI who are discharged directly from the ED, along with the high rates of revisits and readmissions, suggest a role for an established system for follow-up, treatment and care of TBI.

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

PURPOSE

Severely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers.

METHODS

All trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data.

RESULTS

For adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region.

CONCLUSION

The compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.

Compliance to prehospital trauma triage protocols worldwide: A systematic review

BACKGROUND

Emergency medical services (EMS) providers must determine the injury severity on-scene, using a prehospital trauma triage protocol, and decide on the most appropriate hospital destination for the patient. Many severely injured patients are not transported to higher-level trauma centres. An accurate triage protocol is the base of prehospital trauma triage; however, ultimately the quality is dependent on the destination decision by the EMS provider. The aim of this systematic review is to describe compliance to triage protocols and evaluate compliance to the different categories of triage protocols.

METHODS

An extensive search of MEDLINE/Pubmed, Embase, CINAHL and Cochrane library was performed to identify all studies, published before May 2018, describing compliance to triage protocols in a trauma system. The search terms were a combination of synonyms for 'compliance,' 'trauma,' and 'triage'.

RESULTS

After selection, 11 articles were included. The studies showed a variety in compliance rates, ranging from 21% to 93% for triage protocols, and 41% to 94% for the different categories. The compliance rate was highest for the criterion: penetrating injury. The category of the protocol with the lowest compliance rate was: vital signs. Compliance rates were lower for elderly patients, compared to adults under the age of 55. The methodological quality of most studies was poor. One study with good methodological quality showed that the triage protocol identified only a minority of severely injured patients, but many of whom were transported to higher-level trauma centres.

CONCLUSIONS

The compliance rate ranged from 21% to 94%. Prehospital trauma triage effectiveness could be increased with an accurate triage protocol and improved compliance rates. EMS provider judgment could lower the undertriage rate, especially for severely injured patients meeting none of the criteria. Future research should focus on the improvement of triage protocols and the compliance rate.

Teenage Trauma Patients Are at Increased Risk for Readmission for Mental Diseases and Disorders

BACKGROUND

Most studies of readmission after trauma are limited to single institutions or single states. The purpose of this study was to determine the risk factors for readmission after trauma for mental illness including readmissions to different hospitals across the United States.

MATERIALS AND METHODS

The Nationwide Readmission Database for 2013 and 2014 was queried for all patients aged 13 to 64 y with a nonelective admission for trauma and a nonelective readmission within 30 d. Multivariable logistic regression was performed for readmission for mental diseases and disorders.

RESULTS

During the study period, 53,402 patients were readmitted within 30 d after trauma. The most common major diagnostic category on readmission was mental diseases and disorders (12.1%). The age group with the highest percentage of readmissions for mental diseases and disorders was 13 to 17 y (38%). On multivariable regression, the teenage group was also the most likely to be readmitted for mental diseases and disorders compared to 18-44 y (odds ratio [OR] 0.45, P < 0.01) and 45-64 y (OR 0.24, P < 0.01). Other high-risk comorbidities included HIV infection (OR 2.4, P < 0.01), psychosis (OR 2.2, P < 0.01), drug (OR 2.0, P < 0.01), and alcohol (OR 1.4, P < 0.01) abuse.

CONCLUSIONS

Teenage trauma patients are at increased risk for hospital readmission for mental illness. Efforts to reduce these admissions should be targeted toward individuals with high-risk comorbidities such as HIV infection, psychosis, and substance abuse.

US pediatric trauma patient unplanned 30-day readmissions

PURPOSE

We sought to determine readmission rates and risk factors for acutely injured pediatric trauma patients.

METHODS

We produced 30-day unplanned readmission rates for pediatric trauma patients using the 2013 National Readmission Database (NRD).

RESULTS

In US pediatric trauma patients, 1.7% had unplanned readmissions within 30days. The readmission rate for patients with index operating room procedures was no higher at 1.8%. Higher readmission rates were seen in patients with injury severity scores (ISS)=16-24 (3.4%) and ISS ≥25 (4.9%). Higher rates were also seen in patients with LOS beyond a week, severe abdominal and pelvic region injuries (3.0%), crushing (2.8%) and firearm injuries (4.5%), and in patients with fluid and electrolyte disorders (3.9%). The most common readmission principal diagnoses were injury, musculoskeletal/integumentary diagnoses and infection. Nearly 39% of readmitted patients required readmission operative procedures. Most common were operations on the musculoskeletal system (23.9% of all readmitted patients), the integumentary system (8.6%), the nervous system (6.6%), and digestive system (2.5%).

CONCLUSIONS

Overall, the readmission rate for pediatric trauma patients was low. Measures of injury severity, specifically length of stay, were most useful in identifying those who would benefit from targeted care coordination resources.

LEVEL OF EVIDENCE

This is a Level III retrospective comparative study.

Comparative Effectiveness of Initial Treatment at Trauma Center vs Neurosurgery-Capable Non-Trauma Center for Severe, Isolated Head Injury

BACKGROUND

Head injury is an increasing contributor to death and disability, particularly among the elderly. Older patients are less likely to be treated at trauma centers, and head injury is the most common severe injury treated at non-trauma centers. We hypothesized that patients initially triaged to trauma centers would have lower rates of mortality and higher rates of discharge home without services than those treated at non-trauma centers.

STUDY DESIGN

We used the State Emergency Department and Inpatient Databases (2011 to 2012) for 6 states to conduct a retrospective cohort study of patients with severe, isolated head injury. Combined, these databases capture all visits to non-federal emergency departments. We compared in-hospital mortality and discharge status for all adults and for the subgroup aged 65 years or older who initially presented to either a trauma center or a neurosurgery-capable non-trauma center. To account for selection bias, we used differential distance from patients' homes to a trauma center as an instrumental variable and performed a multivariable matched analysis.

RESULTS

Of 62,198 patients who presented with severe, isolated head injury, 44.2% presented to non-trauma centers and 55.8% to trauma centers. In multivariable matched instrumental variable analysis, initial presentation to a trauma center was associated with no significant difference in overall mortality (-1.06%; 95% CI -3.36% to 1.19%), but a 5.8% higher rate of discharge home (95% CI 1.7% to 10.0%). Among patients aged 65 years or older, initial presentation to a trauma center was associated with a 3.4% reduction in mortality (95% CI 0.0% to 7.1%).

CONCLUSIONS

Patients with isolated, severe head injury have better outcomes if initially treated in designated trauma centers. As 40% of such patients were triaged to non-trauma centers, there are major opportunities for improving outcomes.

Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission

Background

Unplanned hospital readmissions increase healthcare costs and patient morbidity. We hypothesized that a program designed to reduce trauma readmissions would be effective.

Methods

A Trauma Transitional Care Coordination (TTCC) program was created to support patients at high risk for readmission. TTCC interventions included call to patient (or caregiver) within 72 hours of discharge to identify barriers to care, complete medication reconciliation, coordination of appointments, and individualized problem solving. Information on all 30-day readmissions was collected. 30-day readmission rates were compared with center-specific readmission rates and population-based, risk-adjusted rates of readmission using published benchmarks.

Results

260 patients were enrolled in the TTCC program from January 2014 to September 2015. 30.8% (n=80) of enrollees were uninsured, 41.9% (n=109) reported current substance abuse, and 26.9% (n=70) had a current psychiatric diagnosis. 74.2% (n=193) attended outpatient trauma appointments within 14 days of discharge. 96.3% were successfully followed. Only 6.6% (n=16) of patients were readmitted in the first 30 days after discharge. This was significantly lower than both center-specific readmission rates before start of the program (6.6% vs. 11.3%, P=0.02) and recently published population-based trauma readmission rates (6.6% vs. 27%, P<0.001).

Discussion

A nursing-led TTCC program successfully followed patients and was associated with a significant decrease in 30-day readmission rates for patients with high-risk trauma. Targeted outpatient support for these most vulnerable patients can lead to better utilization of outpatient resources, increased patient satisfaction, and more consistent attainment of preinjury level of functioning or better.

Level of evidence

Level IV.

Hospitalization in low-level trauma centres after severe traumatic brain injury: review of a population-based emergency department data base

OBJECTIVE

To achieve the best possible recovery, individuals with severe TBI should be treated at Level I/II trauma centres (I/II TC). Increased morbidity and mortality can result when injured patients are admitted to facilities that may not have the appropriate resources or expertise to treat the injury. The purpose of this study was to estimate the proportion of severe TBI visits resulting in hospitalization in lower-level trauma centres (OTH) and evaluate the characteristics associated with such hospitalizations.

METHODS

The 2012 National Emergency Department Sample (NEDS) data set was analysed. Weighted descriptive analysis and multivariable logistic regression were used to describe the association of hospitalization in OTH with demographic, clinical and hospital characteristics.

RESULTS

Of visits for severe TBI, 112 208 were admitted to I/II TC and 43 294 admitted to OTH. The adjusted odds of hospitalization in OTH were higher for isolated TBI, falls, women, in those with ≥3 chronic conditions and increasing age.

CONCLUSIONS

An estimated 19.5% of visits for severe TBI resulted in hospitalization in OTH. These findings show the need to further evaluate the relationship between sex, age and mechanism of injury to inform efforts to appropriately triage individuals with TBI to ensure the best possible recovery.

Risk factors and costs associated with nationwide nonelective readmission after trauma

BACKGROUND

Most prior studies of readmission after trauma have been limited to single institutions, whereas multi-institutional studies have been limited to single states and an inability to distinguish between elective and nonelective readmissions. The purpose of this study was to identify the risk factors and costs associated with nonelective readmission after trauma across the United States.

METHODS

The Nationwide Readmission Database was queried for all patients with nonelective admissions in 2013 and 2014 with a primary diagnosis of trauma. Univariate and multivariate logistic regression identified risk factors for 30-day nonelective same- and different-hospital readmission. The diagnosis groups on readmission were evaluated, and the total cost of readmissions was calculated.

RESULTS

There were 1,180,144 patients admitted for trauma, the 30-day readmission rate was 9.4%, and 26.4% of readmissions occurred at a different hospital. The median readmission cost for patients readmitted to the same hospital was $8,298 (interquartile range, $4,899-$14,911), whereas the median readmission cost for patients readmitted to a different hospital was $8,568 (interquartile range, $4,935-$16,078; p < 0.01). Multivariate regression revealed that patients discharged against medical advice were at increased risk of readmission (odds ratio, 2.79; p < 0.01) and readmission to a different facility (odds ratio, 1.58; p < 0.01). Home health care was associated with a decreased risk of readmission to a different hospital (odds ratio, 0.74; p < 0.01). Septicemia and disseminated infections were the most common diagnoses on readmission (8.4%) and readmission to a different hospital (8.6%).

CONCLUSIONS

A significant portion of US readmissions occur at different hospitals with implications for continuity of care, quality metrics, cost, and resource allocation. Home health care reduces the likelihood of nonelective readmission to a different hospital. Infection was the most common reason for readmission, with ramifications for outcomes research and quality improvement.

LEVEL OF EVIDENCE

Care management/epidimeological, level IV.

Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review

BACKGROUND

Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate corresponding level of trauma care. Incorrect triage results in undertriage and overtriage. The American College of Surgeons Committee on Trauma recommends an undertriage rate below 5% and an overtriage rate below 50% for prehospital trauma triage protocols. To find the most accurate prehospital trauma triage protocol, a clear overview of all currently available protocols and corresponding outcomes is necessary.

OBJECTIVES

The aim of this systematic review was to evaluate the current literature on all available prehospital trauma triage protocols and determine accuracy of protocol-based triage quality in terms of sensitivity and specificity.

METHODS

A search of Pubmed, Embase, and Cochrane Library databases was performed to identify all studies describing prehospital trauma triage protocols before November 2016. The search terms included "trauma," "trauma center," or "trauma system" combined with "triage," "undertriage," or "overtriage." All studies describing protocol-based triage quality were reviewed. To assess the quality of these type of studies, a new critical appraisal tool was developed.

RESULTS

In this review, 21 articles were included with numbers of patients ranging from 130 to over 1 million. Significant predictors for severe injury were: vital signs, suspicion of certain anatomic injuries, mechanism of injury, and age. Sensitivity ranged from 10% to 100%; specificity from 9% to 100%. Nearly all protocols had a low sensitivity, thereby failing to identify severely injured patients. Additionally, the critical appraisal showed poor quality of the majority of included studies.

CONCLUSION

This systematic review shows that nearly all protocols are incapable of identifying severely injured patients. Future studies of high methodological quality should be performed to improve prehospital trauma triage protocols.

LEVEL OF EVIDENCE

Systematic review, level III.

Estimate of mortality reduction with implementation of advanced automatic collision notification

OBJECTIVE

Advanced Automatic Collision Notification (AACN) is a system on a motor vehicle that notifies a public safety answering point (PSAP), either directly or through a third party, that the vehicle has had a crash. AACN systems enable earlier notification of a motor vehicle crash and provide an injury prediction that can help dispatchers and first responders make better decisions about how and where to transport the patient, thus getting the patient to definitive care sooner. The purposes of the current research are to identify the target population that could benefit from AACN, and to develop a reasonable estimate range of potential lives saved with implementation of AACN within the vehicle fleet.

METHODS

Data from the Fatality Analysis Reporting System (FARS) years 2009-2015 and National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) years 2000-2015 were obtained. FARS data were used to determine absolute estimates of the target population who may receive benefit from AACN. These estimates accounted for a number of factors, such as whether a fatal occupant had nearby access to a trauma center and also was correctly identified by the injury severity prediction algorithm as having a "high probability of severe injury." NASS-CDS data were used to provide relative comparisons among subsets of the population. Specifically, relative survival rate ratios between occupants treated at trauma centers versus at non-trauma centers were determined using the nonparametric Kaplan-Meier estimator. Finally, the fatality reduction rate associated with trauma center care was combined with the previously published fatality reduction rate for faster notification time to develop a range for possible lives saved.

RESULTS

Two relevant target populations were identified. A larger subset of 6893 fatalities can benefit only from earlier notification associated with AACN. A smaller subgroup of between 1495 and 2330 fatalities can benefit from both earlier notification and change in treatment destination (i.e., non-trauma center to trauma center). A Kaplan-Meier life curve and a multiple proportional hazard model were used to predict the benefits associated with transport to a trauma center. The resulting range for potential lives saved annually was 360 to 721.

CONCLUSIONS

This analysis provides the estimates of lives that could potentially be saved with full implementation of AACN and universal cell coverage availability. This represents a fatality reduction of approximately 1.6% to 3.3% per year, and more than double the lives saved by earlier notification alone. In conclusion, AACN is a postcrash technology with a promising potential for safety benefit. AACN is therefore a key component of integrated safety systems that aim to protect occupants across the entire crash spectrum.