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Hietbrink F, Mohseni S, Mariani D, Naess PA, Rey-Valcárcel C, Biloslavo A, Bass GA, Brundage SI, Alexandrino H, Peralta R, Leenen LPH, Gaarder T. What trauma patients need: the European dilemma. Eur J Trauma Emerg Surg 2024; 50:627-634. [PMID: 35798972 PMCID: PMC11249462 DOI: 10.1007/s00068-022-02014-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Diego Mariani
- Department of General Surgery, ASST Ovest Milanese, Milan, Italy
| | - Päl Aksel Naess
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | | | - Alan Biloslavo
- General Surgery Department, Cattinara University Hospital, Trieste, Italy
| | - Gary A Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA
| | - Susan I Brundage
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, USA
| | | | - Ruben Peralta
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
- Department of Surgery, Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic
- Hamad Injury Prevention Program, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tina Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
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Fenton SJ, Swendiman RA, Eyre M, Larsen K, Russell KW. The Utah Pediatric Trauma Network, a statewide pediatric trauma collaborative can safely help nonpediatric hospitals admit children with mild traumatic brain injury. J Trauma Acute Care Surg 2023; 95:376-382. [PMID: 36728128 DOI: 10.1097/ta.0000000000003871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Created in 2019, the Utah Pediatric Trauma Network (UPTN) is a transparent noncompetitive collaboration of all hospitals in Utah with the purpose of improving pediatric trauma care. The UPTN implements evidence-based guidelines based on hospital resources and capabilities with quarterly review of data collected in a network-specific database. The first initiative was to help triage the care of traumatic brain injury (TBI) to prevent unnecessary transfers while ensuring appropriate care. The purpose of this study was to review the effectiveness of this network wide guideline. METHODS The UPTN REDCap database was retrospectively reviewed between January 2019 and December 2021. Comparisons were made between the pediatric trauma center (PED1) and nonpediatric hospitals (non-PED1) in admissions of children with very mild, mild, or complicated mild TBI. RESULTS Of the total 3,315 cases reviewed, 294 were admitted to a non-PED1 hospital and 1,061 to the PED1 hospital with very mild/mild/complicated mild TBI. Overall, kids treated at non-PED1 were older (mean, 14.9 vs. 7.7 years; p = 0.00001) and more likely to be 14 years or older (37% vs. 24%, p < 0.00001) compared with those at PED1. Increased admissions occurred post-UPTN at non-PED1 hospitals compared with pre-UPTN (43% vs. 14%, p < 0.00001). Children admitted to non-PED1 hospitals post-UPTN were younger (9.1 vs. 15.7 years, p = 0.002) with more kids younger than 14 years (67% vs. 38%, p = 0.014) compared with pre-UPTN. Two kids required next-day transfer to a higher-level center (1 to PED1), and none required surgery or neurosurgical evaluation. The mean length of stay was 21.8 hours (interquartile range, 11.9-25.4). Concomitantly, less children with very mild TBI were admitted to PED1 post-UPTN (6% vs. 27%, p < 0.00001) and more with complicated mild TBI (63% vs. 50%, p = 0.00003) than 2019. CONCLUSION Implementation of TBI guidelines across the UPTN successfully allowed nonpediatric hospitals to safely admit children with very mild, mild, or complicated mild TBI. In addition, admitted kids were more like those treated at the PED1 hospital. LEVEL OF EVIDENCE Prognostic/Epidemiological; Level IV.
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Affiliation(s)
- Stephen J Fenton
- From the Division of Pediatric Surgery, Department of Surgery (S.J.F., R.A.S., K.L., K.W.R.), University of Utah School of Medicine; and Utah Pediatric Trauma Network (M.E.), Utah Department of Health, Salt Lake City, Utah
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Zogg CK, Becher RD, Dalton MK, Hirji SA, Davis KA, Salim A, Cooper Z, Jarman MP. Defining Referral Regions for Inpatient Trauma Care: The Utility of a Novel Geographic Definition. J Surg Res 2022; 275:115-128. [PMID: 35272088 PMCID: PMC9038698 DOI: 10.1016/j.jss.2021.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Geographic variation is an inherent feature of the US health system. Despite efforts to account for geographic variation in trauma system strengthening, it remains unclear how trauma "regions" should be defined. The objective of this study is to evaluate the utility of a novel definition of Trauma Referral Regions (TRR) for assessing geographic variation in inpatient trauma across the age span of hospitalized trauma patients. METHODS Using 2016-2017 State Inpatient Databases, we assessed the extent of geographic variability in three common metrics of hospital use (localization index, market share index, net patient flow) among TRRs and, as a comparison, trauma regions alternatively defined based on Hospital Referral Regions, Hospital Service Areas, and counties. RESULTS A total of 860,593 admissions from 102 TRRs, 127 Hospital Referral Regions, 884 Hospital Service Areas, and 583 counties were included. Consistent with expectations for distinct trauma regions, TRR presented with high average localization indices (mean [standard deviation]: 83.4 [11.7%]), low market share indices (mean [standard deviation]: 11.9 [7.0%]), and net patient flows close to 1.00. Similar results were found among stratified pediatric, adult, and older adult patients. Associations between TRRs and variations in important demographic features (e.g., travel time by road to the nearest Level I or II Trauma Center) suggest that while indicative of standalone trauma regions, TRRs are also able to simultaneously capture critical variations in regional trauma care. CONCLUSIONS TRRs offer a standalone set of geographic regions with minimal variation in common metrics of hospital use, minimal geographic clustering, and preserved associations with important demographic factors. They provide a needed, valid means of assessing geographic variation among trauma systems.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut; Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts.
| | | | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Sameer A Hirji
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | | | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
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Establishing National Stakeholder Priorities for Quality Improvement in Pediatric Trauma Care: Consensus Results Using a Modified Delphi Process. J Trauma Acute Care Surg 2022; 93:467-473. [PMID: 35713930 DOI: 10.1097/ta.0000000000003731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Quality improvement (QI) efforts within pediatric trauma centers (PTCs) are robust, but the majority of children do not receive initial post-injury care at PTCs. Disparities in access to quality trauma care remain, particularly for children that initially access the trauma system outside of a PTC. The purpose of this project was to identify unmet needs for injured children within the pediatric emergency care system, and to determine national priorities for quality improvement across the continuum of pediatric trauma care. METHODS A panel of delegates representing patients and families, prehospital providers, federal funding partners, nurses, and physicians was recruited from ten national stakeholder organizations. Potential targets were identified using an initial stakeholder meeting followed by a free text response survey. Free text items were coded and condensed as themes, then ranked by the panel using a modified Delphi approach to determine consensus priorities. Items not achieving >35% prioritization on a given iteration were dropped from subsequent iterations. Consensus was defined as 75% of members designating an item as a top-four priority. RESULTS Nineteen themes were identified as potential targets for QI initiatives. Four iterations of panel ranking were utilized to achieve consensus, with four priorities identified: 1) creation of a toolkit and standard provider training for pediatric trauma triage, shock recognition, and early recognition for need to transfer to higher level of care; 2) development of minimum standards for pediatric trauma resuscitation and stabilization capability in non-pediatric centers; 3) facilitating creation of local nursing and physician champions for pediatric trauma; and 4) development and dissemination of best practice guidelines to improve imaging practices for injured children. CONCLUSIONS System-level quality improvement priorities for pediatric trauma care should focus resources on developing and implementing minimum pediatric standards for injury care, frontline provider training, stabilization protocols, imaging guidelines, and local pediatric champions. LEVEL OF EVIDENCE Level V.
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Urology Education In The United States Military. Urology 2022; 165:18-22. [DOI: 10.1016/j.urology.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/24/2022] [Accepted: 02/15/2022] [Indexed: 11/19/2022]
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Abstract
OBJECTIVES We aim to extract a subset of social factors from clinical notes using common text classification methods. DESIGN Retrospective chart review. SETTING We collaborated with a local level I trauma hospital located in an underserved area that has a housing unstable patient population of about 6.5% and extracted text notes related to various social determinants for acute care patients. PARTICIPANTS Notes were retrospectively extracted from 43 798 acute care patients. METHODS We solely use open source Python packages to test simple text classification methods that can potentially be easily generalisable and implemented. We extracted social history text from various sources, such as admission and emergency department notes, over a 5-year timeframe and performed manual chart reviews to ensure data quality. We manually labelled the sentiment of the notes, treating each text entry independently. Four different models with two different feature selection methods (bag of words and bigrams) were used to classify and predict housing stability, tobacco use and alcohol use status for the extracted clinical text. RESULTS From our analysis, we found overall positive results and metrics in applying open-source classification techniques; the accuracy scores were 91.2%, 84.7%, 82.8% for housing stability, tobacco use and alcohol use, respectively. There were many limitations in our analysis including social factors not present due to patient condition, multiple copy-forward entries and shorthand. Additionally, it was difficult to translate usage degrees for tobacco and alcohol use. However, when compared with structured data sources, our classification approach on unstructured notes yielded more results for housing and alcohol use; tobacco use proved less fruitful for unstructured notes.
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Affiliation(s)
- Andrew Teng
- Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Adam Wilcox
- Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
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Darnell D, Areán PA, Dorsey S, Atkins DC, Tanana MJ, Hirsch T, Mooney SD, Boudreaux ED, Comtois KA. Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospitalized Patients: Protocol for Formative and Pilot Feasibility Research. JMIR Res Protoc 2021; 10:e33695. [PMID: 34914618 PMCID: PMC8717131 DOI: 10.2196/33695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Abstract
Background Suicide is the 10th leading cause of death in the United States, with >47,000 deaths in 2019. Most people who died by suicide had contact with the health care system in the year before their death. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill-building are resource intensive and difficult to implement. Advances in artificial intelligence technology hold promise for improving the scalability and sustainability of training methods, as it is now possible for computers to assess the intervention delivery skills of trainees and provide feedback to guide skill improvements. Much remains to be known about how best to integrate these novel technologies into continuing education for health care providers. Objective In Project WISE (Workplace Integrated Support and Education), we aim to develop e-learning training in suicide safety planning, enhanced with novel skill-building technologies that can be integrated into the routine workflow of nurses serving patients hospitalized for medical or surgical reasons or traumatic injury. The research aims include identifying strategies for the implementation and workflow integration of both the training and safety planning with patients, adapting 2 existing technologies to enhance general counseling skills for use in suicide safety planning (a conversational agent and an artificial intelligence–based feedback system), observing training acceptability and nurse engagement with the training components, and assessing the feasibility of recruitment, retention, and collection of longitudinal self-report and electronic health record data for patients identified as at risk of suicide. Methods Our developmental research includes qualitative and observational methods to explore the implementation context and technology usability, formative evaluation of the training paradigm, and pilot research to assess the feasibility of conducting a future cluster randomized pragmatic trial. The trial will examine whether patients hospitalized for medical or surgical reasons or traumatic injury who are at risk of suicide have better suicide-related postdischarge outcomes when admitted to a unit with nurses trained using the skill-building technology than those admitted to a unit with untrained nurses. The research takes place at a level 1 trauma center, which is also a safety-net hospital and academic medical center. Results Project WISE was funded in July 2019. As of September 2021, we have completed focus groups and usability testing with 27 acute care and 3 acute and intensive care nurses. We began data collection for research aims 3 and 4 in November 2021. All research has been approved by the University of Washington institutional review board. Conclusions Project WISE aims to further the national agenda to improve suicide prevention in health care settings by training nurses in suicide prevention with medically hospitalized patients using novel e-learning technologies. International Registered Report Identifier (IRRID) DERR1-10.2196/33695
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Affiliation(s)
- Doyanne Darnell
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Patricia A Areán
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle, WA, United States
| | - David C Atkins
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Michael J Tanana
- Social Research Institute, University of Utah, Salt Lake City, UT, United States
| | - Tad Hirsch
- College of Arts, Media, and Design, Northeastern University, Boston, MA, United States
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Edwin D Boudreaux
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Katherine Anne Comtois
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
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Wang CJ, Yang TH, Hung KS, Wu CH, Yen ST, Yen YT, Shan YS. Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study. BMC Emerg Med 2021; 21:150. [PMID: 34861821 PMCID: PMC8641219 DOI: 10.1186/s12873-021-00543-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/21/2021] [Indexed: 11/22/2022] Open
Abstract
Background Undertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes. Method This retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed. Results A total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p < 0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076). Conclusion This study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.
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Affiliation(s)
- Chih-Jung Wang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shu-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan.
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Cuschieri J, Robinson B, Lynch J, Mitchell S, Arbabi S, Bryson C, Sayre M, Maier RV, Bulger E. The Covid-19 Pandemic: Lessons Learned for Sustained Trauma Preparedness and Responses. Ann Surg 2021; 273:1051-1059. [PMID: 33378302 DOI: 10.1097/sla.0000000000004695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The emergence of coronavirus disease 2019 (COVID-19) that is caused by the SARS-CoV-2 virus has led to an overwhelming strain on healthcare delivery. This pandemic has created a sustained stress on the modern healthcare system, with unforeseen and potential drastic effects. Although the initial focus during this pandemic has been preparedness and response directed to the pandemic itself, traumatic injury has continued to remain a common problem that requires immediate evaluation and care to provide optimal outcomes. The State of Washington had the first reported case and death related to COVID-19 in the United States. Harborview Medical Center, which serves as the sole Level-1 adult and pediatric trauma center for the state, was rapidly affected by COVID-19, but still needed to maintain preparedness and responses to injured patients for the region. Although initially the focus was on the emerging pandemic on institutional factors, it became obvious that sustained efforts for regional trauma care required a more global focus. Because of these factors, Harborview Medical Center was quickly entrusted to serve as the coordinating center for the regions COVID-19 response, while also continuing to provide optimal care for injured patients during the pandemic. This response allowed the care of injured patients to be maintained within designated trauma centers during this pandemic. This present report summarizes the evolution of trauma care delivery during the first phase of this pandemic and provides informative recommendations for sustained responses to the care of injured patients during the pandemic based on lessons learned during the initial response.
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Affiliation(s)
- Joseph Cuschieri
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Bryce Robinson
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - John Lynch
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Steve Mitchell
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Saman Arbabi
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Chloe Bryson
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Michael Sayre
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ronald V Maier
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Eileen Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
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Lifting the burden: State Medicaid expansion reduces financial risk for the injured. J Trauma Acute Care Surg 2020; 88:51-58. [PMID: 31524838 DOI: 10.1097/ta.0000000000002493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain because of high out-of-pocket (OOP) health care costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington (WA) state, which extended coverage to more than 600,000 WA residents, was associated with a reduction in financial risk among trauma patients. METHODS We analyzed all trauma patients aged 18 to 64 years admitted to the sole level 1 trauma center in WA from 2012 to 2017. We defined 2012 to 2013 as the prepolicy period and 2014 to 2017 as the postpolicy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate postsubsistence income and OOP expenses for our sample and then applied these two estimates to determine catastrophic health expenditure (CHE) risk as defined by the World Health Organization (OOP health expenses ≥40% of estimated household postsubsistence income). RESULTS A total of 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0%, and the uninsured rate decreased from 19.2% to 3.7% (p < 0.001 for both). There was no significant change in private insurance coverage. Medicaid expansion was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and less than 0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p < 0.01). CONCLUSION State ME led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers. LEVEL OF EVIDENCE Economic analysis, level II.
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Pozdeyev N, Patel A, Pottinger PS, Leu M, Payne TH. Adherence to Recommended Post-Splenectomy Immunizations to Reduce the Risk of Sepsis: The University of Washington Experience. Am J Med Qual 2020; 35:405-410. [DOI: 10.1177/1062860619897289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Immunizations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b are recommended for patients undergoing splenectomy to decrease the risk of developing overwhelming infections. The authors sought to determine adherence to these recommendations by providers at UW Medicine. Regional immunization records for patients who underwent splenectomy between October 2015 and January 2019 were analyzed to measure compliance with immunization guidelines from the US Centers for Disease Control and Prevention (CDC). Among 253 patients who underwent splenectomy, 38 (15%) received all 7 immunizations against S pneumoniae, N meningitidis, and H influenzae type b recommended by the CDC; 95% of patients received at least 1 pneumococcal vaccine; 26% percent of patients did not receive MenB-4C vaccine. Many patients (3% to 10%) received redundant immunizations not in accordance with CDC recommendations. Development of state and national immunization registries and systems to improve adherence with post-splenectomy immunization guidelines may reduce risk for life-threatening infections.
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Limb Salvage Does Not Predict Functional Limb Outcome after Revascularization for Traumatic Acute Limb Ischemia. Ann Vasc Surg 2019; 66:220-224. [PMID: 31676382 DOI: 10.1016/j.avsg.2019.10.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/13/2019] [Accepted: 10/16/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Traumatic vascular injury leading to acute limb ischemia (ALI) is an uncommon problem with a potential for high morbidity. We describe a contemporary series of patients with traumatic ALI managed primarily by vascular surgeons at a tertiary referral center and review factors associated with limb salvage and functional limb outcomes. METHODS We conducted a single institution, retrospective review of all patients requiring revascularization for upper extremity (UE) and lower extremity (LE) ALI secondary to trauma from 2013 to 2016. Demographic data, transfer timing, injury severity score (ISS), Rutherford classification (RC), preoperative imaging, level of occlusion, procedural information, fasciotomy characteristics, and discharge disposition were reviewed. Outcome measures included limb salvage and functional limb outcomes. RESULTS We identified 68 patients with traumatic ALI requiring revascularization. The majority of patients had moderate ISS scores, were RC 2a or 2b on presentation (65%), were transferred from another institution (53%), and underwent preoperative imaging (62%) with expeditious time to operation (median 4.5 hr). The most common location of vascular injury for UE was axillary-brachial (88%) and for LE was femoral-popliteal (69%). Open vascular procedures dominated the treatment strategy, and the median number of operations was 3. Fasciotomy was performed in 25% of UE and 58% of LE injuries. Shunts were utilized in only 2 patients. Overall LS was 94% for UE and 78% for LE. The median length of stay (LOS) was 11 days, with 25% of patients discharged to a skilled nursing facility. Follow-up was obtained for 59% of patients. For UE injuries, 57% of patients had no or minimal functional deficits, while 33% had major functional deficits and 10% underwent amputation. For LE injuries, 68% of patients had no or minimal functional deficits, while 6% had major functional deficits, and 26% had undergone amputation. Rutherford class and the number of operations performed were independent predictors of amputation and functional limb at follow-up in our logistic regression model (P < 0.05). CONCLUSIONS Revascularization for traumatic ALI yields high limb salvage rates in patients with RC 1 and 2 ischemia and patients with UE injuries. However, limb salvage does not necessarily equate to good functional outcomes. This signifies the complex nature of injuries in this patient population, especially when multiple operations are required.
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Palmer A, Taitsman LA, Reed MJ, Nair BG, Bentov I. Utility of Geriatric Assessment in the Projection of Early Mortality Following Hip Fracture in the Elderly Patients. Geriatr Orthop Surg Rehabil 2018; 9:2151459318813976. [PMID: 30546923 PMCID: PMC6287303 DOI: 10.1177/2151459318813976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 09/16/2018] [Accepted: 09/22/2018] [Indexed: 01/10/2023] Open
Abstract
Hip fractures result in significant morbidity and mortality in elders. Indicators of frailty are associated with poor outcomes. Commonly used frailty tools rely on motor skills that cannot be performed by this population. We determined the association between the Charlson Comorbidity Score (CCS), intraoperative hypotension (IOH), and a geriatric medicine consult index (GCI) with short-term mortality in hip fracture patients. A retrospective cohort study was conducted at a single institution over a 2-year period. Patients aged 65 years and older who sustained a hip fracture following a low-energy mechanism were identified using billing records and our orthopedic fracture registry. Medical records were reviewed to collect demographic data, fracture classification and operative records, calculation of CCS, intraoperative details including hypotension, and assessments recorded in the geriatric consult notes. The GCI was calculated using 30 dichotomous variables contained within the geriatric consult note. The index, ranging from 0 to 1, included markers for physical and cognitive function, as well as medications. A higher GCI score indicated more markers for frailty. One hundred eight patients met inclusion criteria. Sixty-four (59%) were females and the average age was 77.3 years. Thirty-five (32%) patients sustained femoral neck fractures, and 73 (68%) patients sustained inter-/pertrochanteric hip fractures. The 30-day mortality was 6%; the 90-day mortality was 13%. The mean GCI was 0.30 in the 30-day survivor group as compared to 0.52 in those who died. The mean GCI was 0.28 in patients who were alive at 90 days as compared to 0.46 in those who died. In contrast, the CCS and IOH were not associated with 30- or 90-day mortality. In our older hip fracture patients, an index calculated from information routinely obtained in the geriatric consult evaluation was associated with 30- and 90-day mortality, whereas the CCS and measures of IOH were not.
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Affiliation(s)
| | | | - May J Reed
- Harborview Medical Center, Seattle, WA, USA
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