Study to evaluate the readability and visual appearance of online resources for blunt chest trauma: an evaluation of online resources using mixed methods.

OBJECTIVES: Blunt chest trauma (BCT) is characterised by forceful and non-penetrative impact to the chest region. Increased access to the internet has led to online healthcare resources becoming used by the public to educate themselves about medical conditions. This study aimed to determine whether online resources for BCT are at an appropriate readability level and visual appearance for the public. DESIGN: We undertook a (1) a narrative overview assessment of the website; (2) a visual assessment of the identified website material content using an adapted framework of predetermined key criteria based on the Centers for Medicare and Medicaid Services toolkit and (3) a readability assessment using five readability scores and the Flesch reading ease score using Readable software. DATA SOURCES: Using a range of key search terms, we searched Google, Bing and Yahoo websites on 9 October 2023 for online resources about BCT. RESULTS: We identified and assessed 85 websites. The median visual assessment score for the identified websites was 22, with a range of -14 to 37. The median readability score generated was 9 (14-15 years), with a range of 4.9-15.8. There was a significant association between the visual assessment and readability scores with a tendency for websites with lower readability scores having higher scores for the visual assessment (Spearman's r=-0.485; p<0.01). The median score for Flesch reading ease was 63.9 (plain English) with a range of 21.1-85.3. CONCLUSIONS: Although the readability levels and visual appearance were acceptable for the public for many websites, many of the resources had much higher readability scores than the recommended level (8-10) and visually were poor.Better use of images would improve the appearance of websites further. Less medical terminology and shorter word and sentence length would also allow the public to comprehend the contained information more easily.

Treatment of Severe Blunt Splenic Injury Varies Across Race and Insurance Type of Pediatric Patients.

INTRODUCTION: Racial and ethnic disparities in the management of adult patients with blunt splenic injuries (BSIs) have been previously demonstrated. It is unknown if similar disparities exist in pediatric patients with BSIs. Management of BSIs can include operative management, but nonoperative management (NOM) is preferred. This study assesses the association of race and insurance status on use of NOM among pediatric (aged < 18 y) patients following BSI. MATERIALS AND METHODS: Data were abstracted from the American College of Surgeons Trauma Quality Improvement Program Participant Use Files for calendar years 2013-2017. Multivariate logistic regression was used to evaluate the associations between race or insurance status and NOM while controlling for injury severity, age, and facility type. Secondary outcomes included blood transfusion within 24 h and hospital length of stay. RESULTS: We analyzed 1436 pediatric BSI patients. Black, non-Hispanic patients were less likely (odds ratio: 0.45, 95% confidence interval: 0.21-1.02, P = 0.043) to undergo NOM and stayed 0.6 d longer (P = 0.010) than White, non-Hispanic patients. Uninsured patients were less likely (odds ratio: 0.52, 95% CI: 0.25-1.11, P = 0.080) to undergo NOM and publicly insured patients stayed 0.24 d (P = 0.048) longer than privately insured patients. CONCLUSIONS: We found disparities in use of NOM for Black patients and uninsured patients as well as differences in length of stay. These results extend the literature on racial and socioeconomic disparities in care of trauma patients to pediatric BSI patients. Addressing these disparities requires additional studies aimed at identifying the underlying causes.

Reducing Phlebotomy, Length of Stay, Cost: Development of a Blunt Abdominal Trauma Pathway in a Level I, Pediatric Trauma Center.

OBJECTIVES: Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients. METHODS: A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses. RESULTS: After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED. CONCLUSIONS: Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care.

Immune Function After Splenic Artery Embolization for Blunt Trauma: Long-Term Assessment of CD27+ IgM B-Cell Levels.

Splenic artery embolization (SAE) plays a critical role in the treatment of high-grade splenic injury not requiring emergent laparotomy. SAE preserves splenic tissue, and growing evidence demonstrates preserved short-term splenic immune function after SAE. However, long-term function is less studied. Patients who underwent SAE for blunt abdominal trauma over a 10-year period were contacted for long-term follow-up. Sixteen participants (sex: women, 10, and men, 6; age: median, 34 years, and range, 18-67 years) were followed up at a median of 7.7 years (range, 4.7-12.8 years) after embolization. Splenic lacerations were of American Association for the Surgery of Trauma grades III to V, and 14 procedures involved proximal embolization. All individuals had measurable levels of IgM memory B cells (median, 14.30 as %B cells), splenic tissue present on ultrasound (median, 122 mL), and no history of severe infection since SAE. In conclusion, this study quantitatively demonstrated that long-term immune function remains after SAE for blunt abdominal trauma based on the IgM memory B cell levels.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes.

BACKGROUND: Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. OBJECTIVE: To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. METHODS: The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. RESULTS: A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. CONCLUSION: Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.

Developing a measure of overall intensity of injury care: A latent class analysis.

BACKGROUND: While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization. METHODS: We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013-2014), to identify emergency department-based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored. RESULTS: A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay. CONCLUSION: This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure. LEVEL OF EVIDENCE: For prognostic/epidemiological studies, level III.

Epidemiology and management of isolated blunt renal artery injuries.

BACKGROUND: Isolated blunt renal artery injury (BRAI) is uncommon. Treatment options include observation, nephrectomy, surgical reconstruction and endovascular stenting. Over the last decade, there has been an increasing use of angiointervention techniques in vascular trauma. Previous studies reported underutilization of endovascular stenting in BRAI, in favor of observation. The aim of this study was to examine the epidemiology and assess changes in the management of isolated BRAI over the last decade. METHODS: Patients with BRAI identified from the National Trauma Data Bank (2016-2017). Deaths in the emergency department, transferral from outside hospital, and those with associated high-grade kidney injuries were excluded. Demographics, type of renal artery injury, and renal artery management were analyzed. Multivariate analysis was used to identify independent factors associated with isolated BRAI. RESULTS: During the study period, there were 1,708,076 patients with blunt trauma and 873 (0.05%) of them had BRAI. After exclusions, 563 patients with isolated BRAI who met the criteria for inclusion in the analysis. Auto versus pedestrian mechanism and male sex were associated with the highest risk for isolated BRAI. Comorbidities, such as hypertension or diabetes, were not associated with an increased risk of BRAI. Seatbelt use had a protective effect against BRAI. In the majority of patients (534, 95%), the renal artery injury was treated with observation, 23 (4%) with nephrectomy, 5 (0.9%) with endovascular stent and 1 (0.2%) with open renal artery repair. Among the 103 patients with isolated major renal artery laceration, 91.2% were treated with observation, 7.8% with nephrectomy and 1% with stenting. CONCLUSION: Isolated blunt renal artery trauma is rare. The vast majority of patients with BRAI is managed with observation with only a small number undergoing endovascular intervention. Endovascular stenting utilization has remained very low and has not changed in the last decade.

"Do You Need a Doctor's Note?" Factors Leading to Delayed Return to Work after Blunt Chest Trauma.

BACKGROUND: Blunt chest trauma is associated with significant morbidity, but the long-term functional status for these patients is less well-known. Return to work (RTW) is a benchmark for functional recovery in trauma patients, but minimal data exist regarding RTW following blunt chest trauma. MATERIALS AND METHODS: Patients ≥ 18 y old admitted to a Level 1 trauma center following blunt chest trauma with ≥ 3 rib fractures and length of stay (LOS) ≥ 3 d were included. An electronic survey assessing RTW was administered to patients after discharge. Patients were stratified as having delayed RTW (> 3 mo after discharge) or self-reported worse activities-of-daily-living (ADL) function after injury. Patient demographics, outcomes, and injury characteristics were compared between groups. RESULTS: Median time to RTW was 3 mo (IQR 2,5). Patients with delayed RTW had higher odds of having more rib fractures than those with RTW ≤ 3 mo (median 10 versus 7; OR:1.24, 95%CI:1.04,1.48) as well as a longer LOS (median 13 versus 7 d; OR:1.15, 95% CI:1.04,1.30). Patients with stable ADL after trauma returned to work earlier than those reporting worse ADL (median 2 versus 3.5 mo, P < 0.01). 23.6% of respondents took longer than 5 mo to return to independent functioning, and 50% of respondents' report limitations in daily activities due to physical health after discharge. CONCLUSIONS: The significant proportion of patients with poor physical health and functional status suggests ongoing burden of injury after discharge. Patients with longer LOS and greater number of rib fractures may be at highest risk for delayed RTW after injury.

How common are traumatic injuries to the epididymis? A study of prevalence, imaging appearance, and management implications.

PURPOSE: To evaluate the prevalence of epididymal injuries with scrotal trauma, review imaging appearance, clinical management, and outcomes. METHODS: In this retrospective study, the radiology report database was queried for scrotal ultrasounds containing keywords pertaining to trauma, from 1998 to 2019. Exams with no clinically documented trauma, exams with trauma > 1 year ago, and duplicate exams were excluded. Chart review was conducted for age, trauma mechanism, time interval between trauma and ultrasound, signs of infection, and clinical management. Reports were reviewed to record the presence of scrotal injury, traumatic epididymitis, or epididymal hematoma. Cases with epididymal injury underwent image review. Descriptive statistics, Fisher's exact test, and Mann-Whitney's U test were performed to evaluate for associations between clinical parameters and epididymal injury. RESULTS: Initial search yielded 385 exams. A total of 103 exams met inclusion criteria. Trauma mechanisms included straddle injury (35%), blunt scrotal trauma by ball or other object (29%), assault (28%), penetrating injury (4%), and fall (3%). Sixty-eight patients (66%) had scrotal injury on imaging. Twenty-six (25%) had epididymal injury. Thirteen were isolated to the epididymis, and 13 had associated testicular or extra-testicular findings. There were 12 cases of traumatic epididymitis and 14 epididymal hematomas. All epididymal injuries were managed non-operatively. A total of 7 were prescribed antibiotics, including 1 subject who otherwise had no evidence of infection. CONCLUSION: Epididymal injury is encountered in 25% of scrotal ultrasounds for trauma evaluation. Traumatic epididymitis can be seen in 12%. It is important for radiologists to recognize this entity, as it can be mistaken for infection.

Splenic artery angioembolization for high-grade splenic injury: Are we wasting money?

BACKGROUND: Non-operative management (NOM) is accepted treatment of splenic injury, but this may fail leading to splenectomy. Splenic artery embolization (SAE) may improve rate of salvage. The purpose is to determine the cost-utility of the addition of SAE for high-grade splenic injuries. METHODS: A cost-utility analysis was developed to compared NOM to SAE in patients with blunt splenic injury. Sensitivity analysis was completed to account for uncertainty. Utility outcome was quality-adjusted life years (QALY). RESULTS: For patients with grade III, IV and V injury NOM is the dominant strategy. The probability of NOM being the more cost-effective strategy is 87.5% in patients with grade V splenic injury. SAE is not the favored strategy unless the probability of failure of NOM is greater than 70.0%. CONCLUSION: For grade III-V injuries, NOM without SAE yields more quality-adjusted life years. NOM without SAE is the most cost-effective strategy for high-grade splenic injuries.

The cost to perform splenic artery embolisation following blunt trauma: Analysis from a level 1 Australian trauma centre.

INTRODUCTION: Splenic artery embolisation (SAE) has been shown to be an effective treatment for haemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. The purpose of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma at an Australian level 1 trauma centre. METHODS: This was a single-centre retrospective review of 10 patients who underwent splenic embolisation from December 2017 to December 2018 for the treatment of isolated blunt splenic injury, including cost of procedure and the entire admission. Costs included angiography costs including equipment, machine, staff, and post-procedural costs including pharmacy, general ward costs, orderlies, ward nursing, allied health, and further imaging. RESULTS: During the study period, patients remained an inpatient for a mean of 4.8 days and the rate of splenic salvage was 100%. The mean total cost of splenic embolisation at our centre was AUD$10,523 and median cost AUD$9959.6 (range of $4826-$16,836). The use of a plug as embolic material was associated with increased cost than for coils. Overall cost of patients requiring ICU was mean AUD$11,894 and median AUD$11,435.8. Overall cost for those not requiring ICU was mean AUD$7325 and median AUD$8309.8. CONCLUSION: Splenic embolisation is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our centre was much lower than previously modelled data from overseas studies. From a cost perspective, the use of ICU for monitoring after the procedure significantly increased cost and necessity may be considered on a case-by-case basis. Further research is advised to directly compare the cost of SAE and splenectomy in an Australian setting.

Penetrating Spinal Cord Injury in civilians: analysis of a national database.

BACKGROUND: Spinal trauma is common in polytrauma; spinal cord injury (SCI) is present in a subset of these patients. Penetrating SCI has been studied in the military; however, civilian SCI is less studied. Civilian injury pathophysiology varies given the generally lower velocity of the projectiles. We sought to investigate civilian penetrating SCI in the United States. METHODS: We queried the National Inpatient Sample for data regarding penetrating spinal cord injury from the past 10 years (2006-2015). The National Inpatient Sample includes data of 20% of discharged patients from U.S. hospitals. We analyzed trends of penetrating SCI regarding its diagnosis, demographics, surgical management, length of stay, and hospital costs. RESULTS: In the past 10 years the incidence of penetrating SCI in all SCI patients has remained stable with a mean of 5.5% (range 4.3%-6.6%). Of the patients with penetrating SCI, only 17% of them underwent a surgical procedure, compared with 55% for nonpenetrating SCI. Patients with penetrating SCI had a longer length of stay (average 23 days) compared with nonpenetrating SCI (15 days). Hospital charges were higher for penetrating SCI: $230,186 compared with $192,022 for closed SCI. Males patients were more affected by penetrating SCI, as well as black and Hispanic populations compared with whites. CONCLUSIONS: Penetrating SCI represents 5.5% of all SCI patients. Men, blacks, and Hispanics are disproportionally more affected by penetrating SCI. Patients with penetrating SCI have fewer surgical interventions, but their overall length of stay and hospital costs are greater compared with nonpenetrating SCI.

Epidemiological state, predictive model for mortality, and optimal management strategy for pancreatic injury: A multicentre nationwide cohort study.

BACKGROUND: Data for establishing the optimal management modalities for pancreatic injury are lacking. Herein, we aimed to describe the epidemiology, identify mortality predictors, and determine the optimal management strategy for pancreatic injury. METHODS: We identified patients with pancreatic injury between 2004 and 2017 recorded in the Japan Trauma Data Bank. The primary outcome was mortality. Multivariable logistic regression analyses were used to identify factors significantly associated with mortality and to develop a predictive model. Patients were also classified according to the Organ Injury Scaling of the American Association for the Surgery of Trauma (AAST grade I/II or III/IV). Outcomes were compared based on significant confounder-adjusted treatment strategy. RESULTS: Overall, 743 (0.25%) patients had pancreatic injury. Traffic accident was the most common aetiology. The overall mortality rate was 17.5%, while it was 4.7% for isolated pancreatic injury. AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were independently associated with mortality. A predictive model for mortality comprising these four variables showed excellent performance, with an area under the receiver operating characteristic curve of 0.89 (95% confidence interval [CI], 0.85-0.93). The in-hospital mortality was higher in patients who underwent celiotomy than in those who did not among those with AAST grade I/II (15.1% vs. 5.3%) and III/IV (13.8% vs. 12.3%). After adjusting for confounders, these differences were not significant with the adjusted odds ratios of 1.41 (95% CI, 0.55-3.60) and 0.54 (95% CI, 0.17-1.67) for AAST grade I/II and III/IV, respectively. CONCLUSIONS: AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were prognostic factors of mortality after pancreatic injury. Confounder-adjusted analysis did not show that operative management was superior to non-operative management for survival. Non-operative management may be a reasonable strategy for select pancreatic injury patients, especially in institutions where expertise in interventional endoscopy is available.

Bedside Ultrasound Assessment of Lung Reaeration in Patients With Blunt Thoracic Injury Receiving High-Flow Nasal Cannula Oxygen Therapy: A Retrospective Study.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy has been shown to reduce the need for mechanical ventilation and decrease the duration of hospital and intensive care unit (ICU) stays for patients with a severely compromised respiratory system. This study aims to observe the evolution of lung aeration via lung ultrasound score (LUS) in a chest-injured population who had been treated with HFNC oxygen therapy, and to assess the benefit of the HFNC oxygen therapy in trauma patients. METHODS: A retrospective study examined trauma patients with moderate to severe thoracic injuries who were admitted to the ICU at a tertiary hospital between October 2015 and March 2017. The decision to initiate HFNC oxygen therapy was made at the discretion of the trauma surgeon and respiratory therapist when supplemental oxygen delivery was required. All of the patients were assessed by transthoracic lung ultrasound every day after being admitted into the ICU. We retrospectively analyzed 3 time points for this study: the initial emergency intensive care units presentation within 12 hours (T1), 24 to 48 hours after the treatment (T2), and 72 to 96 hours after the treatment (T3). Transthoracic lung ultrasound was performed by an experienced investigator with level 3 certification using a Mindray M9 echograph and a 2- to 4-MHz round-tipped probe. Primary outcomes were the need for intubation after HFNC oxygen therapy for respiratory failure during the treatment within 72 hours, the length of ICU stay, and mortality of 28 days. RESULTS: During the study period, 50 patients with blunt chest trauma were admitted to the study; 18 patients received HFNC therapy and 32 received conventional oxygen therapy (COT); there was no significant difference in the baseline clinical characteristics between the 2 groups. The length of ICU stay and intubation rate for respiratory failure within 72 hours were significantly different between the 2 groups (P < .05), but there was no difference in the 28-day mortality. The LUS of the COT group was not significantly different from T1 to T2 or from T2 to T3 (P > .05). However, the LUS decreased significantly-by 25% from T1 to T2 (P < .05) and by 31% from T1 to T3 (P < .05) in the HFNC therapy group. The LUS of the patients intubated for respiratory failure within 72 hours, in the COT group increased from T1 (17 ± 3) to T3 (21 ± 3), and the LUS (21 ± 3) was much higher than the patients who were not intubated (11 ± 3) at T3; the LUS of the HFNC group was all above 15, which was not significantly different from T1 to T2 or from T2 to T3 (P > .05). CONCLUSIONS: High-flow nasal cannula oxygen therapy may be considered as an initial respiratory therapy for trauma patients with blunt chest injury. High-flow nasal cannula therapy could improve lung aeration as noted by the transthoracic lung ultrasound assessment, and LUS may help the attending physicians identify the usefulness of HFNC therapy and decide whether to continue the use of HFNC therapy or intubate the patient.

Predictors of Delayed Emergency Department Throughput Among Blunt Trauma Patients.

BACKGROUND: Delayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. METHODS: The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. RESULTS: 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). CONCLUSIONS: ED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.

Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis.

OBJECTIVE: The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury. METHODS: We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year. RESULTS: The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%. CONCLUSION: A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.

Blunt versus penetrating trauma: Is there a resource intensity discrepancy?

BACKGROUND: The rising cost of healthcare requires responsible allocation of resources. Not all trauma centers see the same types of patients. We hypothesized that patients with blunt injuries require more resources than patients with penetrating injuries. METHODS: This was a retrospective analysis of all highest-level activation trauma patients at our busy urban Level I Trauma Center over five years. Data included demographics, injuries, hospital charges, and resources used. A p value < 0.05 was significant. RESULTS: 4578 patients were included (2037 blunt and 2541 penetrating). Blunt patients were more severely injured, more often admitted, required more radiographic studies, had longer hospital, intensive care unit, and mechanical ventilation days, and therefore, higher hospital charges. CONCLUSIONS: Within one center, patients with blunt injuries required more resources than those with penetrating injuries. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution.

Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol.

INTRODUCTION: A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS: In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION: The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER: NTR6833.

Trauma system resource preservation: A simple scene triage tool can reduce helicopter emergency medical services overutilization in a state trauma system.

BACKGROUND: Helicopter emergency medical services improve survival in some injured patients but current utilization leads to significant overtriage with considerable numbers of transported patients discharged home from the emergency department or found to have non-time-sensitive injuries. Current triage models for utilization are complex and untested. METHODS: Data from a state trauma registry were reviewed from 1987 to 1993 and from 2013 to 2015 and compared. Data from 2013 to 2015 were analyzed for field information found to influence mortality and a model for low mortality-risk patients designed. RESULTS: Indexed to population, a major increase in numbers of injured patients transported directly to designated trauma centers (39.849-167.626/100,000/year) occurred with an increased portion transported by helicopter emergency medical services from 7.28% to 9.26%. A simple triage tool to predict low mortality rates was designed utilizing results from logistic regression. Nongeriatric adult patients (age, 16.0-69.9 years) with a blunt injury mechanism, normal Glasgow Coma Scale motor score, pulse rate of 60 bpm to 120 bpm and respiratory rate of 10 breaths per minute to 29 breaths per minute are at low risk for mortality. Cost for helicopter transportation was substantially higher than ground transportation based on available data. Cost differentials in transport mode increased patient financial risk when helicopter transportation was utilized. CONCLUSION: Implementing a simple decision tool designating nongeriatric adult patients with a blunt injury mechanism, normal Glasgow Coma Scale motor score, systolic blood pressure greater than 90 mm Hg, pulse rate of 60 bpm to 120 bpm, and respiratory rate of 10 breaths per minute to 29 breaths per minute to ground transportation would result in substantial savings without an increase in mortality and reduce risk of patient financial harm. LEVEL OF EVIDENCE: Prognostic/Epidemiological study, level IV. Economic and value based evaluation, level IV.

A multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL Trial.

OBJECTIVE: A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). The aim of this trial is to assess the feasibility and acceptability of a definitive impact trial investigating the clinical and cost-effectiveness of a new prognostic model for the management of patients with blunt chest wall trauma in the ED. DESIGN: Stepped wedge feasibility trial. SETTING: Four EDs in England and Wales. PARTICIPANTS: Adult blunt chest wall trauma patients presenting to the ED with no concurrent, life-threatening injuries. INTERVENTION: A prognostic model (the STUMBL score) to guide clinical decision-making. OUTCOME MEASURES: Primary: participant recruitment rate and clinicians' use of the STUMBL score. Secondary: composite outcome measure (mortality, pulmonary complications, delayed upgrade in care, unplanned representations to the ED), physical and mental components of quality of life, clinician feedback and health economic data gathering methodology for healthcare resource utilisation. RESULTS: Quantitative data were analysed using the intention-to-treat principle. 176 patients were recruited; recruitment targets were achieved at all sites. Clinicians used the model in 96% of intervention cases. All feasibility criteria were fully or partially met. After adjusting for predefined covariates, there were no statistically significant differences between the control and intervention periods. Qualitative analysis highlighted that STUMBL was well-received and clinicians would support a definitive trial. Collecting data on intervention costs, health-related quality of life and healthcare resource use was feasible. DISCUSSION: We have demonstrated that a fully powered randomised clinical trial of the STUMBL score is feasible and desirable to clinicians. Minor methodological modifications will be made for the full trial. TRIAL REGISTRATION NUMBER: ISRCTN95571506; Post-results.