Charlene Mancuso

Trauma in the very elderly: A community-based study of outcomes at trauma and nontrauma centers

BACKGROUND Little research has examined trauma outcomes in the very elderly (>80 years), the fastest growing subset of our geriatric population. Our objective was to describe demographics, mechanism of injury and injury severity of very elderly trauma patients and examine the association between trauma center (TC) verification and hospital mortality in this age group. METHODS Retrospective cohort study. Database consisted of a 1996 countywide trauma registry. Subjects consisted of patients > 80 years of age. The setting consisted of Level I (TCI) and Level II (TCII) trauma centers, and acute care (AC) hospitals. The z score analysis was performed using the Major Trauma Outcome Study and a county-specific risk/outcome equation. In addition, a logistic regression model examined hospital mortality (outcome variable) using age, ISS, arrival GCS, and TC verification as predictor variables. Statistical analysis included descriptive statistics; ANOVA; and forward stepwise logistic regression model (OR; 95% CI). RESULTS Four hundred fifty-five patients with a mean age of 85.9 (+/-4.8) years (range 80-101). Overall mortality was 9.9%. Using z score analysis, survival at TCII performed as predicted (-1.59), while AC performed less than predicted (-3.41). In the regression model, GCS (OR 0.68; CI 0.57-0.79), ISS (OR 1.1; CI 1.05-1.2) and AC setting (OR 3.2; CI 1.1-9.5) predicted hospital mortality. TCs had significantly better outcomes than AC hospitals in a subset of severely injured patients (ISS 21-45) (56% v 8% survival; p < 0.01). CONCLUSION Risk-adjusted outcomes, in this population, differed between TC and AC settings. Head injury, injury severity, and lack of TC verification are associated with hospital mortality in very elderly trauma patients.

Benchmarking the Quality-monitoring Process: A Comparison of Outcomes Analysis by Trauma and Injury Severity Score (TRISS) Methodology with the Peer-review Process

BACKGROUND One measure of optimal function within a trauma center is the ability to critically examine outcomes from the process of care within the institution, yet guidelines for evaluation of the peer-review process are lacking. This study was conducted to determine the correlation between mortality analysis performed by the peer-review process (PR) within a trauma division and outcome analysis as determined by Trauma and Injury Severity Score (TRISS) methodology. METHODS The mortality peer-review data for an entire year at our level I trauma center served as the study population. Information was obtained on probability of survival, and a determination of preventability was made using standard, preexisting criteria. Peer review involves assigning each outcome to a specific category through the process of multidisciplinary assessment. Probability of survival data was not used for this purpose. Kappa analysis was performed to determine the degree of agreement in each category and then tested for significance. RESULTS One hundred four deaths in 1,868 trauma patients (5.5%) were reviewed at our multidisciplinary conference. Outcomes were judged as preventable, potentially preventable, or nonpreventable. Death directly related to exsanguination was typically categorized as potentially preventable. Kappa analysis demonstrated the greatest agreement between PR and TRISS in the nonpreventable category (kappa = 0.213) and the least agreement in the potentially preventable category (kappa = -0.197). Overall, the kappa Z statistic was nonsignificant (Z = 1.24). CONCLUSIONS Multidisciplinary peer-review outcomes analysis is at least as effective as the computer-generated TRISS probability of survival data for evaluating quality of care in a trauma center and may be more effective for analysis of potentially preventable outcomes.

Life after 80 Hours: The Impact of Resident Work Hours Mandates on Trauma and Emergency Experience and Work Effort for Senior Residents and Faculty

BACKGROUND The purpose of this study was to evaluate the impact of work hours mandates on (1) senior resident patient exposure and operating experience in trauma and emergency surgery and (2) faculty work effort. METHODS We measured resident and faculty work on the trauma and emergency surgery services at our Level I trauma center during two comparable 6-month periods. Period 1 (July 1-December 31, 2002) had no call restrictions, separate trauma and emergency service resident call, and some overlap of faculty call responsibilities. Period 2 (July 1-December 31, 2003) had resident work hours compliance and complete integration of resident and faculty trauma and emergency call. Work hours were measured by surveys for faculty and residents. All data were collected prospectively. RESULTS Resident exposure to trauma patients was similar during both time periods. Emergency surgery admissions declined during period 2; however, intensive care unit admissions increased. The number of operations performed by senior residents did not change; however, there was a shift in the median number of emergency surgery cases to more senior residents. Faculty work hours increased slightly despite a decrease in faculty call. CONCLUSION Work hours compliance resulted in a 50% reduction in senior resident call and a 19% decrease in their work hours with no significant change in trauma/emergency patient care exposure or operative case load. Service call amalgamation reduced faculty call by 21% but did not result in a corresponding change in work hours or productivity.

Efficacy of 24-Hour Shifts: Prepared or Impaired? A Prospective Study

BACKGROUND The effect of duty duration on performances is unknown. In a prospective cohort study model using repeated measures, we evaluated the effect of shift length on a battery of neuropsychologic performance indicators using our flight program as the test site. METHODS Flight nurses completing 24- and 12-hour shifts were tested on memory, attention, reasoning, motor, and speed measures. Ratings of stress, fatigue, sleep quality, and logged amount of work and sleep were evaluated from personal journals kept for this purpose. Data were analyzed by linear regression and repeated measures multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA). Clinical significance was set at P < 0.05. RESULTS Fifteen subjects completed the testing and evaluation process. Neuropsychologic testing demonstrated that performance was not predicted by shift length, time of shift (day versus night), amount or quality of sleep before or during shift, or fatigue ratings. Age, gender, and education did not mediate shift length/test performance relationships. Uninterrupted sleep, stress ratings, and number of flights per shift modestly reduced some test scores. Predictably, repeated testings resulted in practice effects that reduced analysis power. We found that 24-hour shifts per se do not result in a cognitive decline compared with 12-hour shifts. Inconsistent sleep, number of flights, and the stressfulness of flights may have greater impact.

Using Trauma and Injury Severity Score (TRISS)-based analysis in the development of regional risk adjustment tools to trend quality in a voluntary trauma system: the experience of the Trauma Foundation of Northeast Ohio.

BACKGROUND Presently, no trauma system exists in Ohio. Since 1993, all hospitals in Cuyahoga County (CUY), northeast Ohio (n = 22) provide data to a trauma registry. In return, each received hospital-specific data, comparison data by trauma care level and a county-wide aggregate summary. This report describes the results of this approach in our region. METHODS All cases were entered by paper abstract or electronic download. Interrater reliability audits and z score analysis was performed by using the Major Trauma Outcome Study and the CUY 1994 baseline groups. Risk adjustment of mortality data was performed using statistical modeling and logistic regression (Trauma and Injury Severity Score, Major Trauma Outcome Study, CUY). Trauma severity measures were defined. RESULTS In 1995, 3,375 patients were entered. Two hundred ninety-one died (8.6%). Severity measures differed by level of trauma care, indicating differences in case mix. Probability of survival was lowest in the Level I centers, highest in the acute care hospitals. Outcomes z scores demonstrated survival differences for all levels. CONCLUSIONS In a functioning trauma system, the most severely injured patients should be cared for at the trauma centers. A low volume at acute care hospitals is desirable. By using Trauma and Injury Severity Score with community-specific constants, NE Ohio is accomplishing these goals. The Level I performance data are an interesting finding compared with the data from the Level II centers in the region