RESUMO
STUDY OBJECTIVE: Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. METHODS: Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). RESULTS: A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. CONCLUSION: In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.
Assuntos
Traumatismos Craniocerebrais , Fibrinolíticos , Adulto , Humanos , Idoso , Tomografia Computadorizada por Raios X/métodos , Hemorragias Intracranianas , Escala de Coma de Glasgow , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
BACKGROUND: Only a fraction of pediatric trauma patients are treated in pediatric-specific facilities, leaving the remaining to be seen in centers that must decide to admit the patient to a pediatric or adult unit. Thus, there may be inconsistencies in pediatric trauma admission practices among trauma centers. OBJECTIVE: Describe current practices in admission decision making for pediatric patients. METHODS: An email survey was distributed to members of three professional organizations: The American Association for the Surgery of Trauma, Society of Trauma Nurses, and Pediatric Trauma Society. The survey contained questions regarding pediatric age cutoffs, institutional placement decisions, and scenario-based assessments to determine mitigating placement factors. RESULTS: There were 313 survey responses representing freestanding children's hospitals (114, 36.4%); children's hospitals within general hospitals (107, 34.2%), and adult centers (not a children's hospital; 90, 28.8%). The mean age cutoff for pediatric admission was 16.6 years. The most reported cutoff ages were 18 years (77, 25.6%) and 15 years (76, 25.2%). The most common rationales for the age cutoffs were "institutional experience/tradition" (139, 44.4%) and "physician preference" (89, 28.4%). CONCLUSION: There was no single widely accepted age cutoff that distinguished pediatric from adult trauma patients for admission placement. There was significant variability between and within the types of facilities, with noted ambiguity in the definition of a "pediatric" patient. Thresholds appear to be based primarily on subjective criteria such as traditions or preferences rather than scientific data. Institutions should strive for objective, evidence-based policies for determining the appropriate placement of pediatric patients.
Assuntos
Hospitais Pediátricos , Centros de Traumatologia , Adolescente , Adulto , Criança , Tomada de Decisões , Hospitais Gerais , Humanos , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: Assessment of patient satisfaction is central to understanding and improving system performance with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national standard survey. However, no large, multi-institutional study exists, which examines the role of nurses in trauma patient satisfaction. OBJECTIVE: To assess the impact of nurses on trauma patient satisfaction. METHODS: This retrospective, descriptive study of Level I-IV trauma centers in a multistate hospital system evaluated patients 18 years and older admitted with at least an overnight stay. Data were obtained electronically for patients discharged in 2018-2019 who returned an HCAHPS survey. Surveys were linked by an honest broker to demographic and injury data from the trauma registry, and then anonymized prior to analysis. Patients were categorized as "trauma" per the National Trauma Data Standard (NTDS) definition or as "medical" or "surgical" per the HCAHPS definition. RESULTS: Of 112,283 surveys from 89 trauma centers, "trauma" patients (n = 5,126) comprised 4.6%, "surgical" 39.0% (n = 43,763), and "medical" 56.5% (n = 63,394). Nurses had an overwhelming impact on "trauma" patient satisfaction, accounting for 63.9% (p < .001) of the variation (adjusted R2) in the overall score awarded the institution-larger than for "surgery" (59.6%; p < .001) or "medical" (58.4%; p < .001) patients. The most important individual domain contributor to the overall rating of a facility was "nursing communication." CONCLUSIONS: The magnitude of the effect of trauma nurses was noteworthy, with their communication ability being the single biggest driver of institutional ratings. These data provide insight for future performance benchmark development and emphasize the critical impact of trauma nurses on the trauma patient experience.
Assuntos
Satisfação do Paciente , Hospitalização , Humanos , Estudos Retrospectivos , Inquéritos e Questionários , Centros de TraumatologiaRESUMO
BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability in older adults. The aim of this study was to characterize the burden of TBI in older adults by describing demographics, care location, diagnoses, outcomes, and payments in this high-risk group. METHODS: Using 2016-2019 Centers for Medicare & Medicaid Services (CMS) Inpatient Standard Analytical Files (IPSAF), patients >65 years with TBI (>1 injury ICD-10 starting with "S06") were selected. Trauma center levels were linked to the IPSAF file via American Hospital Association Hospital Provider ID and fuzzy-string matching. Patient variables were compared across trauma center levels. RESULTS: Three hundred forty-eight thousand eight hundred inpatients (50.4% female; 87.1% white) from 2963 US hospitals were included. Level I/II trauma centers treated 66.9% of patients; non-trauma centers treated 21.5%. Overall inter-facility transfer rate was 19.2%; in Level I/II trauma centers transfers-in represented 23.3% of admissions. Significant TBI (Head AIS ≥3) was present in 70.0%. Most frequent diagnoses were subdural hemorrhage (56.6%) and subarachnoid hemorrhage (30.6%). Neurosurgical operations were performed in 10.9% of patients and operative rates were similar regardless of center level. Total unadjusted mortality for the sample was 13.9%, with a mortality of 8.1% for those who expired in-hospital, and an additional 5.8% for those discharged to hospice. Medicare payments totaled $4.91B, with the majority (73.4%) going to Level I/II trauma centers. CONCLUSIONS: This study fills a gap in TBI research by demonstrating that although the majority of older adult TBI patients in the United States receive care at Level I/II trauma centers, a substantial percentage are managed at other facilities, despite 1 in 10 requiring neurosurgical operation regardless of level of trauma center. This analysis provides preliminary data on the function of regionalized trauma care for older adult TBI care. Future studies assessing the efficacy of early care guidelines in this population are warranted.
Assuntos
Lesões Encefálicas Traumáticas , Pacientes Internados , Humanos , Feminino , Idoso , Estados Unidos/epidemiologia , Masculino , Medicare , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/terapia , Hospitalização , Alta do Paciente , Estudos RetrospectivosRESUMO
Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50 years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50 years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.
Assuntos
Obstrução Intestinal , Adulto , Humanos , Masculino , Feminino , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Meios de Contraste , Tomografia Computadorizada por Raios X , Inquéritos e Questionários , Intestino Delgado/diagnóstico por imagemRESUMO
BACKGROUND: Few large investigations have addressed the prevalence of COVID-19 infection among trauma patients and impact on providers. The purpose of this study was to quantify the prevalence of COVID-19 infection among trauma patients by timing of diagnosis, assess nosocomial exposure risk, and evaluate the impact of COVID-19 positive status on morbidity and mortality. METHODS: Registry data from adults admitted 4/1/2020-10/31/2020 from 46 level I/II trauma centers were grouped by: timing of first positive status (Day 1, Day 2-6, or Day ≥ 7); overall Positive/Negative status; or Unknown if test results were unavailable. Groups were compared on outcomes (Trauma Quality Improvement Program complications) and mortality using univariate analysis and adjusted logistic regression. RESULTS: There were 28 904 patients (60.7% male, mean age: 56.4, mean injury severity score: 10.5). Of 13 274 (46%) patients with known COVID-19 status, 266 (2%) were Positive Day 1, 119 (1%) Days 2-6, 33 (.2%) Day ≥ 7, and 12 856 (97%) tested Negative. COVID-19 Positive patients had significantly worse outcomes compared to Negative; unadjusted comparisons showed longer hospital length of stay (10.98 vs 7.47;P < .05), higher rates of intensive care unit (57.7% vs 45.7%; P < .05) and ventilation use (22.5% vs 16.9%; P < .05). Adjusted comparisons showed higher rates of acute respiratory distress syndrome (1.7% vs .4%; P < .05) and death (8.1% vs 3.4%; P < .05). CONCLUSIONS: This multicenter study conducted during the early pandemic period revealed few trauma patients tested COVID-19 positive, suggesting relatively low exposure risk to care providers. COVID-19 positive status was associated with significantly higher mortality and specific morbidity. Further analysis is needed with consideration for care guidelines specific to COVID-19 positive trauma patients as the pandemic continues.
Assuntos
COVID-19 , Ferimentos e Lesões , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Feminino , COVID-19/epidemiologia , Prevalência , Unidades de Terapia Intensiva , Escala de Gravidade do Ferimento , Morbidade , Centros de Traumatologia , Estudos Retrospectivos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapiaRESUMO
Background: Bacteremia is a potentially lethal complication. Limited research exists describing its incidence and associated outcomes in trauma patients. This descriptive study characterized the incidence, risk factors, and outcomes of bacteremia in trauma patients. Methods: This study used 2017-2020 system-wide Trauma Registry/Electronic Data Warehouse to select trauma activations aged ≥18 years. Blood culture information, including pathogen genera and species, was obtained from electronic laboratory records. Bacteremia positive was defined as two blood cultures within two hours of each other, growing the same organism; bacteremia negative as no growth, only one blood culture with growth, or growth of two different organisms. Bacteremia-positive and bacteremia-negative patients were compared with patients without blood cultures. Logistic regression compared blood culture results with outcomes, adjusting for age, gender, Injury Severity Score (ISS), and comorbidities. Results: Of 158,884 patients at 89 centers, 17,166 (10.8%) had blood cultures. Of those with blood cultures, 1214 were bacteremia positive (7.1%). Compared with no blood cultures, bacteremia-positive patients were more likely male, with higher ISS, and more comorbidities and intensive care unit use. Bacteremia-positive patients were more likely to die (adjusted odds ratio [aOR], 3.78; 95% confidence interval [CI], 3.17-4.51; p < 0.001) and have severe sepsis/septic shock (aOR, 114.91; 95% CI, 95.09-138.85; p < 0.001). Most common isolates were Staphylococcus epidermidis (14%), non-methicillin resistant Staphylococcus aureus (12%), and Escherichia coli (6%), with highest mortality associated with Pseudomonas aeruginosa (45%), Enterococcus faecalis (30%), and Escherichia coli (28%). Conclusions: Bacteremia in trauma is uncommon (<1%) but associated with increased resource use and poorer outcomes. Bacteremia, or suspicion thereof, identifies a high-risk population and justifies aggressive empiric intervention to maximize survival.
Assuntos
Bacteriemia , Staphylococcus aureus Resistente à Meticilina , Sepse , Humanos , Masculino , Adolescente , Adulto , Bacteriemia/epidemiologia , Hemocultura , Escherichia coli , Estudos RetrospectivosRESUMO
BACKGROUND: The adverse impact of acute hyperglycemia is well documented but its specific effects on nondiabetic trauma patients are unclear. The purpose of this study was to analyze the differential impact of hyperglycemia on outcomes between diabetic and nondiabetic trauma inpatients. METHODS: Adults admitted 2018 to 2019 to 46 Level I/II trauma centers with two or more blood glucose tests were analyzed. Diabetes status was determined from International Classification of Diseases-10th Rev.-Clinical Modification, trauma registry, and/or hemoglobin A1c greater than 6.5. Patients with and without one or more hyperglycemic result >180 mg/dL were compared. Logistic regression examined the effects of hyperglycemia and diabetes on outcomes, adjusting for age, sex, Injury Severity Score, and body mass index. RESULTS: There were 95,764 patients: 54% male; mean age, 61 years; mean Injury Severity Score, 10; diabetic, 21%. Patients with hyperglycemia had higher mortality and worse outcomes compared with those without hyperglycemia. Nondiabetic hyperglycemic patients had the highest odds of mortality (diabetic: adjusted odds ratio, 3.11; 95% confidence interval, 2.8-3.5; nondiabetics: adjusted odds ratio, 7.5; 95% confidence interval, 6.8-8.4). Hyperglycemic nondiabetics experienced worse outcomes on every measure when compared with nonhyperglycemic nondiabetics, with higher rates of sepsis (1.1 vs. 0.1%, p < 0.001), more SSIs (1.0 vs. 0.1%, p < 0.001), longer mean hospital length of stay (11.4 vs. 5.0, p < 0.001), longer mean intensive care unit length of stay (8.5 vs. 4.0, p < 0.001), higher rates of intensive care unit use (68.6% vs. 35.1), and more ventilator use (42.4% vs. 7.3%). CONCLUSION: Hyperglycemia is associated with increased odds of mortality in both diabetic and nondiabetic patients. Hyperglycemia during hospitalization in nondiabetics was associated with the worst outcomes and represents a potential opportunity for intervention in this high-risk group. LEVEL OF EVIDENCE: Therapeutic/care management; Level III.
Assuntos
Diabetes Mellitus , Hiperglicemia , Glicemia , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Hiperglicemia/complicações , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
BACKGROUND: Geriatric trauma care (GTC) represents an increasing proportion of injury care, but associated public health research on outcomes and expenditures is limited. The purpose of this study was to describe GTC characteristics, location, diagnoses, and expenditures. METHODS: Patients at short-term nonfederal hospitals, 65 years or older, with ≥1 injury International Classification of Diseases, Tenth Revision, were selected from 2016 to 2019 Centers for Medicare and Medicaid Services Inpatient Standard Analytical Files. Trauma center levels were linked to Inpatient Standard Analytical Files data via American Hospital Association Hospital ID and fuzzy string matching. Demographics, care location, diagnoses, and expenditures were compared across groups. RESULTS: A total of 2,688,008 hospitalizations (62% female; 90% White; 71% falls; mean Injury Severity Score, 6.5) from 3,286 hospitals were included, comprising 8.5% of all Medicare inpatient hospitalizations. Level I centers encompassed 7.2% of the institutions (n = 236) but 21.2% of hospitalizations, while nontrauma centers represented 58.5% of institutions (n = 1,923) and 37.7% of hospitalizations. Compared with nontrauma centers, patients at Level I centers had higher Elixhauser scores (9.0 vs. 8.8) and Injury Severity Score (7.4 vs. 6.0; p < 0.0001). The most frequent primary diagnosis at all centers was hip/femur fracture (28.3%), followed by traumatic brain injury (10.1%). Expenditures totaled $32.9 billion for trauma-related hospitalizations, or 9.1% of total Medicare hospitalization expenditures and approximately 1.1% of the annual Medicare budget. The overall mortality rate was 3.5%. CONCLUSION: Geriatric trauma care accounts for 8.5% of all inpatient GTC and a similar percentage of expenditures, the most common injury being hip/femur fractures. The largest proportion of GTC occurs at nontrauma centers, emphasizing their vital role in trauma care. Public health prevention programs and GTC guidelines should be implemented by all hospitals, not just trauma centers. Further research is required to determine the optimal role of trauma systems in GTC, establish data-driven triage guidelines, and define the impact of trauma centers and nontrauma centers on GTC mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.
Assuntos
Fraturas do Quadril , Medicare , Idoso , Centers for Medicare and Medicaid Services, U.S. , Feminino , Hospitalização , Humanos , Pacientes Internados , Masculino , Saúde Pública , Estudos Retrospectivos , Centros de Traumatologia , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: As the prevalence of geriatric trauma patients has increased, protocols are being developed to address the unique requirements of this demographic. However, categorical definitions for geriatric patients vary, potentially creating confusion concerning which patients should be cared for according to geriatric-specific standards. The aim of this study was to identify data-driven cut points for mortality based on age to support implementation of age-driven guidelines. METHODS: Adults aged 18 to 100 years with blunt or penetrating injury were selected from 95 hospitals' trauma registries. Change point analysis techniques were used to detect inflection points in the proportion of deaths at each age. Based on these calculated points, patients were allocated into age groups, and their characteristics and outcomes were compared. Logistic regression was used to estimate risk-adjusted in-hospital mortality controlling for sex, race, Injury Severity Score, Glasgow Coma Scale, and number of comorbidities. RESULTS: A total of 255,099 patients were identified (female, 45.7%; mean age, 59.3 years; mean Injury Severity Score, 8.69; blunt injury, 92.6%). Statistically significant increases in mortality rate were noted at ages 55, 77, and 82 years. Compared with the referent group (age, <55 years), adjusted odds ratios (AORs) showed increases in mortality if age 55 to 76 years (AOR, 2.42), age 77 to 81 years (AOR, 4.70), or age 82 years or older (AOR, 6.43). National Trauma Data Standard-defined comorbidities significantly increased once age surpassed 55 years, as the rate more than doubled for each of the older age categories (p < 0.001). As age increased, each group was more likely to be female, have dementia, sustain a ground level fall, and be discharged to a skilled nursing facility (p < 0.001). CONCLUSION: This large multicenter analysis established a clinically and statistically significant increase in mortality at ages 55, 77, and 82 years. This research strongly suggests that trauma patients older than 55 years be considered for inclusion in geriatric trauma protocols. The other age inflection points identified (77 and 82 years) may also warrant additional specialized care considerations. LEVEL OF EVIDENCE: Epidemiological study, level III; Care management, level IV.
Assuntos
Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Acidentes por Quedas/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Avaliação Geriátrica , Escala de Coma de Glasgow , Hospitalização , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Taxa de Sobrevida , Centros de Traumatologia , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia , Adulto JovemRESUMO
BACKGROUND: Falls are the leading cause of traumatic brain injury (TBI) and TBI-related deaths for older persons (age, ≥65 years). Antiplatelet and/or anticoagulant therapy (antithrombotics [ATs]) is generally felt to increase this risk, but the literature is inconsistent. The purpose of this study was to determine the impact of AT use on the rate, severity, and outcomes of TBI in older patients following ground level falls. METHODS: Ground level fall patients from 90 hospitals' trauma registries were selected. Patients were excluded if younger than 65 years or had an Abbreviated Injury Scale score of >2 in a region other than head. Electronic medical record data for preinjury AT therapy were obtained. Patients were grouped by regimen for no AT, single, or multiple agents. Groups were compared on rates of diagnosed TBI, TBI surgery, and mortality. RESULTS: There were 33,710 patients (35% male; mean age, 80.5 years; mean Glasgow Coma Scale, 14.6), with 47.6% on single or combination AT therapy. The proportion of patients with TBI diagnoses did not differ between those on no AT (21.25%) versus AT (21.61%; p = 0.418). Apixaban (15.7%; p < 0.001) and rivaroxaban (13.19%; p = 0.011) were associated with lower rates of TBI, and acetylsalicylic acid-clopidogrel was associated with a higher TBI rate (24.34%; p = 0.002) versus no AT. acetylsalicylic acid-clopidogrel was associated with a higher cranial surgery rate (2.9%; p = 0.006) versus no AT (1.96%), but surgery rates were similar for all other regimens. No regimen was associated with higher mortality. CONCLUSION: In this large multicenter study, the intake of ATs in older patients with ground level falls was associated with inconsistent effects on risk of TBI and no significant increases in mortality, indicating that AT use may have negligible impact on patient clinical management. A large, confirmatory, prospective study is needed because the commonly held belief that ATs uniformly increase the risk of traumatic intracranial bleeding and mortality is not supported. LEVEL OF EVIDENCE: Therapeutic/care management, level II.
Assuntos
Acidentes por Quedas/mortalidade , Anticoagulantes/efeitos adversos , Lesões Encefálicas Traumáticas/mortalidade , Inibidores da Agregação Plaquetária/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Lesões Encefálicas Traumáticas/cirurgia , Causas de Morte , Estudos Transversais , Feminino , Escala de Coma de Glasgow , Hospitais Comunitários , Humanos , Masculino , Inibidores da Agregação Plaquetária/administração & dosagem , Fatores de RiscoRESUMO
BACKGROUND: As the prevalence of obesity has increased, trauma centers are faced with managing this expanding demographics' unique care requirements. Research on the effects of body mass index (BMI) in trauma patients remains conflicting. This study aims to evaluate the impact of BMI on patterns of injury and patient outcomes following trauma. METHODS: Patients from 87 hospitals' trauma registries were selected. Those missing height, weight, disposition, or who died in the emergency department were excluded. The BMI categories were calculated from admission height and weight and verified against the electronic medical records. Patients were grouped by the National Institutes of Health-defined obesity class and compared by rate of mortality and in-hospital complications. Logistic regression was used to estimate associations, adjusting for age, gender, race, Injury Severity Score, and number of comorbidities. RESULTS: There were 191,274 patients, 53% male; mean age was 60.4 years, mean Glasgow Coma Scale score 14.4, mean Injury Severity Score of 8.8, and 40.4% normal weight. Increased BMI was associated with an injury pattern of increased rates of extremity fractures (humerus, femur, tibia/fibula) and decreased rates of hip fractures and head injuries. Compared with the normal weight group, patients were more likely to die if they were Underweight (adjusted odds ratio [AOR], 1.18; 95% confidence interval [CI], 1.01-1.38), obese class II (AOR, 1.24; 95% CI, 1.07-1.45), or obese class III (AOR, 1.55; 95% CI, 1.29-1.87). Obese class III was associated with higher odds of a National Trauma Data Standard complication (AOR, 1.20; 95% CI, 1.11-1.30). CONCLUSION: In this large multicenter study, increasing BMI and lower than normal BMI were strongly associated with higher mortality. Increasing BMI was also associated with longer length of stay, increased complications, and unique injury patterns. These untoward outcomes, coupled with a distinct injury pattern, warrant care guidelines specific to trauma patients with higher BMI, as well as those with BMI lower than normal. LEVEL OF EVIDENCE: Epidemiological, Level III.
Assuntos
Traumatismos Craniocerebrais , Fraturas Ósseas , Mortalidade , Obesidade , Magreza , Ferimentos e Lesões , Índice de Massa Corporal , Comorbidade , Traumatismos Craniocerebrais/epidemiologia , Traumatismos Craniocerebrais/etiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/etiologia , Hospitalização/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Prognóstico , Sistema de Registros/estatística & dados numéricos , Magreza/diagnóstico , Magreza/epidemiologia , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos/epidemiologia , Ferimentos e Lesões/classificação , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidadeRESUMO
Objective: The study objective was to evaluate effects of the COVID-19 pandemic on rates of emergency department (ED) acute appendicitis presentation, management strategies, and patient outcomes. Summary Background Data: Acute appendicitis is the most commonly performed emergency surgery in the United States and is unlikely to improve without medical or surgical intervention. Dramatic reductions in ED visits prompted concern that individuals with serious conditions, such as acute appendicitis, were deferring treatment for fear of contracting COVID-19. Methods: Patients from 146 hospitals with diagnosed appendicitis and arrival between March 2016 and May 2020 were selected. Electronic medical records data were retrospectively reviewed to retrieve patient data. Daily admissions were averaged from March 2016 through May 2019 and compared with March 2020. April-specific admissions were compared across the 5-year pre-COVID-19 period to April 2020 to identify differences in volume, demographics, disease severity, and outcomes. Results: Appendicitis patient admissions in 2020 decreased throughout March into April, with April experiencing the fewest admissions. April 2020 experienced a substantial decrease in patients who presented with appendicitis, dropping 25.4%, from an average of 2030 patients (2016-2019) to 1516 in 2020. An even greater decrease of 33.8% was observed in pediatric patients (age <18). Overall, 77% of the 146 hospitals experienced a reduction in appendicitis admissions. There were no differences between years in percent of patients treated nonoperatively (P = 0.493) incidence of shock (P = 0.95), mortality (P = 0.24), or need for postoperative procedures (P = 0.81). Conclusions: Acute appendicitis presentations decreased significantly during the COVID-19 pandemic, while overall management and patient outcomes did not differ from previous years. Further research is needed focusing on putative explanations for decreased hospital presentations unrelated to COVID-19 infection and possible implications for surgical management of uncomplicated acute appendicitis.Keywords: acute appendicitis, COVID-19, decreasing volumes, multicenter study.
RESUMO
BACKGROUND: Trauma and emergency surgery patients are unique with regard to the sudden and unexpected nature of their hospitalization and this can adversely affect patient satisfaction, but, to our knowledge, no large study exists examining this issue. The purpose of this study was to investigate the major factors that affect satisfaction scores in trauma and emergency surgery patients. STUDY DESIGN: Consumer Assessment of Healthcare Providers and Systems, Hospital Version survey data from patients discharged in 2018-2019 from facilities in a national hospital system were obtained. Patients were categorized as trauma, emergency surgery, or direct admit surgery (elective surgery). Individual Consumer Assessment of Healthcare Providers and Systems, Hospital Version question scores were regressed on the score for "overall rating" to determine the primary, secondary, and tertiary satisfaction drivers. RESULTS: There were 186,779 patients from 168 hospitals included. As expected, the primary determinant of patient satisfaction was nursing communication for all groups. However, trauma and emergency surgery patients differed from elective surgery patients in that physician communication was the second most important factor in patient satisfaction, accounting for 12.0% (trauma) and 8.6% (emergency surgery) of the total variability in the overall rating beyond the variability explained by the primary driver. If physician communication received low ratings, it was unlikely that high scores in other metrics could compensate to bring the overall score above the 50th percentile. CONCLUSIONS: Acute care surgeons appear to play a uniquely important role in support of Consumer Assessment of Healthcare Providers and Systems, Hospital Version scores. These data emphasize the importance of physician communication, particularly when a prehospital physician-patient relationship does not exist. Future research should explore specific mechanisms by which physicians effectively communicate with patients.
Assuntos
Serviço Hospitalar de Emergência/organização & administração , Satisfação do Paciente/estatística & dados numéricos , Papel Profissional , Cirurgiões/organização & administração , Centros de Traumatologia/organização & administração , Idoso , Comunicação , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Feminino , Pesquisas sobre Atenção à Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Estudos Retrospectivos , Cirurgiões/psicologia , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos , Ferimentos e Lesões/cirurgiaRESUMO
BACKGROUND: Reports indicate social distancing guidelines and other effects of the COVID-19 pandemic impacted trauma patient volumes and injury patterns. This report is the first analysis of a large trauma network describing the extent of these impacts. The objective of this study was to describe the effects of the COVID-19 pandemic on patient volumes, demographics, injury characteristics, and outcomes. METHODS: For this descriptive, multicenter study from a large, multistate hospital network, data were collected from the system-wide centralized trauma registry and retrospectively reviewed to retrieve patient information including volume, demographics, and outcomes. For comparison, patient data from January through May of 2020 and January through May of 2019 were extracted. RESULTS: A total of 12 395 trauma patients (56% men, 79% white, mean age 59 years) from 85 trauma centers were included. The first 5 months of 2020 revealed a substantial decrease in volume, which began in February and continued into June. Further analysis revealed an absolute decrease of 32.5% in patient volume in April 2020 compared with April 2019 (4997 from 7398; p<0.0001). Motor vehicle collisions decreased 49.7% (628 from 1249). There was a statistically significant increase in injury severity score (9.0 vs. 8.3; p<0.001). As a proportion of the total trauma population, blunt injuries decreased 3.1% (87.3 from 90.5) and penetrating injuries increased 2.7% (10.0 from 7.3; p<0.001). A significant increase was found in the proportion of patients who did not survive to discharge (3.6% vs. 2.8%; p=0.010; absolute decrease: 181 from 207). DISCUSSION: Early phases of the COVID-19 pandemic were associated with a 32.5% decrease in trauma patient volumes and altered injury patterns at 85 trauma centers in a multistate system. This preliminary observational study describes the initial impact of the COVID-19 pandemic and warrants further investigation. LEVEL OF EVIDENCE: Level II (therapeutic/care management).