Incidence and characteristics of vascular trauma at a level 2 trauma center.

OBJECTIVE: Despite the significant number of trauma patients treated at level 2 trauma centers (L2TCs) in the United States, most of the literature describing vascular trauma is from level 1 trauma centers (L1TCs). Currently, trauma center designation criteria do not require vascular surgery as a necessary component service. METHODS: A retrospective chart review was performed for all trauma patients with a vascular surgery consultation seen at our L2TC between 2013 and 2018. Patient demographics, injury characteristics, and outcomes were collected and analyzed with descriptive statistics. RESULTS: Of the 3062 trauma patients evaluated at our L2TC, 110 (3.6%) had a vascular surgery consultation. Operative intervention was performed in 35.2% of consults, and 1.0% of all trauma patients had a vascular intervention. Average age was 57 years, and the majority were male (n = 75; 68.2%). Mean Injury Severity Score was 12.0 ± 9.6, and blunt injury (n = 77; 87.5%) was more common than penetrating (n = 11; 12.5%). The most common location of injury was the lower extremity (n = 23; 74.2%), followed by upper extremity (n = 3; 9.7%), chest (n = 2; 6.5%), neck (n = 2; 6.5%), and pelvis (n = 1; 3.2%). Endovascular interventions were performed by the vascular surgery service in 67.7% (n = 21) of all injuries. There was one amputation (3.2%) and one postoperative mortality (3.2%). CONCLUSIONS: At our L2TC, postoperative morbidity and mortality rates at 30 days were substantially lower compared with previously reported data. However, mean injury severity score and the incidence of penetrating and polytrauma were also lower at our institution. Most patients were managed nonoperatively, but when they did require an operation, endovascular therapies were more commonly implemented. Vascular surgery should be considered an integral service in trauma level designation, and there is a need for further investigation of these outcomes in L2TCs.

Variation in Risk-Adjusted Ventilator-Associated Pneumonia Days Within a Quality Collaborative.

INTRODUCTION: Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged mechanical ventilation, and longer intensive care unit stays. The rate of VAP (VAPs per 1000 ventilator days) within a hospital is an important quality metric. Despite adoption of preventative strategies, rates of VAP in injured patients remain high in trauma centers. Here, we report variation in risk-adjusted VAP rates within a statewide quality collaborative. METHODS: Using Michigan Trauma Quality Improvement Program data from 35 American College of Surgeons-verified Level I and Level II trauma centers between November 1, 2020 and January 31, 2023, a patient-level Poisson model was created to evaluate the risk-adjusted rate of VAP across institutions given the number of ventilator days, adjusting for injury severity, physiologic parameters, and comorbid conditions. Patient-level model results were summed to create center-level estimates. We performed observed-to-expected adjustments to calculate each center's risk-adjusted VAP days and flagged outliers as hospitals whose confidence intervals lay above or below the overall mean. RESULTS: We identified 538 VAP occurrences among a total of 33,038 ventilator days within the collaborative, with an overall mean of 16.3 VAPs per 1000 ventilator days. We found wide variation in risk-adjusted rates of VAP, ranging from 0 (0-8.9) to 33.0 (14.4-65.1) VAPs per 1000 d. Several hospitals were identified as high or low outliers. CONCLUSIONS: There exists significant variation in the rate of VAP among trauma centers. Investigation of practices and factors influencing the differences between low and high outlier institutions may yield information to reduce variation and improve outcomes.

Effects of Transport to Trauma Centers on Survival Outcomes Among Severe Trauma Patients in Korea: Nationwide Age-Stratified Analysis.

BACKGROUND: Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea. METHODS: Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19-65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted. RESULTS: Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group. CONCLUSION: We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.

Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study.

BACKGROUND: Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking. METHOD: This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT. RESULTS: A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (- 40.5%). Patients were younger (median age, 63 [45-77] vs. 61[44-74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158-480] vs. 263[180-674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025). CONCLUSION: We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

[Welcoming severely traumatized patients]. / L'accueil du patient traumatisé grave.

Severe trauma accounts for around 15% of all traumas, but remains the leading cause of death in people under 45. The organization of networked care for severe trauma is becoming a necessity in France. Thanks to this kind of organization, it is possible to speed up the care of these patients, and optimize their referral to the most appropriate reception center. The Bicêtre University Hospital (CHU) is one of six trauma centers in the Île-de-France region, all working to the same specifications set out by the Île-de-France regional health agency.

The Bottom Line: Trauma Center Viability During COVID-19.

INTRODUCTION: The COVID-19 pandemic was a potential threat to the viability of trauma centers and health systems in general. We sought to answer the question of how COVID-19 was associated with patient characteristics as well as trauma center volume, finances, and viability. METHODS: We reviewed 6375 patients admitted to our verified Level 1 trauma center during two time periods: pre-COVID (February 2019-February 2020) and COVID (March 2020-March 2021). Three thousand ninety-nine patients were admitted pre-COVID and 3276 were admitted during COVID. Data including case-mix index (CMI), total contribution margin, insurance status, age, race, gender, ethnicity, and injury mechanism were collected from the trauma registry and finance databases and analyzed. A P < 0.05 was considered significant. RESULTS: Trauma admissions decreased initially during COVID but returned to and ultimately surpassed admission trends pre-COVID. Trauma revenue and patient acuity increased significantly along with a decrease in the number of underinsured patients during COVID. When evaluating all service lines, the trauma center was the highest contributor to overall hospital revenue. CONCLUSIONS: Despite a decrease in admissions for other service lines and a pause in elective surgeries during the pandemic, the trauma center remained unaffected. In addition, trauma was the most significant contributor to the bottom line of the health system. These findings underscore the need to maintain and even increase trauma center resources and staffing to ensure that optimal care is provided to critically ill and injured patients.

Disparities in computed tomography utilization for pediatric blunt trauma: a systematic review and meta-analysis comparing pediatric and non-pediatric trauma centers.

Pediatric blunt trauma is a major cause of morbidity and mortality, and computed tomography (CT) imaging is vital for accurate evaluation and management. Pediatric trauma centers (PTCs) have selective CT practices, while non-PTCs may differ, resulting in potential variations in CT utilization. The objective of this study is to delineate disparities in CT utilization for pediatric blunt trauma patients between PTCs and non-PTCs. A systematic review and meta-analysis were conducted following established guidelines, searching PubMed, Scopus, and Web of Science up to March 3, 2023. All studies examining CT utilization in the management of pediatric (aged < 21 years) blunt trauma and specifying the type of trauma center(s) were included, and data were extracted and analyzed using STATA software version 17.0. An analysis of 30 studies revealed significant variations in CT scan utilization among pediatric blunt trauma patients across different types of trauma centers. PTCs exhibited lower pooled rates of abdominopelvic CT scans (35.4% vs. 44.9%, p < 0.01), cranial CT scans (36.9% vs. 42.9%, p < 0.01), chest CT scans (14.5% vs. 25.4%, p < 0.01), and cervical spine CT scans (23% vs. 45%, p < 0.01) compared to adult or mixed trauma centers (ATCs/MTCs). PTCs had a pooled rate of 54% for receiving at least one CT scan, while ATCs/MTCs had a higher rate of 69.3% (p < 0.05). The studies demonstrated considerable heterogeneity. These findings underscore the need to conduct further research to understand the reasons for the observed variations and to promote appropriate imaging usage, minimize radiation exposure, and encourage collaboration between pediatric and adult trauma centers.

Epidemiology of hand injuries that presented to a tertiary care facility in Germany: a study including 435 patients.

BACKGROUND: Hand injuries compose up to 30% of all injuries in emergency care. However, there is a lack of epidemiological data reflecting patient or accident-related variables, injury types, injured anatomical structures or trauma localization. OBJECTIVE: The objective of this study is (1) to provide epidemiological information on hand injuries and their patterns and (2) to visualise the frequencies of affected areas of the hand in relation to the most common trauma mechanisms using color-coded heatmaps. METHODS: This prospective single-center observational trial conducted at a surgical emergency department in Germany collected data of hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, diagnostic and therapeutic measures were analyzed. Color-coded heatmaps were generated marking anatomic danger zones. RESULTS: 435 patients with a mean age of 39.5 were included. Most patients admitted on their own initiative (79%). Leisure and sport injuries were most frequent (75%). Digiti II-V were injured most commonly (43%), followed by metacarpals (19%) and the thumb (14%). Blunt trauma and cuts accounted for most injuries (74%). Hand-graphics depicted color-coded frequencies of the affected areas of the palmar and dorsal aspect of the hand for the most common types of injury, as well as the most frequent circumstances of accident. Elective surgery was recommended in 25% of cases, and hand surgical follow-up was proposed in over 50% of cases. CONCLUSIONS: The dorsal aspect of the hand including the 5th metacarpal, the radial wrist and thenar region, as well as the fingertips of Digiti II/III represent anatomic danger zones to injury of the hand. Due to the large variety of potentially injured structures, diagnosis and treatment is not trivial. Specific training is required for all surgical specialties in emergency care, to increase quality of diagnostic work-up and management of hand injuries.

Nurse, Provider, and Emergency Department Technician: Perceptions and Experiences of Violence and Aggression in the Emergency Department.

INTRODUCTION: Patient/visitor violence and aggression (V&A) in the emergency department occurs daily. Few interventions exist to decrease V&A. Research describing prevalence, severity, and perceived safety among ED clinicians is limited. METHODS: A descriptive survey explored V&A against ED clinicians in one urban emergency department. A sample of nurses, ED technicians, physicians and advanced practice providers participated. Participants completed a demographic survey, Personal Workplace Safety Instrument for Emergency Nurses (PWSI-EN), and ENA V&A frequency checklist. Analysis of Variance (ANOVA) for unadjusted and Analysis of Covariance (ANCOVA) for adjusted associations were used to assess differences in the PWSI-EN survey composite score and "feeling safe in the ED" among ED roles. ANCOVA was adjusted for potential confounders: sex, race, years working in emergency department, and shift worked. RESULTS: Sixty-five (46.4%) of the 140 ED clinicians returned surveys, which were almost evenly distributed between ED clinician roles and sex. Mean age was 37.2 (range: 21-64) years. All (100%) nurses and providers reported being verbally abused. More nurses reported physical violence (n = 21, 87.5%) than providers (n = 7, 36.8%) and ED technicians (n = 11, 55%). Nurses and ED technicians reported experiencing greater prevalence of physical violence than providers (P < .05). Nurses (mean 3.29, range 2.95 to 3.63) were more fearful for their personal safety than ED technicians (mean 3.88, range 3.48 to 4.28) (P < .03). DISCUSSION: V&A are common creating a fearful environment. However, little research regarding clinician perceptions exists. Our study aids in identifying areas for clinician-targeted strategies to prevent ED V&A.

Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey.

Background: Trauma is the leading cause of death in India resulting in a significant public health burden. Indian Society of Critical Care Medicine (ISCCM) has established a trauma network committee to understand current practices and identify the gaps and challenges in trauma management in Indian settings. Material and methods: An online survey-based, cross-sectional, descriptive study was conducted with high-priority research questions based on hospital profile, resource availability, and trauma management protocols. Results: Data from 483 centers were analyzed. A significant difference was observed in infrastructure, resource utilization, and management protocols in different types of hospitals and between small and big size hospitals across different tier cities in India (p < 0.05). The advanced trauma life support (ATLS)-trained emergency room (ER) physician had a significant impact on infrastructure organization and trauma management protocols (p < 0.05). On multivariate analysis, the highest impact of ATLS-trained ER physicians was on the use of extended focused assessment with sonography in trauma (eFAST) (2.909 times), followed by hospital trauma code (2.778 times), dedicated trauma team (1.952 times), and following trauma scores (1.651 times). Conclusion: We found that majority of the centers are well equipped with optimal infrastructure, ATLS-trained physician, and management protocols. Still many aspects of trauma management need to be prioritized. There should be proactive involvement at an organizational level to manage trauma patients with a multidisciplinary approach. This survey gives us a deep insight into the current scenario of trauma care and can guide to strengthen across the country. How to cite this article: Sodhi K, Khasne RW, Chanchalani G, Jagathkar G, Kola VR, Mishra M et al. Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey. Indian J Crit Care Med 2023;27(1):38-51.

Analysis of diagnoses of chest injuries in a Nigerian trauma center.

Background: Chest injury is one of the most common types of trauma-related injuries accounting for about 10% of trauma admissions in emergency services. The injuries may be immediate, life-threatening, or potentially life-threatening based on diagnosis after initial assessment. This study is intended to analyze the pattern of diagnosis found in chest-injured patients in a trauma center of a developing country. Methods: This is a retrospective study carried out in the trauma center of the National Hospital Abuja, Nigeria, between January 2015 and December 2017, as an analysis of the existing trauma registry. Data procession was done using SPSS version 24.0. Results were presented in tables and figures. Results: A total of 637 patients' data was studied, male to female ratio of 3.58 and mean age of 34.18 ± 11.34 years. More patients sustained isolated chest injury (59.5%) and blunt chest injury (78%). The most frequent diagnosis was chest wall soft tissue injury (CWSTI) (46.6%) despite the exclusion of minor chest wall injuries who did not require any form of observation. Haemothorax and rib fractures were the next most common diagnoses after CWSTI constituting 13.5% and 8.7%, respectively, while flail chest and aortic injuries were the least comprising 0.6% and 0.2%, respectively. The commonest associated injuries were traumatic brain injury (11.3%), extremity fractures (11.1%), and abdominal injuries (7.8%). Penetrating injuries were more significantly associated with male gender and isolated chest injuries (P < 0.001). Conclusion: Chest wall soft tissue injuries constitute a large proportion of chest injuries seen in our setting. Despite its relatively low importance in the medical literature, it should be given attention in resource-poor settings in order to minimize missed significant injuries in the absence of diagnostic facilities. Therefore, high index of suspicion and low threshold for observation should be practiced in this group of patients.

Evaluation of an Expedited Trauma Transfer Protocol: Right Place, Right Time.

BACKGROUND: Trauma patients may initially be evaluated at non-trauma centers. This may cause a delay in treatment, which could affect their outcome. Additionally, advanced imaging may be performed which may be suboptimal or unnecessary, increase time to transfer, or unable to be viewed when the patient reaches a trauma center increasing the delays to treatment or need for repeat imaging. Rapid identification and transfer to definitive trauma care, minimizing unnecessary delays should be the priority. METHODS: The trauma registry at a regional Level 1 Adult/Pediatric Trauma center was queried for transferred trauma patients over a 3-y period. A retrospective review was performed. Transferred trauma patients were compared prior to an expedited transfer protocol to after implementation. Demographics, mechanism of injury, injury severity score, computerized tomography scans performed prior to transfer, mortality, hospital and intensive care unit length of stay were compared using bivariate and multivariable regression statistics where appropriate. RESULTS: Transferred trauma patients were identified, 683 in the pre-protocol group and 821 in the post-protocol group, an increase of 16.8%. There were no differences in age, sex, injury severity score, mechanism of injury, mortality, hospital, or intensive care unit length of stay (LOS) throughout the study period. There was a significant decrease in time to transfer (263 min ± 222 versus 227 ± 189, P < 0.001) and computerized tomography scans performed prior to transfer (Head 47% versus 32%, C-spine 36% versus 23%, Thorax 22% versus 16%, Abdomen/Pelvis 24% versus 14%, all P values <0.001 except CT Thorax). Interestingly, the rate of underinsured patients did not increase (21% versus 25%, P = 0.05). Risk-adjusted mortality and hospital LOS also did not change during the study period. CONCLUSIONS: After implementation of an expedited trauma transfer protocol to a regional Level 1 trauma center there was an associated reduced time of arrival to definitive care and decreased advanced imaging done prior to transfer. However, there was no associated decrease in mortality or LOS among transferred patients. Further studies examining prehospital transport or hospital choice decisions and subsequent care provided at non-trauma facilities regarding imaging obtained, care rendered, and transfer decisions can be explored.

A Statewide Analysis of Pediatric Liver Injuries Treated at Adult Versus Pediatric Trauma Centers.

INTRODUCTION: Hemodynamically normal pediatric trauma patients with solid organ injury receive nonoperative management. Prior research supports that pediatric patients have higher rates of nonoperative management at pediatric trauma centers (PTCs). We sought to evaluate differences in outcomes of pediatric trauma patients with liver injuries. We hypothesized that the type of trauma center (PTC versus adult trauma center [ATC]) would not be associated with any difference in mortality. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all patients (<15 y) with liver injuries by International Classification of Disease 9 and 10 codes. Patients were categorized based on admission to the PTC or ATC. The primary endpoint was mortality with secondary endpoints being operative intervention and length of stay. Multivariate logistic regressions assessed the adjusted impact on mortality and surgical intervention. RESULTS: Of the 1600 patients with liver trauma, 607 met inclusion criteria. A total of 78.4% were treated at PTCs. Patients underwent hepatobiliary surgery more frequently at ATCs (11.5% [n = 15] versus 2.74% [n = 13], P < 0.001). Adjusted analysis showed lower odds of surgical intervention for hepatobiliary injuries at PTCs (adjusted odds ratio: 0.17, P = 0.001). There was a decrease in mortality at PTCs versus ATCs (adjusted odds ratio: 0.38, P = 0.032). CONCLUSIONS: Our statewide analysis showed that pediatric trauma patients with liver injuries treated at ATCs were associated with having higher odds of mortality and higher incidence of operative management for hepatobiliary injuries than those treated at PTCs. In addition, between centers, patients had similar functional status at discharge.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States.

BACKGROUND: Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. METHODS: All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. RESULTS: 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. CONCLUSIONS: Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Undertriage of Geriatric Trauma Patients in Florida.

INTRODUCTION: Elderly undertriage rates are estimated up to 55% in the United States. This study examined risk factors for undertriage among hospitalized trauma patients in a state with high volumes of geriatric trauma patients. MATERIALS AND METHODS: This is a population-based retrospective cohort study of 62,557 patients admitted to Florida hospitals between 2016 and 2018 from the Agency for Healthcare Administration database. Severely injured trauma patients were defined by American College of Surgeons definitions and an International Classification of Disease Injury Severity Score <0.85. Undertriage was defined as definitive care of these severely injured patients at any Florida hospital other than a state-designated trauma center (TC). Univariate analyses were used to identify risk factors associated with inpatient mortality and undertriage. Multiple variable regression was used to estimate risk-adjusted odds of mortality after admission to either a designated or nondesignated TC. RESULTS: Undertriaged patients were more likely to have isolated traumatic brain injuries, lower International Classification of Disease Injury Severity Scores, multiple comorbidities, and older age. Trauma patients aged 65 and older were more than twice as likely to be undertriaged (34% versus 15.7%, P < 0.0001). Undertriaged patients of all ages were also more likely to suffer from pneumonia, urinary tract infection, arrhythmias, and sepsis. After risk adjustment, severely injured trauma patients admitted to non-TC were also more likely to be at risk for mortality (adjusted odds ratio, 1.27; 95% confidence interval, 1.17-1.38). CONCLUSIONS: Age and multiple comorbidities are significant predictors of mortality among undertriage of trauma patients. As a result, trauma triage guidelines should account for high-risk geriatric trauma patients who would benefit from definitive treatment at designated TCs.

Effect of the COVID-19 pandemic at a major Danish trauma center in 2020 compared with 2018-2019: A retrospective cohort study.

BACKGROUND: The COVID-19 pandemic demanded changes in societal behavior and health care worldwide. Previous studies have compared trauma patient admissions in COVID-19-related lockdowns to prior years. This study describes the COVID-19 impact on trauma patient admissions during entire 2020 at a major trauma center in Denmark. METHODS: We retrospectively analyzed trauma patients received by a trauma team and admitted at Aarhus University Hospital in 2020 compared with 2018-2019. The incidence of injuries, mechanism of injury, 30-day mortality, and Injury Severity Score (ISS) were investigated. RESULTS: The incidence of minor injuries (ISS 1-15) increased by 24% in 2020 compared with 2018-2019 (incidence rate ratio 1.24 [95% CI: 1.11-1.39]). The incidence of severe injuries (ISS >15) in 2020 did not change compared with 2018-2019 (incidence rate ratio 0.97 [95% CI: 0.80-1.17]). The 30-day mortality was similar in 2020 compared with 2018-2019. Comparing 2020 with 2018-2019, the risk ratio of traffic injuries decreased (0.90 [95% CI: 0.82-0.99]), risk ratio for fall injuries was 1.13 (95% CI: 0.97-1.30), for violence 1.13 (95% CI: 0.51-2.50), and for self-harm 1.94 (95% CI: 0.95-3.94). During the first lockdown of 2020, trauma team activations declined from 49.5 to 42 and the risk ratio for traffic injuries was 0.74 (95% CI: 0.50-1.10) compared with the same period in 2018-2019. CONCLUSION: The incidence of minor injuries increased, but the incidence of severe injuries was similar in 2020 compared with 2018-2019. Societal restrictions might alter the mechanism of injuries. The first lockdown indicated an association with reduced traffic injuries.

Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States.

Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police.Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police.Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13-15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321-2.333); p = 0.776).Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.

Locating trauma centers considering patient safety.

Trauma continues to be the leading cause of death and disability in the U.S. for those under the age of 44, making it a prominent public health problem. Recent literature suggests that geographical maldistribution of Trauma Centers (TCs), and the resultant increase of the access time to the nearest TC, could impact patient safety and increase disability or mortality. To address this issue, we introduce the Trauma Center Location Problem (TCLP) that determines the optimal number and location of TCs in order to improve patient safety. We model patient safety through a surrogate measure of mistriages, which refers to a mismatch in the injury severity of a trauma patient and the destination hospital. Our proposed bi-objective optimization model directly accounts for the two types of mistriages, system-related under-triage (srUT) and over-triage (srOT), both of which are estimated using a notional tasking algorithm. We propose a heuristic based on the Particle Swarm Optimization framework to efficiently derive a near-optimal solution to the TCLP for realistic problem sizes. Based on 2012 data from the state of Ohio, we observe that the solutions are sensitive to the choice of weights for srUT and srOT, volume requirements at a TC, and the two thresholds used to mimic EMS decisions. Using our approach to optimize that network resulted in over 31.5% reduction in the objective with only 1 additional TC; redistribution of the existing 21 TCs led to 30.4% reduction.

Designing and conducting initial application of a performance assessment model for in-hospital trauma care.

BACKGROUND: Trauma is a major cause of death worldwide, especially in Low and Middle-Income Countries (LMIC). The increase in health care costs and the differences in the quality of provided services indicates the need for trauma care evaluation. This study was done to develop and use a performance assessment model for in-hospital trauma care focusing on traffic injures. METHODS: This multi-method study was conducted in three main phases of determining indicators, model development, and model application. Trauma care performance indicators were extracted through literature review and confirmed using a two-round Delphi survey and experts' perspectives. Two focus group discussions and 16 semi-structured interviews were conducted to design the prototype. In the next step, components and the final form of the model were confirmed following pre-determined factors, including importance and necessity, simplicity, clarity, and relevance. Finally, the model was tested by applying it in a trauma center. RESULTS: A total of 50 trauma care indicators were approved after reviewing the literature and obtaining the experts' views. The final model consisted of six components of assessment level, teams, methods, scheduling, frequency, and data source. The model application revealed problems of a selected trauma center in terms of information recording, patient deposition, some clinical services, waiting time for deposit, recording medical errors and complications, patient follow-up, and patient satisfaction. CONCLUSION: Performance assessment with an appropriate model can identify deficiencies and failures of services provided in trauma centers. Understanding the current situation is one of the main requirements for designing any quality improvement programs.

Establishing an open and robotic pancreatic surgery program in a level 1 trauma center community teaching hospital and comparing its outcomes to high-volume academic center outcomes: a retrospective review.

BACKGROUND: The debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers. METHODS: The current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital's trauma center had been verified; and (4) the hospital's surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses. RESULTS: The study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P < 0.001). The 90-day study mortality proportion (0%) was similar to the literature proportion (2.3%; P = 0.397). The study postoperative pancreatic fistula proportion was lower (3.2%), when compared to the literature proportion (18.4%; P < 0.001; risk ratio = 5.8). The study patients had a lower reoperation proportion (3.1%) than the literature proportion (8.7%; mid-P = 0.051; risk ratio = 2.8). The study patients had a lower surgical site infection proportion (3.1%) than those in the literature (21.1%; P < 0.001; risk ratio = 6.8). The study patients had equivalent delayed gastric emptying (15.6%) when compared to literature patients (10.6%; P = 0.216). The study patients had decreased Clavien-Dindo grades III-IV complications (10.9%) compared to the literature patients (21.8%; mid-P = 0.018). Lastly, the study patients had a similar readmission proportion (20.3%) compared to literature patients (18.4%; P = 0.732). CONCLUSION: Despite pancreatic surgical patients having greater preoperative medical comorbidities, the current community study outcomes were comparable to or better than high-volume academic center results.