Is computerized tomography of trauma patients associated with a transfer delay to a regional trauma centre?

ABSTRACT Objective: Many trauma patients undergo advanced diagnostic imaging before being transferred to a regional trauma centre, but this step can delay definitive care. This study compared the length-of-stay at the primary hospital between patients who underwent CT scans and those who did not. Methods: This was a medical record review of all consecutive trauma cases transferred to a regional trauma centre servicing 2.2 million people during a 2-year period. Two trained abstractors, blind to each other's results, collected data independently. Results: Of 249 cases, 79 (31%) underwent a CT scan before being transferred. There was no significant difference in the Injury Severity Score between the 2 groups (p = 0.16), yet the CT group remained at the primary hospital approximately 90 minutes longer before transfer (p < 0.001). Conclusion: A significant proportion of trauma patients transferred to a regional trauma centre undergo CT scanning at the primary hospital. These patients experience an increased length-of-stay of 90 minutes, on average, before transfer. This appears to be a common practice that does not appear to contribute to definitive trauma management.

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Does emergency medicine length of stay predict trauma outcomes at a Level 1 Trauma Center?

Journal of Hospital Administration ◽

10.5430/jha.v4n5p1 ◽

2015 ◽

Vol 4 (5) ◽

pp. 1 ◽

Cited By ~ 2

Author(s):

Erin Powers Kinney ◽

Kamal Gursahani ◽

Eric Armbrecht ◽

Preeti Dalawari

Keyword(s):

Length Of Stay ◽

Trauma Center ◽

Injury Severity ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Hospital Capacity ◽

Significant Difference ◽

Level 1 ◽

Level 1 Trauma Center

Objective: Previous studies looking at emergency department (ED) crowding and delays of care on outcome measures for certain medical and surgical patients excluded trauma patients. The objectives of this study were to assess the relationship of trauma patients’ ED length of stay (EDLOS) on hospital length of stay (HLOS) and on mortality; and to examine the association of ED and hospital capacity on EDLOS.Methods: This was a retrospective database review of Level 1 and 2 trauma patients at a single site Level 1 Trauma Center in the Midwest over a one year period. Out of a sample of 1,492, there were 1,207 patients in the analysis after exclusions. The main outcome was the difference in hospital mortality by EDLOS group (short was less than 4 hours vs. long, greater than 4 hours). HLOS was compared by EDLOS group, stratified by Trauma Injury Severity Score (TRISS) category (< 0.5, 0.51-0.89, > 0.9) to describe the association between ED and hospital capacity on EDLOS.Results: There was no significant difference in mortality by EDLOS (4.8% short and 4% long, p = .5). There was no significant difference in HLOS between EDLOS, when adjusted for TRISS. ED census did not affect EDLOS (p = .59), however; EDLOS was longer when the percentage of staffed hospital beds available was lower (p < .001).Conclusions: While hospital overcrowding did increase EDLOS, there was no association between EDLOS and mortality or HLOS in leveled trauma patients at this institution.

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P008: Evaluation of outcomes after implementation of a provincial prehospital bypass standard for trauma patients – an Eastern Ontario experience

CJEM ◽

10.1017/cem.2019.199 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S65-S66

Author(s):

M. Austin ◽

J. Sinclair ◽

S. Leduc ◽

S. Duncan ◽

J. Rouleau ◽

...

Keyword(s):

Injury Severity ◽

Univariate Analysis ◽

Vital Signs ◽

Trauma Centre ◽

Trauma Patients ◽

Level Of Consciousness ◽

Orthopedic Operation ◽

Eastern Ontario ◽

Record Review ◽

The Impact

Introduction: Trauma and injury play a significant role in the population's burden of disease. Limited research exists evaluating the role of trauma bypass protocols. The objective of this study was to assess the impact and effectiveness of a newly introduced prehospital field trauma triage (FTT) standard, allowing paramedics to bypass a closer hospital and directly transport to a trauma centre (TC) provided transport times were within 30 minutes. Methods: We conducted a 12-month multi-centred health record review of paramedic call reports and emergency department health records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness, step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as an urgent transport to hospital, that met one of the 4 steps of the FTT standard and would allow for a bypass consideration. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions. The primary outcome was the rate of appropriate triage to a TC, defined as any of the following: injury severity score ≥12, admitted to an intensive care unit, underwent non-orthopedic operation, or death. We report descriptive and univariate analysis where appropriate. Results: 570 adult patients were included with the following characteristics: mean age 48.8, male 68.9%, attended by Advanced Care Paramedic 71.8%, mechanisms of injury: MVC 20.2%, falls 29.6%, stab wounds 10.5%, median initial GCS 14, mean initial BP 132, prehospital fluid administered 26.8%, prehospital intubation 3.5%, transported to a TC 74.6%. Of those transported to a TC, 308 (72.5%) had bypassed a closer hospital prior to TC arrival. Of those that bypassed a closer hospital, 136 (44.2%) were determined to be “appropriate triage to TC”. Bypassed patients more often met the step 1 or step 2 of the standard (186, 66.9%) compared to the step 3 or step 4 (122, 39.6%). An appropriate triage to TC occurred in 104 (55.9%) patients who had met step 1 or 2 and 32 (26.2%) patients meeting step 3 or 4 of the FTT standard. Conclusion: The FTT standard can identify patients who should be bypassed and transported to a TC. However, this is at a cost of potentially burdening the system with poor sensitivity. More work is needed to develop a FTT standard that will assist paramedics in appropriately identifying patients who require a trauma centre.

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MP06: Predictors of hypothermia upon emergency department arrival in severe trauma patients transported to hospital via emergency medical services

CJEM ◽

10.1017/cem.2018.160 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S42-S42

Author(s):

C. Forristal ◽

K. Van Aarsen ◽

M. Columbus ◽

J. Wei ◽

K. Vogt ◽

...

Keyword(s):

Length Of Stay ◽

Emergency Medical Services ◽

Blunt Trauma ◽

Major Trauma ◽

Injury Severity ◽

Severe Trauma ◽

Trauma Centre ◽

Trauma Patients ◽

Local Trauma ◽

Continental Climate

Introduction: Hypothermia in severe trauma patients can increase mortality by 25%. Active re-warming decreases mortality and is recommended in trauma management guidelines. Despite this, many emergency medical services (EMS) vehicles do not carry equipment for active re-warming. This study sought to determine the local rate of hypothermia in major trauma patients on trauma centre arrival (TCA), and to establish which patients are at highest risk by identifying factors present in the pre-hospital setting associated with hypothermia in a humid continental climate. Methods: This single-centre retrospective chart review included adults (age 18) in the local trauma registry (trauma team activation or injury severity score >12) from January 2009-June 2016. Patients were excluded if: temperature on TCA unknown or 38°C, not transported by EMS, or if there was >24 hrs from injury to TCA. The primary outcome was the rate of hypothermia (<35°C) in major trauma patients transported by EMS on arrival at the local trauma centre. Secondary outcomes included hospital length of stay and survival to discharge. Logistic regression was used to identify predictors of hypothermia on TCA; it included the following factors: age, sex, weight, number of comorbidities, injury severity, injury mechanism, EMS modality, direct transport from scene or referred from peripheral hospital, time on scene, transport time, local temperature, and pre-hospital heart rate, systolic blood pressure (SBP), intubation, and volume of crystalloid. Results: A total of 3070 adult traumas were included, 159 of which were hypothermic on TCA a rate of 5%. Multivariate analysis identified seven risk factors for hypothermia: intubation pre-hospital (OR 8.10, p<0.001), blunt trauma (OR 3.37, p=0.044 vs. penetrating, and OR 7.35, p=0.023 vs. other), direct transport (OR 1.94, p=0.005), number of comorbidities (OR 1.14, p=0.036), injury severity (OR 1.03, p<0.001), 1°C local temperature drop (OR 1.03, p<0.001), and 1mmHg SBP drop (OR 1.01, p<0.001). Ninety-four percent of normothermic patients and 69.2% of hypothermic patients survived to discharge. Average length of stay was 7.98 and 15.23 days respectively. Conclusion: Avoidance of hypothermia is imperative to the management of major trauma patients. Those at highest risk in a humid continental climate are severely injured blunt trauma patients with multiple co-morbidities, a low pre-hospital SBP and EMS intubation. Future studies should focus on the benefits of pre-hospital rewarming in these high-risk patients.

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Advancing the Use of Laparoscopy in Trauma: Repair of Intraperitoneal Bladder Injuries

The American Surgeon ◽

10.1177/000313481908501237 ◽

2019 ◽

Vol 85 (12) ◽

pp. 1402-1404 ◽

Cited By ~ 1

Author(s):

Michael R. Arnold ◽

Caroline D. Lu ◽

Bradley W. Thomas ◽

Gaurav Sachdev ◽

Kyle W. Cunningham ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Bladder Rupture ◽

Trauma Patients ◽

Average Hospital ◽

Early Return ◽

Significant Difference ◽

Intraperitoneal Bladder Rupture

Traumatic intraperitoneal bladder rupture (IBR) requires surgical repair. Traditionally performed via laparotomy, experience with laparoscopic bladder repair (LBR) after blunt trauma is limited. Benefits of laparoscopy include decreased length of stay (LOS), less pain, early return to work, fewer adhesions, and lower risk of incisional hernia. The aim of this series is to demonstrate the potential superiority of LBR in select trauma patients. This is a retrospective review performed of all IBR patients from 2008 to 2016. Demographics, clinical management, outcomes, and follow-up were compared between LBR and open bladder repair (OBR) patients. Twenty patients underwent OBR, and seven underwent LBR. There was no significant difference in gender, age, or Injury Severity Score. There were no deaths or reoperations in either group. Average hospital length of stay and ICU days were similar between groups. There was one patient with UTI and one with readmission in each group. There were two incisional hernias and two bowel obstructions in the OBR group, with one patient requiring operative intervention. No such complications occurred in the LBR group. LBR for traumatic IBR can be safely performed in select patients, even in those with multiple extra-abdominal injuries.

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A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

European Geriatric Medicine ◽

10.1007/s41999-021-00546-9 ◽

2021 ◽

Author(s):

Y. Kalbas ◽

M. Lempert ◽

F. Ziegenhain ◽

J. Scherer ◽

V. Neuhaus ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Descriptive Analysis ◽

Patient Characteristics ◽

Severe Trauma ◽

Diagnostic Tools ◽

Trauma Patients ◽

Treatment Algorithms ◽

Injured Patients ◽

Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

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LO89: Factors associated with delay in trauma team activation and impact on patient outcomes

CJEM ◽

10.1017/cem.2017.151 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S58-S59

Author(s):

R. Connolly ◽

M. Woo ◽

J. Lampron ◽

J.J. Perry

Keyword(s):

Length Of Stay ◽

Trauma Team ◽

Operative Management ◽

Trauma Patients ◽

Early Group ◽

Emergency Physicians ◽

Trauma Team Activation ◽

Factors Associated ◽

Significant Difference ◽

Delayed Group

Introduction: Trauma code activation is initiated by emergency physicians using physiologic and anatomic criteria, mechanism of injury and patient demographic factors in conjunction with data obtained from emergency medical service personnel. This enables rapid definitive treatment of trauma patients. Our objective was to identify factors associated with delayed trauma team activation. Methods: We conducted a health records review to supplement data from a regional trauma center database. We assessed consecutive cases from the trauma database from January 2008 to March 2014 including all cases in which a trauma code was activated by an emergency physician. We defined a delay in trauma code activation as a time greater than 30 minutes from time to arrival to trauma team activation. Data were collected in Microsoft Excel and analyzed in Statistical Analysis System (SAS). We conducted univariate analysis for factors potentially influencing trauma team activation and we subsequently used multiple logistic regression analysis models for delayed activation in relation to mortality, length of stay and time to operative management. Results: 1020 patients were screened from which 174 patients were excluded, as they were seen directly by the trauma team. 846 patients were included for our analysis. 4.1% (35/846) of trauma codes were activated after 30 minutes. Mean age was 40.8 years in the early group versus 49.2 in the delayed group p=0.01. There was no significant difference in type of injury, injury severity or time from injury between the two groups. Patients were over 70 years in 7.6% in the early activation group vs 17.1% in the delayed group (p=0.04). 77.7% of the early group were male vs 71.4% in the delayed group (p=0.39). There was no significant difference in mortality (15.2% vs 11.4% p=0.10), median length of stay (10 days in both groups p=0.94) or median time to operative management (331 minutes vs 277 minutes p=0.52). Conclusion: Delayed activation is linked with increasing age with no clear link with increased mortality. Given the severe injuries in the delayed cohort which required activation of the trauma team further emphasis on the older trauma patient and interventions to recognize this vulnerable population should be made. When assessing elderly trauma patients emergency physicians should have a low threshold to activate trauma teams.

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Assessing the need for resuscitative endovascular balloon occlusion of the aorta (REBOA) for management of non-compressible hemorrhage at a Canadian urban trauma centre

10.21203/rs.3.rs-198760/v1 ◽

2021 ◽

Author(s):

Elizabeth Purssell ◽

Sean Patrick ◽

Joseph Haegert ◽

Vesna Ivkov ◽

John Taylor

Keyword(s):

Injury Severity ◽

Retrospective Chart Review ◽

Balloon Occlusion ◽

Trauma Centre ◽

Trauma Patients ◽

Potential Candidate ◽

Study Objective ◽

Resuscitative Thoracotomy ◽

Less Invasive ◽

Endovascular Balloon Occlusion

Abstract Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less invasive alternative to resuscitative thoracotomy (RT) for life threatening, infra-diaphragmatic, non-compressible hemorrhage from trauma. Existing evidence surrounding the efficacy of REBOA is conflicting; nevertheless, expert consensus suggests that REBOA should be considered in select trauma patients. There has been a paucity of studies that evaluate the potential utility of REBOA in the Canadian setting. The study objective was to evaluate the percentage of trauma patients presenting to a Level 1 Canadian trauma centre that would have met criteria for REBOA. Methods We conducted a retrospective chart review of patients recorded in the British Columbia Trauma Registry who warranted a trauma team activation (TTA) at our institution. We identified REBOA candidates using pre-defined criteria based on published guidelines. Each TTA case was screened by a reviewer, and then each Potential Candidate was reviewed by a panel of trauma physicians for determination of final candidacy. Results Fourteen patients were classified as Likely REBOA Candidates (2.2% of TTAs, median age 46.1 years, 64.3% female). These patients had a median Injury Severity Score of 31.5 (IQR 26.8). The main sources of hemorrhage in these patients were from abdominal injuries (71.4%) and pelvic fractures (42.9%). Conclusion The percentage of patients who met criteria for REBOA is similar to that of RTs performed at our Canadian institution. While REBOA would be performed infrequently, it is a less-invasive alternative to RT, which could be a potentially life-saving procedure in a small group of the most severely injured trauma patients.

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CORRELATION OF FACIAL INJURY SEVERITY SCALE (FISS) WITH LENGTH OF STAY, THE NEED FOR SURGERY AND THE INVOLVEMENT OF OTHER SPECIALISTS IN MAXILLOFACIAL TRAUMA PATIENTS AT H. ADAM MALIK GENERAL HOSPITAL MEDAN

10.36106/gjra/9407348 ◽

2019 ◽

pp. 1-3

Author(s):

Darwin Firmansyah Siregar ◽

Frank Bietra Buchari ◽

Utama Abdi Tarigan ◽

Aznan Lelo

Keyword(s):

Length Of Stay ◽

General Hospital ◽

Injury Severity ◽

The Body ◽

Maxillofacial Trauma ◽

Mandibular Fractures ◽

Trauma Patients ◽

Facial Injury ◽

Single Operator ◽

Surgery Department

Background: Facial Injury Severity Severity Score (FISS) has been used to assess the severity of facial injuries. However, FISS scores as a useful predictor of length of stay and changes between FISS scores and injuries to other parts of the body have not evaluated. In this study, we want to know the relationship between FISS score as the clinical assessment of maxillofacial trauma with the length of stay, the need for surgery, and the involvement of other specialist elds. Method: This research was conducted using analytical research through a retrospective approach by looking at the medical records of patients who suffered maxillofacial trauma at H. Adam Malik General Hospital Medan from June to August 2019. Result : From a total of 43 patients included in the study, there were 22 mandibular fractures, with mandibular angulus (29.0%), parasymphysis (22.4%), and mandibular corpus (21.5%). Thirty subjects (69.8%) needed surgery, and xation of the fracture and subjects without intervention were 13 (30.2%). Patients who needed surgical intervention, the average time needed for hospitalization was 10.98 + 7.72 days (p = 0.007). The most collaboration found with neurosurgeons specialists, 39.53% of subjects who performed the surgery. A total of 55.8% of surgeries performed by a single operator from the plastic surgery department. Relationship between the length of stay with FISS, obtained for FISS> 3 (OR 14.37) (p = 0.01), meaning that patients with FISS> 3 are likely to stay longer for 14 times. Subsequent results related to the need for surgery obtained signicant results (OR = 8.26, p = 0.026). signicant (p = 0.059). Conclusion: A FISS score signicantly affects the length of stay for a maxillofacial trauma patient. FISS score also affects the involvement of other specialists in maxillofacial trauma patients but not statistically signicant.

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Intraabdominal Injury is Common in Blunt Trauma Patients who Sustain Spinal Cord Injury

The American Surgeon ◽

10.1177/000313480707301025 ◽

2007 ◽

Vol 73 (10) ◽

pp. 1035-1038

Author(s):

Ali Salim ◽

Marcus Ottochian ◽

Ryan J. Gertz ◽

Carlos Brown ◽

Kenji Inaba ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Length Of Stay ◽

Blunt Trauma ◽

Injury Severity ◽

Unit Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Cord Injury ◽

Intraabdominal Injury

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.

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Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery

The American Surgeon ◽

10.1177/0003134820923302 ◽

2020 ◽

Vol 86 (6) ◽

pp. 635-642

Author(s):

Peter I. Cha ◽

Ronald M. Jou ◽

David A. Spain ◽

Joseph D. Forrester

Keyword(s):

Length Of Stay ◽

Abdominal Surgery ◽

Injury Severity ◽

Unit Length ◽

Feeding Tube ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Fascial Closure ◽

Trauma Patients ◽

Percutaneous Endoscopic Gastrostomy Placement

Objectives The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation. Methods We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery. Results Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, P = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, P = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay. Conclusions Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.

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