Utilizing predictive machine-learning modelling unveils feature-based risk assessment system for hyperinflammatory patterns and infectious outcomes in polytrauma.

Purpose: Earlier research has identified several potentially predictive features including biomarkers associated with trauma, which can be used to assess the risk for harmful outcomes of polytraumatized patients. These features encompass various aspects such as the nature and severity of the injury, accompanying health conditions, immune and inflammatory markers, and blood parameters linked to organ functioning, however their applicability is limited. Numerous indicators relevant to the patients` outcome are routinely gathered in the intensive care unit (ICU) and recorded in electronic medical records, rendering them suitable predictors for risk assessment of polytraumatized patients. Methods: 317 polytraumatized patients were included, and the influence of 29 clinical and biological features on the complication patterns for systemic inflammatory response syndrome (SIRS), pneumonia and sepsis were analyzed with a machine learning workflow including clustering, classification and explainability using SHapley Additive exPlanations (SHAP) values. The predictive ability of the analyzed features within three days after admission to the hospital were compared based on patient-specific outcomes using receiver-operating characteristics. Results: A correlation and clustering analysis revealed that distinct patterns of injury and biomarker patterns were observed for the major complication classes. A k-means clustering suggested four different clusters based on the major complications SIRS, pneumonia and sepsis as well as a patient subgroup that developed no complications. For classification of the outcome groups with no complications, pneumonia and sepsis based on boosting ensemble classification, 90% were correctly classified as low-risk group (no complications). For the high-risk groups associated with development of pneumonia and sepsis, 80% of the patients were correctly identified. The explainability analysis with SHAP values identified the top-ranking features that had the largest impact on the development of adverse outcome patterns. For both investigated risk scenarios (infectious complications and long ICU stay) the most important features are SOFA score, Glasgow Coma Scale, lactate, GGT and hemoglobin blood concentration. Conclusion: The machine learning-based identification of prognostic feature patterns in patients with traumatic injuries may improve tailoring personalized treatment modalities to mitigate the adverse outcomes in high-risk patient clusters.

[Is polytrauma treatment in deficit in the aG-DRG system?] / Ist die Polytraumaversorgung im aG-DRG-System defizitär?

BACKGROUND: The interdisciplinary care of severely injured patients is staff and resource intensive. Since the introduction of the G­DRG system in Germany in 2003, most studies have identified a financial deficit in the care of severely injured patients. The aim of this study was to analyze the effects of the new aG-DRG system introduced in 2020 on cost recovery in the treatment of severely injured patients. For the first time, the costs for organization, certification and documentation as well as the costs for non-seriously injured shock room patients were included. METHODS: All patients who were treated in the surgical shock room of the emergency department of the Leipzig University Hospital in 2017 were included. For the analysis, the cost model according to Pape et al. was extended by the module organization, documentation and certification and for the first time the costs for overtriaged patients were considered. A cost calculation was performed for the years 2017-2020 as well a comparison with the respective earnings. RESULTS: A total of 834 patients were treated in the shock room and 258 severely injured patients were divided into 3 groups: ISS 9-15 + ICU (n 72; ∅ ISS 11.9; costs per patient 14,715 €),ISS ≥ 16 (n 186; ∅ ISS 27.7; costs per patient 30,718 €) and DRG polytrauma (n 59; ∅ ISS 32.4; costs per patient 26,102 €). CONCLUSION: Polytrauma care under the aG-DRG 2020 is in deficit. Overall, in 2020 a deficit of 5858 € per severely injured patient resulted.

Interobserver variability of injury severity assessment in polytrauma patients: does the anatomical region play a role?

BACKGROUND: The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are widely used to assess trauma patients. In this study, the interobserver variability of the injury severity assessment for severely injured patients was analyzed based on different injured anatomical regions, and the various demographic backgrounds of the observers. METHODS: A standardized questionnaire was presented to surgical experts and participants of clinical polytrauma courses. It contained medical information and initial X-rays/CT-scans of 10 cases of severely injured patients. Participants estimated the severity of each injury based on the AIS. Interobserver variability for the AIS, ISS, and New Injury Severity Score (NISS) was calculated by employing the statistical method of Krippendorff's α coefficient. RESULTS: Overall, 54 participants were included. The major contributing medical specialties were orthopedic trauma surgery (N = 36, 67%) and general surgery (N = 13, 24%). The measured interobserver variability in the assessment of the overall injury severity was high (α ISS: 0.33 / α NISS: 0.23). Moreover, there were differences in the interobserver variability of the maximum AIS (MAIS) depending on the anatomical region: αhead and neck: 0.06, αthorax: 0.45, αabdomen: 0.27 and αextremities: 0.55. CONCLUSIONS: Interobserver agreement concerning injury severity assessment appears to be low among clinicians. We also noted marked differences in variability according to injury anatomy. The study shows that the assessment of injury severity is also highly variable between experts in the field. This implies the need for appropriate education to improve the accuracy of trauma evaluation in the respective trauma registries.

Patterns and Predictors of Firearm-related Spinal Cord Injuries in Adult Trauma Patients.

INTRODUCTION: Firearm-related spinal cord injuries are commonly missed in the initial assessment as they are often obscured by concomitant injuries and emergent trauma management. These injuries, however, have a significant health and financial impact. The objective of this study was to examine firearm-related spinal cord injuries and identify predictors of presence of such injuries in adult trauma patients. METHODS: This retrospective cohort study examined adult trauma patients (≥16 years) with injuries from firearms included in the 2015 United States National Trauma Data Bank. We performed descriptive and bivariate analyses and compared two groups: patients with no spinal cord injury (SCI) or vertebral column injury (VCI); and patients with SCI and/or VCI. Predictors of SCI and/or VCI in patients with firearm-related injuries were identified using a multivariate logistic regression analysis. RESULTS: There were 34,898 patients who sustained a firearm-induced injury. SCI and/or VCI were present in 2768 (7.9%) patients. Patients with SCI and/or VCI had more frequently severe injuries, higher Injury Severity Score (ISS), lower mean systolic blood pressure, and lower Glasgow Coma Scale (GCS). The mortality rate was not significantly different between the two groups (14.7%, N = 407 in SCI and/or VCI vs 15.0%, N = 4,811 in no SCI or VCI group). Significant general positive predictors of presence of SCI and/or VCI were as follows: university hospital; assault; public or unspecified location of injury; drug use; air medical transport; and Medicaid coverage. Significant clinical positive predictors included fractures, torso injuries, blood vessel or internal organ injuries, open wounds, mild (13-15) and moderate GCS scores (9 - 12), and ISS ≥ 16. CONCLUSION: Firearm-induced SCI and/or VCI injuries have a high burden on affected victims. The identified predictors for the presence of SCI and/or VCI injuries can help with early detection, avoiding management delays, and improving outcomes. Further studies defining the impact of each predictor are needed.

[Care Management for Polytrauma Patients in a Level-1 Trauma Centre]. / Care Management für Polytrauma-Patientinnen und -Patienten in einem überregionalen Level-1- Traumazentrum.

Care Management for Polytrauma Patients in a Level-1 Trauma Centre Abstract. In our level-1 trauma institution, polytrauma patients with an Injury Severity Score of 16 or higher are facing waiting times for transfer to a rehabilitation facility, causing a negative financial outcome for our institution. The purpose of this study is to stimulate rapid transfer to a rehabilitation facility. In a single-centre case study, care management for (poly)trauma patients was started to ensure time-directed treatment for trauma patients related to Diagnosis-Related Groups (DRG). In the period of 2013-2018 there was an increase in trauma admissions up to 14 % (n = 16 157) with a mean length of hospital stay of 6.4 days, together with a reduction in the number of trauma bed capacity from 50 to 42. In relation to the DRGs, regular trauma patients who were not in need of a stationary rehabilitation facility stayed in line with the expected time of hospital stay. But (poly)trauma patients (n = 1831) with the need of a stationary stay in a rehabilitation centre were faced with waiting times before they could be transferred. The average excess waiting time in relation to DRG for polytrauma patients was 5.1 days. Trauma patients for a rehabilitation centre have a higher Case Mix Index (CMI) compared to those who do not require inpatient rehabilitation (4.22 versus 1.04, p <0.0001). With about 280 trauma patients annually waiting an extra 5.1 days for transfer to a rehabilitation facility, the financial burden for our department amounts to Swiss francs 885,360 without reimbursement. Since no extra bed capacities in rehabilitation facilities are available in our area, it may be advised to set up an early in-hospital trauma rehabilitation program in a level-1 trauma centre in order to reduce financial loss.

Injury severity level and associated factors among road traffic accident victims attending emergency department of Tirunesh Beijing Hospital, Addis Ababa, Ethiopia: A cross sectional hospital-based study.

BACKGROUND: Road Traffic Accidents have become an enormous global public health problem killing approximately 1.25 million people and injuring 20 to 50 million others yearly. It is the 10th leading cause of death universally and the number one cause of mortality of the young population between the ages of 5 and 29. Only few studies have been conducted on the severity of road traffic injuries in Ethiopia hence the need for the study. OBJECTIVE: To assess injury severity level and associated factors among road traffic accident victims. METHODS: A cross-sectional study of patients involved in road traffic accident and attended Tirunesh Beijing hospital, Addis Ababa, Ethiopia. Victims were consecutively recruited until sample size (164) attained during the study period. Data collectors administered a structured questionnaire. The collected data was then entered and cleaned using Epi info and exported to IBM SPSS for statistical analysis. Independent factors associated with injury severity were assessed using bivariate and multivariate logistic regression. RESULTS: A total of 164 road traffic injury victims were included to the study. Prevalence of severe injury accounted for 36.6% of cases. "can read and write" educational status OR 35.194(95% CI; 3.325-372.539), sustaining multiple injury OR 18.400(95% CI; 5.402-62.671), sustaining multiple injury type OR 6.955(95% CI; 1.716-28.185) and being transported by ambulance from the scene of accident OR 13.800(95% CI; 1.481-128.635) were the explanatory variables found to have a statistically significant association with severe injury. CONCLUSION: This study showed road traffic accident is predominantly affecting the economically active, male young population. Not a single victim received pre-hospital care, majority were extracted by bystanders and most used commercial vehicle to be transported to a health institution reflecting the need for improvements in pre-hospital emergency services and socio-economic related infrastructures.

Rehabilitation Assessment and Management of Neurosensory Deficits After Traumatic Brain Injury in the Polytrauma Veteran.

Neurosensory deficits after traumatic brain injury can frequently lead to disability; therefore, diagnosis and treatment are important. Posttraumatic headaches typically resemble migraines and are managed similarly, but adjuvant physical therapy may be beneficial. Sleep-related issues are treated pharmacologically based on the specific sleep-related complaint. Fatigue is difficult to treat; cognitive behavioral therapy and aquatic therapy can be beneficial. Additionally, methylphenidate and modafinil have been used. Peripheral and central vestibular dysfunction causes dizziness and balance dysfunction, and the mainstay of treatment is vestibular physical therapy. Visual dysfunction incorporates numerous different diagnoses, which are frequently treated with specific rehabilitation programs.

[Costs and proceeds from patients admitted via the emergency room with mild craniocerebral trauma]. / Kosten und Erlöse von über den Schockraum eingelieferten Patienten mit leichtem Schädel-Hirn-Trauma.

The introduction of the diagnosis-related groups (DRG) in 2003 radically changed the billing of the treatment costs. From the very beginning, trauma surgeons questioned whether the introduction of the DRG could have a negative impact on the care of the severely injured. "Trauma centers in need" was the big catchword warning against shortfalls at trauma centers due to the billing via DRG. This situation was confirmed in the first publications after introduction of the DRG, showing a clearly deficient level of care of polytrauma cases. Over the years, adjustments have led to an improvement in the remuneration for polytraumatized patients. In the emergency room, polytrauma is not always the final diagnosis. A considerable proportion of patients are only slightly injured, but must be admitted via the emergency room due to the circumstances of the accident or suspected diagnosis at the scene of the accident to exclude life-threatening injuries. In this study, patients with the billing diagnosis of mild craniocerebral trauma were selected as an example. The proportion of these patients was 22% during the period of observation in 2017. For these patients, the proportional costs during treatment were calculated. It could be shown that 60.36% of the costs during a 2­day treatment of these patients were incurred in the emergency room. Costs for material and personnel could not be considered. Despite not including these expenses, the costs were never covered for any of these patients. For patients with slight injuries after trauma management in the emergency room, the present adjustments to the DRG system by increasing the basic case value seem to be insufficient. Additional remuneration for these patients seems absolutely justified to further ensure adequate quality of care.

Gunshot Injuries to the Extremity: Is Immediate General Surgery Presence Needed?

Gunshot wounds (GSW) are becoming increasingly prevalent in urban settings. GSW to the trunk mandate full trauma activation and immediate surgeon response because of the high likelihood of operative intervention. Extremity GSW proximal to the knee/elbow also require full trauma activation based on American College of Surgeons Committee on trauma standards. However, whether isolated extremity GSW require frequent operative intervention is unclear. We evaluated GSW at our Level I trauma center from January 2012 to December 2016. Demographic data and injury patterns were abstracted from the trauma registry and charts. The number of GSW increased yearly but the age, gender, Injury Severity Score and injury pattern did not change (P = ns, not shown). There were 504 GSW that included an extremity and 194 (38%) involved multiple body regions. There were 310 GSW (62%) isolated to an extremity and 176 were proximal to the elbow/knee. If proximal GSW had an Emergency Department systolic blood pressure <90 mm Hg, 53 per cent underwent vascular repair, 12 per cent had soft tissue repair, and 29 per cent required no operation. If proximal GSW had an Emergency Department blood pressure >90 mm Hg, 57 per cent underwent orthopedic repair, 22 per cent required no surgery, and only 13 per cent required vascular repair (P < 0.01). In the absence of other criteria for full trauma activation such as shock, the need for the immediate presence of a general surgeon to perform emergency surgery for a GSW isolated to the extremity is low.

Assessment of clinical parameters of the polytraumatized patient as predictors of hospital expenditure and of its distribution. / Valoración de parámetros clínicos del paciente politraumatizado como predictores del gasto hospitalario y de su distribución.

INTRODUCTION: Traumatic pathology continues to represent an important socio-health problem. The aim of the study was to assess the clinical predictors of total expenditure, as well as to analyze which components of the cost are modified with each clinical parameter of the polytraumatized patient. MATERIAL AND METHODS: Retrospective study of 131 polytrauma patients registered prospectively. A statistical analysis was carried out to assess the relationship between clinical parameters, the total cost and the cost of various treatment components. RESULTS: The total cost of hospital admission was 3,791,879 euros. The average cost per patient was € 28,945. Age and gender were not predictors of cost. The scales ISS, NISS and PS were predictors of the total cost and of multiple treatment components. The AIS of Skull and Thorax predicted a higher cost of admission to ICU and Total Cost. The AIS of lower limbs was associated with greater spending on facets of treatment related to surgical activity. DISCUSSION: There are clinical parameters that are predictors of the treatment cost of the polytraumatized patient. The study describes how the type of trauma that the patient suffers modifies the type of expenses that will present in their hospital admission. CONCLUSIONS: Polytraumatized patients with severe multisystem injury present increased costs in multiple components of the treatment cost. Patients with TBI or chest trauma present a higher cost for admission to ICU and those with orthopaedic trauma are associated with greater expenditure on surgical activity.

Assessment of polytraumatized patients according to the Berlin Definition: Does the addition of physiological data really improve interobserver reliability?

BACKGROUND: Several new definitions for categorizing the severely injured as the Berlin Definition have been developed. Here, severely injured patients are selected by additive physiological parameters and by the general Abbreviated Injury Scale (AIS)-based assessment. However, all definitions should conform to an AIS severity coding applied by an expert. We examined the dependence of individual coding on defining injury severity in general and in identifying polytrauma according to several definitions. A precise definition of polytrauma is important for quality management. METHODS: We investigated the interobserver reliability (IR) between several polytrauma definitions for identifying polytrauma using several cut-off levels (ISS ≥16, ≥18, ≥20, ≥25 points, and the Berlin Definition). One hundred and eighty-seven patients were included for analyzing IR of the polytrauma definitions. IR for polytrauma definitions was assessed by Cohen's kappa. RESULTS: IR for identifying polytrauma according to the relevant definitions showed moderate agreement (<0.60) in the ISS cutoff categories (ISS ≥16, ≥18, and ≥20 points), while ISS ≥25 points just reached substantial agreement (0.62) and the Berlin Definition demonstrated a correlation of 0.77 which is nearly perfect agreement (>0.80). CONCLUSION: Compared with the ISS-based definitions of polytrauma, the Berlin Definition proved less dependent on the individual rater. This underlines the need to redefine the selection of severely injured patients. Using the Berlin Definition for identifying polytrauma could improve the comparability of patient data across studies, in trauma center benchmarking, and in quality assurance.

Revenue for Initial Orthopaedic Trauma Care: Effects of Patient and Injury Characteristics.

OBJECTIVE: To characterize the charges and collections associated with the initial inpatient management of trauma patients who undergo operative fracture management. DESIGN: Retrospective. SETTING: Level 1 trauma center. PARTICIPANTS: Four hundred forty consecutive, adult, trauma patients. INTERVENTION: Fixation for fracture of the spine, pelvis, acetabulum, and/or femur fractures. MAIN OUTCOME MEASURES: Professional and technical (facility) charges and collections from the initial inpatient management and 6 months of subsequent related care. RESULTS: Patients were predominantly male (74.3%) and white (63.2%) with a mean age of 41 years and mean injury severity score of 18.5. Uninsured (self-pay) patients represented the largest payer class (35.0%), and 34.5% of all patients were unemployed. Professional and technical charges totaled US $12,382,028 (US $28,140/patient) and US $39,682,225 (US $90,187/patient), respectively. Injury severity score, longer lengths of stay (LOS), and the presence of a complication were positive predictors of initial charges (P < 0.0001; adjusted R = 0.799). Professional and technical collections totaled US $2,418,096 (US $5,496/patient) and US $16,921,959 (US $38,459/patient) (percent of charge: 21.5% vs. 41.3%; P < 0.0001). Of the self-pay patients, 34.4% had no collections, resulting in potential lost revenue of US $2,513,988. Greater collections were predicted to occur in females, employed patients, and those with insurance (P < 0.0001; adjusted R = 0.35). CONCLUSIONS: Trauma patients often present without insurance, which compromises hospital revenue. Expectedly, charges are higher in more severely injured patients, those with longer LOS, and those experiencing complications. A bundled model will proportionately decrease reimbursements for a given episode of care in the event of longer LOS or occurrence of complications.

[Treatment of advanced age patients with polytrauma through lethal outcome risk assessment]. / Taktika lecheniia patsientov starshikh vozrastnykh grupp s politravmoi na osnovanii otsenki riska nastupleniia letal'nogo iskhoda.

AIM: To objectify timing of DCS stages implementation in advanced age patients through lethal outcome risk assessment. MATERIAL AND METHODS: 128 advanced age patients with polytrauma were enrolled. RESULTS: It was concluded that specialized prognosis scale for advanced age patients with polytrauma allowed to objectify the transition time between DCS stages that led to decrease of mortality by 10.6%.

[Medical information system (PMSI) does not adequately identify severe trauma]. / La codification PMSI identifie mal les traumatismes graves.

BACKGROUND: Resource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims. METHODS: We studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient. RESULTS: During the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %). CONCLUSION: DCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding.

The Assignment of American Society of Anesthesiologists Physical Status Classification for Adult Polytrauma Patients: Results From a Survey and Future Considerations.

BACKGROUND: The American Society of Anesthesiologists (ASA) physical status (PS) classification system assesses the preoperative health of patients. Previous studies demonstrated poor interrater reliability and variable ASA PS scores, especially in trauma scenarios. There are few studies that evaluated the assignment of ASA PS scores in trauma patients and no studies that evaluated ASA PS assignment in severely injured adult polytrauma patients. Our objective was to assess interrater reliability and identify sources of discrepancy among anesthesiologists and trauma surgeons in designating ASA PS scores to adult polytrauma patients. METHODS: A link to an online survey containing questions assessing attitudes regarding ASA PS classification, demographic information, and 8 fictional trauma cases was e-mailed to anesthesiologists and trauma surgeons. The participants were asked to assign an ASA PS score to each scenario and explain their choice. Rater-versus-reference and interrater reliability, beyond that expected by chance, among respondents was analyzed using the Fleiss kappa analysis. RESULTS: A total of 349 participants completed the survey. All 8 cases had inconsistent ASA PS scores; several cases had scores ranging from I to VI and variable emergency (E) designations. Using weighted kappa (Kw) analysis for a subset of 201 respondents (101 trauma surgeons [S] and 100 anesthesiologists [A]), we found moderate (Kw = 0.63; SE = 0.024; 95% confidence interval, 0.594-0.666; P < .001) interrater-versus-reference reliability. The interrater reliability was fair (Kw = 0.43; SE = 0.037; 95% confidence interval, 0.360-0.491; P < .001). CONCLUSIONS: This study demonstrates fair interrater reliability beyond that expected by chance of the ASA PS scores among anesthesiologists and trauma surgeons when assessing adult polytrauma patients. Although the ASA PS is used in some trauma risk stratification models, discrepancies of ASA PS scores assigned to trauma cases exist. Future modifications of the ASA PS guidelines should aim to improve the interrater reliability of ASA PS scores in trauma patients. Further studies are warranted to determine the value of the ASA PS score as a trauma prognostic metric.

[Prehospital assessment of injury type and severity in severely injured patients by emergency physicians : An analysis of the TraumaRegister DGU®]. / Präklinische Einschätzung der Verletzungsart und ­schwere beim Schwerverletzten durch den Notarzt : Eine Auswertung des TraumaRegister DGU®.

BACKGROUND: Prehospital assessment of injury type and severity by emergency medical services physicians impacts treatment including appropriate destination hospital selection, especially in (potentially) life-threatening cases. Injuries which are underestimated or overlooked by the emergency physician can delay adequate therapy and thus significantly influence the overall outcome. The current study used data from the TraumaRegister DGU® to evaluate the reliability of prehospital injury assessments made by emergency physicians. MATERIAL AND METHODS: Data of 30,777 patients from the TraumaRegister DGU® between 1993 and 2009 were retrospectively evaluated. Using the abbreviated injury scale (AIS), subjective prehospital assessments of injury severity by emergency physicians were correlated with objectively identified injuries diagnosed after admission to hospital. For this evaluation, prehospital injury assessments rated moderate or severe by the emergency physician as well as injuries diagnosed in hospital with an AIS score ≥3 points were deemed relevant. RESULTS: The 30,777 patients with an injury severity score (ISS) ≥ 9 suffered a total of 202,496 injuries and of these 26 % (51,839 out of 202,496) were considered relevant with an AIS ≥3 points. The most frequent relevant injuries were to the head (47 %) and chest (46 %). Of the 51,839 relevant injuries, the prehospital assessment by the emergency physician was accurate for 71 % and in 29 % of the cases relevant injuries were underestimated. Relevant injuries were unrecognized or underestimated in prehospital assessments for almost 1 out of every 7 cases of head trauma, almost 1 out of every 3 thoracic trauma and almost 1 out of every 2 abdominal and pelvic trauma. CONCLUSION: The assessment of injury severity by emergency medical services physicians based on physical examination at the scene of the trauma is not very reliable. Thus, mechanisms of injury and overall presentation as well as identifiable injuries and vital parameters should be recognized by the emergency physician when considering treatment strategies and choice of appropriate destination hospital. The patient should be re-evaluated in a priority-oriented manner at the latest on arrival in the trauma room to avoid the consequences of unrecognized or underestimated injuries.

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

Assessment of injury severity in patients with major trauma.

Major trauma centres provide specialised care for patients who have experienced serious traumatic injury. This article provides information about major trauma centres and outlines the assessment tools used in this setting. Since patients in major trauma centres will be transferred to other settings, including inpatient wards and primary care, this article is relevant for both nurses working in major trauma centres and in these areas. Traumatic injuries require rapid assessment to ensure the patient receives prompt, adequate and appropriate treatment. A range of assessment tools are available to assist nurses in major trauma centres and emergency care to assess the severity of a patient's injury. The most commonly used tools are triage, Catastrophic Haemorrhage Airway to Exposure assessment, pain assessment and the Glasgow Coma Scale. This article summarises the use of these assessment tools in these settings, and discusses the use of the Injury Severity Score (ISS) to determine the severity of patient injuries.