Asad Azim

The impact of frailty on failure-to-rescue in geriatric trauma patients: A prospective study

INTRODUCTION Failure-to-rescue (FTR) (defined as death from a major complication) is considered as an index of hospital quality in trauma patients. However, the role of frailty in FTR events remains unclear. We hypothesized that FTR rate is higher in elderly frail trauma patients. METHODS We performed a prospective cohort study of all elderly (age ≥ 65 years) trauma patients presenting at our level one trauma center. Patient’s frailty status was calculated utilizing the Trauma Specific Frailty Index (TSFI) within 24 hours of admission. Patients were stratified into non-frail, pre-frail, and frail. FTR was defined as death from a major complication (respiratory, infectious, cardiac, and renal). Binary logistic regression analysis was performed after adjusting for age, gender, injury severity (ISS), and vital parameters to assess the relationship between frailty status and FTR. RESULTS A total of 368 elderly trauma patients were evaluated of which 25% (n = 93) were non-frail, 38% (n = 139) pre-frail, and 37% (n = 136) frail. Overall, 30% of the patients developed in-hospital complications; of them, mortality occurred in 26% of the patients (FTR group). In the FTR group, 69% of the patients were frail compared to 17% pre-frail and 14% non-frail (p = 0.002). On multivariate regression analysis for predictors of FTR, frail status was an independent predictor of FTR (OR [95% CI] = 2.67 [1.37–5.20]; p = 0.004). On sensitivity analysis, positive predictive value of TSFI for FTR was 69% and negative predictive value for FTR was 67%. CONCLUSION In elderly trauma patients, the presence of frailty increased the odds of FTR almost threefold as compared to non-frail. Although FTR has been considered as an indicator of health care quality, the findings of this study suggest that frailty status independently contributes to FTR. This needs to be considered in the future development of quality metrics, particularly in the case of geriatric trauma patients. LEVEL OF EVIDENCE Prognostic study, level II.

Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: Analysis of 1,030 consecutive trauma laparotomies

BACKGROUND The aim of this study was to evaluate the related change in outcomes (mortality, complications) in patients undergoing trauma laparotomy (TL) with the implementation of damage control resuscitation (DCR). We hypothesized that the implementation of DCR in patients undergoing TL is associated with better outcomes. METHODS We analyzed 1,030 consecutive patients with TL. Patients were stratified into three phases: pre-DCR (2006–2007), transient (2008–2009), and post-DCR (2010–2013). Resuscitation fluids (crystalloids and blood products), injury severity score (ISS), vital signs, and laboratory (hemoglobin, international normalized ratio, lactate) parameters were recorded. Regression analysis was performed after adjusting for age, ISS, laboratory and vital parameters, comorbidities, and resuscitation fluids to identify independent predictors for outcomes in each phase. RESULTS Patient demographics and ISS remained the same throughout the three phases. There was a significant reduction in the volume of crystalloid (p = 0.001) and a concomitant increase in the blood product resuscitation (p = 0.04) in the post-DCR phase compared to the pre-DCR and transient DCR phases. Volume of crystalloid resuscitation was an independent predictor of mortality in the pre-DCR (OR [95% CI]: 1.071 [1.03–1.1], p = 0.01) and transient (OR [95% CI]: 1.05 [1.01–1.14], p = 0.01) phases; however, it was not associated with mortality in the post-DCR phase (OR [95% CI]:1.01 [0.96–1.09], p = 0.1). Coagulopathy (p = 0.01) and acidosis (p = 0.02) were independently associated with mortality in all three phases. CONCLUSION The implementation of DCR was associated with improved outcome in patients undergoing TL. There was a decrease in the use of damage control laparotomy, with a decrease in the use of crystalloid and an increase in the use of blood products. LEVEL OF EVIDENCE Prognostic study, level III.

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

INTRODUCTION The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. METHODS We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). RESULTS A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001). On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). CONCLUSION The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. LEVEL OF EVIDENCE Economic and value-based evaluation, level III.

Redefining the association between old age and poor outcomes after trauma: The impact of frailty syndrome.

BACKGROUND Frailty syndrome (FS) is a well-established predictor of outcomes in geriatric patients. The aim of this study was to quantify the prevalence of FS in geriatric trauma patients and to determine its association with trauma readmissions, repeat falls, and mortality at 6 months. METHODS we performed a 2-year (2012–2013) prospective cohort analysis of all consecutive geriatric (age, ≥ 65 years) trauma patients. FS was assessed using a Trauma-Specific Frailty Index (TSFI). Patients were stratified into: nonfrail, TSFI ⩽ 0.12; prefrail, TSFI = 0.1 to 0.27; and frail, TSFI > 0.27. Patient follow-up occurred at 6 months to assess outcomes. Regression analysis was performed to assess independent associations between TSFI and outcomes. RESULTS Three hundred fifty patients were enrolled. Frail patients were more likely to develop in-hospital complications (nonfrail, 12%; prefrail, 17.4%; and frail, 33.4%; p = 0.02) and an adverse discharge disposition compared with nonfrail and prefrail (nonfrail, 8%; prefrail,18%; and frail, 47%; p = 0.001). Six-month follow-up was recorded in 80% of the patients. Compared with nonfrail patients, frail patients were more likely to have had a trauma-related readmission (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2–3.6) and/or repeated falls (OR, 1.6; 95%CI, 1.1–2.5) over the 6-month period. Overall 6-month mortality was 2.8% (n = 10), and frail elderly patients were more likely to have died (OR, 1.1; 95% CI, 1.04–4.7) compared with nonfrail patients. CONCLUSION Over a third of geriatric trauma patients had FS. TSFI provides a practical and accurate assessment tool for identifying elderly trauma patients who are at increased risk of both short-term and long-term outcomes. Early focused intervention in frail geriatric patients is warranted to improve long-term outcomes. LEVEL OF EVIDENCE Prognostic study, level II.

Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol.

INTRODUCTION The National Trauma Triage Protocol (NTTP) is an algorithm that guides emergency medical services providers through four decision steps to identify the patients that would benefit from trauma center care. The NTTP defines a systolic blood pressure (SBP) of less than 90 mm Hg as one of the criteria for trauma center need. The aim of our study was to determine the impact of substituting SBP of less than 90 mm Hg with shock index (SI) on triage performance. METHODS A 2-year (2011–2012) retrospective analysis of all trauma patients 18 years or older in the National Trauma Databank was performed. Transferred patients, patients dead on arrival, and those with missing data were excluded. Our outcome measure was trauma center need defined by Injury Severity Score greater than 15, need for emergent operation, death in the emergency department, and intensive care unit stay of more than 1 day. Area under the characteristic curve and triage characteristics were compared between SBP of less than 90 mm Hg and SI of more than 1.0. Logistic regression analysis was performed to compare the mortality between patients triaged under current protocol of SBP of less than 90 mm Hg and patients triaged using the new defined protocol (SI >1.0). RESULTS A total of 505,296 patients were included. Compared with SBP of less than 90 mm Hg, SI of more than 1.0 had a higher sensitivity (44.4% vs. 41.7%) but lower specificity (80.2% vs. 82.4%). The area under the curve was significantly higher for SI of more than 1.0 (0.623 [95% confidence interval, 0.622–.625] vs. 0.620 [95% confidence interval, 0.619–0.622]). Substituting SBP of less than 90 mm Hg with SI of more than 1.0 resulted in a decrease in undertriage rate of 30,233 patients (5.9%) but an increase in overtriage of only 6,386 patients (1.3%). CONCLUSION Substituting the current criterion of SBP of less than 90 mm Hg in the NTTP with an SI of more than 1.0 results in significant reduction in undertriage rate without causing large increase in overtriage. Because of simplicity of use, better discrimination power, and minimal effect on overtriage rates, future studies should consider exploring the possibility of replacing the current SBP of less than 90 mm Hg criterion with SI of more than 1.0 in the NTTP. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Early feeds not force feeds: Enteral nutrition in traumatic brain injury.

BACKGROUND Brain Trauma Foundation guidelines recommend the early use of enteral nutrition to optimize recovery following traumatic brain injury (TBI). Our aim was to examine the effect of early feeds (⩽24 hours) on clinical outcomes after TBI. METHODS We performed a 3-year retrospective study of patients with severe TBI (Glasgow Coma Scale score <8) who were intubated, admitted to the intensive care unit (ICU), and received tube feeds. Early tube feeds (early TF) were defined as initiation of tube feeds within 24 hours, whereas late tube feeds (late TF) were defined as initiation of tube feeds after 24 hours. Outcome measures included pneumonia rates, days on ventilator, hospital and ICU stay, and mortality rates. RESULTS A total of 90 patients (early TF: 58, late TF: 32) were included, of which 73.3% were male, mean age was 42 (SD, 20) years, and median head Abbreviated Injury Scale score was 4 (range, 3–5). There was no difference in age (p = 0.1), head Abbreviated Injury Scale score (p = 0.5), or admission Glasgow Coma Scale score (p = 0.9) between the two groups. Patients with early TF were associated with higher number of ICU days (p = 0.03) and higher pneumonia rates (p = 0.04), but there was no significant difference in mortality (p = 0.44) as compared with those who underwent late TF. CONCLUSIONS Although early tube feeds are known to improve outcomes in TBI patients, our data suggest that early feeds in TBI patients are associated with higher rates of pneumonia and greater hospital resource utilization. LEVEL OF EVIDENCE Therapeutic study, level IV.

American College of Surgeons Level I trauma centers outcomes do not correlate with patients’ perception of hospital experience

BACKGROUND The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a data collection methodology for measuring a patient’s perception of his/her hospital experience, and it has been selected by the Centers of Medicare and Medicaid Services as the validated and transparent national survey tool with publicly available results. Since 2012, hospital reimbursements rates have been linked to HCAHPS data based on patient satisfaction scores. The aim of this study was, therefore, to assess whether HCAHPS scores of Level I trauma centers correlate with actual hospital performance. METHODS Retrospective analysis of the latest publicly available HCAHPS data (2014–2015) was performed. American College of Surgeons (ACS) verified Level I trauma centers for each state were identified from the ACS registry and then the following data points were collected for each hospital: HCAHPS linear mean scores regarding cleanliness of the hospital, doctor and nurse communication with the patient, staff responsiveness, pain management, overall hospital rating, and patient willingness to recommend the hospital. Our outcome measure were serious complication scores, failure-to-rescue (FTR) scores and readmission-after-discharge scores. Spearman correlation analysis was performed. RESULTS A total of 119 ACS verified Level I trauma centers across 46 states were included. The median [IQR] overall hospital rating score for Level I trauma centers was 89 (87–90). The mean ± SD score for serious complication was 0.96 ± 0.266, FTR was 123.06 ± 22.5, and readmission after discharge was 15.71 ± 1.07. The Spearman correlation analysis showed that overall HCAHP-based hospital rating scores did not correlate with serious complications (correlation coefficient = 0.14 p = 0.125), FTR (correlation coefficient = −0.15 p = 0.073), or readmission after discharge (correlation coefficient = −0.18 p = 0.053). CONCLUSION The findings of our study suggest that no correlation exists between HCAHPS patient satisfaction scores and hospital performance for Level I trauma centers. Consequently, the Centers of Medicare and Medicaid Services should reconsider hospital reimbursement decisions based on HCAHP patient satisfaction scores. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Revitalizing Vital Signs: The Role of Delta Shock Index.

Introduction: Although variability in vital parameters has been shown to predict outcomes, the role of change in shock index (delta SI) as a predictive tool remains unknown. Methods: The National Trauma Data Bank (2011–2012) was abstracted for all patients aged 18 to 85 years and Injury Severity Score more than 15 with complete data. Transferred patients and patients dead on arrival were excluded. Patient demographics and injury parameters were recorded, and SI in the field, SI in the emergency department (ED), and change in SI (delta SI = ED SI−field SI) were calculated. Our outcome measure was mortality. Cox regression and Kaplan-Meier analysis was performed. Results: A total of 95,088 patients were included, and the overall mortality rate was 11.9%. Patients with a positive delta SI had a mortality rate of 13.3% compared with 9.6% mortality rate in patients who had an unchanged or negative delta SI. After controlling for confounders, a delta SI more than 0.1 was found to be associated with an increased hazard of death (hazard ratio [95% CI] = 1.36 [1.29–1.45]) and mortality (16.6% vs. 9.5%, P < 0.001). Even in hemodynamically stable patients, a delta SI more than 0.1 was associated with increased hazard of death (hazard ratio [95% CI] = 1.29 [1.20–1.39]). Conclusions: Delta SI from field to hospital independently predicts higher mortality. It predicts higher mortality even in apparently hemodynamically stable patients with normal traditional vital signs and normal SI. Delta SI may serve as an adjunct to existing traditional vital signs for the identification of occult hypovolemic shock and higher risk of death in trauma patients.

How does marijuana affect outcomes after trauma in ICU patients? A propensity-matched analysis

INTRODUCTION In the United States, marijuana abuse and dependence are becoming more prevalent among adult and adolescent trauma patients. Unlike several studies that focus on the effects of marijuana on the outcomes of diseases, our aim was to assess the relationship between a positive toxicology screen for marijuana and mortality in such patients. METHODS A 5-year (2008–2012) analysis of adult trauma patients (older than 18 years old) in Arizona State Trauma Registry. We included patients admitted to the intensive care unit (ICU) with a positive toxicology screen for marijuana. We excluded patients with positive alcohol or other substance screening. Outcome measures were mortality, ventilator days, ICU, and hospital length of stay. We matched patients who tested positive for marijuana (marijuana positive) to those who tested negative (marijuana negative) using propensity score matching in a 1:1 ratio controlling for age, injury severity score, and Glasgow Coma Scale. RESULTS We included a total of 28,813 patients, of which 2,678 were matched (1,339, marijuana positive; 1,339, marijuana negative). The rate of positive screening for marijuana was 7.4% (2,127/28,813). Mean age was 31 ± 9 years, and injury severity score was 13 (8–20). There was no difference between the two groups in hospital (6.4 days vs. 5.4 days, p = 0.08) or ICU (3 days vs. 4 days, p = 0.43) length of stay. Of the marijuana-positive patients, 55.3% received mechanical ventilation, while 32% of marijuana-negative patients received mechanical ventilation (p < 0.001). On subanalysis of patients who received mechanical ventilation, the marijuana-positive patients had a higher number of ventilator days (2 days vs. 1 day, p = 0.02) and a lower mortality rate (7.3% vs. 16.1%, p < 0.001) than those who were marijuana negative. CONCLUSION A positive marijuana screen is associated with decreased mortality in adult trauma patients admitted to the ICU. This association warrants further investigation of the possible physiologic effects of marijuana in trauma patients. LEVEL OF EVIDENCE Prognostic studies, level III.

Decompressive craniectomy versus craniotomy only for intracranial hemorrhage evacuation: A propensity matched study

BACKGROUND Decompressive craniectomy (DC) is often performed in conjunction with evacuation of intracranial hemorrhage (ICH) to control intracranial pressure (ICP) in patients with a traumatic brain injury (TBI). The efficacy of DC in lowering ICP is well established; however, its effect on clinical outcomes remains controversial. The aim of our study is to assess outcomes in TBI patients undergoing DC versus craniotomy only (CO) for the evacuation of ICH. METHODS We performed a 5-year retrospective analysis of TBI patients with ICH who underwent craniotomy or craniectomy for traumatic ICH. Patients were divided into two groups, those who underwent CO and those who underwent DC. Propensity scoring matched patients in a 1:2 ratio for demographics, admission Glasgow Coma Scale (GCS) score, severity of injury, type and size of ICH, and anticoagulant use. Outcome measures included mortality, adverse discharge disposition (skilled nursing facility), discharge GCS and Glasgow Outcome Scale scores, and complications. RESULTS We reviewed 1,831 patients with TBI, of which 155 underwent craniotomy and/or craniectomy. After propensity score matching, we included 99 of those patients in our study (DC, 33; CO, 66). Matched groups were similar in age (p = 0.68), admission GCS score (p = 0.50), Injury Severity Score (p = 0.70), head Abbreviated Injury Scale score (p = 0.32), and intracranial bleeding characteristics. Overall, 26.3% (n = 26) of the patients died and 62.6% (n = 62) were discharged to Rehab/skilled nursing facility. There was no difference in the mortality rate (27.3% vs. 25.0%; p = 0.99), adverse discharge disposition (45% vs. 33%; p = 0.66), GCS score (p = 0.53), and Glasgow Outcome Scale (p = 0.80) at discharge between the DC and the CO groups. However, patients in DC group had higher complication rates and ventilator days. CONCLUSION This study showed no significant difference in clinical outcomes for patients undergoing evacuation of ICH regardless of the procedure performed. DC did not appear to be superior to craniotomy alone for the treatment of acute ICH. LEVEL OF EVIDENCE Therapeutic, level III.