Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction.

INTRODUCTION: Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management. MATERIALS AND METHODS: A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO. RESULTS: Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission. CONCLUSIONS: Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.

Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment.

BACKGROUND: The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services. METHODS: We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications. RESULTS: This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03). CONCLUSIONS: With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.

Increased Screening for Child Physical Abuse in Emergency Departments in a Regional Trauma System: Response to a Sentinel Event.

A pediatric patient was assaulted while being treated at a Level 1 pediatric trauma center, prompting a Centers for Medicare & Medicaid Services site visit. The process of screening for physical abuse and protection of patients was reevaluated and revised, and a new guideline was implemented and shared with referral hospitals. During this same time period, 13 referral hospitals participated in an unrelated federally funded study determining the impact of recognition and care of injured children in states with and without a pediatric emergency care facility recognition program. A pre-post study analysis revealed that screening for abuse doubled during this time period.

Has the incidence of thoracolumbar spine injuries increased in the United States from 1998 to 2011?

BACKGROUND: While most motor vehicle crash (MVC)-related injuries have been decreasing, one study showed increases in MVC-related spinal fractures from 1994 to 2002 in Wisconsin. To our knowledge, no studies evaluating nationwide trends of MVC-related thoracolumbar spine injuries have been published. Such fractures can cause pain, loss of functionality or even death. If the incidence of such injuries is increasing, it may provide a motive for reassessment of current vehicle safety design. QUESTIONS/PURPOSES: We questioned whether the incidence of thoracolumbar spine injuries increased in the United States population with time (between 1998 and 2011), and if there was an increased incidence of thoracolumbar injuries, whether there were identifiable compensatory "trade-off injury" patterns, such as reductions in sacropelvic injuries. PATIENTS AND METHODS: Institutional review board approval was obtained for retrospective review of three national databases: the National Trauma Databank® (NTDB®), 2002-2006, National Automotive Sampling System (NASS), 2000-2011, and National Inpatient Sample (NIS), 1998-2007. In each database, the total number of MVC-related injuries and the number of MVC-related thoracolumbar injuries per year were identified using appropriate Abbreviated Injury Scale (AIS) or ICD-9 codes. Sacropelvic injuries also were identified to evaluate their potential as trade-off injuries. Poisson regression models adjusting for age were used to analyze trends in the data with time. RESULTS: All databases showed increases in MVC-related thoracolumbar spine injuries when adjusting for age with time. These age-adjusted relative annual percent increases ranged from 8.22% (95% CI, 5.77%-10.72%; p<0.001) using AIS of 2 or more (AIS2 +) injury codes in the NTDB®, 8.59% (95% CI, 5.88%-11.37%; p<0.001) using ICD-9 codes in the NTDB®, 8.12% (95% CI, 7.20%-9.06%; p<0.001) using ICD-9 codes in the NIS, and 8.10 % (95% CI 5.00%-11.28%; p<0.001) using AIS2+ injury codes in the NASS. As these thoracolumbar injuries have increased, there has been no consistent trend toward a compensatory reduction in terms of sacropelvic injuries. CONCLUSIONS: While other studies have shown that rates of many MVC-related injuries are declining with time, our data show increases in the incidence of thoracolumbar injury. Although more sensitive screening tools likely have resulted in earlier and increased recognition of these injuries, it cannot be stated for certain that this is the only driver of the increased incidence observed in this study. As seatbelt use has continued to increase, this trend may be the result of thoracolumbar injuries as trade-offs for other injuries, although in our study we did not see a compensatory decrease in sacropelvic injuries. Investigation evaluating the root of this pattern is warranted.

Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment.

OBJECTIVE: We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending. DESIGN: We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications. SETTING: Tertiary care center, single institution. PARTICIPANTS: Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period. RESULTS: Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09). CONCLUSIONS: Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.

Immunoneutralization of human angiotensin-(1-12) with a monoclonal antibody in a humanized model of hypertension.

We engineered a monoclonal antibody (mAb) against the human C-terminus of angiotensin-(1-12) [h-Ang-(1-12)] and performed a biochemical characterization in concert with direct in vivo and ex vivo (carotid artery strips) assessments of h-Ang-(1-12) vasoconstrictor activity in 78 (36 females) transgenic rats expressing the human angiotensinogen gene [TGR(hAGT)L1623] and 26 (10 female) Sprague Dawley (SD) controls. The mAb shows high specificity in neutralizing angiotensin II formation from h-Ang-(1-12) and did not cross-react with human and rat angiotensins. Changes in arterial pressure and heart rate in Inactin® hydrate anesthetized rats were measured before and after h-Ang-(1-12) injections [dose range: 75-300 pmol/kg i.v.] prior to and 30-60 minutes after administration of the h-Ang-(1-12) mAb. Neutralization of circulating Ang-(1-12) inhibited the pressor action of h-Ang-(1-12), prevented Ang-(1-12) constrictor responses in carotid artery rings in both SD and TGR(hAGT)L1623 rats, and caused a fall in the arterial pressure of male and female transgenic rats. The Ang-(1-12) mAb did not affect the response of comparable dose-related pressor responses to Ang II, pre-immune IgG, or the rat sequence of Ang-(1-12). This h-Ang-(1-12) mAb can effectively suppress the pressor actions of the substrate in the circulation of hypertensive rats or in carotid artery strips from both SD and transgenic rats. The demonstration that this Ang-(1-12) mAb by itself, induced a fall in arterial pressure in transgenic hypertensive rats supports further exploring the potential abilities of Ang-(1-12) mAb in the treatment of hypertension.

Advanced Automatic Crash Notification Algorithm for Children.

BACKGROUND: Advanced automatic crash notification (AACN) can improve triage decision-making by using vehicle telemetry to alert first responders of a motor vehicle crash and estimate an occupant's likelihood of injury. The objective was to develop an AACN algorithm to predict the risk that a pediatric occupant is seriously injured and requires treatment at a Level I or II trauma center. METHODS: Based on 3 injury facets (severity; time sensitivity; predictability), a list of Target Injuries associated with a child's need for Level I/II trauma center treatment was determined. Multivariable logistic regression of motor vehicle crash occupants was performed creating the pediatric-specific AACN algorithm to predict risk of sustaining a Target Injury. Algorithm inputs included: delta-v, rollover quarter-turns, belt status, multiple impacts, airbag deployment, and age. The algorithm was optimized to achieve under-triage ≤5% and over-triage ≤50%. Societal benefits were assessed by comparing correctly triaged motor vehicle crash occupants using the AACN algorithm against real-world decisions. RESULTS: The pediatric AACN algorithm achieved 25% to 49% over-triage across crash modes, and under-triage rates of 2% for far-side, 3% for frontal and near-side, 8% for rear, and 14% for rollover crashes. Applied to real-world motor vehicle crashes, improvements of 59% in under-triage and 45% in over-triage are estimated: more appropriate triage of 32,320 pediatric occupants annually. CONCLUSIONS: This AACN algorithm accounts for pediatric developmental stage and will aid emergency personnel in correctly triaging pediatric occupants after a motor vehicle crash. Once incorporated into the trauma triage network, it will increase triage efficiency and improve patient outcomes.

Variation in hospital complication rates and failure-to-rescue for trauma patients.

OBJECTIVE: To examine whether failure-to-rescue is an important mechanism driving outcome differences across low- and high-mortality hospitals caring for trauma patients. BACKGROUND: Reducing medical errors and complications has become the focus of quality improvement efforts. Patients undergoing general and vascular surgery in high-mortality hospitals have similar rates of complications but higher failure-to-rescue rates compared to patients in low-mortality hospitals. METHODS: Retrospective cohort study based on 54,713 patient records in the National Trauma Databank in 2007. Hospitals were classified as low-mortality, average, and high-mortality hospitals using the Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and on the incidence of failure-to-rescue (death after a major complication), adjusting for injury severity, mechanism of trauma, and patient physiology. RESULTS: Trauma patients in low-mortality hospitals had similar unadjusted rates of major complications compared to patients in high-mortality hospitals (5.9% vs. 5.5%). However, patients in low-mortality hospital had a lower failure-to-rescue rate compared to patients in high-mortality hospitals (adj OR 0.26: 95% CI 0.20, 0.39) CONCLUSION: Our findings suggest that the primary driver of differences in hospital quality for trauma patients is failure-to-rescue as opposed to differences in complication rates. Achieving lower mortality rates in trauma patients may require reducing both the incidence of major complications and the incidence of death after major complications.

Emergency department length of stay is an independent predictor of hospital mortality in trauma activation patients.

BACKGROUND: The early resuscitation occurs in the emergency department (ED) where intensive care unit protocols do not always extend and monitoring capabilities vary. Our hypothesis is that increased ED length of stay (LOS) leads to increased hospital mortality in patients not undergoing immediate surgical intervention. METHODS: We examined all trauma activation admissions from January 2002 to July 2009 admitted to the Trauma Service (n = 3,973). Exclusion criteria were as follows: patients taken to the operating room within the first 2 hours of ED arrival, nonsurvivable brain injury, and ED deaths. Patients spending >5 hours in the ED were not included in the analysis because of significantly lower acuity and mortality. RESULTS: Patients spent a mean of 3.2 hours ± 1 hour in the ED during their initial evaluation. Hospital mortality increases for each additional hour a patient spends in the ED, with 8.3% of the patients staying in the ED between 4 hours and 5 hours ultimately dying (p = 0.028). ED LOS measured in minutes is an independent predictor of mortality (odds ratio, 1.003; 95% confidence interval, 1.010-1.006; p = 0.014) when accounting for Injury Severity Score, Revised Trauma Score, and age. Linear regression showed that a longer ED LOS was associated with anatomic injury pattern rather than physiologic derangement. CONCLUSION: In this patient population, a longer ED LOS is associated with an increased hospital mortality even when controlling for physiologic, demographic, and anatomic factors. This highlights the importance of rapid progression of patients through the initial evaluation process to facilitate placement in a location that allows implementation of early goal directed trauma resuscitation.

Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective.

BACKGROUND: Since the promulgation of emergency department (ED) thoracotomy>40 years ago, there has been an ongoing search to define when this heroic resuscitative effort is futile. In this era of health care reform, generation of accurate data is imperative for developing patient care guidelines. The purpose of this prospective multicenter study was to identify injury patterns and physiologic profiles at ED arrival that are compatible with survival. METHODS: Eighteen institutions representing the Western Trauma Association commenced enrollment in January 2003; data were collected prospectively. RESULTS: During the ensuing 6 years, 56 patients survived to hospital discharge. Mean age was 31.3 years (15-64 years), and 93% were male. As expected, survival was predominant in those with thoracic injuries (77%), followed by abdomen (9%), extremity (7%), neck (4%), and head (4%). The most common injury was a ventricular stab wound (30%), followed by a gunshot wound to the lung (16%); 9% of survivors sustained blunt trauma, 34% underwent prehospital cardiopulmonary resuscitation (CPR), and the presenting base deficit was >25 mequiv/L in 18%. Relevant to futile care, there were survivors of blunt torso injuries with CPR up to 9 minutes and penetrating torso wounds up to 15 minutes. Asystole was documented at ED arrival in seven patients (12%); all these patients had pericardial tamponade and three (43%) had good functional neurologic recovery at hospital discharge. CONCLUSION: Resuscitative thoracotomy in the ED can be considered futile care when (a) prehospital CPR exceeds 10 minutes after blunt trauma without a response, (b) prehospital CPR exceeds 15 minutes after penetrating trauma without a response, and (c) asystole is the presenting rhythm and there is no pericardial tamponade.

Automated Frailty Screening At-Scale for Pre-Operative Risk Stratification Using the Electronic Frailty Index.

BACKGROUND: Frailty is associated with numerous post-operative adverse outcomes in older adults. Current pre-operative frailty screening tools require additional data collection or objective assessments, adding expense and limiting large-scale implementation. OBJECTIVE: To evaluate the association of an automated measure of frailty integrated within the Electronic Health Record (EHR) with post-operative outcomes for nonemergency surgeries. DESIGN: Retrospective cohort study. SETTING: Academic Medical Center. PARTICIPANTS: Patients 65 years or older that underwent nonemergency surgery with an inpatient stay 24 hours or more between October 8th, 2017 and June 1st, 2019. EXPOSURES: Frailty as measured by a 54-item electronic frailty index (eFI). OUTCOMES AND MEASUREMENTS: Inpatient length of stay, requirements for post-acute care, 30-day readmission, and 6-month all-cause mortality. RESULTS: Of 4,831 unique patients (2,281 females (47.3%); mean (SD) age, 73.2 (5.9) years), 4,143 (85.7%) had sufficient EHR data to calculate the eFI, with 15.1% categorized as frail (eFI > 0.21) and 50.9% pre-frail (0.10 < eFI ≤ 0.21). For all outcomes, there was a generally a gradation of risk with higher eFI scores. For example, adjusting for age, sex, race/ethnicity, and American Society of Anesthesiologists class, and accounting for variability by service line, patients identified as frail based on the eFI, compared to fit patients, had greater needs for post-acute care (odds ratio (OR) = 1.68; 95% confidence interval (CI) = 1.36-2.08), higher rates of 30-day readmission (hazard ratio (HR) = 2.46; 95%CI = 1.72-3.52) and higher all-cause mortality (HR = 2.86; 95%CI = 1.84-4.44) over 6 months' follow-up. CONCLUSIONS: The eFI, an automated digital marker for frailty integrated within the EHR, can facilitate pre-operative frailty screening at scale.

Challenging issues in surgical critical care, trauma, and acute care surgery: a report from the Critical Care Committee of the American Association for the Surgery of Trauma.

Critical care workforce analyses estimate a 35% shortage of intensivists by 2020 as a result of the aging population and the growing demand for greater utilization of intensivists. Surgical critical care in the U.S. is particularly challenged by a significant shortfall of surgical intensivists, with only 2586 surgeons currently certified in surgical critical care by the American Board of Surgery, and even fewer surgeons (1204) recertified in surgical critical care as of 2009. Surgical critical care fellows (160 in 2009) represent only 7.6% of all critical care trainees (2109 in 2009), with the largest number of critical care fellowship positions in internal medicine (1472, 69.8%). Traditional trauma fellowships have now transitioned into Surgical Critical Care or Acute Care Surgery (trauma, surgical critical care, emergency surgery) fellowships. Since adult critical care services are a large, expensive part of U.S. healthcare and workforce shortages continue to impact our healthcare system, recommendations for regionalization of critical care services in the U.S. is considered. The Critical Care Committee of the AAST has compiled national data regarding these important issues that face us in surgical critical care, trauma and acute care surgery, and discuss potential solutions for these issues.

Centers for Medicare and Medicaid services quality indicators do not correlate with risk-adjusted mortality at trauma centers.

OBJECTIVES: The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital compliance with evidence-based processes of care as quality indicators. We hypothesized that compliance with CMS quality indicators would correlate with risk-adjusted mortality rates in trauma patients. METHODS: A previously validated risk-adjustment algorithm was used to measure observed-to-expected mortality ratios (O/E with 95% confidence interval) for Level I and II trauma centers using the National Trauma Data Bank data. Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Score >or=3) were included (127,819 patients). Compliance with CMS quality indicators in four domains was obtained from Hospital Compare website: acute myocardial infarction (8 processes), congestive heart failure (4 processes), pneumonia (7 processes), surgical infections (3 processes). For each domain, a single composite score was calculated for each hospital. The relationship between O/E ratios and CMS quality indicators was explored using nonparametric tests. RESULTS: There was no relationship between compliance with CMS quality indicators and risk-adjusted outcomes of trauma patients. CONCLUSIONS: CMS quality indicators do not correlate with risk-adjusted mortality rates in trauma patients. Hence, there is a need to develop new trauma-specific process of care quality indicators to evaluate and improve quality of care in trauma centers.

The Trauma Quality Improvement Program: pilot study and initial demonstration of feasibility.

OBJECTIVE: The American College of Surgeons Committee on Trauma has created a "Trauma Quality Improvement Program" (TQIP) that uses the existing infrastructure of Committee on Trauma programs. As the first step toward full implementation of TQIP, a pilot study was conducted in 23 American College of Surgeons verified or state designated Level I and II trauma centers. This study details the feasibility and acceptance of TQIP among the participating centers. METHODS: Data from the National Trauma Data Bank for patients admitted to pilot study hospitals during 2007 were used (15,801 patients). A multivariable logistic regression model was developed to estimate risk-adjusted mortality in aggregate and on three prespecified subgroups (1: blunt multisystem, 2: penetrating truncal, and 3: blunt single-system injury). Benchmark reports were developed with each center's risk adjusted mortality (expressed as an observed-to-expected [O/E] mortality ratio and 90% confidence interval [CI]) and crude complication rates available for comparison. Reports were deidentified with only the recipient having access to their performance relative to their peers. Feedback from individual centers regarding the utility of the reports was collected by survey. RESULTS: Overall crude mortality was 7.7% and in cohorts 1 to 3 was 16.4%, 12.4%, and 5.1%, respectively. In the aggregate risk-adjusted analysis, three trauma centers were low outliers (O/E and 90% CI <1) and two centers were high outliers (O/E and 90% CI >1) with the remaining 18 centers demonstrating average mortality. Challenges identified were in benchmarking mortality after penetrating injury due to small sample size and in the limited capture of complications. Ninety-two percent of survey respondents found the report clear and understandable, and 90% thought that the report was useful. Sixty-three percent of respondents will be taking action based on the report. CONCLUSIONS: Using the National Trauma Data Bank infrastructure to provide risk-adjusted benchmarking of trauma center mortality is feasible and perceived as useful. There are differences in O/E ratios across similarly verified or designated centers. Substantial work is required to allow for morbidity benchmarking.

Trauma systems: improving trauma outcomes in North Carolina.

Since the 1970s, there has been a tremendous improvement in the outcomes for injured patients in North Carolina; the scope, significance, and virtue of this achievement are remarkable. This commentary reviews how the state has consistently decreased the burden of injury through its integrated, systems-based approach to trauma care.

Characterization of crash-induced thoracic loading resulting in pulmonary contusion.

BACKGROUND: Pulmonary contusion (PC) is commonly sustained in motor vehicle crash. This study utilizes the Crash Injury Research and Engineering Network (CIREN) database and vehicle crash tests to characterize the occupants and loading characteristics associated with PC. A technique to match CIREN cases to vehicle crash tests is applied to quantify the thoracic loading associated with this injury. METHODS: The CIREN database and crash test data from the National Highway Traffic Safety Administration were used in this study. An analysis of CIREN data were conducted between three study cohorts: patients that sustained PC and any other chest injury (PC+ and chest+), patients with chest injury and an absence of PC (PC- and chest+), and a control group without chest injury and an absence of PC (PC- and chest-). Forty-one lateral impact crash tests were analyzed and thoracic loading data from onboard crash tests dummies were collected. RESULTS: The incidence of PC in CIREN data were 21.7%. Crashes resulting in PC demonstrated significantly greater mortality (23.9%) and Injury Severity Score (33.1 +/- 15.7) than the control group. The portion of lateral impacts increased from 27% to 48% between the control group and PC+ and chest+ cohort, prompting the use of lateral impact crash tests for the case-matching portion of the study. Crash tests were analyzed in two configurations; vehicle-to-vehicle tests and vehicle-to-pole tests. The average maximum chest compression and deflection velocity from the dummy occupants were found to be 25.3% +/- 2.6% and 4.6 m/s +/- 0.42 m/s for the vehicle-to-pole tests and 23.0% +/- 4.8% and 3.9 m/s +/- 1.1 m/s for the vehicle-to-vehicle tests. Chest deflection versus time followed a roughly symmetric and sinusoidal profile. Sixteen CIREN cases were identified that matched the vehicle crash tests. Of the 16 matched cases, 12 (75%) sustained chest injuries, with half of these patients presenting with PC. CONCLUSIONS: Quantified loading at the chest wall indicative of PC and chest injury in motor vehicle crash is valuable boundary condition data for bench-top studies or computer simulations focused on this injury. In addition, because PC often exhibits a delayed onset, knowing the population and crash modes highly associated with this injury may promote earlier detection and improved management of this injury.

Predicting Pediatric Patients Who Require Care at a Trauma Center: Analysis of Injuries and Other Factors.

BACKGROUND: Triage decision correctness for children in motor vehicle crashes can be affected by occult injuries. There is a need to develop a transfer score (TS) metric for children that can help quantify the likelihood that an injury is present that would require transfer to a trauma center (TC) from a non-TC, and improve triage decision making. Ultimately, the TS metric might be useful in an advanced automatic crash notification algorithm, which uses vehicle telemetry data to predict the risk of serious injury after a motor vehicle crash using an approach that includes metrics to describe injury severity, time sensitivity, and predictability. STUDY DESIGN: Transfer score metrics were calculated in 4 pediatric age groups (0 to 4, 5 to 9, 10 to 14, 15 to 18 years) for the most frequent motor vehicle crash injuries using the proportions of children transferred to a TC or managed at a non-TC using the National Inpatient Sample years 1998 to 2007. To account for the maximum Abbreviated Injury Scale (MAIS) injury, a co-injury adjusted transfer score (TSMAIS) was calculated. The TS and TSMAIS range from 0 to 1, with 1 indicating highly transferred injuries. RESULTS: Injuries in younger patients were more likely to be transferred (median TS 0.48, 0.35, 0.25, and 0.23 for 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years, respectively). Injuries more likely to be transferred in younger children occurred in the thorax and abdomen. Regardless of age, spine (median TSMAIS 0.59), head (median TSMAIS 0.48), and thorax (median TSMAIS 0.46) injuries had the highest frequency for transfer. CONCLUSIONS: The TS metrics quantitatively describe age-specific transfer practices for children with particular injuries. This information can be useful in advanced automatic crash notification systems to alert first responders to the possibility of occult injuries and reduce undertriage of commonly missed injuries.