Rural versus urban trauma: demographic influences on autopsy rates.

BACKGROUND: The autopsy has long been considered the gold standard for quality assurance review. Studies characterizing autopsies have been completed in large urban centers, but there is a paucity of research regarding autopsies at rural trauma centers. This is problematic considering that a majority of preventable trauma deaths occur in rural areas and death rates for unintentional injuries in rural populations are higher than urban populations. Rural trauma centers have differing characteristics warranting further research into the demographic differences between rural and urban trauma patients and the effects on autopsy rates. MATERIALS AND METHODS: This is a demographic study of a rural trauma center, University of Iowa Hospitals and Clinics (UIHC), with the goal of identifying characteristics of trauma patients on whom autopsy was performed. Four hundred ninety-six deaths were identified from the trauma registry between January 2002 and May 2007 (231 of which were autopsied) and demographic data (including age, race, length of hospital stay, etc.) regarding these patients was gathered into a database. Univariate and multivariate linear regression models were used to analyze differences between autopsied and non-autopsied trauma patients. Autopsy rate and basic demographics were also compared with 2 recent reports from urban trauma centers. RESULTS: Autopsied patients were younger than non-autopsied patients (mean age 45 y versus 71 y; P < 0.0001) and have a shorter median length of hospital stay (1 d versus 4 d; P < 0.0001). Autopsy rates for patients with blunt trauma were lower than rates for patients with penetrating or burn trauma (42% versus 67% and 56%; P = 0.004). If patients died while on a subspecialty service, they were less likely to have an autopsy. Compared with urban centers, this rural trauma center had lower autopsy rates, higher rates of blunt trauma, a higher mean age of deceased patients, and a lower percentage of males. CONCLUSIONS: UIHC, a rural trauma center, has a number of demographic characteristics that make it unique from urban trauma centers: an older population, lower percentage of male trauma patients, higher rates of blunt trauma, and lower rates of penetrating trauma. All of these factors influenced the lower rate of autopsies completed at rural trauma centers. Within a rural trauma center, those patients less likely to receive autopsy were older patients, those who died after 48 h in the hospital, and patients who suffered blunt injuries. The demographics of trauma patients most likely to receive an autopsy tend to correspond with those of an urban trauma population, thus providing a demographic explanation for the variation in autopsy rates among trauma systems.

An Evaluation of Factors Related to Postoperative Pain Control in Burn Patients.

Satisfactory treatment of burn pain continues to be elusive. The perioperative period is particularly challenging. The contributions of acute tolerance and opioid-induced hyperalgesia have not been previously explored in burn patients. As these phenomena have been identified perioperatively in other patient populations, we sought to characterize the burn perioperative period and to determine variables associated with poor postoperative (post-OR) pain control. A retrospective review of 130 adult burn patients who underwent surgical treatment for their burn injuries was performed. Variables collected included: demographics, burn injury data, perioperative self-reported pain scores, and perioperative opioid amounts. Correlations and multiple logistic regressions were used to assess the relationship between these variables and post-OR pain control. Pain increased throughout the perioperative period from 2.64 24 hours prior to the operation (pre-OR) to 3.81 24 hours following the OR (post-OR, P < .0001). Post-OR pain was correlated with pre-OR pain, pre-OR opioid amounts, OR opioid amounts, and post-OR opioid amounts. When the subgroup of patients with controlled pre-OR pain (<3 pain rating) was analyzed, only pre-OR opioids and post-OR opioids remained correlated with worse post-OR pain. While this study is retrospective, there is a suggestion that opioid amounts given pre-OR and intraoperatively are correlated with worse post-OR pain. While an increase in pain ratings postoperatively are anticipated, the additional contributions of acute tolerance and opioid-induced hyperalgesia need to be determined. Pharmacologic intervention directed at these mechanisms can then be administered to achieve better postoperative pain control.

Methamphetamine-associated burn injuries: a retrospective analysis.

Methamphetamine production and use has increased dramatically during the past 10 years. Methamphetamine production requires combining hazardous and volatile chemicals that expose the manufacturer to burn injuries from explosions and chemical spills. We sought to review the epidemiology of burn injuries in a rural burn center secondary to the use of amphetamine or methamphetamine and/or the manufacture of methamphetamine. Review of the records of 507 patients who were admitted to our burn unit from December 1, 1998, to December 31, 2001, revealed 34 patients who were involved in the use of amphetamines or methamphetamines and/or the manufacture of methamphetamine. Thirty-one patients tested positive for either amphetamine (n = 2) or methamphetamine (n = 29) on routine admission urine drug screens. Twenty of these patients were involved in the manufacture of methamphetamines. Three additional patients were identified as methamphetamine manufacturers but tested negative for the use of methamphetamines. The mean age of the study population was 31.88 +/- 7.65 years, with a male:female ratio of 10.3:1. The average burn size was 18.86 +/- 20.72, with the majority secondary to flame (n = 26). Patient burn admission histories were vague, and the patient's involvement in the manufacture of methamphetamine was often only later confirmed by media, the fire marshal, family members, or the patient. Fifteen patients showed the usual withdrawal pattern of agitation and hypersomnolence, with seven patients requiring detoxification with benzodiazepines. Two were admitted acutely to the psychiatric ward for uncontrollable agitation. Eighteen patients were offered chemical dependency treatment, and two completed therapy. There was one mortality. The mean cost per person was US 77,580 dollars (range, US 112 dollars - US 426,386 dollars). The increasing use of and manufacture of methamphetamine presents new challenges for the burn team because these patients can become violent and frequently need assistance with detoxification. Routine drug screens are mandatory in identifying methamphetamine use to alert burn unit personnel to particular management problems and target individuals who may be receptive to drug rehabilitation.

Onset of symptomatic hydrocephalus requiring emergency cerebrospinal fluid diversion following high-voltage electrical burn injury.

High-voltage electrical injuries have been reported to cause a plethora of neurological complications including cognitive, motor, and sensory deficits in an immediate or delayed fashion. In this setting, new-onset symptomatic hydrocephalus requiring CSF shunt placement has not been described. The authors present the case of an 18-year-old man who sustained a high-voltage electrical injury with a calvarial contact point that required emergency CSF diversion within hours of injury and subsequently required placement of a lumboperitoneal shunt. Management of the open calvarial wound, which required rotational flap reconstruction, and the need for ongoing CSF diversion required care and a team approach.

The evolution of resource utilization in regional burn centers.

Regional burn centers provide unique multidisciplinary care that has been associated with dramatically improved outcomes for burn victims. Patients with complex skin and soft tissue injuries are increasingly admitted to these centers for definitive care. This study was designed to assess current trends in burn center resource utilization. Members of the Multicenter Trials Group of American Burn Association were invited to participate in this retrospective review of all patients admitted to their respective regional burn centers during a 10-year period. Collected data included admission diagnosis, demographics, length of stay (LOS), hospital charges, and mortality. Five regional academic burn centers participated. They collectively admitted 18,246 patients during the study period, of whom 15,219 (83.4%) had a primary burn diagnosis and 3027 (16.6%) were patients with nonburn diagnoses. During this period, annual admissions for the five centers increased by 34.7%, ranging from 19 to 83% for individual centers. Simultaneously, mean burn size decreased from 12.3 to 8.8% TBSA. From 1998 to 2006, admissions for nonburn diagnoses increased by 244.9%, whereas burn admissions increased by 31.1%. Although mean LOS was reduced by >25%, total charges for all patients increased by 37.7% after adjustment for inflation. Nonburn patients had significantly higher mean age, longer LOS, greater mortality, and higher daily charges. This review of admissions to five academic burn centers reveals that these centers are treating more patients with smaller burns and an increasing number of complex nonburn conditions. Nonburn patients represent an older and more debilitated population that consumes disproportionately more resources than burn patients. These data show a dramatic shift in burn center resource utilization and the concurrent evolution of regional burn centers into centers for the care of complex wounds.

Carbon monoxide toxicity.

Inhalation injury consists of a multitude of insults, the first of which is the toxic gases inhaled during the combustion of organic and inorganic substances. Significant morbidity and mortality in patients with burn injury occur due to the varying effects of these gases. This section of the compendium initially addresses two classically described inhaled gases: carbon monoxide and cyanide, followed by a discussion of a gas associated with illicit drug use: metamphetamine. Understanding the varying effects of the toxic gases at the scene of injury may facilitate the development of specific treatment regimens for inhalation injury.

The effect of burn center and burn center volume on the mortality of burned adults--an analysis of the data in the National Burn Repository.

Regional variations of care, and improved outcomes with larger volumes, have been well described in the medical and surgical literature for a variety of conditions including heart surgery, vascular surgery, and orthopedic surgery. Burn care has not been recently subjected to such an analysis. The National Burn Repository (NBR) contains de-identified patient and burn center data to allow this analysis. The NBR was queried for adult burn patients admitted for an acute thermal burn injury. A multivariable regression analysis to identify risk of death was performed incorporating patient characteristics, de-identified burn center, and burn center volume. Patient characteristics such as age, size of burn, mechanism of burn, inhalation injury, race, and sex determine mortality. There is also a statistically significant difference in death rates when individual, de-identified centers are compared. This difference in care persists even when accounting for burn center volume. Analysis of registries like the NBR, insurance claims databases, and statewide hospital discharge databases may help identify opportunities to improve burn care. According to this analysis of data available in the NBR, burn mortality depends not only on patient characteristics but also where the patient is treated. Mortality does not linearly improve with burn center volume and plateaus with increasing burn center size. The optimal burn center size is a complicated and contentious question. Future discussions about burn center size and density should incorporate not only mortality but also the region's ability to absorb surges in volume, and the optimal "staffing" ratios for the multidisciplinary aspects of burn care.

Methamphetamine-related burns in the cornbelt.

Methamphetamine (MA) is a highly addictive drug that is easily manufactured from everyday household products and chemicals found at local farm stores. The proliferation of small MA labs has led to a dramatic increase in patients sustaining thermal injury while making and/or using MA. We hypothesized that these patients have larger injuries with longer hospital stays, and larger, nonreimbursed hospital bills compared with burn patients not manufacturing or using MA. In a retrospective case-control study, all burn patients >or=16 years of age admitted to our burn center from January 2002 to December 2005 were stratified into two groups based on urine MA status. Of the 660 burn patients >or=16 years of age admitted during this 4 year period, urine drug screens were obtained at admission on 410 patients (62%); 10% of urine drug screens were MA (+). MA (+) patients have larger burns compared with MA (-) patients (9.3 vs 8.6% body surface area burns), have higher rates of inhalation injuries (20.4 vs 9.3%, P = .015), and more nonthermal trauma (13.0 vs 3.1%, P = .001). When compared with MA (-) patients, MA (+) patients require longer hospital stays (median 9.5 vs 7.0 days, P = .036), accrue greater hospital bills per day (dollars 4292 vs dollars 2797, P = .01), and lack medical insurance (66.7 vs 17.7%, P < .0001). The epidemic of MA use and its manufacture mandates that burn centers monitor patients for MA use and develop and institute protocols to ensure proper care of this increasingly costly population.

Prospective analysis of nosocomial infection rates, antibiotic use, and patterns of resistance in a burn population.

Despite significant advances in burn care, infection remains a major cause of morbidity and mortality in burn patients. We sought to determine accurate infection rates, risk factors for infection, and the percentage of infections caused by resistant organisms. In addition, we attempted to identify interventions to decrease the use of antimicrobial drugs. Data were collected prospectively from 157 burn patients admitted to the University of Iowa Carver College of Medicine burn treatment center from October 2001 to October 2002. A research assistant reviewed the medical record for each patient identified by burn surgeons as being infected to determine whether these episodes met the infection control criteria for nosocomial infections. The infection control assessment agreed with the surgeon's assessment for 16.7% of the pneumonias, 70.0% of the burn wound infections, 57.1% of the urinary tract infections, and 70.0% of the bloodstream infections. By multiple logistic regression analysis, body surface area burned, comorbidities, and use of invasive devices were significantly related to acquisition of nosocomial infections as identified by both the burn surgeons and the infection control criteria. Staphylococcus aureus and Pseudomonas were the most common resistant organisms identified. In our population, surgeons could decrease antimicrobial use by using explicit criteria for identifying patients with hospital-acquired infections, limiting perioperative prophylaxis to patients at highest risk of infection, and decreasing the incidence of nosocomial infection with reduced use of devices and strict adherence to aseptic technique.

Hyperbaric oxygen for the treatment of fournier's gangrene.

PURPOSE: Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. MATERIALS AND METHODS: The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. RESULTS: A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). CONCLUSIONS: These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.

Characteristics of twice-transferred, rural trauma patients.

OBJECTIVE: Undertriage has seldom been evaluated in the trauma population. In rural states patients often go to the nearest hospital first, where they are evaluated and, if necessary, transferred to another hospital. If they are undertriaged when transferred to the second hospital, they will require a second transfer to a higher-level trauma center. METHODS: The authors retrospectively reviewed the charts of all trauma patients at a level I trauma center from 1996 to 1999 who were seen at two acute care facilities because of a single acute traumatic event before reaching the trauma center. Ninety-three patient charts were analyzed. RESULTS: Forty-six percent of the patients were victims of a motor vehicle crash. Patients were mostly transferred to the level I trauma center for non-spine orthopedic injuries (28%), followed by spine injuries (14%) and head injuries (13%). These patients were stable, as manifested by an average trauma score of 11.6. However, there was a significant positive interaction between injury severity score and time to definitive care. CONCLUSIONS: The authors infer from the data analysis that more serious or complex injuries took longer to evaluate. Since these patients were physiologically stable, reducing the number of twice-transferred trauma patients will involve refining transfer protocols concerning the need for specialty care.