Changing paradigms in the management of 2184 patients with traumatic brain injury.

OBJECTIVES: The aim of this study was to assess the change in trends in the management of traumatic brain injury (TBI) at a level I trauma center and the utilization of resources as a result of this change in management. BACKGROUND: The management of TBI has been evolving with trends toward management of minimally injured patients with intracranial hemorrhage exclusively by trauma surgeons. METHODS: A 5-year (2009-2014) prospective database on all patients with TBI (skull fracture/intracranial hemorrhage on head computed tomography) presenting to a level I trauma center was analyzed for patient demographics, injuries, admission physiology, computed tomographic scan results, and hospital outcomes. These records were matched to the institutional registry and hospital financial database. RESULTS: A total of 2184 patients were included with median (interquartile range) Glasgow Coma Scale score of 15 (12-15), and median (interquartile range) head-abbreviated injury scale score of 3 (2-4). The distribution of types and size of intracranial bleeds remained unchanged throughout the study period. The proportion of TBI managed exclusively by trauma surgeons increased significantly over the years from 6.8% to 40.1% (P < 0.001). Proportion of patients who received neurosurgical consultations (P < 0.001) and repeat head computed tomographic scans (P < 0.001), hospital length of stay (P = 0.028), and costs (P < 0.001) decreased significantly over time. The overall mortality rate (18.5%) and rate of intervention (14.1%) remained unchanged. CONCLUSIONS: TBI patients can be selectively managed without initially involving neurosurgeons safely in a cost-effective manner, resulting in more effective use of precious resources.

Obesity and trauma mortality: Sizing up the risks in motor vehicle crashes.

BACKGROUND: Protective effects of safety devices in obese motorists in motor vehicle collisions (MVC) remain unclear. Aim of our study is to assess the association between morbid obesity and mortality in MVC, and to determine the efficacy of protective devices. We hypothesised that patients with morbid obesity will be at greater risk of death after MVC. METHODS: A retrospective analysis of MVC patients (age ≥16 y.o.) was performed using the National Trauma Data Bank from 2007 to 2010. Patients with recorded comorbidity of morbid obesity (BMI≥40) were identified. Patients dead on arrival, with isolated traumatic brain injury, or incomplete data were excluded. The primary outcome was in-hospital mortality. Multivariate logistic regression was performed. RESULTS: Our sample of 214,306 MVC occupants included 10,260 (4.8%) morbidly obese patients. Mortality risk was greatest among occupants with morbid obesity (ORcrude 1.74 [1.54-1.98]). After adjusting for patient demographics, safety device and physiological severity, odds of death was 1.52 [1.33-1.74] times greater in motorists with morbid obesity. Motorists with morbid obesity were at greater risk of death if no restraint (OR 1.84 [1.47-2.31]), seatbelt only (OR 1.48 [1.17-1.86]), or both seatbelt and airbag were present (OR 1.49 [1.13-1.97]). No significant differences in the odds of death exist between drivers with morbid obesity and non-morbidly obese drivers with only airbag deployment (OR 0.99 [0.65-1.51]). CONCLUSIONS: Motorists with morbid obesity are at greater risk of MVC. Regardless of safety device use, occupants with morbid obesity remained at greater risk of death. Further research examining the effectiveness of vehicle restraints in drivers with morbid obesity is warranted.

Bicycle helmets work when it matters the most.

BACKGROUND: Helmets are known to reduce the incidence of traumatic brain injury (TBI) after bicycle-related accidents. The aim of this study was to assess the association of helmets with severity of TBI and facial fractures after bicycle-related accidents. METHODS: We performed an analysis of the 2012 National Trauma Data Bank abstracted information of all patients with an intracranial hemorrhage after bicycle-related accidents. Regression analysis was also performed. RESULTS: A total of 6,267 patients were included. About 25.1% (n = 1,573) of bicycle riders were helmeted. Overall, 52.4% (n = 3,284) of the patients had severe TBI, and the mortality rate was 2.8% (n = 176). Helmeted bicycle riders had 51% reduced odds of severe TBI (odds ratio [OR] .49, 95% confidence interval [CI] .43 to .55, P < .001) and 44% reduced odds of mortality (OR .56, 95% CI .34 to .78, P = .010). Helmet use also reduced the odds of facial fractures by 31% (OR .69, 95% CI .58 to .81, P < .001). CONCLUSION: Bicycle helmet use provides protection against severe TBI, reduces facial fractures, and saves lives even after sustaining an intracranial hemorrhage.

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

INTRODUCTION: The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. METHODS: We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). RESULTS: A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). CONCLUSION: The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. LEVEL OF EVIDENCE: Economic and value-based evaluation, level III.

Stress among surgical attending physicians and trainees: A quantitative assessment during trauma activation and emergency surgeries.

BACKGROUND: The adverse effects of stress on the wellness of trauma team members are well established; however, the level of stress has never been quantitatively assessed. The aim of our study was to assess the level of stress using subjective data and objective heart rate variability (HRV) among attending surgeons (ASs), junior residents (JRs) (PGY2/PGY3), and senior residents (SRs) (PGY5/PGY6) during trauma activation and emergency surgery. METHODS: We preformed a prospective study enrolling participants over eight 24-hour calls in our Level I trauma center. Stress was assessed based on decrease in HRV, which was recorded using body worn sensors. Stress was defined as HRV of less than 85% of baseline HRV. We collected subjective data on stress for each participant during calls. Three groups (ASs, JRs, SRs) were compared for duration of different stress levels through trauma activation and emergency surgery. RESULTS: A total of 22 participants (ASs: n = 8, JRs: n = 7, SRs: n = 7) were evaluated over 192 hours, which included 33 trauma activations and 50 emergency surgeries. Stress level increased during trauma activations and operations regardless of level of training. The ASs had significantly lower stress when compared with SRs and JRs during trauma activation (21.9 ± 10.7 vs. 51.9 ± 17.2 vs. 64.5 ± 11.6; p < 0.001) and emergency surgery (30.8 ± 7.0 vs. 53.33 ± 6.9 vs. 56.1 ± 3.8; p < 0.001). The level of stress was similar between JRs and SRs during trauma activation (p = 0.37) and emergency surgery (p = 0.19). There was no correlation between objectively measured stress level and subjectively measured stress using State-Trait Anxiety Inventory (R = 0.16; p = 0.01) among surgeons or residents. CONCLUSIONS: Surgeon wellness is a significant concern, and this study provides empirical evidence that trauma and acute care surgeons encounter mental strain and fail to recognize it. Stress management and burnout are very important in this high-intensity field, and this research may provide some insight in finding those practitioners who are at risk. LEVEL OF EVIDENCE: Epidemiologic study, level II.

Identifying the broken heart: predictors of mortality and morbidity in suspected blunt cardiac injury.

BACKGROUND: Blunt cardiac injury (BCI) is an infrequent but potentially fatal finding in thoracic trauma. Its clinical presentation is highly variable and patient characteristics and injury pattern have never been described in trauma patients. The aim of this study was to identify predictors of mortality in BCI patients. METHODS: We performed an 8-year retrospective analysis of all trauma patients diagnosed with BCI at our Level 1 trauma center. Patients older than 18 years, blunt chest trauma, and a suspected diagnosis of BCI were included. BCI was diagnosed based on the presence of electrocardiography (EKG), echocardiography, biochemical cardiac markers, and/or radionuclide imaging studies. Elevated troponin I was defined as more than 2 recordings of greater than or equal to .2. Abnormal EKG findings were defined as the presence of bundle branch block, ST segment, and t-wave abnormalities. Univariate and multivariate regression analyses were performed. RESULTS: A total of 117 patients with BCI were identified. The mean age was 51 ± 22 years, 65% were male, mean systolic blood pressure was 93 ± 65, and overall mortality rate was 44%. Patients who died were more likely to have a lactate greater than 2.5 (68% vs 31%, P = .02), hypotension (systolic blood pressure < 90) (86% vs 14%, P = .001), and elevated troponin I (86% vs 11%, P = .01). There was no difference in the rib fracture (58% vs 56%, P = .8), sternal fracture (11% vs 21%, P = .2), and abnormal EKG (89% vs 90%, P = .6) findings. Hypotension and lactate greater than 2.5 were the strongest predictors of mortality in BCI. CONCLUSIONS: BCI remains an important diagnostic and management challenge. However, once diagnosed resuscitative therapy focused on correction of hypotension and lactate may prove beneficial. Although the role of troponin in diagnosing BCI remains controversial, elevated troponin may have prognostic significance.

Early feeds not force feeds: Enteral nutrition in traumatic brain injury.

BACKGROUND: Brain Trauma Foundation guidelines recommend the early use of enteral nutrition to optimize recovery following traumatic brain injury (TBI). Our aim was to examine the effect of early feeds (≤24 hours) on clinical outcomes after TBI. METHODS: We performed a 3-year retrospective study of patients with severe TBI (Glasgow Coma Scale score <8) who were intubated, admitted to the intensive care unit (ICU), and received tube feeds. Early tube feeds (early TF) were defined as initiation of tube feeds within 24 hours, whereas late tube feeds (late TF) were defined as initiation of tube feeds after 24 hours. Outcome measures included pneumonia rates, days on ventilator, hospital and ICU stay, and mortality rates. RESULTS: A total of 90 patients (early TF: 58, late TF: 32) were included, of which 73.3% were male, mean age was 42 (SD, 20) years, and median head Abbreviated Injury Scale score was 4 (range, 3-5). There was no difference in age (p = 0.1), head Abbreviated Injury Scale score (p = 0.5), or admission Glasgow Coma Scale score (p = 0.9) between the two groups. Patients with early TF were associated with higher number of ICU days (p = 0.03) and higher pneumonia rates (p = 0.04), but there was no significant difference in mortality (p = 0.44) as compared with those who underwent late TF. CONCLUSIONS: Although early tube feeds are known to improve outcomes in TBI patients, our data suggest that early feeds in TBI patients are associated with higher rates of pneumonia and greater hospital resource utilization. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study.

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010-2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13-15), and median head Abbreviated Injury Scale score was 3 (2-4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay (P = 0.02) and longer intensive care unit length of stay (P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.

Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol.

INTRODUCTION: The National Trauma Triage Protocol (NTTP) is an algorithm that guides emergency medical services providers through four decision steps to identify the patients that would benefit from trauma center care. The NTTP defines a systolic blood pressure (SBP) of less than 90 mm Hg as one of the criteria for trauma center need. The aim of our study was to determine the impact of substituting SBP of less than 90 mm Hg with shock index (SI) on triage performance. METHODS: A 2-year (2011-2012) retrospective analysis of all trauma patients 18 years or older in the National Trauma Databank was performed. Transferred patients, patients dead on arrival, and those with missing data were excluded. Our outcome measure was trauma center need defined by Injury Severity Score greater than 15, need for emergent operation, death in the emergency department, and intensive care unit stay of more than 1 day. Area under the characteristic curve and triage characteristics were compared between SBP of less than 90 mm Hg and SI of more than 1.0. Logistic regression analysis was performed to compare the mortality between patients triaged under current protocol of SBP of less than 90 mm Hg and patients triaged using the new defined protocol (SI >1.0). RESULTS: A total of 505,296 patients were included. Compared with SBP of less than 90 mm Hg, SI of more than 1.0 had a higher sensitivity (44.4% vs. 41.7%) but lower specificity (80.2% vs. 82.4%). The area under the curve was significantly higher for SI of more than 1.0 (0.623 [95% confidence interval, 0.622-.625] vs. 0.620 [95% confidence interval, 0.619-0.622]). Substituting SBP of less than 90 mm Hg with SI of more than 1.0 resulted in a decrease in undertriage rate of 30,233 patients (5.9%) but an increase in overtriage of only 6,386 patients (1.3%). CONCLUSION: Substituting the current criterion of SBP of less than 90 mm Hg in the NTTP with an SI of more than 1.0 results in significant reduction in undertriage rate without causing large increase in overtriage. Because of simplicity of use, better discrimination power, and minimal effect on overtriage rates, future studies should consider exploring the possibility of replacing the current SBP of less than 90 mm Hg criterion with SI of more than 1.0 in the NTTP. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Assessing the Efficacy of Prothrombin Complex Concentrate in Multiply Injured Patients With High-Energy Pelvic and Extremity Fractures.

OBJECTIVES: Prothrombin complex concentrate (PCC) is being increasingly used for reversing induced coagulopathy of trauma. However, the use of PCC for reversing coagulopathy in multiply injured patients with pelvic and/or lower extremity fractures remains unclear. The aim of our study was to assess the efficacy of PCC for reversing coagulopathy in this group of patients. DESIGN: Two-year retrospective analysis. SETTING: Our level I trauma center. PATIENTS/PARTICIPANTS: All coagulopathic [International normalized ratio (INR) ≥1.5] trauma patients. Patients with femur, tibia, or pelvic fracture were included. Patients were divided into 2 groups: PCC (single dose) and fresh frozen plasma (FFP). Patients in the 2 groups were matched using propensity score matching. MAIN OUTCOME MEASUREMENTS: Time to correction of INR, time to intervention, development of thromboembolic complications, mortality, and cost of therapy. RESULTS: A total of 81 patients (PCC: 27, FFP: 54) were included. Patients who received PCC had faster correction of INR and shorter time to surgical intervention in comparison to patients who received FFP. PCC therapy was also associated with lower overall blood product requirement (P = 0.02) and lower transfusion costs (P = 0.0001). CONCLUSIONS: In a matched cohort of multiply injured patients with pelvic and/or lower extremity fractures, administration of a single dose of PCC significantly reduced the time to correction of INR and time to intervention compared with patients who received FFP therapy. This may allow orthopaedic surgeons to more safely proceed with early, definitive fixation strategies. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Identifying potential utility of resuscitative endovascular balloon occlusion of the aorta: An autopsy study.

BACKGROUND: Resuscitative thoracotomy (RT) has been the standard therapy in patients with acute arrest due to hemorrhagic shock. However, with the development of resuscitative endovascular balloon occlusion of the aorta (REBOA), its role as a potential adjunct to a highly morbid intervention such as RT is being discussed. The aim of this study was to identify patients who most likely would have potentially benefited from REBOA use based on autopsy findings. METHODS: We performed a 4-year retrospective review of all RTs performed at our Level I trauma center. Patients with in-hospital mortality and who underwent subsequent autopsies were included. Patients were divided into blunt and penetrating trauma with and without thoracic injuries. Autopsy reports were reviewed to identify vascular and solid organ injuries. Outcome measure was potential benefit with REBOA. Potential benefit with REBOA was defined based on the ability to safely deploy REBOA. In patients without cardiac, aortic, and major pulmonary vasculature injuries, REBOA was considered potentially beneficial. In all other patients, it was considered as nonbeneficial. RESULTS: A total of 98 patients underwent an RT, of whom 87 had subsequent autopsies and were reviewed. The mean age was 35.25 (SD, 17.85) years, mean admission systolic blood pressure was 51.38 (SD, 70.11) mm Hg, median Injury Severity Score was 29 (interquartile range [IQR], 25-42), and 44 had penetrating injury. Resuscitative endovascular balloon occlusion of the aorta would have been potentially beneficial in 51.2% of patients (22 of 43 patients) with blunt mechanism of trauma, whereas REBOA would have been potentially beneficial in 38.6% of patients (17 of 44 patients) with penetrating mechanism of trauma. A subgroup analysis showed that REBOA use would have been potentially beneficial in 50.0% of blunt thoracic and 33.3% of penetrating thoracic trauma patients. CONCLUSIONS: There are a great enthusiasm and premature efforts to introduce REBOA as an alternative to RT. While there exists a great potential for benefit with REBOA use in the management of noncompressible torso hemorrhage, the current indications for REBOA need to be defined better. Patients with penetrating chest trauma in extremis should be considered an absolute contraindication for REBOA use. The majority of patients with blunt trauma in extremis may potentially benefit from REBOA. However, better criteria will help increase these patients who may potentially benefit from REBOA placement. LEVEL OF EVIDENCE: Therapeutic study, level V.

Multicenter evaluation of temporary intravascular shunt use in vascular trauma.

BACKGROUND: The indications and outcomes associated with temporary intravascular shunting (TIVS) for vascular trauma in the civilian sector are poorly understood. The objective of this study was to perform a contemporary multicenter review of TIVS use and outcomes. METHODS: Patients sustaining vascular trauma, requiring TIVS insertion (January 2005 to December 2013), were retrospectively identified at seven Level I trauma centers. Clinical demographics, operative details, and outcomes were abstracted. RESULTS: A total of 213 injuries (2.7%; 94.8% arterial) requiring TIVS were identified in 7,385 patients with vascular injuries. Median age was 27.0 years (range, 4-89 years), 91.0% were male, Glasgow Coma Scale (GCS) score was 15.0 (interquartile range, 4.0), Injury Severity Score (ISS) was 16.0 (interquartile range, 15.0), 26.0% had an ISS of 25 or greater, and 71.1% had penetrating injuries. The most common mechanism was gunshot wound (62.7%), followed by auto versus pedestrian (11.4%) and motor vehicle collision (6.5%). Shunts were placed for damage control in 63.4%, staged repair for combined orthopedic and vascular injuries in 36.1%, and for insufficient surgeon skill set in 0.5%. The most common vessel shunted was the superficial femoral artery (23.9%), followed by popliteal artery (18.8%) and brachial artery (13.2%). An argyle shunt (81.2%) was the most common conduit, followed by Pruitt-Inahara (9.4%). Dwell time was less than 6 hours in 61.4%, 24 hours in 86.5%, 48 hours in 95.9%, with only 4.1% remaining in place for more than 48 hours. Of the patients, 81.6% survived to definitive repair, and 79.6% survived overall. Complications included shunt thrombosis (5.6%) and dislodgment (1.4%). There was no association between dwell time and shunt thrombosis. The use of a noncommercial shunt (chest tube/feeding tube) did not impact shunt thrombosis but was an independent risk factor for subsequent graft failure. The limb salvage rate was 96.3%. No deaths could be attributed to a shunt complication. CONCLUSION: In the largest civilian TIVS experience insertion to date, both damage control and staged orthopedic vascular injuries were common indications for shunting. With an acceptable complication burden and no associated mortality attributed to this technique, shunting should be considered a viable treatment option. LEVEL OF EVIDENCE: Therapeutic study, level V.

A second look at the utility of serial routine repeat computed tomographic scans in patients with traumatic brain injury.

BACKGROUND: The practice of a routine repeat head computed tomographic scans in patients with traumatic brain injury (TBI) is under question. The aim of our study was to evaluate the utility of a more than 1 repeat head computed tomography (M1CT) scans in patients with TBI. METHODS: We performed a 3-year analysis of a prospectively collected database of all TBI patients presenting to our level I trauma center. Patients who received M1CT scans were included. Findings and reason (without neurologic decline vs after neurologic decline) for M1CT were recorded. Primary outcome measure was neurosurgical intervention. RESULTS: A total of 296 patients that underwent M1CT were included. Of those, 291 patients (98.6%) had M1CT without a neurologic decline, and neurosurgical intervention was performed in 1 patient (.3%) who was inexaminable (Glasgow coma scale score = 6). The remaining (n = 5) had M1CT due to a neurologic decline; 4 patients (80%) of the 5 had worsening of ICH; and neurosurgical intervention was performed in 3 (75%) of the 4 patients. CONCLUSIONS: The practice of multiple repeat head computed tomographic scans should be limited to inexaminable patients or patients with neurological deterioration.

Impact of Hemorrhagic Shock on Pituitary Function.

BACKGROUND: Hypopituitarism after hypovolemic shock is well established in certain patient cohorts. However; the effects of hemorrhagic shock on pituitary function in trauma patients remains unknown. The aim of this study was to assess pituitary hormone variations in trauma patients with hemorrhagic shock. STUDY DESIGN: Patients with acute traumatic hemorrhagic shock presenting to our level 1 trauma center were prospectively enrolled. Hemorrhagic shock was defined as systolic blood pressure (SBP) ≤ 90 mmHg on arrival or within 10 minutes of arrival in the emergency department, and requirement of ≥2 units of packed red blood cell transfusion. Serum cortisol and serum pituitary hormones (vasopressin [ADH], adrenocorticotrophic hormone [ACTH], thyroid stimulating hormone [TSH], follicular stimulating hormone [FSH], and luteinizing hormone [LH]) were measured in each patient on admission and at 24, 48, 72, and 96 hours after admission. Outcome measure was variation in pituitary hormones. RESULTS: A total of 42 patients were prospectively enrolled; mean age was 37 ± 12 years, mean SBP 85.4 ± 64.5 mmHg, and median Injury Severity Score was 26 (range 18 to 38). There was an increase in the levels of cortisol (p < 0.001), a decrease in the levels of ACTH (p < 0.001) and ADH (p < 0.001), but no change in the levels of LH (p = 0.30), FSH (p = 0.07), and TSH (p = 0.89) over 96 hours. Ten patients died during their hospital stay. Patients who died had higher mean admission ADH levels (p = 0.03), higher mean admission ACTH levels (p < 0.001), and lower mean admission cortisol levels (p = 0.04) compared with patients who survived. CONCLUSIONS: Acute hypopituitarism does not occur in trauma patients with acute hemorrhagic shock. In patients who died, there was a decrease in cortisol levels, which appears to be adrenal in origin.

Factors associated with failure-to-rescue in patients undergoing trauma laparotomy.

INTRODUCTION: Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater risk of mortality; however, factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy. METHODS: An -8-year, retrospective analysis of patients undergoing trauma laparotomy was performed. Patients who developed major in-hospital complications were included. Major complications were defined as respiratory, infectious, cardiac, renal, or development of compartment syndrome. Regression analysis was performed to identify independent factors associated with failure-to-rescue after we adjusted for demographics, mechanism of injury, abdominal abbreviated injury scale, initial vital signs, damage control laparotomy, and volume of crystalloids and blood products administered. RESULTS: A total of 1,029 patients were reviewed, of which 21% (n = 217) patients who developed major complications were included. The mean age was 39 ± 18 years, 82% were male, 61% had blunt trauma, and median abdominal abbreviated injury scale was 25 [16-34, interquartile range]. Respiratory complications (n = 77) followed by infectious complications (n = 75) were the most common complications. The failure-to-rescue rate was 15.7% (n = 34/217). Age, blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictor for failure-to-rescue. CONCLUSION: When major complications develop, age, uninsured status, severity of head injury, and prolonged resuscitation are associated independently with failure-to-rescue, whereas initial resuscitation, coagulopathy, and acidosis did not predict failure to rescue. Quality-of-care programs focus in patient level should be on improving the patient's insurance status, preventing secondary brain injury, and further development of resuscitation guidelines.

Improving Hospital Quality and Costs in Nonoperative Traumatic Brain Injury: The Role of Acute Care Surgeons.

IMPORTANCE: The role of acute care surgeons is evolving; however, no guidelines exist for the selective treatment of patients with traumatic brain injury (TBI) exclusively by acute care surgeons. We implemented the Brain Injury Guidelines (BIG) for managing TBI at our institution on March 1, 2012. OBJECTIVE: To compare the outcomes in patients with TBI before and after implementation of the BIG protocol. DESIGN, SETTING, AND PARTICIPANTS: We conducted a 2-year analysis of our prospectively maintained database of all patients with TBI (findings of skull fracture and/or intracranial hemorrhage on an initial computed tomographic scan of the head) who presented to our level I trauma center. The pre-BIG group included patients with TBI from March 1, 2011, through February 29, 2012, and the post-BIG group included patients from July 1, 2012, through June 30, 2013. MAIN OUTCOMES AND MEASURES: The primary outcome measures were patients with repeated computed tomography of the head and neurosurgical consultations. Secondary outcome measures were findings of progression of intracranial hemorrhage on repeated computed tomographic scans, neurosurgical intervention, hospital admission, intensive care unit admission, hospital and intensive care unit length of stay, 30-day readmission rate, and hospital costs per patient. RESULTS: A total of 796 patients (415 in the pre-BIG group and 381 in the post-BIG group) were included. There was a significant reduction (19.0%) in the rate of neurosurgical consultation (post-BIG group, 273 patients [71.7%]; pre-BIG group, 376 [90.6%]; P < .001), repeated computed tomography of the head (post-BIG group, 255 patients [66.9%]; pre-BIG group, 381 patients [91.8%]; P < .001), hospital (post-BIG group, 330 [86.6%]; pre-BIG group, 398 [95.9%]; P < .001) and intensive care unit admission (post-BIG group, 202 [53.0%]; pre-BIG group, 257 [61.9%]; P = .01), hospital length of stay (post-BIG group, 5.4 [4.5] days; pre-BIG group, 6.1 [4.8] days; P = .03), and hospital costs per patient ($4772 per patient; P = .03) with implementation of BIG. There was no difference in the in-hospital mortality rate (post-BIG group, 62 patients [16.3%]; pre-BIG group, 69 patients [16.6%]; P = .89), progression of intracranial hemorrhage on repeated scans (post-BIG group, 41 patients [10.8%]; pre-BIG group, 59 patients [14.2%]; P = .14), neurosurgical intervention (post-BIG group, 61 patients [16.0%]; pre-BIG group, 59 patients [14.2%]; P = .48), and 30-day readmission rate (post-BIG group, 31 patients [8.1%]; pre-BIG group, 37 patients [8.9%]; P = .69) after implementation of BIG. CONCLUSIONS AND RELEVANCE: Implementation of BIG is safe and cost-effective. BIG defines the management of TBI without the need for neurosurgical consultation and unnecessary imaging. Establishing a national, multi-institutional study implementing the BIG protocol is warranted.