Annette L. Adams

The Optimum Follow-Up Period for Assessing Mortality Outcomes in Injured Older Adults

OBJECTIVES: To compare mortality rates of hospitalized injured aged 67 and older across commonly used follow‐up periods (e.g., in‐hospital, 30‐day, 1‐year) and to determine the postinjury time after which mortality rates stabilize.

ATLS practices and survival at rural level III trauma hospitals, 1995-1999.

Objective: To determine whether Advanced Trauma Life Support (ATLS) practices characterizing initial resuscitation and interfacility transfer at rural trauma hospitals are associated with risk-adjusted survival. Methods: Retrospective, observational analysis of rural injured patient survival. Process-of-care variables were associated with TRISS (trauma and injury severity score)-derived Z-statistics (95% confidence intervals) for high-risk population subsets (defined below). Inclusion criteria: all patients ≥12 years of age entered into a statewide trauma system, January 1, 1995, to December 31, 1999, and initially presenting to Level III trauma centers (N = 4,961). Exclusion criteria: pronounced dead on arrival (n = 26), directly admitted to hospital (n = 3), and unknown disposition at first hospital (n = 2). Process variables include: intubation in emergency department (ED) given Glasgow Coma Scale (GCS) score < 9 [ INTUB ], administration of blood products in ED given systolic blood pressure (SBP) < 90 mm Hg [ BLOOD ], trauma surgeon presence within 5 minutes of patient arrival given GCS < 9 mm Hg or SBP < 90 mm Hg [ UNSTABLE-TS ], trauma surgeon presence within 5 minutes of patient arrival given injury severity score (ISS) > 15 [ ISS-TS ], transfer to higher level of care given ISS > 20 and no hypotension [ TRAN ], transfer to higher level of care given GCS < 9 [ TRAN-GCS ]. Results: For the high-risk subpopulations, the following Z-scores (with and without an intervention) were found: Conclusions: Some ATLS interventions ( BLOOD , TRAN , and TRAN-GCS ) are associated with improved survival for selected high-risk subgroups in these 21 rural Level III trauma hospitals.

HIV infection risk, behaviors, and attitudes about testing: are perceptions changing?

Background People at high risk for HIV infection could be increasing their risk behaviors, especially now that improved treatments for HIV infection are available. Goal The goal was to investigate whether risk behaviors, perceptions of personal risk for HIV infection, and attitudes toward HIV testing among high-risk persons in Oregon differed in 1996 and 1998. Study Design Data from the HIV Testing Survey (HITS), a cross-sectional survey administered to HIV-negative men who have sex with men (MSM), heterosexual adults at high-risk for sexually transmitted diseases (STD), and intravenous drug users (IDUs) at high risk for HIV infection in 1996 (HITS-I), were compared with data from a similar group surveyed in 1998 (HITS-II). Results Proportions of participants reporting specific risk behaviors remained relatively constant in 1996 and 1998. Personal risk of HIV infection was perceived as low by 54% of HITS-II participants and 61.2% of HITS-I participants (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.9-1.7). IDUs in HITS-II were more likely than IDUs in HITS-I to perceive their risk as low (OR, 2.1; 95% CI, 1.2-3.7). Conclusion Persons at high risk might underestimate their risk for HIV infection while practicing risky behaviors. The prevalence of risk behaviors in these populations could be considered the baseline against which to measure future prevention efforts.

Is it possible to safely triage callers to EMS dispatch centers to alternative resources

Objective. To develop guidelines allowing emergency medical services (EMS) dispatchers to safely match callers to an EMS response or, alternatively, to a nontraditional resource. Methods. This was a prospective cohort study of callers to an urban EMS dispatch center and an associated review of EMS patient care forms and emergency department (ED) patient care records. The following five “nature codes” (patient chief complaints) were included: back pain, fall, bleeding or laceration, sick, and trauma. Callers included in the study had been assigned the lowest severity level (Alpha), according to existing dispatch criteria. An a priori list of EMS and ED “important findings,” indicating need for an EMS response, was used as the outcome variable. Classification and regression tree (CART) analysis was used to develop a decision rule to further identify a low-risk subgroup of patients who could potentially be served by alternative resources. Results. From November 1, 1998, to May 31, 1999, 656 subjects were entered into the study, including 263 males (40%) and 389 females (59%). The mean age was 51 years (range, 0–101 years). One hundred twenty-five (19%) callers had an important EMS finding, including the administration of comfort medications, morphine, benzodiazepines, and droperidol. Forty-six subjects (7%) had an important ED finding. When EMS and ED findings were combined, 158 subjects (24%) had an “important finding.” Using CART analysis, having an age <12 years predicted a subset of patients who did not have an important finding suggesting the need for an EMS response. Using cross-validation, this decision rule had a 99% sensitivity, 13% specificity, and 98% negative predictive value. Conclusion. The authors were able to use a demographic variable (age) to predict a population of callers to a 911 dispatch center triaged to the lowest acuity category, who have a very low risk of having an EMS or ED important finding. The decision rule developed here is preliminary, requiring further validation.

Skiing, snowboarding, and sledding injuries in a northwestern state.

OBJECTIVE Winter sports continue to be a popular form of recreation, but few studies have focused on serious injuries. The objectives of this study were to evaluate the major morbidity associated with downhill skiing, snowboarding, and sledding and to determine the incidence of serious injuries sustained while downhill skiing and snowboarding. METHODS State trauma registry data from the 1992-93 through 1998-99 ski seasons on all snow sports participants transported to tertiary trauma hospitals in Oregon were analyzed. RESULTS Of 132 patients, 80% were male and 20% were female, with a mean age of 30.4 +/- 15.6 for skiers, 24.1 +/- 10.5 for snowboarders, and 18.8 +/- 11.9 for sledders. The mean Injury Severity Score was 12.3 +/- 7.6 for skiers, 10.3 +/- 7.4 for snowboarders, and 12.8 +/- 8.5 for sledders. Head injuries accounted for 55% of sledding injuries and 39% of all injuries. Skiers and snowboarders were less likely to have head injuries than sledders (odds ratio [OR] = 0.45; 95% CI, 0.21 to 0.98). A higher proportion of injuries sustained by snowboarders were due to falls from heights (29%) compared with injuries sustained by skiers or sledders (OR = 4.8; 95% CI, 1.6 to 13.7). Sledders were more likely to be injured during collisions than were skiers or snowboarders (OR = 16.7; 95% CI, 5.8 to 47.6). The incidence of serious skiing and snowboarding injuries was 6.4 injuries per million visits. There were 4 deaths (3%), 1 each from snowboarding and skiing (head injuries) and 2 from sledding (1 from head and 1 from head and thoracic injuries). CONCLUSIONS Serious snow sports injuries are rare but potentially debilitating. Head injuries account for the majority of deaths and functional impairment.

Search Is a Time-Critical Event: When Search and Rescue Missions May Become Futile

Abstract Category 1 Continuing Medical Education credit for WMS member physicians is available for this article. Go to http://wms.org/cme/cme.asp?whatarticle=1822 to access the test questions. Objectives.—The purpose of this study was to derive and validate a rule for duration of search (ie, search time) that maximizes survivors and after which a search and rescue (SAR) mission may be considered for termination. Methods.—This was a retrospective cohort study of all SAR missions initiated in Oregon over a 7-year period, which were documented in a population-based administrative database. The following types of search missions were excluded from analysis: redundant reports of a single search; lost helicopters and airplanes; support of organized events; law-enforcement searches; searches for persons actively avoiding rescue; body recovery missions; and cases without outcome information. The cohort was divided into a derivation cohort (searches from 1997–2000) and a validation cohort (2001–2003). The primary outcome was survival. Variables considered in the model included age, gender, minimum and maximum daily temperatures, precipitation, search time, and whether the search involved an air or water incident. Missing data were handled using multiple imputation. Classification and regression tree (CART) methods were used to derive the model. Results.—The derivation cohort included 1040 searches involving 1509 victims, 70 (4.6%) of whom died. The validation cohort included 1262 searches involving 1778 victims; 115 (6.5%) died. Search time was the only variable retained in the final model, with a cut-point of 51 hours. The derivation model was 98.9% sensitive; the same model run using the validation cohort was 99.3% sensitive. Conclusions.—This time-based model may aid search managers in the decision about starting a search or changing search tactics for missing persons.

Secondary Triage: Early Identification of High-Risk Trauma Patients Presenting to Non-Tertiary Hospitals

Objective. We sought to identify a combination of highly specific clinical variables that could be used to quickly identify a subset of high-need injured patients initially presenting to non-tertiary hospitals. Methods. This was a retrospective cohort analysis of all injured adults 15 years or older meeting state trauma criteria, presenting to one of 42 non-tertiary hospital emergency departments (EDs) from January 1, 1998, through December 31, 2003, andsurviving to ED disposition. The outcome included measures of timely resource need: early mortality (within 3 days of ED presentation), major nonorthopedic surgery within 3 days, or intensive care unit stay 2 days or longer. Results. A total of 12,183 persons were included in the analysis, of which 3,643 (30%) patients had one or more of the outcome measures. The variables of greatest importance in identifying high-risk injured adults included (in order or priority): emergent airway intervention (prehospital or ED), initial ED GCS less than 11, ED blood transfusion, initial ED SBP less than 100 or more than 220 mmHg, andinitial ED RR less than 10 or more than 32. These five variables had high specificity (89.1%, 95% confidence interval [CI] 88.2%–89.9%) in identifying 37.9% (95% CI 35.0%–40.7%) of high-risk trauma patients presenting to non-tertiary facilities. The positive likelihood ratio (+LR) for early mortality/early resource need increased for patients with one or more (+LR 3.5), two or more (+LR 9.1), andthree or more (+LR 16.2) of the five risk criteria. Conclusions. There are five highly specific clinical risk criteria that may be useful in quickly identifying high-need injured persons presenting to non-tertiary hospitals. If validated, presence of these criteria may justify early higher level of care transfer by emergency medical services or mobilization of trauma resources without waiting for results of further diagnostic studies.

Physician Consultation, Multidisciplinary Care, and 1-Year Mortality in Medicare Recipients Hospitalized with Hip and Lower Extremity Injuries

OBJECTIVE: To determine whether routine surgeon consultation with medicine specialists and multidisciplinary care conferences—potentially modifiable hospital characteristics—are associated with lower 1‐year mortality in older adults with hip and lower extremity injuries.

Early neurosurgical procedures enhance survival in blunt head injury: propensity score analysis.

BACKGROUND Studies of trauma systems have identified traumatic brain injury as a frequent cause of death or disability. Due to the heterogeneity of patient presentations, practice variations, and potential for secondary brain injury, the importance of early neurosurgical procedures upon survival remains controversial. Traditional observational outcome studies have been biased because injury severity and clinical prognosis are associated with use of such interventions. OBJECTIVE We used propensity analysis to investigate the clinical efficacy of early neurosurgical procedures in patients with traumatic brain injury. METHODS We analyzed a retrospectively identified cohort of 518 consecutive patients (ages 18-65 years) with blunt, traumatic brain injury (head Abbreviated Injury Scale score of >or= 3) presenting to the emergency department of a Level-1 trauma center. The propensity for a neurosurgical procedure (i.e., craniotomy or ventriculostomy) in the first 24 h was determined (based upon demographic, clinical presentation, head computed tomography scan findings, intracranial pressure monitor use, and injury severity). Multivariate logistic regression models for survival were developed using both the propensity for a neurosurgical procedure and actual performance of the procedure. RESULTS The odds of in-hospital death were substantially less in those patients who received an early neurosurgical procedure (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.05-0.41). The mortality benefit of early neurosurgical intervention persisted after exclusion of patients who died within the first 24 h (OR 0.13; 95% CI 0.04-0.48). CONCLUSIONS Analysis of observational data after adjustment using the propensity score for a neurosurgical procedure in the first 24 h supports the association of early neurosurgical intervention and patient survival in the setting of significant blunt, traumatic brain injury. Transfer of at-risk head-injured patients to facilities with high-level neurosurgical capabilities seems warranted.

Injury Hospitalization as a Marker for Emergency Medical Services Use in Elderly Patients

Abstract Background. The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs. Objective. To assess injury hospitalization as a potential marker for subsequent EMS utilization and costs by Medicare patients. Methods. This observational study analyzed a retrospective cohort of all Medicare patients (≥67 years old) with an International Classification of Diseases, Ninth Revision (ICD-9) injury diagnosis admitted to 125 Oregon and Washington hospitals during 2001 and 2002 who survived to hospital discharge. The numbers of EMS transports and the total EMS costs were compared one year before and one year following the index hospitalization. Results. There were 30,655 injured elders in our cohort. Their median ICD-9–based injury severity score was 0.97, with 4.1% meeting a definition of serious injury and 37% having hip fractures. The mean (range) numbers of EMS transports before and after the injury were 0.5 (0–45) and 0.9 (0–56), for an unadjusted incidence rate ratio (IRR) of 1.7 (95% confidence interval [CI] 1.7–1.8). The increase in EMS utilization following an injury hospitalization was even greater after adjusting for risk period and other model predictors (IRR 2.4, 95% CI 2.3–2.5). Annual mean EMS costs rose 74% following the injury hospitalization, from