Sarah Majercik

Transfer Times to Definitive Care Facilities Are Too Long: A Consequence of an Immature Trauma System

Objective:The purpose of this study was to review our experience with interfacility transfers to identify problems that could be addressed in the development of a statewide trauma system. Background:The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. This hinges on well-defined prehospital destination criteria, interfacility transfer protocols, and education of caregivers. Patients arriving at local community hospitals (LOCs) benefit from stabilization and transfer to trauma centers (TCs) for definitive care. However, in the absence of a formalized trauma system, patients may not reach the TC in a timely fashion and may not be appropriately treated or stabilized at LOCs prior to transfer. Methods:Our facility is a level I TC and regional referral center for a compact geographic area without a formal trauma system. The Trauma Registry was queried for adult patients admitted to the trauma service between January 1, 2001 and March 30, 2003. Patients were divided into 2 groups: those received directly from the scene (DIR) and those transferred from another institution (TRAN). Medical records were reviewed to elucidate details of the early care. Data are presented as mean ± SEM. Continuous data were compared using Student t test, and categorical data using χ2. Transfer times were analyzed by one-way ANOVA. Results:A total of 3507 patients were analyzed. The TRAN group had a higher Injury Severity Score (ISS) (17.5 versus 11.0, P < 0.05), lower Glasgow Coma Score (GCS) (13.3 versus 14.1, P < 0.05), lower initial systolic blood pressure (SBP) (130 versus 140, P< 0.05), and higher mortality (10% versus 79%, P < 0.05) than the DIR group. The average time spent at the LOC was 162 ± 8 minutes. The subgroup of patients with hypotension spent an average of 134 minutes at the LOC, often receiving numerous diagnostic tests despite unavailability of surgeons to provide definitive care. Severe head injury (GCS = 3) triggered more prompt transfer, but high ISS was underappreciated and did not result in a prompt transfer in all but the most severely injured group (ISS > 40). Some therapeutic interventions were initiated at the LOCs, but many were required at the TC. A total of 23 (8%) TRAN patients required critical interventions within 15 minutes of arrival; mortality in this group was 52%. Mortality among those requiring laparotomy after transfer was 33%. Conclusions:All but the most severely injured patients spend prolonged periods of time in LOCs, and many require critical interventions upon arrival at the TC. It is unreasonable to expect immediate availability of surgeons or operating rooms in LOCs. Thus, trauma system planning efforts should focus on 1) prehospital destination protocols that allow direct transport to the TC; and 2) education of caregivers in LOCs to enhance intervention skill sets and expedite transfer to definitive care.

Long-term patient outcomes after surgical stabilization of rib fractures

BACKGROUND Rib fractures are common, and can be disabling. Recently, there has been increased interest in surgical stabilization of rib fractures (SSRF). It is difficult to define long-term benefits of the procedure. This is a descriptive study of patient outcomes after SSRF. METHODS SSRF patients between April 2010 and August 2012 at a Level I trauma center were identified. Data were collected from the medical records. A telephone survey asking about pain, satisfaction, and employment was administered to patients after hospital discharge. RESULTS One hundred-one patients met inclusion criteria. Fifty (50%) patients completed the survey. Indications for SSRF included flail chest, displaced fractures, pain, and inability to wean from mechanical ventilation. Pain was gone at 5.4 ± 1.1 weeks post discharge. Satisfaction with SSRF on a scale of 1 to 10 was 9.2 ± .2. Ninety percent of employed patients returned to the same work at 8.5 ± 1.2 weeks. CONCLUSIONS SSRF patients are satisfied and are able to return to normal activity with few limitations. A prospective study using modern rib fixation technology is needed to further define benefits.

Re: Red cell distribution width is predictive of mortality in trauma patients.

BACKGROUND Red blood cell distribution width (RDW) is a component of the complete blood count (CBC) that is traditionally used to identify iron-deficiency anemia. RDW has been shown to predict mortality in patients with multiple different medical conditions and in general populations. It is unknown whether RDW predicts outcomes in trauma patients. This study tested whether RDW predicts mortality in a trauma population at a Level I trauma center. METHODS Trauma patients with a CBC from October 2005 to December 2011 were evaluated. Sex-specific 30-day and 1-year all-cause mortality and RDW were studied using Cox regression adjusted for age, Injury Severity Score (ISS), hospital length of stay, blunt versus penetrating trauma, and other CBC parameters. RESULTS A total of 3,637 females and 5,901 males were evaluated at 30 days and 1 year. With full adjustment, RDW predicted 30-day mortality in males (for RDW quintiles 1–5: 2.2%, 1.8%, 3.6%, 4.8%, 10.1%, respectively; p < 0.001) but not in females (3.4%, 1.9%, 3.0%, 3.9%, 6.2%; p = 0.036). At 1 year, RDW predicted mortality in both males (p < 0.001; 0.5%, 0.4%, 0.8%, 1.7%, and 8.3%) and females (p < 0.001; 0.5%, 2.1%, 3.0%, 4.2%, and 8.8%). Receiver operating characteristic analysis found c = 0.705 in males and c = 0.625 in females at 30 days and c = 0.820 in males and c = 0.723 in females at 1 year. CONCLUSION RDW independently predicted mortality in trauma patients at this single Level I trauma center. RDW may reveal underlying health status and be clinically useful for prognostication. The mechanistic relationship between RDW and mortality in trauma remains unknown and should be further evaluated. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.

Weight-based enoxaparin dosing for venous thromboembolism prophylaxis in the obese trauma patient

BACKGROUND Limited data exist regarding the efficacy of weight-based dosing of low-molecular weight heparin for venous thromboembolism (VTE) prophylaxis in obese trauma patients. METHODS Consecutive obese trauma patients were placed on a weight-based protocol for VTE prophylaxis (enoxaparin .5 mg/kg subcutaneously every 12 hours). Peak anti-Xa levels were drawn, and bilateral lower extremity duplex ultrasound was performed. The incidence of VTE and bleeding complications were recorded. RESULTS Eighty-six patients met the study criteria. Seventy-four patients achieved target prophylactic anti-Xa concentrations, with a mean level of .42 ± .01 IU/mL. Eighteen patients were found to have deep vein thrombosis. However, in 16 of these patients, deep vein thrombosis was diagnosed before weight-based low-molecular weight heparin initiation. No bleeding complications occurred, and no symptomatic pulmonary emboli were identified. CONCLUSIONS In obese trauma patients, weight-based enoxaparin is an efficacious regimen that provides adequate VTE prophylaxis, as measured by anti-Xa levels, and appears to be safe without bleeding complications.

Effects of Patient Preinjury and Injury Characteristics on Acute Rehabilitation Outcomes for Traumatic Brain Injury

OBJECTIVE To examine associations of patient and injury characteristics with outcomes at inpatient rehabilitation discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN Prospective, longitudinal observational study. SETTING Inpatient rehabilitation centers. PARTICIPANTS Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, and divided into 5 subgroups based on rehabilitation admission FIM cognitive score. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS Severity indices increased explained variation in outcomes beyond that accounted for by patient characteristics. FIM motor scores were generally the most predictable. Higher functioning subgroups had more predictable outcomes then subgroups with lower cognitive function at admission. Age at injury, time from injury to rehabilitation admission, and functional independence at rehabilitation admission were the most consistent predictors across all outcomes and subgroups. CONCLUSIONS Findings from previous studies of the relations among patient and injury characteristics and rehabilitation outcomes were largely replicated. Discharge outcomes were most strongly associated with injury severity characteristics, whereas predictors of functional independence at 9 months postdischarge included both patient and injury characteristics.

Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines

Please cite this article as: Pieracci Fredric M, Majercik Sarah, Ali-Osman Francis, Ang Darwin, Doben Andrew, Edwards John G, French Bruce, Gasparri Mario, Marasco Silvana, Minshall Christian, Sarani Babak, Tisol William, VanBoerum Don H, White Thomas W.Consensus Statement: Surgical Stabilization of Rib Fractures Rib Fracture Colloquium Clinical Practice Guidelines.Injury http://dx.doi.org/10.1016/j.injury.2016.11.026

In-hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures.

BACKGROUND One factor that has precluded the wide adoption of surgical stabilization of rib fractures (SSRF) is the perception that it is too expensive to surgically repair an injury that will eventually heal without intervention. The purpose of this study was to compare in-hospital outcomes, costs, and charges for SSRF patients with a series of propensity-matched, nonoperatively managed rib fracture (NON-OP) patients at a single Level 1 trauma center. METHODS All patients admitted with rib fractures between January 2009 and June 2013 were identified. Patient demographics, injury, cost, and charge data were collected. Two-to-one propensity score matching was used to identify NON-OP patients who were similar to the SSRF patients. Zero-inflated negative binomial regression was conducted to assess the relationship among SSRF, intensive care unit (ICU) length of stay (LOS), and ventilator days. Cost and charge information was compared using Wilcoxon rank-sum tests. RESULTS A total of 411 patients (137 SSRF, 274 NON-OP) were included in the analysis. Ventilator days and ICU LOS in days were not different between the SSRF and NON-OP groups when compared using the Wilcoxon rank-sum test. Ventilator and ICU days were less for SSRF by 2.24 days and 1.62 days, respectively, using zero-inflated negative binomial analysis to exclude the large number of patients who had 0 day on the ventilator and/or in the ICU. SSRF patients had higher hospital costs and total relevant charges compared with the NON-OP patients. Subgroup analysis of patients requiring mechanical ventilation who did not have head injury showed decreased ventilator days (median, 3 days vs. 5 days; p = 0.03) and need for tracheostomy (5% vs. 23%, p = 0.02) in SSRF versus NON-OP, respectively. In this subgroup, there was no difference in hospital costs and charges between SSRF and NON-OP. CONCLUSION SSRF patients have shorter ICU LOS and less ventilator days than NON-OP across a diverse group of patients. Hospital costs and charges for SSRF patients are higher. In mechanically ventilated patients who do not have head injury, in-hospital outcomes are better, and there is no difference in hospital costs and charges. Further prospective cost-effectiveness research will determine whether improved quality of life and ability to return to meaningful activity sooner outweighs the increased costs of the acute care episode for SSRF patients. LEVEL OF EVIDENCE Epidemiologic study, level III.

Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema

BACKGROUND Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF). METHODS Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank-sum tests. RESULTS One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF (P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group (P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group (P = .002). CONCLUSIONS Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked.

Chest Wall Trauma

Chest wall trauma is common, and contributes significantly to morbidity and mortality of trauma patients. Early identification of major chest wall and concomitant intrathoracic injuries is critical. Generalized management of multiple rib fractures and flail chest consists of adequate pain control (including locoregional modalities); management of pulmonary dysfunction by invasive and noninvasive means; and, in some cases, surgical fixation. Multiple studies have shown that patients with flail chest have substantial benefit (decreased ventilator and intensive care unit days, improved pulmonary function, and improved long-term functional outcome) when they undergo surgery compared with nonoperative management.

Quantifying and exploring the recent national increase in surgical stabilization of rib fractures

BACKGROUND Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization. METHODS Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis. RESULTS Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.50–1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57–1.71), south (OR, 1.48; 95% CI, 1.43–1.54), then midwest (OR, 1.4; 95% CI, 1.34–1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65–0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22–0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%). Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39–2.39; p < 0.0001), controlled by Injury Severity Score. CONCLUSION Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation. LEVEL OF EVIDENCE Epidemiological study, level III.