Outcomes after Motor Vehicle Trauma: Transfers to Level I Trauma Centers Compared with Direct Admissions.

BACKGROUND: The multilevel designation system given to U.S. trauma centers has proven useful in providing injury-level-appropriate care and guiding field triage. Despite the system, patients are often transferred to Level I trauma centers for higher-level care/specialized services. OBJECTIVES: The objective of this study is to assess whether there is a difference in outcomes of patients transferred to Level I centers compared with direct admissions. METHODS: The Nationwide Inpatient Sample was queried to identify patients involved in motor vehicle accidents, using International Classification of Diseases, Ninth Revision, Clinical Modification E-codes. Patients that were admitted to Level I trauma centers were identified using American College of Surgeons or American Trauma Society designations. RESULTS: There were 343,868 patients that met inclusion criteria. Of these patients, 29.2% (100,297) were admitted to Level I trauma centers, 5.7% (5691) of which were identified as trauma transfers. The lead admitting diagnosis for transfers was pelvic fracture (11.5%). Caucasians were 2.62 times as likely to be transferred as African-Americans (confidence interval 2.32-2.97), and 3.71 times as likely as Hispanics (confidence interval 3.25-4.23). Despite transfer patients having higher adjusted severity scores and higher adjusted risk of mortality, there were no differences in mortality (p = 0.95). CONCLUSIONS: Nationally, trauma transfers do not have an increase in mortality when compared with directly admitted patients, despite a higher adjusted severity of illness and higher adjusted risk of mortality.

Can an Alternative Outflow Strategy be Utilized for High-Risk Bridged Patients with Previous Cardiac Surgery?

The HeartWare ventricular assist device (HVAD) is an implantable continuous-flow centrifugal pump that has allowed the development of sternal-sparing techniques, with the use of alternative outflow strategies. We compared early outcomes for patients bridged with the conventional versus alternative outflow graft strategy. From January 2013 to October 2014, 89 patients with HVAD implantation were identified. Survival was analyzed with Kaplan-Meier methods, and a log-rank test was used to compare outcomes between groups. Thirty patients (34%) had ≥1 previous sternotomy before HVAD implantation. Eight patients (27%) were approached using an alternative outflow graft technique with outflow graft connection to the descending aorta (n = 4, 50%) or left subclavian artery (n = 4, 50%), whereas 22 (73%) were implanted via a conventional sternotomy approach with the outflow graft to the ascending aorta. Preoperative characteristics (age, Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS], and Lietz-Miller score) were comparable between groups (all p > 0.05). Median follow-up was 4.7 (2.8-9.3) months of support. Outcomes were comparable between conventional and alternative outflow groups; survival at 6 months was 74% for the conventional group and 83% in the alternative outflow group. An alternative outflow graft strategy can be utilized to support bridged patients with a history of prior sternotomy.