Alan D. Cook

Ventilator-associated pneumonia is more common and of less consequence in trauma patients compared with other critically ill patients.

BACKGROUND Ventilator-associated pneumonia (VAP) incidence is used as a quality measure. We hypothesized that patient and provider factors accounted for the higher incidence of VAP in trauma patients compared with other critically ill patients. METHODS We conducted a 2-year study of all intubated adult patients at our Trauma Center. VAP was identified according to the Centers for Disease Control and Prevention definition. Groups were compared for the incidence of VAP and outcomes. RESULTS The cohort of 2,591 patients included 511 trauma patients and 2,080 nontrauma patients. VAP occurred in 161 patients and more frequently in trauma patients (17.8% vs. 3.4%, p < 0.001). The overall death rate (17.4% vs. 9.8%, p < 0.001) and the death rate for VAP patients (31.4% vs. 11%, p = 0.002) was higher in the nontrauma group. Bronchoalveolar lavage was performed more frequently in the trauma patient group (22.1% vs. 8.9%, p < 0.001), and gram-negative organisms were isolated more commonly in trauma patients (65.9% vs. 30%, p < 0.001), respectively. VAP occurred earlier among the trauma group (mean 8.9 days vs. 14.1 days, p < 0.001). Trauma represented an odds ratio of 3.9 (95% confidence interval 2.4-6.3, p < 0.001) for the development of VAP. CONCLUSION The incidence of VAP is greatest among trauma patients at our institution. The increased use of bronchoalveolar lavage, the earlier onset of VAP, and the higher incidence of gram-negative pneumonias suggest that both patient and provider factors may influence this phenomenon. VAP was associated with increased mortality in the nontrauma group only. These factors should be considered before VAP is applied as a quality indicator.

An Acute Care Surgery Model Provides Safe and Timely Care for Both Trauma and Emergency General Surgery Patients

BACKGROUND The impact by integration of emergency general surgery (EGS) with trauma in an acute care surgery model on the timeliness and quality of care in patients of each type at a high volume level I trauma center is still indeterminate. We hypothesized that trauma and EGS can be successfully integrated in an academic institution. METHODS Retrospective review of prospectively collected trauma/EGS database was conducted at a high-volume, urban academic level I trauma center. Patients admitted to or requested consultation from trauma and EGS services were included. We explored the covariates affecting time to operating room (TOR), morbidity and in-hospital mortality rate. RESULTS There were 1794 trauma patients and 1565 EGS patients identified over a 6-month period. Linear regression models failed to demonstrate a correlation between TOR and surgical team workload (WL), injury severity score (ISS), and caseload for the operating room staff and facility. While lower TOR, Glasgow coma scale, ISS and age were associated with an increased likelihood of complications, WL did not correlate with the occurrence of complications. TOR and surgical team WL had no association with death in trauma patients. The occurrence of complications was associated with a nearly 8-fold increase in the risk of death (odds ratio 7.56, 95% confidence interval [CI] 1.49-39.32, P = 0.02). CONCLUSION Increased workload during combined trauma/EGS call in an acute care surgery model did not affect the TOR nor worsen patient outcome. Implementation of a trauma/EGS model is justified even in high-volume academic institutions, if appropriately staffed and resourced.

Parenteral nutrition: a clear and present danger unabated by tight glucose control

BACKGROUND The infectious risks of parenteral nutrition (PN) in critical illness are well described, although most literature predates tight glucose control (TGC) practice. The authors hypothesized that PN-related complications are ameliorated by TGC and are equivalent to those in enteral nutrition (EN) patients. METHODS A prospective cohort study of patients admitted to the surgical intensive care unit was conducted, comparing PN and EN patients. TGC target was 80 to 110 mg/dL. Univariate and multivariate logistic regression was used to explore the association between infectious outcomes and PN use. RESULTS One hundred fifty-five patients were studied. Mean daily glucose values were lower for the PN group than for the EN patients (118.2 vs 125.6 mg/dL, P = .002). Nonetheless, the incidence of bloodstream infection and catheter-related bloodstream infection was significantly associated with the administration of PN. In a multivariate logistic regression model, PN was associated with a >4-fold increase in the odds of having a catheter-related bloodstream infection (odds ratio, 4.48; 95% confidence interval, 1.14-17.49; P = .03). CONCLUSIONS Despite the successful implementation of TGC, PN is still a significant risk factor for infectious complications among surgical intensive care unit patients.

Big Children or Little Adults? A Statewide Analysis of Adolescent Isolated Severe Traumatic Brain Injury Outcomes at Pediatric versus Adult Trauma Centers.

BACKGROUND The appropriate managing center for adolescent trauma patients is debated. We sought to determine whether outcome differences existed for adolescent severe traumatic brain injury (sTBI) patients treated at pediatric versus adult trauma centers. We hypothesized that no difference in mortality, functional status at discharge (FSD), or overall complication rate would be observed between center types. METHODS All adolescent trauma patients (aged 15–17 years) presenting with isolated sTBI (head Abbreviated Injury Scale [AIS] score ≥3; all other AIS body region scores ⩽2) to accredited Levels I to II trauma centers in Pennsylvania from 2003 to 2015 were extracted from the Pennsylvania Trauma Outcome Study database. Dead on arrival, transfer, and penetrating trauma patients were excluded from analysis. Adult trauma centers were defined as non-pediatirc (PED) (n = 24), whereas standalone pediatric hospitals and adult centers with pediatric affiliation were considered Pediatric (n = 9). Multilevel mixed effects logistic regression models and a generalized linear mixed models assessed the adjusted impact of center type on mortality, overall complications, and FSD. Significance was defined as a p value less than 0.05. RESULTS A total of 1,109 isolated sTBI patients aged 15 to 17 years presented over the 13-year study period (non-PED, 685; PED, 424). In adjusted analysis controlling for age, shock index, head AIS, Glasgow Coma Scale motor, trauma center level of managing facility, case volume of managing facility, and injury year, no significant difference in mortality (adjusted odds ratio, 0.82; 95% confidence interval [CI], 0.23–2.86; p = 0.754), FSD (coefficient, −0.85; 95% CI, −2.03 to 0.28; p = 0.136), or total complication rate (adjusted odds ratio, 1.21; 95% CI, 0.43–3.39; p = 0.714) was observed between center types. CONCLUSION Although the optimal treatment facility for adolescent patients is frequently debated, patients aged 15 to 17 years presenting with isolated sTBI may experience similar outcomes when managed at pediatric and adult trauma centers. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level IV.

Ground-level falls: 9-year cumulative experience in a regionalized trauma system

Ground-level falls (GLFs) are the leading cause of nonfatal hospitalized injuries in the US. We hypothesized that risk-adjusted mortality would not vary between levels of trauma center verification if regional triage functioned appropriately. Data were collected from our regional trauma registry for the years 2001 through 2009. A multilevel mixed-effects logistic regression model was developed to compare risk-adjusted mortality rates by trauma center level and by year. GLF patients numbered 8202 over 9 years with 2.1% mortality. Mean age was 74.5 years and mean probability of death was 0.021 (95% confidence interval [CI], 0.020–0.021). The level I center-treated patients had the highest probability of death (0.033) compared to levels II and III/IV patients (0.023 and 0.018, respectively; P < 0.001), with the highest mortality (6.0%, 3.1%, and 1.1% for levels I, II, and III/IV; P < 0.001). The adjusted odds ratio of mortality was lowest at the level I center (0.71; 95% CI, 0.56–0.91), while no difference existed between level II (1.17; 95% CI, 0.90–1.51) and level III/IV centers (1.22; 95% CI, 0.90–1.66). The 95% CIs for risk-adjusted mortality by year overlapped the 1.0 reference line for each year from 2002 to 2009. In conclusion, regional risk-adjusted mortality for GLF has varied little since 2002. More study is warranted to understand the lower risk-adjusted GLF mortality at the level I center for this growing patient population.

The incidence and complications of methicillin-resistant Staphylococcus aureus in a community level I Trauma Center.

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a growing cause of infections among hospitalized trauma patients. We examined the incidence and infectious consequences of MRSA among trauma patients admitted to our Level I Trauma Center during 24 months. METHODS Nasal swab cultures were obtained at admission and on hospital day 5. Patient demographics and infectious complications were recorded and compared. Differences with p values less than 0.05 were considered significant. RESULTS Admission MRSA screening was positive in 71 patients, yielding a carrier prevalence rate of 5.8% (95% CI 4.5-7.1%). No admission characteristic was associated with positive MRSA screening. Twelve patients (1.7%, 95% CI 0.7-2.6%) who were MRSA negative at admission tested positive for MRSA on hospital day 5. The clinical MRSA infection incidence rate was 1.4% (95% CI 0.7-2.0%). The screening test for MRSA at admission demonstrated a sensitivity of 23.5% (95% CI 6.8-49.9%) and specificity of 94.5% (95% CI 93-95.7%) for predicting MRSA infection. MRSA infections were associated with increased lengths of stay: intensive care unit 17.7 versus 5.1 days, p < 0.001, hospital 23.1 versus 8.6 days, p < 0.001. CONCLUSIONS MRSA infections affect a minority of our trauma patients yet prolong length of stay. Admission MRSA screening of trauma patients does not sufficiently identify patients at risk for infectious complications and should not be practiced.

An analysis of neurosurgical practice patterns and outcomes for serious to critical traumatic brain injuries in a mature trauma state.

BACKGROUND We sought to characterize trends in neurosurgical practice patterns and outcomes for serious to critical traumatic brain injuries from 2003 to 2013 in the mature trauma state of Pennsylvania. METHODS All 2003 to 2013 admissions to Pennsylvanias 30 accredited Level I to II trauma centers with serious to critical traumatic brain injuries (head Abbreviated Injury Scale [AIS] score ≥ 3, Glasgow Coma Scale [GCS] score < 13) were extracted from the state registry. Adjusted temporal trend tests controlling for demographic and injury severity covariates assessed the impact of admission year on intervention rates (craniotomy, craniectomy, and intracranial pressure monitor/ventriculostomy [ICP]) and outcome measures for the total population as well as serious (head AIS score ≥ 3; GCS score, 9–12) and critical (head AIS score ≥ 3, GCS score ⩽ 8) subgroups. RESULTS A total of 22,229 patients met inclusion criteria. Admission year was significantly associated with an adjusted increase in craniectomy (adjusted odds ratio [AOR], 1.12 [1.09–1.14]; p < 0.001) and ICP rates (AOR, 1.03 [1.02–1.04]; p < 0.001) and a decrease in craniotomy rate (AOR, 0.96 [0.95–0.97]; p < 0.001). No significant trends in adjusted mortality were found for the total study population (AOR, 1.01 [1.00–1.02]; p = 0.150); however, a significant reduction was found for the serious subgroup (AOR, 0.95 [0.92–0.98]; p = 0.002), and a significant increase was found for the critical subgroup (AOR, 1.02 [1.01–1.03]; p = 0.004). CONCLUSION Total study population trends showed a reduction in rates of craniotomy and increase in craniectomy and ICP rates without any change in outcome. Despite significant adaptations in neurosurgical practice patterns from 2003 to 2013, only patients with serious head injuries are experiencing improved survival. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III; therapeutic study, level IV.

Under-triage in Trauma: Does an Organized Trauma Network Capture the Major Trauma Victim? A Statewide Analysis

BACKGROUND Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-TCs (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. METHODS All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9, 800–959; Injury Severity Score [ISS], > 9 or > 15) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on ISSs throughout the state. RESULTS For ISS > 9, 173,022 cases were identified from 2003 to 2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS > 15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to TCs comprise the highest proportion of undertriaged trauma patients. CONCLUSION Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and health care system imperatives. LEVEL OF EVIDENCE Epidemiological study, level III; Therapeutic, level IV.

310 Common mortality models fail to use anatomic injury information optimally

Background Comparison of trauma centres requires accurate injury severity metrics. The Trauma Audit and Research Network (TARN) in the UK, and the Trauma Injury Severity Score (TRISS) provide such risk adjustment. These models incorporate the Injury Severity Score (ISS) as the measure of anatomic injury severity but categorise it differently. The Trauma Mortality Prediction Model (TMPM) better predicts mortality than the ISS. We compared the anatomic injury components of TARN, and TRISS models to TMPM. Methods Data from the National Trauma Data Bank for 2002–2012. Probability of death was estimated for TARN, and TRISS from ISS values according to each model’s treatment and compared these to TMPM using measures of discrimination (area under ROC curves), proximity to the true model (Akaike Information Criterion (AIC)), and calibration (Hosmer-Lemeshow statistic (HL)). Confidence intervals (CI) were estimated by bootstrapping. ISS and TMPM values were estimated for the Abbreviated Injury Scale (AIS) and the International Classification of Diseases, 9th Revision (ICD-9) lexicons. Data are shown as medians and 95% CI. Results N = 1,145,959 AIS ROC AIC HL TMPM 0.8716 0.8695–0.8734 238130 236110–240201 226.5 168.5–289.7 TARN 0.8374 0.8351–0.8396 270017 267958–272213 668.5 586.0–745.4 TRISS 0.8368 0.8346–0.8389 275098 273058–277265 2335.3 2186.9–2516.4 ICD-9 ROC AIC HL TMPM 0.8475 0.8451–0.8498 211424 209531–213377 107.1 76.1–142.3 TRISS 0.8234 0.8211–0.8258 223081 221132–225128 1850.0 1702.9–1998.7 TARN 0.8131 0.8106–0.8153 227002 225115-228955 1033.1 929.0–1152.4 Conclusions TMPM better predicted mortality than did the anatomic injury component of TRISS, or TARN and this was true whether individual injuries were coded in the AIS lexicon or in the ICD-9. As trauma care evolves, so must models of mortality prediction that best capture injury severity.