Irina Radomislensky

Reduction in trauma mortality in Israel during the last decade (2000–2010): The impact of changes in the trauma system

HYPOTHESIS Following the introduction of changes to the trauma system there would be a period of time during which the impact on mortality would be minimal. A decrease in mortality rates would be noted as the TS matured and would continue over time. DESIGN A retrospective cohort study of all severely injured patients (injury severity score ≥ 16) recorded in the Israeli National Trauma Registry at six level I trauma centres in Israel from 2000 to 2010. Inpatient death rates were examined overall and by sub groups. SETTING The National Trauma Registry contains hospitalized patients, transfer patients to or from other hospitals and those who died in the emergency department. It excludes patients who were dead on arrival, discharged following treatment in the emergency department, and patients whose injuries by definition are not classified as trauma. MAIN OUTCOME MEASURES In-hospital mortality RESULTS Data included 23,143 severe trauma patients available for analysis. Inpatient mortality rates decreased significantly from 16% in 2000 to 11% in 2010. The odds ratio for mortality in 2010 vs. 2000, adjusted for year, age, sex, mechanism of injury, traumatic brain injury, penetrating injury, and severity of injury (ISS ≥ 25), was 0.53, confirming a downward trend. CONCLUSIONS A steady significant reduction in the inpatient mortality rate for severe trauma patients hospitalized at all level I trauma centres in Israel between 2000 and 2010 was observed. Although a single factor that explains the reduction was not identified, evidently the establishment of the trauma system brought about a significant decrease in hospital mortality. Integrated cooperation between components of the national trauma system in Israel over the years may explain the reduction.

ISS groups: are we speaking the same language?

Background Despite ISS being a widely accepted tool for measuring injury severity, many researchers and practitioners use different partition of ISS into severity groups. The lack of uniformity in ISS use inhibits proper comparisons between different studies. Creation of ISS group boundaries based on single AIS value squares and their sums was proposed in 1988 during Major Trauma Study (MTOS) in the USA, but was not validated by analysis of large databases. Methods A validation study analysing 316 944 patients in the Israeli National Trauma registry (INTR) and 249 150 patients in the American National Trauma Data Bases (NTDB). A binary algorithm (Classification and Regression Trees (CART)) was used to detect the most significantly different ISS groups and was also applied to original MTOS data. Results The division of ISS into groups by the CART algorithm was identical in both Trauma Registries and very similar to original division in the MTOS. For most samples, the recommended groups are 1–8, 9–14, 16–24 and 25–75, while in very large samples or in studies specifically targeting critical patients there is a possibility to divide the last group into 25–48 and 50–75 groups, with an option for further division into 50–66 and 75 groups. Conclusions Using a statistical analysis of two very large databases of trauma patients, we have found that partitioning of ISS into groups based on their association with patient mortality enables us to establish clear cut-off points for these groups. We propose that the suggested partition of ISS into severity groups would be adopted as a standard in order to have a common language when discussing injury severity.

Sternal fracture: isolated lesion versus polytrauma from associated extrasternal injuries--analysis of 1,867 cases.

BACKGROUND Sternal fractures fall into two distinct categories as follows: (1) isolated sternal fracture (ISF) without associated injury and (2) polytrauma sternal fracture (PSF) with associated extrasternal injury. PSF can be sufficiently severe to require hospitalization, while ISF is usually a mild insult manageable in an ambulatory setting. Nonetheless, most patients with ISF are hospitalized. The disconnect between treatment based on existing evidence and actual clinical practice may be caused in large part by the small patient cohorts in published studies conducive to inaccurate conclusions. This article addresses the issue by analyzing prospectively collected data on a far larger population than hitherto available. METHODS The Israeli National Trauma Registry (INTR) collects data prospectively on patients admitted to trauma centers in Israel. We analyzed the INTR database on sternal fractures for demographics, mechanisms and severity of injury, diagnostic evaluation, treatment, and outcomes. RESULTS Between 1997 and 2008, the INTR received data on 1,867 consecutive patients hospitalized with sternal fractures. The injury was sustained most often during motor vehicle accidents (84.1%), followed by falls (10.3%) and other blunt or penetrating mechanisms (5.6%). ISF was sustained in 26.4%, and PSF was sustained in 73.6%. Associated injuries involved most parts of the body. Cardiac contusions or lacerations were diagnosed in 1.8% of the 1,867 patients. ISF was associated with a lower incidence of cardiorespiratory compromise, more favorable trauma scores (Glasgow Coma Scale [GCS] score > 14, Revised Trauma Score > 11), and use of fewer intensive care facilities or operations compared with PSF. Endotracheal intubation, chest tube insertion, or thoracotomy was not performed in any ISF patient but was performed in 16.9% of the PSF cohort. The differences between ISF and PSF were statistically significant in all analyzed indices of injury severity. CONCLUSION This study produced compelling evidence that ISF is an identifiable and mild injury. Consequently, pain, the major clinical manifestation of ISF, can usually be treated in outpatient settings. To avoid the inconvenience, risk of complications, and cost associated with hospitalization, discharge from the emergency department merits serious consideration. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level II.

Traumatic brain injury: It is all about definition

Abstract Background: TBI may be defined by different methods. Some may be most useful for immediate clinical purposes, however less optimal for epidemiologic research. Other methods, such as the Abbreviated Injury Score (AIS), may prove more beneficial for this task, if the cut-off-points for their categories are defined correctly. Objective: To reveal the optimal cut-off-points for AIS in definition of severity of TBI in order to ensure uniformity between future studies of TBI. Results: Mortality of patients with TBI AIS 3, 4 was 1.9% and 2.9% respectively, comparing with 31.1% among TBI AIS 5+. Predictive discrimination ability of the model with cut-off-points of 5+ for TBI AIS (in comparison with other cut-off-points) was better. Patients with missing Glasgow Coma Scale (GCS) in the ED had an in-hospital mortality rate of 11.5%. In this group, 25% had critical TBI according to AIS. Normal GCS didn’t indicate an absence of head injury, as, among patients with GCS 15 in the ED, 26% had serious/critical TBI injury. Moreover, 7% of patients with multiple injury and GCS 3–8 had another reason than head injury for unconsciousness. Conclusions: This study recommends the adoption of an AIS cut-off ≥ 5 as a valid definition of severe TBI in epidemiological studies, while AIS 3–4 may be defined as ‘moderate’ TBI and AIS 1–2 as ‘mild’.

Incidence and injury characteristics of traumatic brain injury: Comparison between children, adults and seniors in Israel

Abstract Aim: To assess the incidence and injury characteristics of hospitalized trauma patients diagnosed with TBI. Methods: A retrospective study of all injured hospitalized patients recorded in the National Trauma Registry at 19 trauma centres in Israel between 2002–2011. Incidence and injury characteristics were examined among children, adults and seniors. Results: The annual incidence rate of hospitalized TBI for the Israeli population in 2011 was 31.8/100 000. Age-specific incidence was highest among seniors with a dramatic decrease in TBI-related mortality rate among them. Adults, in comparison to children and seniors, had higher rates of severe TBI, severe and critical injuries, more admission to the intensive care unit, underwent surgery, were hospitalization for more than 2 weeks and were discharged to rehabilitation. After adjusting for age, gender, ethnicity, mechanism of injury and injury severity score, TBI-related in-hospital mortality was higher among seniors and adults compared to children. Conclusion: Seniors are at high risk for TBI-related in-hospital mortality, although adults had more severe and critical injuries and utilized more hospital resources. However, seniors showed the most significant reduction in mortality rate during the study period. Appropriate intervention programmes should be designed and implemented, targeted to reduce TBI among high risk groups.

The casualties from electric bike and motorized scooter road accidents.

ABSTRACT Objective: The objective of this study was to describe demographic and injury characteristics of hospitalized injured patients involved in e-bike and motorized scooter accidents at a national level in Israel divided by different road user groups: riders and pedestrians. Methods: This was a retrospective study based on data from the National Trauma Registry, between January 1, 2013, and December 31, 2015. All hospitalized casualties due to the involvement of an e-bike or motorized scooter were included. The type of hospitalized road user was further categorized and described by different variables. Results: During the study period, the Israel Trauma Registry identified 795 hospitalized patients due to an e-bike or motorized scooter accident, with a dramatic 6-fold increase from 2013 to 2015. Although the majority of the injured patients were riders, 8% were pedestrians. Among the total casualties, 33% were children aged 0–14 years and among pedestrians 42% were children and 33% were seniors (ages 60+). Five persons died in hospital, 3 riders and 2 pedestrians. Conclusions: E-bike and motorized scooter riders represent the majority of patients hospitalized due to related traffic incident. This finding questions the social and economic advantages of electric-powered 2-wheeled vehicles.

Prehospital administration of freeze-dried plasma, is it the solution for trauma casualties?

BACKGROUND Hemorrhage is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the prehospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze-dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this article, we present our experience with the use of FDP at the POI and prehospital setting regarding the feasibility, safety, adverse reactions, and adherence to clinical practice guidelines. METHODS This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment, and outcome characteristics from POI until hospital discharge. RESULTS During the study period, 109 casualties received FDP. The majority were men, aged 18 years to 35 years. Multiple severe injuries were found in almost half of the casualties, 78% had penetrating injury, and more than half were involved in a multicasualty event. Eighty-three percent were treated with one unit of FDP, 13% with two units, and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with packed red blood cells. Fifty-seven percent fulfilled at least one criterion for the administration of FDP. Lifesaving interventions were required in 64%. In five (4.6%) cases, there were difficulties with FDP administration. Side effects were reported in one female patient. CONCLUSION This study supports the usage feasibility of FDP at the POI and in the prehospital setting. Further adjustment of the clinical practice guidelines is required basing it not only on pathophysiologic parameters but also on clinical judgment. Further investigation of the available data is required to learn about the effectiveness of FDP at POI. Level of Evidence Retrospective case series study, level IV.BACKGROUND Hemorrhage, is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the pre-hospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this manuscript we present our experience with the use of FDP at the POI and pre-hospital setting regarding the feasibility, safety, adverse reactions and adherence to clinical practice guidelines (CPG). METHODS This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment and outcome characteristics from POI until hospital discharge. RESULTS During the study period 109 casualties received FDP. The majority were male, aged 18-35 years old. Multiple severe injuries, were found in almost half of the casualties, 78% had penetrating injury and more than half were involved in a multi casualty event. 83% were treated with one unit of FDP, 13% with two units and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with PRBC. 57% fulfilled at least one criteria for the administration of FDP. Lifesaving interventions were required in 64%. In five cases (4.6%) there were difficulties with FDP administration, Side effects were reported in one female patient. CONCLUSION This study supports the usage feasibility of FDP at the POI and in the pre-hospital setting. Further adjustment of the CPG is required basing it not only on patho-physiological parameters but also on clinical judgment. Further investigation of the available data is required in order to learn about the effectiveness of FDP at POI. LEVEL OF EVIDENCE Level IV retrospective case series study.

Characteristics and circumstances of injuries vary with ethnicity of different population groups living in the same country

ABSTRACT Objective. To examine whether characteristics and circumstances of injuries are related to ethnicity. Design. The study was based on the Israeli National Trauma Registry data for patients hospitalized between 2008 and 2011. Data included demographics, injury, hospital resource utilization characteristics and outcome at discharge. Univariate analysis followed by logistic regression models were undertaken to examine the relationship between injury and ethnicity. Results. The study included 116,946 subjects; 1% were Ethiopian Born Israelis (EBI), 11% Israelis born in the Former Soviet Union (FSUBI) and 88% the remaining Israelis (RI). EBI were injured more on street or at work place and had higher rates of penetrating and severe injuries. However, FSUBI were mostly injured at home, and had higher rates of fall injuries and hip fracture. Adjusted analysis showed that EBI and FSUBI were more likely to be hospitalized because of violence-related injuries compared with RI but less likely because of road traffic injuries. Undergoing surgery and referral for rehabilitation were greater among FSUBI, while admission to intensive care unit was greater among EBI. Conclusion. Targeted intervention programmes need to be developed for immigrants of different countries of origin in accordance with the identified characteristics.

Do modern conflicts create different medical needs

PURPOSES This study involved analysis of (a) type of injuries and medical services used by military casualties in 3 conflicts and (b) medical needs of military and civilian casualties from the 2006 conflict. BASIC PROCEDURES Military casualties from 3 conflicts and military and civilian casualties from the 2006 conflict were analyzed. Casualties were compared in relation to type of injury, length of stay (LOS), and operating room use (ORU). MAIN FINDINGS Hospital LOS of soldiers in many departments decreased while increasing in intensive care unit (ICU). Type of injuries sustained by civilians and military casualties differed significantly. More civilian casualties required admission to ICU. Civilian ORU was higher for orthopedic and otolaryngological procedures. PRINCIPAL CONCLUSIONS Civilians are less well protected during military conflicts, therefore, more susceptible to certain kind of injuries. Civilian and military casualties during conflicts have different medical needs. Civilians have higher morbidity than soldiers, which result in an increased need for treatment in ICU.

The impact of neighborhood socioeconomic disparities on injury

ObjectivesTo examine the relationship between neighborhood socioeconomic level (NSEL) and injury-related hospitalization.MethodsThe National Trauma Registry (INTR) and the National Population Census (NPC), including NSEL, were linked by individual identity number. Age-adjusted logistic regression predicted injury hospitalization. Mantel–Haenszel  X2 was used for linear trends. NSEL was divided into 20 clusters.ResultsThe population comprised 7,412,592 residents, of which 125,829 (1.7%) were hospitalized due to injury. The injury hospitalization rate was at least 42 per 10,000 per year. Except for the very low SEL, an inverse relationship between NSEL and all-cause injury was found: 46.1/10,000 in cluster 3 compared to 22.9/10,000 in cluster 20. Hip fracture-related hospitalizations among ages 65 + decreased as SEL increased (2.19% o in cluster 2 compared to 0.95% in cluster 19). In comparison with Jews, non-Jews were 1.5 times more likely to have an injury-related hospitalization [OR 1.5 (95% CI 1.50–1.55)].ConclusionsThe INTR and the NPC were successfully linked providing individual and injury hospitalization data. The outcomes confirm the strong relationship between injury mechanism and NSEL.