Melanie Neal

The attributable mortality and length of stay of trauma-related complications: a matched cohort study.

Objective:To determine the attributable mortality (AM) and excess length of stay because of complications or complication groupings in the National Trauma Data Bank. Summary Background Data:Resources devoted to performance improvement activities should focus on complications that significantly impact mortality and length of stay. To determine which post-traumatic complications impact these outcomes, we conducted a matched cohort study. AM is the proportion of all deaths that can be prevented if the complication did not occur. Methods:We identified severely injured patients (Injury Severity Score, ≥9) at centers that contribute complications to the National Trauma Data Bank. To estimate the AM, a patient with a specific complication was matched to 5 patients without the complication. Matching was based on demographics and injury characteristics. Residual confounding was addressed through a logistic regression model. To estimate excess length of stay, matching covariates were identified through a Poisson regression model. Each case was required to match the control on all variables, and one control was selected per case. Results:Of the 94,795 patients who met the inclusion criteria, 3153 died. The overall mortality rate was 3.33%, and 10,478 (11.1%) patients developed at least 1 complication. Four complication groupings (cardiovascular, acute respiratory distress syndrome, renal failure, and sepsis) were associated with significant AM. Infectious complications (surgical infections, sepsis, and pneumonia) were associated with the greatest excess length of stay. Conclusions:This study used AM and excess length of stay to identify trauma-related complications for external benchmarking. Guideline development and performance improvement activities need to be focused on these complications to significantly reduce the probability of poor outcomes following injury.

Methodology and analytic rationale for the American College of Surgeons Trauma Quality Improvement Program.

Received June 12, 2012; Revised August 12, 2012; Accepte 2012. From the Center for Policy and Research in Emergency Medi ment of Emergency Medicine, Oregon Health & Science Uni land, OR (Newgard), Department of Surgery, University of Vegas, NV (Fildes), American College of Surgeons, Chica Neal, Goble), Department of Surgery, University of Mich System, Ann Arbor, MI (Hemmila), Center for Clinical and Research, Departments of Surgery and Pediatrics, Childre Medical Center, Washington, DC (Burd), Intermountain In Research Center, University of Utah, Salt Lake City, UT (Ma ment of Surgery, University of Texas Southwestern Medical Sc TX (Shafi), Department of Surgery, Maine Medical Center, P (Clark), and Department of Surgery, University of Toron Ontario, Canada (Nathens). Correspondence address: Craig D Newgard, MD, MPH, FAC ment of Emergency Medicine, Center for Policy and Resea gency Medicine, Oregon Health & Science University, 31 Jackson Park Rd, Mail Code CR-114, Portland, OR 97239newgardc@ohsu.edu

Hips Can Lie: Impact of Excluding Isolated Hip Fractures on External Benchmarking of Trauma Center Performance

BACKGROUND Trauma centers (TCs) vary in the inclusion of patients with isolated hip fractures (IHFs) in their registries. This inconsistent case ascertainment may have significant implications on the assessment of TC performance and external benchmarking efforts. METHODS Data were derived from the National Trauma Data Bank (2007-8.1). We included patients (aged 16 years or older) with Injury Severity Score value ≥ 9 who were admitted to Level I and II TCs. To ensure data quality, we limited the study to TC that routinely reported comorbidities and Abbreviated Injury Scale codes. IHF were defined as patients, aged 65 years or older, injured as a result of falls, with Abbreviated Injury Scale codes for hip fracture and without other significant injuries. TCs were stratified according to their reported inclusion of IHF in their registry. Observed-to-expected mortality ratios were used to rank TC performance first with and then, without the inclusion of patients with IHF. RESULTS In total, 91,152 patients in 132 TCs were identified; 5% (n = 4,448) were IHF. The proportion of IHF per TC varied significantly, ranging from 0% to 31%. When risk-adjusted mortality was evaluated, excluding patients with IHF had significant effects: 37% (n = 49) of TCs changed their performance rank by ≥ 3 (range, 1-25) and 12% of centers changed their performance quintile. The greatest change in rank performance was evident in centers that routinely include IHF in their registries. CONCLUSIONS Given the fact that IHFs in the elderly significantly influence risk-adjusted outcomes and are variably reported by TCs, these patients should be excluded from subsequent benchmarking efforts.

Health care reform at trauma centers--mortality, complications, and length of stay.

OBJECTIVE The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications. METHODS The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity. RESULTS Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS. CONCLUSION Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

The effect of dead-on-arrival and emergency department death classification on risk-adjusted performance in the American College of Surgeons Trauma Quality Improvement Program

BACKGROUND The American College of Surgeons’ Trauma Quality Improvement Program is focused on identifying variations in outcomes across trauma centers for the purposes of performance improvement. In previous analyses, patients who died in the emergency department were excluded. We investigated the effect of inclusion and exclusion of emergency department (ED) deaths (dead on arrival [DOA] and died in ED [DIE]) on analyses of overall risk-adjusted trauma center performance. METHODS Data for patients admitted to 65 Trauma Quality Improvement Program hospitals during the 2009 calendar year was used. A logistic regression model was developed to estimate risk-adjusted mortality. Trauma centers were then ranked based on their observed-to-expected (O/E) mortality ratio with 90% confidence intervals (CIs) and classified by outlier status: low outliers/high performers had a 90% CI for O/E mortality ratio of less than 1, and high outliers/low performers had a 90% CI for O/E mortality ratio of greater than 1. Changes in outlier status, rank, and quartile were examined with and without DOA and DIE patients included in the analyses to discern the impact of such exclusions on overall risk-adjusted center-specific performance. RESULTS Thirty-one trauma centers (48%) reported no DOA patients in 2009, while 6 centers (9%) reported more than 10. Of 224 patients, 14 (6.2%) had a documented time of death of more than 30 minutes after ED arrival despite being recorded as DOA. Forty-one trauma centers (63%) changed rank by three positions or less. Ten trauma centers changed their quartile ranking by a single quartile, but no centers were found to change quartile rank more than one quartile. Changes in outlier status occurred for 6 trauma centers (9%). CONCLUSION The relative frequency of patients classified as DOA varies greatly between trauma centers. Misclassification of patients as DOA occurs. Inclusion of ED deaths in risk-adjusted analysis of mortality results in a small but insignificant change in predicting the outcome results of a trauma center. This change is less than the rate of finding a center to be a high or low outlier by chance alone using the 90% CI. Inclusion of DOA and DIE patients in risk-adjusted analysis of mortality is appropriate and eliminates the bias introduced by exclusion of ED deaths owing to misuse of the DOA classification. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Creating a nationally representative sample of patients from trauma centers.

BACKGROUND The National Trauma Data Bank (NTDB) was developed as a convenience sample of registry data from contributing trauma centers (TCs), thus, inferences about trauma patients may not be valid at the national level. The NTDB National Sample was created to obtain nationally representative estimates of trauma patients treated in the US level I and II TCs. METHODS Level I and II TCs in the Trauma Information Exchange Program were identified and a random stratified sample of 100 TCs was selected. The probability-proportional-to-size method was used to select TCs and sample weights were calculated. National Sample Program estimates from 2003 to 2006 were compared with raw NTDB data, and to a subset of TCs in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a population-based dataset drawn from community hospitals. RESULTS Weighted estimates from the NTDB National Sample range from 484,000 (2004) to 608,000 (2006) trauma incidents. Crude NTDB data over-represented the proportion of younger patients (0 years-14 years) compared with the NTDB National Sample, which does not include childrens hospitals. Few TCs in Trauma Information Exchange Program are included in Healthcare Cost and Utilization Project Nationwide Inpatient Sample, but estimates based on this subset indicate a higher percentage of older patients (age 65 year or older, 23.98% versus 17.85%), lower percentage male patients, and a lower percentage of motor vehicle accidents compared with NTDB National Sample. CONCLUSION Although nationally representative data regarding trauma patients are available in other population-based samples, they do not represent TCs patients and lack the specificity of National Sample Program data, which contains detailed information on injury mechanisms, diagnoses, and hospital treatment.

Position statement of the American College of Surgeons Committee on Trauma on the National Academies of Sciences, Engineering and Medicine Report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

Donald H. Jenkins, MD, Robert J. Winchell, MD, Raul Coimbra, MD, PhD, Michael F. Rotondo, MD, Leonard J. Weireter, MD, Eileen M. Bulger, MD, Rosemary A. Kozar, MD, PhD, Avery B. Nathens, MD, Patrick M. Reilly, MD, Sharon M. Henry, MD, Maria F. Jimenez, MD, Michael C. Chang, MD, Michael Coburn, MD, Jimm Dodd, MA, Melanie L. Neal, MS, Justin Rosen, Jean Clemency, David B. Hoyt, MD, and Ronald M. Stewart, MD, Chicago, Illinois

Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma: A propensity-matched analysis.

BACKGROUND Pulmonary embolism (PE) is a leading cause of delayed mortality in patients with severe injury. While low-molecular-weight heparin (LMWH) is often favored over unfractionated heparin (UH) for thromboprophylaxis, evidence is lacking to demonstrate an effect on the occurrence of PE. This study compared the effectiveness of LMWH versus UH to prevent PE in patients following major trauma. METHODS Data for adults with severe injury who received thromboprophylaxis with LMWH or UH were derived from the American College of Surgeons Trauma Quality Improvement Program (2012–2015). Patients who died or were discharged within 5 days were excluded. Rates of PE were compared between propensity-matched LMWH and UH groups. Subgroup analyses included patients with blunt multisystem injury, penetrating truncal injury, shock, severe traumatic brain injury, and isolated orthopedic injury. A center-level analysis was performed to determine if practices with respect to choice of prophylaxis type influence hospital PE rates. RESULTS We identified 153,474 patients at 217 trauma centers who received thromboprophylaxis with LMWH or UH. Low-molecular-weight heparin was given in 74% of patients. Pulmonary embolism occurred in 1.8%. Propensity score matching yielded a well-balanced cohort of 75,920 patients. After matching, LMWH was associated with a significantly lower rate of PE compared with UH (1.4% vs. 2.4%; odds ratio, 0.56; 95% confidence interval, 0.50–0.63). This finding was consistent across injury subgroups. Trauma centers in the highest quartile of LMWH utilization (median LMWH use, 95%) reported significantly fewer PE compared with centers in the lowest quartile (median LMWH use, 39%; 1.2% vs. 2.0%; odds ratio, 0.59; 95% confidence interval, 0.48–0.74). CONCLUSIONS Thromboprophylaxis with LMWH (vs. UH) was associated with significantly lower risk of PE. Trauma centers favoring LMWH-based prophylaxis strategies reported lower rates of PE. Low-molecular-weight heparin should be the anticoagulant agent of choice for prevention of PE in patients with major trauma. LEVEL OF EVIDENCE Therapeutic study, level III.

Penetrating oesophageal injury: A contemporary analysis of the National Trauma Data Bank

BACKGROUND Oesophageal trauma is uncommon. The aim of this study was to conduct a descriptive analysis of penetrating oesophageal trauma and determine risk factors for oesophageal related complications and mortality in the National Trauma Data Bank (NTDB). METHODS Patients with penetrating oesophageal trauma from Levels 1 and 2 trauma centres in the NTDB (2007 and 2008) that specified how complication and comorbidity data were recorded were selected. Data collected included age, injury severity score (ISS), abbreviated injury scores (AIS), lengths of stay (LOS) and ventilation days, systolic blood pressure (SBP) in the emergency department (ED), comorbidities, oesophageal related procedures, and oesophageal related complications. Univariate and multivariable analyses were conducted to identify significant predictors of oesophageal-related complications and mortality in patients with LOS>24 h. RESULTS 227 patients from 107 centres were studied. The mean number of patients per centre was 2 (range 1-15). Overall mortality was found to be 44% with 92% of these deaths in less than 24 h. In patients with LOS>24 h, 62% had primary repair, 13% drainage, 4% resection, 1% diversion, and 20% unspecified. No significant difference in mortality was found in patients with oesophageal related complications. The time to first oesophageal related procedure was not significantly different in those with oesophageal related complications or those who died. Significant predictors of oesophageal related complications were age and AIS of the abdomen or pelvic contents ≥3 and the only significant predictor of mortality was ISS. CONCLUSIONS Most deaths in penetrating oesophageal trauma occur in the first 24 h due to severe associated injuries. Primary repair was the most common intervention, followed by drainage and resection. Oesophageal related complications were not found to significantly increase mortality and time to first oesophageal related procedure did not affect outcomes in this subset of patients from the NTDB.

Good Neighbors? The Effect of a Level 1 Trauma Center on the Performance of Nearby Level 2 Trauma Centers

Objective: In this study, we sought to determine whether the proximity of a level 1 trauma center (TC) might affect the performance of a nearby level 2 TC. Background: With the exception of research and teaching programs, level 2 TC must function at a level similar to that of level 1 TC, and provide high quality, definitive care to severely injured patients. However, the role of a level 2 TC within a region might vary significantly depending on the local trauma care environment. We postulated that the case mix, regional role and outcomes of level 2 TC are greatly influenced by the regional presence of a level 1 TC. Methods: Data were derived from the National Trauma Databank (9.0), limiting to adults with Injury Severity Score ≥9. Level 2 TC were classified as either isolated trauma centers (ITC, >30 miles from the closest level 1 TC) or neighbored trauma centers (NTC, ⩽30 miles from the closest level 1 TC). Regression was used to calculate risk-adjusted mortality at each center type. Results: Fifty-five thousand six hundred and fifty-five patients were identified at 161 centers; 55% of patients were cared for at ITC (n = 84 centers). Case mix varied significantly across center type; in particular, ITC received significantly more transfer patients than NTC. After adjusting for differences in case mix, patients at ITC had a 12% lower risk of death than patients treated at NTC (0.88, 95% CI 0.78–0.98). Conclusions: Level 2 TC assume different roles depending on the local trauma system configuration. Ideally, a level 2 TC should benefit from the presence of a nearby level 1 TC through collaborations in care protocols and shared case reviews. However, these data suggest the opposite: level 2 centers in proximity to level 1 centers might perform at a lower than expected level.