Outcomes of Injured Patients Before and After the Institution of a Third-Tier Activation at a Level 1 Trauma Center

BACKGROUND

We hypothesized that the addition of a third-level trauma activation would improve outcomes by formalizing an evaluation process for patients in need of urgent evaluation who did not meet the criteria for full or partial trauma alert activation.

METHODS

Admission records for all trauma patients admitted between 2000 and 2021 were obtained. The gamma alert trauma activation was implemented in 2011. A washout period of 6 months was used to account for adjustment to the new protocol. Propensity score matching was performed based on ISS scores, age, injury mechanism, and best-validated comorbidities to create a balanced patient distribution. Patients with missing data were excluded from this study. The association between era and outcomes was determined using logistic and linear regression analyses.

RESULTS

The matched cohort was well balanced (SMD <.1, all balanced covariates) and included 18,572 patients. Patients in the gamma alert era had decreased ED dwell time, hospital length of stay, and intensive care unit (ICU) length of stay. Readmission rates and rates of upgrade to ICU status were reduced in the gamma alert era. This era was also associated with lower rates of renal failure, UTI, and pneumonia. There was no significant difference in mortality following implementation of the gamma alert.

DISCUSSION

Implementation of the gamma alert was associated with an improvement in ED dwell times, fewer unplanned admissions to the ICU, decreased readmissions, and a reduction in other in-hospital events. We believe that this reflects improved triage of patients to the ICU and more effective care of trauma patients.

Isolated vehicle rollover is not an independent predictor of trauma injury severity

OBJECTIVES

The objective of this study was to determine if vehicle rollover in a motor vehicle crash is an independent predictor of major injury.

METHODS

A retrospective cohort study of all patients injured in motor vehicle crashes presenting to a major trauma center between July 2012 and June 2016 was conducted. Crashes were classified into groups: non-rollover, isolated rollover (without other mechanisms of injury), or mixed-mechanism rollover (with other mechanisms of injury). Associations between rollover group, other covariates (entrapment, encapsulation, ejection, death on scene, high speed, seat belt usage, airbag deployment, trauma team activation), and major injury (injury severity score >15, major surgery, intensive care unit admission, or in-hospital death) were tested using binary logistic regression models. Vehicle rollover was categorized either as "present" or "absent" on 1 model or as either "none," "isolated," or "mixed mechanism" in the other.

RESULTS

In 2446 motor vehicle crashes, there were 423 rollovers (196 isolated, 227 mixed mechanisms). Compared with crashes without rollovers, the prevalence of patients with major injury was lower in crashes with isolated rollovers and higher in crashes with mixed-mechanism rollovers (13.8% vs 9.5% vs 27.5%, respectively; P < 0.001). Rollover (present vs absent) was not an independent predictor of major injury (odds ratio [OR], 1.10; 95% confidence interval [CI], 0.78-1.53). Patients in crashes with mixed-mechanism but not isolated rollovers had increased odds (OR, 2.04; 95% CI, 1.41-2.96) of major injury compared with patients from crashes without rollovers.

CONCLUSIONS

Patients from crashes with isolated vehicle rollovers may not need to be transported to a trauma center as they carry a lower risk of injury.

Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population

BACKGROUND

Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury.

OBJECTIVES

The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients.

METHODS

A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests.

RESULTS

More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle.

CONCLUSION

Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.

Factors affecting team size and task performance in pediatric trauma resuscitation

OBJECTIVES

Varying team size based on anticipated injury acuity is a common method for limiting personnel during trauma resuscitation. While missing personnel may delay treatment, large teams may worsen care through role confusion and interference. This study investigates factors associated with varying team size and task completion during trauma resuscitation.

METHODS

Video-recorded resuscitations of pediatric trauma patients (n = 201) were reviewed for team size (bedside and total) and completion of 24 resuscitation tasks. Additional patient characteristics were abstracted from our trauma registry. Linear regression was used to assess which characteristics were associated with varying team size and task completion. Task completion was then analyzed in relation to team size using best-fit curves.

RESULTS

The average bedside team ranged from 2.7 to 10.0 members (mean, 6.5 [SD, 1.7]), with 4.3 to 17.7 (mean, 11.0 [SD, 2.8]) people total. More people were present during high-acuity activations (+4.9, P < 0.001) and for patients with a penetrating injury (+2.3, P = 0.002). Fewer people were present during activations without prearrival notification (-4.77, P < 0.001) and at night (-1.25, P = 0.002). Task completion in the first 2 minutes ranged from 4 to 19 (mean, 11.7 [SD, 3.8]). The maximum number of tasks was performed at our hospital by teams with 7 people at the bedside (13 total).

CONCLUSIONS

Resuscitation task completion varies by team size, with a nonlinear association between number of team members and completed tasks. Management of team size during high-acuity activations, those without prior notification, and those in which the patient has a penetrating injury may help optimize performance.

A novel prospective approach to evaluate trauma recidivism: the concept of the past trauma history

BACKGROUND

The purpose of this study was to determine the incidence and burden of trauma recidivism at a regional Level 1 trauma center by incorporating the concept of the past trauma history (PTHx) into the general trauma history.

METHODS

All trauma patients who met prehospital trauma criteria and activated the trauma team during a 13-month period were asked about their PTHx, that is, their history of injury in the previous 5 years. A recidivist presented more than once for separate severe injuries. Recurrent recidivists presented multiple times during the study period.

RESULTS

Of the 4,971 trauma activations during the study period, 1,246 (25.2%) were identified as recidivists. Recidivists were 75% male, 62% white, 36% unemployed, 26% uninsured, and 90% unmarried. The recidivism rate among admitted patients was 23.4% compared with 29.3% in those discharged from the emergency department. The highest recidivism rates were noted in patients who reported alcohol or illegal drug use on the day of injury and in victims of interpersonal violence (IPV), defined as those who sustained gunshot wounds, stab wounds, or assaults, Those involved in IPV were more likely to have been involved in IPV at the previous trauma than those with other trauma mechanisms. Key risk factors for recidivism among all patients were male sex and single marital status. Seventy-three patients (1.5%) were recurrent recidivists, representing 157 unique encounters.

CONCLUSION

This is the highest trauma recidivism rate reported on a large population of all consecutive trauma activations at a regional Level 1 trauma center. These data illustrate the tremendous burden of recidivism in the modern era, more than previously recognized. Efforts specifically targeting those involved in IPV may reduce recidivism rates. Incorporating the concept of the PTHx into the general history of the trauma patient is feasible and provides valuable information to the provider.

LEVEL OF EVIDENCE

Prognostic study, level II.

Use of computed tomography in the setting of a tiered trauma team activation system in Australia

This study aims to describe the patterns in the use of computed tomography (CT) imaging in the setting of a two-tiered trauma team activation system without a mandatory whole-body ("panscan") trauma CT protocol. A prospective study was conducted at a single inner city major trauma centre in Sydney, Australia. Adult patients presenting to the emergency department requiring a trauma team activation were studied over 1 year. Patients in the trauma consult group met predetermined criteria for mechanism of injury without vital sign abnormalities or clinical evidence of major injury. Full trauma team response patients were those who had abnormal predetermined vital signs or evidence of major injury on initial assessment. The outcomes measured were severe injury, multiregion injury and positive CT scans. Of the patients, 1,058 were studied of whom 63 % had at least one CT scan performed. The most common CT studies were CT brain in combination with cervical spines (23 %) and isolated abdominal CT scans (17 %). The full trauma response group was associated with significantly higher rates of severe injury (34 versus 8 %, p<0.001), multiregion injury (13 versus 3 %, p<0.001), need for operative intervention (37 versus 15 %, p<0.001) and in-hospital mortality (4 versus 0.7 %, p<0.001). This group was also associated with significantly higher odds of whole-body CT use [odds ratio (OR) 5.6, 95 % confidence interval (CI) 3.6-8.8, p<0.001] and higher odds of positive CT brain studies compared to the trauma consult group (OR 2.6, 95 % CI 1.7-4.1, p<0.001). A tiered trauma team activation criteria in combination with trauma team assessment may be used to triage patients requiring CT without the need for mandatory CT protocols based on mechanism alone.