The injured elderly: a rising tide.

BACKGROUND: Injury remains a public health challenge despite advances in trauma care. Periodic survey of injury epidemiology is essential to the trauma system's continuous performance improvement. We undertook this study to characterize the changes in Florida injury rates during the past 15 years. METHODS: Injured patients were identified with the use of a statewide database over 15 years ending in 2010. Population data were obtained from the U.S. Census. Severe injury was defined by International Classification Injury Severity Scores less than 0.85. Injury rates were expressed in discharges per 100,000 residents. Trends were analyzed by linear regression. RESULTS: The 1.5 million patient discharges consisted of 5.2% children, 39.7% adults, and 55.1% elderly. The overall injury rate decreased in children by 18% but increased in adults by 2% and in the elderly by 17% during the study period. The proportion of severe injuries decreased in children and the elderly but did not change in adults. Injury patterns changed in all age groups. CONCLUSION: Injury in the elderly is increasing at a rate seven times that of adults. In 2010, the elderly accounted for only 17% of the population but 55% of injury-related discharges. These trends have dramatic implications for the design of future trauma systems and health care resource use.

Fifteen-year trauma system performance analysis demonstrates optimal coverage for most severely injured patients and identifies a vulnerable population.

BACKGROUND: Trauma systems are designed to deliver timely and appropriate care. Prehospital triage regulations and interfacility transfer guidelines are the primary determinants of system efficacy. We analyzed the effectiveness of the Florida trauma system in delivering trauma patients to trauma centers over time. STUDY DESIGN: Injured patients were identified by ICD-9 codes from a statewide discharge dataset, and they were categorized as children (less than 16 years old), adult (16 to 65 years old), or elderly (over 65 years old). Severe injury was defined by International Classification Injury Severity Scores (ICISS) < 0.85. Residence ZIP codes were used as a surrogate for injury location. RESULTS: Severe injury discharges increased at designated trauma centers (DTCs) and decreased at nontrauma centers (NTCs). The proportion of patients with severe injuries discharged from DTCs increased for all age groups, capturing nearly all severely injured children and adults. Access to DTCs was dependent on proximity for severely injured elderly but not for severely injured children and adults. CONCLUSIONS: Triage improved over time, enabling near complete capture of at-risk children and adults independent of DTC proximity. Because distance from a DTC does not limit access for children and adults, existing trauma system resources are sufficient to meet the current demands. Efforts are needed to determine the trauma resource and triage needs of the severely injured elderly.

High-volume trauma centers have better outcomes treating traumatic brain injury.

BACKGROUND: Survival and discharge status from severe traumatic brain injury (TBI) patients treated during the past 11 years in seven state-designated Level I trauma centers was analyzed to test for a relationship between patient volume and outcome. METHODS: Data for patients age 16 years to 64 years were aggregated by quarter for years 2000 to 2010. TBI patients were identified using DRG International Classification of Diseases--9th Rev.--Clinical Modification codes: 800 to 804 and 850.1 to 854. Severity was defined using the International Classification Injury Severity Score (ICISS) less than 0.85 (risk of death > 15%). Using a random effects model controlling for sex, race, ethnicity, and insurance status, TBI volume was analyzed against quarterly inpatient mortality and functional recovery, defined as discharge to home or rehabilitation versus transfer to skilled nursing facilities. Hospitals were categorized into quarterly TBI volume quintiles, using the top quintile (highest-volume center) as control. To account for overall injury severity influence, ICISS was further categorized as less than 20%, 20% to 40%, and 40% to 60%. RESULTS: Two high-volume hospitals consistently treated more TBI patients (>40 patients per quarter). Four treated less than 40 patients per quarter, and one transitioned to high-volume midway through the study period. After controlling for severity, demographics, and insurance status, highest-volume centers demonstrated a 9% lower mortality risk (p < 0.001). Lower-volume hospitals discharged a significantly larger proportion of TBI patients to skilled nursing facilities and fewer patients to home or rehabilitation facilities (p < 0.01). CONCLUSION: High volume (>40 patients per quarter) is associated with improved severe TBI patient survival and, probably, improved quality of life. Efforts to identify best practices and implement educational interventions to improve compliance with best-practice standards will benefit patients with severe traumatic brain injury. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Insurance status, not race, is a determinant of outcomes from vehicular injury.

BACKGROUND: Hypothesizing that outcomes from specific injury mechanisms should not vary by race or socioeconomic status, we analyzed the relationship of race and ethnicity to fatality in motor vehicle crash victims treated during 2008 and 2009. STUDY DESIGN: Logistic regression analysis of pooled administrative data assessed the contribution of patient demographics and injury severity to outcome, defined as mortality during acute hospitalization. Demographic factors included age, sex, race, ethnicity, and insurance. Severe injury was defined using ICD-9 Injury Severity Score (survival probability) p < 0.85, presence of up to 3 comorbidities, and/or diagnosis of spinal cord injury and/or traumatic brain injury. Mortality was stratified by survival time after trauma center arrival to death within 24 hours or thereafter. Factors contributing to outcomes were tested using chi square analysis of the calculated model estimate. RESULTS: For 8,758 motor vehicle crash victims treated in state-designated trauma centers, age, sex, injury severity, and 2 or more comorbidities consistently predicted survival. Neither race nor ethnicity was associated with increased mortality risk. Being uninsured was related to death within 24 hours (p < 0.001). The majority of the uninsured who died within 24 hours had an ICD-9 Injury Severity Score p ≤ 0.5. Mortality risk after 24 hours was driven by traumatic brain injury and comorbidities. CONCLUSIONS: The results of this study indicated that higher immediate mortality of the uninsured is a behavioral and socioeconomic rather than physiologic marker. This higher mortality is driven by increased injury severity that increases cost of care in uninsured survivors. This disparity suggests that risk-taking behavior, especially relating to safety practices and licensing regulations, is an important etiologic factor. Improved outcomes require better public education and enforcement in conjunction with improvements in processes of care.

Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers?

OBJECTIVE: The purposes of the study were to compare the survival associated with treatment of seriously injured patients with pediatric trauma in Florida at designated trauma centers (DTCs) with nontrauma center (NCs) acute care hospitals and to evaluate differences in mortality between designated pediatric and nonpediatric trauma centers. METHODS: Trauma-related inpatient hospital discharge records from 1995 to 2004 were analyzed for children aged from 0 to 19 years. Age, sex, ethnicity, injury mechanism, discharge diagnoses, and severity as defined by the International Classification Injury Severity Score were analyzed, using mortality during hospitalization as the outcome measure. Children with central nervous system, spine, torso, and vascular injuries and burns were evaluated. Instrumental variable analysis was used to control for triage bias, and mortality was compared by probabilistic regression and bivariate probit modeling. Children treated at a DTC were compared with those treated at a nontrauma center. Within the population treated at a DTC, those treated at a DTC with pediatric capability were compared with those treated at a DTC without additional pediatric capability. Models were analyzed for children aged 0 to 19 years and 0 to 15 years. RESULTS: For the 27,313 patients between ages 0 and 19 years, treatment in DTCs was associated with a 3.15% reduction in the probability of mortality (P < .0001, bivariate probit). The survival advantage for children aged 0 to 15 years was 1.6%, which is not statistically significant. Treatment of 16,607 children in a designated pediatric DTC, as opposed to a nonpediatric DTC, was associated with an additional 4.84% reduction in mortality in the 0- to 19-year age group and 4.5% in the 0 to 15 years group (P < .001, bivariate probit). CONCLUSIONS: Optimal care of the seriously injured child requires both the extensive and immediate resources of a DTC as well as pediatric-specific specialty support.

The cost of trauma center readiness.

BACKGROUND: Trauma centers and the services they provide are a unique and necessary component of our health system. By design trauma centers treat all injured patients regardless of their clinical or economic needs. The purpose of this study was to quantify the costs associated with the preparation of the capacity to provide trauma care at trauma centers within the State of Florida. METHODS: Utilizing a survey tool and multiple retreats, we assessed the capability of 20 verified trauma centers throughout the State of Florida. The survey focused on general attributes of each hospital, the costs associated with physician on call coverage, costs associated with verification, and lastly the costs associated with administration, outreach, and prevention. RESULTS: Data were acquired from 10 trauma centers. Ninety percent of the respondents pay on-call coverage. The median annual physician compensation for on-call coverage was approximately 2.1 million US dollars. The total medial cost of readiness for each trauma center approximated 2.7 million US dollars annually. CONCLUSIONS: Trauma centers like fire departments and police services are required to be available 24 hours a day, 7 days a week. This level of commitment by trauma centers and the reciprocal expectation from the community force trauma centers to make considerable investments in readiness. This cost of readiness is expended regardless of the patient volume or insurance status. Thus trauma centers have a large component of costs that are not captured by the traditional billing and cost accounting mechanisms within health systems and this fixed expense is extraordinarily difficult to recover given the current reimbursement environment.

Multiple organ failure in trauma patients.

SUMMARY: BACKGROUND As care of the critically ill patient has improved and definitions of organ failure have changed, it has been observed that the incidence of organ failure and the mortality associated with organ failure appear to be decreasing. In addition, many early studies included large heterogeneous populations of both medical and surgical patients that may have influenced the incidence and outcome of organ failure. The purpose of this study is to establish the current incidence and mortality of organ failure in a homogenous population of critically ill trauma patients. METHODS All trauma patients admitted to the intensive care unit (ICU) at an urban Level I trauma center were prospectively studied. Patients were evaluated for the presence of organ failure using definitions proposed by Knaus and by Fry. Newer definitions of organ failure incorporating organ dysfunction and severity-of-illness scores were also obtained in all patients in an attempt to predict outcome. These included lung injury scores (acute respiratory distress syndrome scores), Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores, Injury Severity Score (ISS), and multiple organ dysfunction scores. Primary outcomes assessed were death and the occurrence of organ failure by the various definitions. RESULTS Eight hundred sixty-nine trauma patients were admitted to the ICU and survived longer than 48 hours. Mean APACHE II and APACHE III scores at admission to the ICU and ISS were 12.2 +/- 22, 30.5 +/- 22.7, and 19 +/- 10, respectively. Single organ failure (SOF) occurred in 163 patients (18.7%) and multiple organ failure occurred in 44 patients (5.1%). All SOF was caused by respiratory failure. Respiratory failure occurred first in the majority of patients with multiple organ failure. Mortality was 4.3% with one organ system failure, 32% with two, 67% with three, and 90% when four organ systems failed. None of the patients with SOF died secondary to respiratory failure. Multiple stepwise regression analysis was performed to determine which of the following risk factors are associated with the occurrence of organ failure: mechanism of injury, lactate at 24 hours, ISS, APACHE II, APACHE III, acute respiratory distress syndrome score at admission, multiple organ dysfunction score at admission and total blood products transfused in 24 hours. Of these factors, APACHE III, lactate at 24 hours, and total blood products transfused in 24 hours were associated with the occurrence of organ failure. CONCLUSION The overall incidence of organ failure in a homogeneous trauma population appears to be lower than that reported in studies performed in heterogeneous patient populations in the 1980s. Mortality for SOF is low and appears to be related primarily to the patient's underlying injuries and not to organ failure. Mortality for two or three organ system failures is lower than reported 15 to 20 years ago. Mortality for patients with four or more organ system failures remains high, approaching 100%.

The role of cardiac morbidity in short- and long-term mortality in injured older patients who survive initial resuscitation.

BACKGROUND: Elderly patients are an increasingly larger group of injured trauma care patients. Comorbidities influence outcome. Little is known of short- and long-term mortality in the elderly who survive initial resuscitation. METHODS: Short- and long-term mortality was retrospectively analyzed in 363 consecutively injured patients (Injury severity score >15) surviving more than 3 days after admission to a level 1 trauma center (including 197 patients >60 years). Cardiac morbidity was the focus. RESULTS: Survival to hospital discharge was similar comparing older patients with the entire group. Mortality increased incrementally with age. In older patients, cardiac morbidity was observed in 28% (fatal in 7); 2-year mortality was 36% (older group) and 60% (patients sustaining cardiac complications). Most elderly (80%) were discharged to long-term care. CONCLUSIONS: Elderly who survive initial resuscitation are as likely to survive to discharge as younger patients, but long-term survival is significantly lower as age increases. Cardiac morbidity is associated with higher long-term mortality. Most elderly are discharged to long-term care.

How early is early laparoscopic treatment of acute cholecystitis?

BACKGROUND: Despite the well-accepted success of laparoscopic cholecystectomy in elective treatment of symptomatic cholelithiasis, the efficacy and timing of this technique has been subject to some debate in the setting of acute cholecystitis. This study was undertaken to evaluate our institution's experience with early cholecystectomy as a safe, effective treatment of acute cholecystitis. METHODS: Charts of all patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis were reviewed. Patients were divided into two groups based on the length of time from onset of symptoms to surgical intervention: less than 48 hours in the early group (n = 14) and more than 48 hours in the late group (n = 31). RESULTS: Comparing the two groups, the conversion rate to an open procedure was significantly less (0 versus 29%, P <0.04) in the early treated patients. Furthermore, the operative time (73 versus 96 minutes, P <0.004), postoperative hospitalization (1.2 versus 3.9 days, P <0.001), and total hospital stay (2.1 versus 5.4 days, P <0.004) were significantly reduced in patients undergoing early laparoscopic cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy performed by experienced surgeons is a safe, effective technique for treatment of acute cholecystitis. Patients treated within 48 hours of onset of symptoms experience a lower conversion rate to an open procedure, shorter operative time and reduced hospitalization.

Barrier precautions in trauma: is knowledge enough?

OBJECTIVES: The risk of blood and body fluid exposure and, therefore, risk of blood-borne disease transmission is increased during trauma resuscitations. Use of barrier precautions (BPs) to protect health care workers (HCWs) from exposure and infection has been codified in hospital rules and in national trauma education policy. Despite these requirements, reported rates of BP compliance vary widely. The reasons for noncompliance are not known. This study assesses self-reported rates of BP usage during resuscitations among trauma professionals, explores reasons for noncompliance, and compares self-reported compliance rates with actual observed compliance rates. METHODS: A survey regarding BPs was distributed to all HCWs involved in trauma resuscitations at our Level I trauma center. All surgical and emergency medicine residents as well as attending faculty from both disciplines and nursing staff were included in this study. A total of 161 surveys were distributed and 123 were returned. RESULTS: Most HCWs (114 of 123 [93%]) reported at least one exposure (usually intact skin contact) to blood or other body fluids. A considerable variation in the type of BP used was reported for those HCWs who reported use of BPs "all of the time." Of the HCWs who reported universal use of BPs, reported usage rates were as follows: gloves, 105 of 123 (85%); eyewear (no side protectors), 58 of 123 (47%); eyewear (side protectors), 20 of 123 (16%); gowns, 22 of 123 (18%); and masks, 5 of 123 (4%). The two most common reasons for noncompliance were "time factors" (61%) and "BPs are too cumbersome" (29%). Observed compliance rates were statistically significantly lower than self-reported rates in all BPs except gloves (p < 0.02). CONCLUSION: The wide variation in BP use and the gap between perceived and actual usage that we have observed suggest that the effectiveness of current educational approaches to ensure BP use is inadequate.