Stefano Di Bartolomeo

The Utstein template for uniform reporting of data following major trauma: A joint revision by SCANTEM, TARN, DGU-TR and RITG

BackgroundIn 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases.MethodsOver a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique.ResultsThe expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping.ConclusionThrough a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.

Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED.

OBJECTIVES The aim of this study is to assess the ability of bedside lung ultrasound (US) to confirm clinical suspicion of pneumonia and the feasibility of its integration in common emergency department (ED) clinical practice. METHODS In this study we performed lung US in adult patients admitted in our ED with a suspected pneumonia. Subsequently, a chest radiograph (CXR) was carried out for each patient. A thoracic computed tomographic (CT) scan was made in patients with a positive lung US and a negative CXR. In patients with confirmed pneumonia, we performed a follow-up after 10 days to evaluate clinical conditions after antibiotic therapy. RESULTS We studied 49 patients: pneumonia was confirmed in 32 cases (65.3%). In this group we had 31 (96.9%) positive lung US and 24 (75%) positive CXR. In 8 (25%) cases, lung US was positive with a negative CXR. In this group, CT scan always confirmed the US results. In one case, US was negative and CXR positive. Follow-up turned out to be always consistent with the diagnosis. CONCLUSION Considering that lung US is a bedside, reliable, rapid, and noninvasive technique, these results suggest it could have a significant role in the diagnostic workup of pneumonia in the ED, even if no sensitivity nor specificity can be inferred from this study because the real gold standard is CT, which could not be performed in all patients.

A population-based study on pneumothorax in severely traumatized patients.

BACKGROUND Pneumothorax (PNX) is a recognized cause of preventable deaths in trauma patients. Our objective was to determine the incidence of traumatic PNX, the characteristics of its victims, and the treatment they receive. METHODS The study consisted of data set of a population-based study on major trauma. RESULTS The incidence of PNX was 81 per 1 million population per year, mostly caused by transport accidents. PNX victims generally had multiple injuries, and they showed on-scene clinical parameters worse than victims of other chest injuries of comparable severity. Fifty-three percent of PNXs were drained during the prehospital and early (< 2 hours) hospital course. There was no uniformity of treatment among different types of rescue facilities, some of them never performing decompression despite clinical need. The z statistic for mortality was -0.63. CONCLUSION PNX can be expected in one in five major trauma victims found alive. PNX is associated with a peculiar on-scene instability. Early decompression is often required. The effects of wider access to prehospital decompression and the reasons for its uneven availability in our setting need elucidation. Nevertheless, the present mortality follows the international standards.

Epidemiology of major injury in the population of Friuli Venezia Giulia—Italy

OBJECTIVE To provide reliable and comparable information on major injury (MIJ) (Injury Severity Score (ISS) > 15) by establishing a comprehensive and Utstein-style compliant registry of all occurrences in a defined geographical area. METHODS Prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia (FVG). Deliberate self-harm was excluded. RESULTS The total number of MIJ cases was 627, the resulting incidence 522 per million per year. Trauma was mostly blunt (98.4%). Young (15-44 years) adults (54.8%) and males (78.6%) were most affected. Leading mechanisms of injury were traffic accidents (81%) and falls (9.1%). Most events occurred in rural (80.9%) areas despite one third of the regional population living in major urban centres. Summer and weekends carried the highest frequency. The mean ISS ( n = 455 ) was 30.0, median 25. On-scene vital parameters were often subnormal, e.g. 53.9%, GCS < 14. The Emergency Medical System was nearly always activated (98.4%). The time intervals were within standards although in part susceptible of improvement. The percentage of direct triage to the definitive hospital was 79.8%. Overall mortality was 45.6% or 238 per million per year. Most fatalities were found already dead (171/300) and no trimodal distribution was verified. Only 1.5% of the patients found alive died outside hospital. Mean GOS was 4.4 +/- 1 (S.D.), median 5. CONCLUSION A considerable amount of information on MIJ in FVG has been gathered, of both local and general interest because it can help to assess the local trauma system and also, given the relative scarcity of prospective, population-based information on MIJ, contribute to scientific research.

HEMS vs. Ground-BLS care in traumatic cardiac arrest.

Objective. To assess whether a top-level type of prehospital care, made of helicopter, physician, andadvanced life support (ALS) procedures, improves the outcome of blunt trauma victims found in cardiac arrest (CA) as compared with a simpler type, composed of ground ambulance, nurse, andexpanded basic life support (BLS). Methods. This was a cohort study from the data set of a prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia. Results. Fifty-six victims received the higher level of care (helicopter emergency medical services [HEMS] group) and73 received the lower one (ground-BLS group). The two groups were homogeneous for mechanism of injury, gender, andtime interval before cardiopulmonary resuscitation (CPR). Age was lower in the ground-BLS group. The percentage of patients in which CPR was attempted was significantly higher in the HEMS group (43% vs. 20%; CI 0.061 to 0.379). On-scene return of spontaneous circulation (ROSC) was also more likely in the HEMS group (37.5% of attempted CPRs vs. 6.6%; CI 0.027 to 0.591). None of the patients evacuated from the scene without ROSC ever attained it in hospital. This policy was virtually exclusive to the ground-BLS group. Survival to hospital discharge was 3.5% (severely disabled) in the HEMS group and0% in the ground-BLS group (CI −0.008 to 0.078). Conclusion. A top-level type of prehospital care had significantly more chances to resuscitate blunt trauma victims found in CA as compared with a simpler level. No significant benefit on long-term outcome was found, but more cases might be needed in future studies because of the inevitably low number of survivors.

Collecting core data in severely injured patients using a consensus trauma template: an international multicentre study

IntroductionNo worldwide, standardised definitions exist for documenting, reporting and comparing data from severely injured trauma patients. This study evaluated the feasibility of collecting the data variables of the international consensus-derived Utstein Trauma Template.MethodsTrauma centres from three different continents were invited to submit Utstein Trauma Template core data during a defined period, for up to 50 consecutive trauma patients. Directly admitted patients with a New Injury Severity Score (NISS) equal to or above 16 were included. Main outcome variables were data completeness, data differences and data collection difficulty.ResultsCentres from Europe (n = 20), North America (n = 3) and Australia (n = 1) submitted data on 965 patients, of whom 783 were included. Median age was 41 years (interquartile range (IQR) 24 to 60), and 73.1% were male. Median NISS was 27 (IQR 20 to 38), and blunt trauma predominated (91.1%). Of the 36 Utstein variables, 13 (36%) were collected by all participating centres. Eleven (46%) centres applied definitions of the survival outcome variable that were different from those of the template. Seventeen (71%) centres used the recommended version of the Abbreviated Injury Scale (AIS). Three variables (age, gender and AIS) were documented in all patients. Completeness > 80% was achieved for 28 variables, and 20 variables were > 90% complete.ConclusionsThe Utstein Template was feasible across international trauma centres for the majority of its data variables, with the exception of certain physiological and time variables. Major differences were found in the definition of survival and in AIS coding. The current results give a clear indication of the attainability of information and may serve as a stepping-stone towards creation of a European trauma registry.

Noninvasive Techniques for Blood Pressure Measurement Are Not a Reliable Alternative to Direct Measurement: A Randomized Crossover Trial in ICU

Introduction. Noninvasive blood pressure (NIBP) monitoring methods are widely used in critically ill patients despite poor evidence of their accuracy. The erroneous interpretations of blood pressure (BP) may lead to clinical errors. Objectives. To test the accuracy and reliability of aneroid (ABP) and oscillometric (OBP) devices compared to the invasive BP (IBP) monitoring in an ICU population. Materials and Methods. Fifty adult patients (200 comparisons) were included in a randomized crossover trial. BP was recorded simultaneously by IBP and either by ABP or by OBP, taking IBP as gold standard. Results. Compared with ABP, IBP systolic values were significantly higher (mean difference ± standard deviation 9.74 ± 13.8; P < 0.0001). Both diastolic (−5.13 ± 7.1; P < 0.0001) and mean (−2.14 ± 7.1; P=0.0033) IBP were instead lower. Compared with OBP, systolic (10.80 ± 14.9; P < 0.0001) and mean (5.36 ± 7.1; P < 0.0001) IBP were higher, while diastolic IBP (−3.62 ± 6.0; P < 0.0001) was lower. Bland-Altman plots showed wide limits of agreement in both NIBP-IBP comparisons. Conclusions. BP measurements with different devices produced significantly different results. Since in critically ill patients the importance of BP readings is often crucial, noninvasive techniques cannot be regarded as reliable alternatives to direct measurements.

ISS mapped from ICD-9-CM by a novel freeware versus traditional coding: a comparative study

BackgroundInjury severity measures are based either on the Abbreviated Injury Scale (AIS) or the International Classification of diseases (ICD). The latter is more convenient because routinely collected by clinicians for administrative reasons. To exploit this advantage, a proprietary program that maps ICD-9-CM into AIS codes has been used for many years. Recently, a program called ICDPIC trauma and developed in the USA has become available free of charge for registered STATA® users. We compared the ICDPIC calculated Injury Severity Score (ISS) with the one from direct, prospective AIS coding by expert trauma registrars (dAIS).MethodsThe administrative records of the 289 major trauma cases admitted to the hospital of Udine-Italy from 1 July 2004 to 30 June 2005 and enrolled in the Italian Trauma Registry were retrieved and ICDPIC-ISS was calculated. The agreement between ICDPIC-ISS and dAIS-ISS was assessed by Cohens Kappa and Bland-Altman charts. We then plotted the differences between the 2 scores against the ratio between the number of traumatic ICD-9-CM codes and the number of dAIS codes for each patient (DIARATIO). We also compared the absolute differences in ISS among 3 groups identified by DIARATIO. The discriminative power for survival of both scores was finally calculated by ROC curves.ResultsThe scores matched in 33/272 patients (12.1%, k 0.07) and, when categorized, in 80/272 (22.4%, k 0.09). The Bland-Altman average difference was 6.36 (limits: minus 22.0 to plus 34.7). ICDPIC-ISS of 75 was particularly unreliable. The differences increased (p < 0.01) as DIARATIO increased indicating incomplete administrative coding as a cause of the differences. The area under the curve of ICDPIC-ISS was lower (0.63 vs. 0.76, p = 0.02).ConclusionsDespite its great potential convenience, ICPIC-ISS agreed poorly with its conventionally calculated counterpart. Its discriminative power for survival was also significantly lower. Incomplete ICD-9-CM coding was a main cause of these findings. Because this quality of coding is standard in Italy and probably in other European countries, its effects on the performances of other trauma scores based on ICD administrative data deserve further research. Mapping ICD-9-CM code 862.8 to AIS of 6 is an overestimation.

Effects of anticoagulant and antiplatelet drugs on the risk for hospital admission for traumatic injuries: a case-control and population-based study.

BACKGROUND The current cardiovascular literature advocates an overall beneficial balance between the advantages of oral anticoagulants and antiplatelet drugs in preventing and treating thromboembolic events and their disadvantages in promoting hemorrhage. However, traumatic injuries have usually received little attention despite several studies from the surgical literature showing worse outcomes in anticoagulated trauma registry patients. To quantify at population level too this seemingly deleterious impact, we investigated the effects of anticoagulants and antiplatelet use on the risk for hospital admission for acute traumatic causes. METHODS A population-based, case-control study in an Italian region with 4.5 million inhabitants was conducted. Cases were all the 59,348 adult residents admitted to the hospital for traumatic injuries in the years 2010 and 2011. Controls were age- and sex-matched residents selected by incidence density sampling. By conditional logistic regression adjusted for comorbidities, we estimated the risk for traumatic hospital admission while on anticoagulant, antiplatelet, and combined medications. RESULTS The odds ratios (ORs) for anticoagulation and combined medications were 1.21 (95% confidence interval [CI], 1.15–1.28) and 1.39 (95% CI, 1.21–1.62). These effects were generally consistent across subgroups of demographic and clinical characteristics and particularly important in the head injured (e.g., OR for anticoagulation, 2.00; 95% CI, 1.77–12.27). Antiplatelets alone had no overall effect (OR, 1.02; 95% CI, 0.99–1.05). The number-needed-to-harm of anticoagulation was 595. CONCLUSION Oral anticoagulation increased the population risk for traumatic hospital admission, with a further increase in case of concurrent antiplatelet use. Because this effect is most likely to derive from the prohemorrhagic properties of these drugs, injured patients should be included in the future evaluations of the cost-benefit profiles of these medications. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Is the TMPM-ICD9 revolution in trauma risk-adjustment compatible with imperfect administrative coding?

BACKGROUND TMPM-ICD9 is the latest injury-severity measure based on empirical estimation from ICD-9-CM codes. It is candidate to replace expert-based AIS measures worldwide because of easier accessibility and better predictive performances. In Italy and other countries administrative ICD coding is generally less complete than dedicated AIS coding. We attempted to ascertain how this affects TMPM performances. METHODS Discrimination (c statistics) and calibration (calibration curves, Akaikes criterion) of hierarchical logistic regression models for hospital mortality comprising TMPM or ISS were compared using trauma-registry data on 3570 patients of years 2007-2009. The completeness of AIS vs. ICD-9-CM coding was also investigated through the ratio of the respective numbers of codes per patient. Model discrimination was further analyzed after stratification according to the above ratio (>1 and ≤ 1). RESULTS The models with TMPM showed worse performances. The differences, concerned calibration (graphical evidence) in univariate models and discrimination (-1.2% of area under the ROC curve, p<0.05) in models completed with age, gender, mechanism of injury, motor GCS and systolic pressure. In parallel, ICD coding was less complete than AIS, as expected: 68% of patients had a ratio >1. The discrimination of TMPM vs. ISS models improved when the ratio changed from >1 to ≤ 1. CONCLUSIONS The predictive performances of TMPM-ICD9 vs. ISS were lower than in the previous studies; the sub-optimal quality of ICD coding was a main cause. Imperfect administrative coding may hence hamper the TMPM-ICD9 revolution, although in our setting the negligible differences and the ready availability of administrative data may still give reason for adopting TMPM-ICD9.