Decreased adult trauma admission volumes and changing injury patterns during the COVID-19 pandemic at 85 trauma centers in a multistate healthcare system

BackgroundReports indicate social distancing guidelines and other effects of the COVID-19 pandemic impacted trauma patient volumes and injury patterns. This report is the first analysis of a large trauma network describing the extent of these impacts. The objective of this study was to describe the effects of the COVID-19 pandemic on patient volumes, demographics, injury characteristics, and outcomes.MethodsFor this descriptive, multicenter study from a large, multistate hospital network, data were collected from the system-wide centralized trauma registry and retrospectively reviewed to retrieve patient information including volume, demographics, and outcomes. For comparison, patient data from January through May of 2020 and January through May of 2019 were extracted.ResultsA total of 12 395 trauma patients (56% men, 79% white, mean age 59 years) from 85 trauma centers were included. The first 5 months of 2020 revealed a substantial decrease in volume, which began in February and continued into June. Further analysis revealed an absolute decrease of 32.5% in patient volume in April 2020 compared with April 2019 (4997 from 7398; p<0.0001). Motor vehicle collisions decreased 49.7% (628 from 1249). There was a statistically significant increase in injury severity score (9.0 vs. 8.3; p<0.001). As a proportion of the total trauma population, blunt injuries decreased 3.1% (87.3 from 90.5) and penetrating injuries increased 2.7% (10.0 from 7.3; p<0.001). A significant increase was found in the proportion of patients who did not survive to discharge (3.6% vs. 2.8%; p=0.010; absolute decrease: 181 from 207).DiscussionEarly phases of the COVID-19 pandemic were associated with a 32.5% decrease in trauma patient volumes and altered injury patterns at 85 trauma centers in a multistate system. This preliminary observational study describes the initial impact of the COVID-19 pandemic and warrants further investigation.Level of evidenceLevel II (therapeutic/care management).

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Multicenter study of US trauma centers examining the effect of the COVID-19 pandemic on injury causes, diagnoses and procedures

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000655 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000655

Author(s):

Kristin Salottolo ◽

Rachel Caiafa ◽

Jalina Mueller ◽

Allen Tanner ◽

Matthew M Carrick ◽

...

Keyword(s):

Hospital Admissions ◽

Motor Vehicle ◽

Traumatic Injury ◽

Trauma Patients ◽

Trauma Centers ◽

Injury Patterns ◽

Level Of Evidence ◽

Study Objective ◽

Time Periods ◽

Injury Causes

BackgroundThe COVID-19 pandemic resulted in nationwide social distancing and shelter-in-place orders meant to curb transmission of the SARS-CoV-2 virus. The effect of the pandemic on injury patterns has not been well described in the USA. The study objective is to determine the effect of the COVID-19 pandemic on the distribution and determinants of traumatic injuries.MethodsThis retrospective multi-institutional cohort study included all hospital admissions for acute traumatic injury at six community level I trauma centers. Descriptive statistics were used to compare injury causes, diagnoses and procedures over two similar time periods: prepandemic (March 11–June 30, 2019) and pandemic (March 11–June 30, 2020).ResultsThere were 7308 trauma patients included: 3862 (53%) prepandemic and 3446 (47%) during the pandemic. Cause of injury significantly differed by period (p<0.001). During the pandemic, there were decreases in motor vehicle crashes (from 17.0% to 14.0%, p<0.001), worksite injuries (from 5.2% to 4.1%, p=0.02), pedestrian injuries (from 3.0% to 2.2%, p=0.02) and recreational injuries (from 3.0% to 1.7%, p<0.001), while there were significant increases in assaults (6.9% to 8.5%, p=0.01), bicycle crashes (2.8% to 4.2%, p=0.001) and off-road vehicle injuries (1.8% to 3.0%, p<0.001). There was no change by study period in falls, motorcycle injuries, crush/strikes, firearm and self-inflicted injuries, and injuries associated with home-improvement projects. Injury diagnoses differed between time periods; during the pandemic, there were more injury diagnoses to the head (23.0% to 27.3%, p<0.001) and the knee/leg (11.7% to 14.9%, p<0.001). There were also increases in medical/surgical procedures (57.5% to 61.9%, p<0.001), administration of therapeutics/blood products (31.4% to 34.2%, p=0.01) and monitoring (11.0% to 12.9%, p=0.01).DiscussionCauses of traumatic injury, diagnoses, and procedures were significantly changed by the pandemic. Trauma centers must adjust to meet the changing demands associated with altered injury patterns, as they were associated with increased use of hospital resources.Level of evidenceIII (epidemiological).

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Mechanisms of Injury Among the Amish Population in Central Pennsylvania

The American Surgeon ◽

10.1177/00031348211050592 ◽

2021 ◽

pp. 000313482110505

Author(s):

Larissa Whitney ◽

Kelly Bonneville ◽

Madison Morgan ◽

Lindsey L. Perea

Keyword(s):

Pediatric Population ◽

Traumatic Injury ◽

Age Groups ◽

Geographic Location ◽

Future Research ◽

Common Mechanism ◽

Trauma Patients ◽

Trauma Centers ◽

Injury Patterns ◽

Level Of Evidence

Background Individuals presenting with traumatic injury in rural populations have significantly different injury patterns than those in urban environments. With an increasing Amish population, totaling over 33 000 in our catchment area, their unique way of life poses additional factors for injury. This study aims to evaluate differences in mechanism of injury, location of injury, and demographic patterns within the Amish population. We hypothesize that there will be an increased incidence of agriculture-related mechanisms of injury. Methods All Amish trauma patients presenting to our level I trauma center over 20 years (1/2000-4/2020) were retrospectively analyzed. Mechanism and geographic location of injury were collected. Demographic and clinical variables were compared between the age groups. Results There were 1740 patients included in the study with 36.4% (n = 634) ≤ 14 years. Only 10% (n = 174) were ≥ 65 years. The most common mechanism across all ages was falls. However, when separating out the pediatric population ( ≤ 14 years), 27.8% (n = 60) fell from a height on average > 8-10 feet. The most common geographic location of injury was at home in all age groups, except for the 15-24 year group, which was roadways. Discussion The Amish population poses a unique set of mechanisms of injury and thus injury patterns to rural trauma centers. We have found the most common injuries to be falls, buggy accidents, animal-related injuries, and farming accidents across all age groups. Future research and collaboration with other rural trauma centers treating large Amish populations would be beneficial to maximize injury prevention in this population. Level of Evidence Level 3a, epidemiological.

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P142: The anticoagulated trauma patient: a Canadian experience in the era of direct oral anticoagulants

CJEM ◽

10.1017/cem.2016.316 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S125-S125 ◽

Cited By ~ 1

Author(s):

B. Wood ◽

A. Ackery ◽

S. Rizoli ◽

B. Nascimento ◽

M. Sholzberg ◽

...

Keyword(s):

Trauma Patient ◽

Injury Severity ◽

Hematological Parameters ◽

Oral Anticoagulants ◽

Demographic Data ◽

Direct Oral Anticoagulants ◽

Significant Proportion ◽

Common Mechanism ◽

Trauma Patients ◽

Trauma Population

Introduction: The anticoagulated trauma patient is a particularly vulnerable population. Our current practice is guided by experience with patients taking vitamin K dependent antagonists (VKA, like warfarin). It is currently unknown how the increasing use of direct oral anticoagulants (DOACs) will change our trauma population. We collected data about this new subset of patients to compare their clinical characteristics to patients on pre-injury VKA therapy. Methods: Retrospective review of anticoagulated trauma patients presenting to Toronto’s two adult trauma centres, Saint Michael’s Hospital and Sunnybrook Health Sciences Centre, from June 2014-June 2015 was undertaken. Patients were recruited through the institutions’ trauma registries and were eligible if they suffered a traumatic injury and taking an oral anticoagulant pre-injury. Clinical and demographic data were extracted by a trained reviewer and analysed with descriptive statistics. Results: Our study recruited 85 patients, 33% were taking DOACs and 67% VKAs. Trauma patients on DOACs & VKAs respectively had similar baseline characteristics such as age (75.9 vs 77.4), initial injury severity score (ISS (16.9 vs 20.6)) and concomitant antiplatelet use (7.1% vs 5.4%). Both groups’ most common mechanism for injury was falls and the most common indication for anticoagulation was atrial fibrillation. Patients on DOACs tended to have lower average INR (1.25 vs 2.3) and serum creatinine (94.9 vs 127.4). Conclusion: Patients on DOACs pre-injury now account for a significant proportion of orally anticoagulated trauma patients. Patients on DOACs tended to have less derangement of basic hematological parameters complicating diagnosis and management of coagulopathy.

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Factors associated with survival in Adult Patients with Traumatic Arrest: A Retrospective Cohort Study from US Trauma Centers

10.21203/rs.3.rs-112660/v1 ◽

2020 ◽

Author(s):

Abdel-Badih Ariss ◽

Rana Bachir ◽

Mazen El Sayed

Keyword(s):

Cohort Study ◽

Hospital Discharge ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Injury Severity ◽

Motor Vehicle ◽

Age Group ◽

Trauma Centers ◽

Level Of Evidence ◽

Factors Associated

Abstract Background: Traumatic arrests (TA) increasingly affect young adults worldwide with low reported survival rates. This study examines factors associated with survival (to hospital discharge) in traumatic arrests transported to US trauma centers. Methods: This retrospective cohort study used the US National Trauma Databank 2015 dataset and included patients who presented to trauma centers with “no signs of life”. Univariate and bivariate analyses were done. Factors associated with survival were identified using multivariate regression analyses. Results: The study included 5,980 patients with traumatic arrests. Only 664 patients (11.1%) survived to hospital discharge. Patients were predominantly in age group 16-64 (84.6%), were mostly males (77.8%) and white (55.1%). Most were admitted to Level I (55.5%) or Level II trauma centers (31.6%). Injuries were mostly blunt (56.7%) or penetrating (39.3%). Mean ISS was 23.71 (± 20.79). Factors associated with decreased survival included: Age group ≥65 (Ref: 16-24), male gender, self-inflicted and other or undetermined types of injuries (Ref: assault), injuries to head & neck, injuries to torso and injury severity score (ISS) ≥ 16 (Ref: <16). While factors associated with increased survival included: All injury mechanisms (with the exception of Motor Vehicle Transportation (MVT)) (Ref: firearm), injuries to extremities or spine & back and all methods of coverage (Ref: self-pay).Conclusion: Patients with traumatic arrests have poor outcomes with only 11.1 % surviving to hospital discharge. Factors associated with survival in traumatic arrests were identified. These findings are important for devising injury prevention strategies and help guide trauma management protocols to improve outcomes in traumatic arrests. Level of evidence: Level III

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Minor change in initial PEEP setting decreases rates of ventilator-associated events in mechanically ventilated trauma patients

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000455 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000455

Author(s):

Ethan Ferrel ◽

Kristina M Chapple ◽

Liviu Gabriel Calugaru ◽

Jennifer Maxwell ◽

Jessica A Johnson ◽

...

Keyword(s):

Logistic Regression ◽

Injury Severity ◽

Trauma Patients ◽

Trauma Centers ◽

Level Of Evidence ◽

Mechanically Ventilated ◽

Change In Practice ◽

Level 1 ◽

The Impact ◽

Level 1 Trauma Center

BackgroundSurveillance of ventilator-associated events (VAEs) as defined by the National Healthcare Safety Network (NHSN) is performed at many US trauma centers and considered a measure of healthcare quality. The surveillance algorithm relies in part on increases in positive end-expiratory pressure (PEEP) to identify VAEs. The purpose of this cohort study was to evaluate the effect of initiating mechanically ventilated trauma patients at marginally higher PEEP on incidence of VAEs.MethodsAnalysis of level-1 trauma center patients mechanically ventilated 2+ days from 2017 to 2018 was performed after an institutional ventilation protocol increased initial PEEP setting from 5 (2017) to 6 (2018)cm H2O. Incidence of VAEs per 1000 vent days was compared between PEEP groups. Logistic regression modelling was performed to evaluate the impact of the PEEP setting change adjusted to account for age, ventilator days, injury mechanism and injury severity.Results519 patients met study criteria (274 PEEP 5 and 245 PEEP 6). Rates of VAEs were significantly reduced among patients with initial PEEP 5 versus 6 (14.61 per 1000 vent days vs. 7.13 per 1000 vent days; p=0.039). Logistic regression demonstrated that initial PEEP 6 was associated with 62% reduction in VAEs.ConclusionsOur data suggest that an incrementally increased baseline PEEP setting was associated with a significantly decreased incidence of VAEs among trauma patients. This minor change in practice may have a major impact on a trauma center’s quality metrics.Level of evidenceIV.

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COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-021-01699-9 ◽

2021 ◽

Author(s):

Eric O. Yeates ◽

Areg Grigorian ◽

Morgan Schellenberg ◽

Natthida Owattanapanich ◽

Galinos Barmparas ◽

...

Keyword(s):

Injury Severity ◽

Pulmonary Complications ◽

Surgical Patients ◽

Trauma Patients ◽

Matched Cohort ◽

Trauma Centers ◽

Propensity Score Model ◽

Trauma Population ◽

Level I ◽

Score Model

Abstract Purpose There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients. Methods A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019–6/30/2019 and 1/1/2020–6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups. Results A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients. Conclusion This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.

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Octogenarian Motor Vehicle Collisions: Injury Patterns Matter

Kansas Journal of Medicine ◽

10.17161/kjm.vol15.15710 ◽

2022 ◽

Vol 15 (1) ◽

pp. 336-340

Author(s):

Michael Lemon ◽

Stephen Helmer ◽

Kathryn Soba ◽

Jeanette Ward ◽

James M Haan

Keyword(s):

Injury Severity ◽

Motor Vehicle ◽

Oldest Old ◽

Rural Setting ◽

Common Mechanism ◽

Trauma Patients ◽

Injury Patterns ◽

Discharge Disposition ◽

Vehicle Collision ◽

Potential Factors

Introduction. Motor vehicle collision (MVC) is the second most common mechanism of injury among octogenarians and is on the rise. These “oldest old” trauma patients have much higher mortality rates than expected. This study examined potential factors influencing this increased mortality including comorbidities, medications, injury patterns, and hospital interventions. Methods. A 10-year retrospective review was conducted of patients aged 80 and over who were injured in a MVC. Data collected included patient demographics, comorbidities, medication use prior to injury, collision details, injury severity and patterns, hospitalization details, outcomes, and discharge disposition. Results. We identified 239 octogenarian patients involved in a MVC. Overall mortality was 18.8%. We recognized an increased mortality for specific injury patterns, patients injured in a rural setting, and those who were transfused, intubated, or admitted to the ICU. We found no correlation between mortality and medications or comorbidities. Conclusions. The high mortality rate for octogenarian patients involved in a MVC is related to injury severity, type of injury, and in-hospital complications, and not due to comorbidities and prior medications.

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Factors associated with survival in adult patients with traumatic arrest: a retrospective cohort study from US trauma centers

BMC Emergency Medicine ◽

10.1186/s12873-021-00473-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Abdel-Badih Ariss ◽

Rana Bachir ◽

Mazen El Sayed

Keyword(s):

Cohort Study ◽

Hospital Discharge ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Injury Severity ◽

Motor Vehicle ◽

Age Group ◽

Trauma Centers ◽

Level Of Evidence ◽

Factors Associated

Abstract Background Traumatic arrests increasingly affect young adults worldwide with low reported survival rates. This study examines factors associated with survival (to hospital discharge) in traumatic arrests transported to US trauma centers. Methods This retrospective cohort study used the US National Trauma Databank 2015 dataset and included patients who presented to trauma centers with “no signs of life”. Univariate and bivariate analyses were done. Factors associated with survival were identified using multivariate regression analyses. Results The study included 5980 patients with traumatic arrests. Only 664 patients (11.1%) survived to hospital discharge. Patients were predominantly in age group 16–64 (84.6%), were mostly males (77.8%) and white (55.1%). Most were admitted to Level I (55.5%) or Level II trauma centers (31.6%). Injuries were mostly blunt (56.7%) or penetrating (39.3%). The median of the injury severity score (ISS) was 19 (interquartile range [IQR]: 9–30). Factors associated with decreased survival included: Age group ≥ 65 (Ref: 16–24), male gender, self-inflicted and other or undetermined types of injuries (Ref: assault), injuries to head and neck, injuries to torso and ISS ≥ 16 (Ref: < 16) and ED thoracotomy. While factors associated with increased survival included: All injury mechanisms (with the exception of motor vehicle transportation) (Ref: firearm), injuries to extremities or spine and back and all methods of coverage (Ref: self-pay). Conclusion Patients with traumatic arrests have poor outcomes with only 11.1% surviving to hospital discharge. Factors associated with survival in traumatic arrests were identified. These findings are important for devising injury prevention strategies and help guide trauma management protocols to improve outcomes in traumatic arrests. Level of evidence Level III.

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An Analysis of Patients Dead on Arrival in the American College of Surgeons Trauma Quality Program Participant Use File Data Set

The American Surgeon ◽

10.1177/00031348211011099 ◽

2021 ◽

pp. 000313482110110

Author(s):

Adel Elkbuli ◽

Scott Rowe ◽

Shahm Raslan ◽

Aleeza Ali ◽

Brad Boserup ◽

...

Keyword(s):

Trauma Patient ◽

Patient Outcomes ◽

Motor Vehicle ◽

Trauma Patients ◽

Data Set ◽

Program Participant ◽

Quality Program ◽

Field Triage ◽

American College Of Surgeons ◽

Mode Of Transportation

Background Trauma patient care begins on-scene as field triage and mode of transportation are determinants of patient outcomes. This study evaluates the US national patterns of dead on arrival (DOA) among the trauma population. Methods A cross-sectional review of the American College of Surgeons (ACS) Trauma Quality Program Participant Use File (TQP-PUF) data set (2013-2017) was performed. Trauma patients reported as DOA were stratified by ISS into low (<15), intermediate (15-24), or high (≥25) severity. Each group was then subdivided by patient demographics, mechanism, type of injury, and mode of transportation. Results Of the 4 336 816 injury cases in the TQP-PUF data set, 33 199 were DOA (.77%). 77.1% (25 604/33 199) of DOAs were male. In the low-ISS group, .36% (13 272/3 639 811) were DOA; in the intermediate-ISS group, 1.2% (4868/421 994) were DOA; and in the high-ISS group, 5.5% (15 059/275 011) were DOA. Motor vehicle collisions (MVCs) (11 262) and firearms (8894) were the most common injury types, equating to 60.7% of DOAs. Falls accounted for 9.1% of all DOAs. The most common DOA age-group was 18-64 years, followed by ≥65 years. Conclusion DOA trauma patients are predominately adult men suffering fatal blunt force injuries most frequently via MVC. DOAs are caused by all ranges of injury severity. We recommend further development of prevention programs thereby reducing the prevalence of common traumatic injuries, notably MVC, falls, and firearms to improve survival. Future studies should also investigate the access to and distribution of trauma centers and the role of helicopter, ground, and police transport modalities and transport time on and reducing DOAs and improving trauma patient outcomes.

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Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000670 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000670

Author(s):

Imad S Dandan ◽

Gail T Tominaga ◽

Frank Z Zhao ◽

Kathryn B Schaffer ◽

Fady S Nasrallah ◽

...

Keyword(s):

Injury Severity ◽

Diagnostic Testing ◽

Trauma Team ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Level Of Evidence ◽

Evaluation Time ◽

Retrospective Comparison ◽

Trauma Bay

BackgroundOvertriage of trauma patients is unavoidable and requires effective use of hospital resources. A ‘pit stop’ (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost.MethodsWe performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05.ResultsThere were 994 TAs and 474 TRs in the first 9 months after implementation. TR’s preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%.DiscussionPS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources.Level of evidenceLevel II, economic/decision therapeutic/care management study.

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