Increased Mortality in Underinsured Penetrating Trauma Patients

Introduction It remains unclear whether an increased mortality risk in uninsured patients exists across Injury Severity Score (ISS) classifications. We hypothesized that penetrating trauma self-pay patients would have a similarly increased mortality risk across all ISS categories. Methods The National Trauma Data Bank (2013-2015) was queried for patients presenting with penetrating firearm, explosive, or stab wound injuries. 115 651 patients were identified and a stratified multivariable logistic regression model was used. Results In the >15 ISS group, self-pay patients had a lower median total hospital Length of Stay (LOS) (3 vs 8, P < .001), lower median Intensive Care Unit LOS (1 vs 3, P < .001), and lower median ventilator days (0 vs 1, P < .001). Self-pay patients had an increased risk for mortality compared to patients with private insurance in both the ≤15 ISS group (OR 2.68, P < .001) and >15 ISS group (OR 1.56, P < .001). Conclusion Uninsured patients have an increased mortality risk in both low and high ISS groups. A higher mortality risk among uninsured patients in the high ISS group can be explained by decreased resource availability and lower ICU days and ventilator time. However, more studies are needed to determine why there is an even greater mortality risk among uninsured patients with mild ISS.

Download Full-text

Association between Insurance Status and Hospital Length of Stay following Trauma

The American Surgeon ◽

10.1177/000313481608200324 ◽

2016 ◽

Vol 82 (3) ◽

pp. 281-288 ◽

Cited By ~ 9

Author(s):

Brian R. Englum ◽

Xuan Hui ◽

Cheryl K. Zogg ◽

Muhammad Ali Chaudhary ◽

Cassandra Villegas ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Insurance Status ◽

Trauma Patients ◽

Uninsured Patients ◽

National Trauma ◽

Insured Patients ◽

The Relationship

Previous research has demonstrated that nonclinical factors are associated with differences in clinical care, with uninsured patients receiving decreased resource use. Studies on trauma populations have also shown unclear relationships between insurance status and hospital length of stay (LOS), a commonly used metric for evaluating quality of care. The objective of this study is to define the relationship between insurance status and LOS after trauma using the largest available national trauma dataset and controlling for significant confounders. Data from 2007 to 2010 National Trauma Data Bank were used to compare differences in LOS among three insurance groups: privately insured, publically insured, and uninsured trauma patients. Multivariable regression models adjusted for potential confounding due to baseline differences in injury severity and demographic and clinical factors. A total of 884,493 patients met the inclusion criteria. After adjusting for the influence of covariates, uninsured patients had significantly shorter hospital stays (0.3 days) relative to privately insured patients. Publicly insured patients had longer risk-adjusted LOS (0.9 days). Stratified differences in discharge disposition and injury severity significantly altered the relationship between insurance status and LOS. In conclusion, this study elucidates the association between insurance status and hospital LOS, demonstrating that a patient's ability to pay could alter LOS in acute trauma patients. Additional research is needed to examine causes and outcomes from these differences to increase efficiency in the health care system, decrease costs, and shrink disparities in health outcomes.

Download Full-text

No Difference in Morbidity or Mortality Between Octogenarians and Other Geriatric Burn Trauma Patients

The American Surgeon ◽

10.1177/00031348211011122 ◽

2021 ◽

pp. 000313482110111

Author(s):

Miriam Alpert ◽

Areg Grigorian ◽

Victor Joe ◽

Theresa L Chin ◽

Nicole Bernal ◽

...

Keyword(s):

Mortality Risk ◽

Injury Severity ◽

Frailty Index ◽

Total Body Surface Area ◽

Past Study ◽

Trauma Patients ◽

Multivariable Logistic Regression Model ◽

Improvement Program ◽

Burn Trauma ◽

Severity Scores

Background Geriatric burn trauma patients (age ≥65 years) have a 5-fold higher mortality rate than younger adults. With the population of the US aging, the number of elderly burn and trauma patients is expected to increase. A past study using the National Burn Repository revealed a linear increase in mortality for those >65 years old. We hypothesized that octogenarians with burn and trauma injuries would have a higher rate of in-hospital complications and mortality, than patients aged 65-79 years old. Methods The Trauma Quality Improvement Program (2010-2016) was queried for burn trauma patients. To detect mortality risk a multivariable logistic regression model was used. Results From 282 patients, there were 73 (25.9%) octogenarians and 209 (74.1%) aged 65-79 years old. The two cohorts had similar median injury severity scores (16 vs. 15 in octogenarians, P = .81), total body surface area burned ( P = .30), and comorbidities apart from an increased smoking (12.9% vs. 4.1%, P = .04) and decreased hypertension (52.2% vs. 65.8%, P = .04) in the younger cohort. Octogenarians had similar complications, including acute respiratory distress syndrome, pulmonary embolism, deep vein thrombosis ( P > .05), and mortality (15.1% vs. 10.5%, P = .30), compared to the younger cohort. Octogenarians were not associated with an increased mortality risk (odds ratio 1.51, confidence interval 0.24-9.56, P = .67). Discussion Among burn trauma patients ≥65 years, age should not be a sole predictor for mortality risk. Continued research is necessary in order to determine more accurate approaches to prognosticate mortality in geriatric burn trauma patients, such as the validation and refinement of a burn-trauma-related frailty index.

Download Full-text

Dabigatran Use Does Not Increase Intracranial Hemorrhage in Traumatic Geriatric Falls When Compared with Warfarin

The American Surgeon ◽

10.1177/000313481508101025 ◽

2015 ◽

Vol 81 (10) ◽

pp. 1039-1042 ◽

Cited By ~ 4

Author(s):

Anthony Pozzessere ◽

Jonathan Grotts ◽

Stephen Kaminski

Keyword(s):

Length Of Stay ◽

Intracranial Hemorrhage ◽

Injury Severity ◽

Unit Length ◽

Hospital Length Of Stay ◽

Geriatric Trauma ◽

Trauma Patients ◽

Exact Matching ◽

Increased Risk ◽

Community Trauma

Patients on anticoagulation are at increased risk for intracranial hemorrhage (ICH) after trauma. This is important for geriatric trauma patients, who are increasing in number, frequently fall, and often take anticoagulants. This study sought to evaluate whether prehospital use of dabigatran, a newer anticoagulant, is associated with outcome differences in geriatric trauma patients suffering falls when compared with warfarin. The registry of a Level II community trauma center was used to identify 247 patients aged 65 and older who sustained a fall while taking prehospital dabigatran or warfarin admitted between December 2010 and March 2014. Patients on warfarin were included if their International Normalized Ratio was therapeutic (2–3). About 176 of the 247 patients were then compared using coarsened exact matching. In the matched analysis, overall population means for age, Glasgow Coma Score, and Injury Severity Score were 83.5, 14.7, and 5.1, respectively. The overall rate of ICH was 12.5 per cent, with a mortality rate of 16.1 per cent for patients who sustained an ICH. There were no observed differences in ICH, hospital length of stay, intensive care unit length of stay, or mortality between patients taking prehospital warfarin or dabigatran.

Download Full-text

Community Need Index (CNI): a simple tool to predict emergency department utilization after hospital discharge from the trauma service

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2018-000239 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000239 ◽

Cited By ~ 1

Author(s):

Dih-Dih Huang ◽

Mahmoud Z Shehada ◽

Kristina M Chapple ◽

Nathaniel S Rubalcava ◽

Jonathan L Dameworth ◽

...

Keyword(s):

Emergency Department ◽

Hospital Discharge ◽

Injury Severity ◽

Hospital Length Of Stay ◽

Emergency Department Utilization ◽

Blunt Injury ◽

Trauma Patients ◽

Increased Risk ◽

Ed Visits ◽

Zip Code

BackgroundEmergency department (ED) visits after hospital discharge may reflect failure of transition of care to the outpatient setting. Reduction of postdischarge ED utilization represents an opportunity for quality improvement and cost reduction. The Community Need Index (CNI) is a Zip code-based score that accounts for a community’s unmet needs with respect to healthcare and is publicly accessible via the internet. The purpose of this study was to determine if patient CNI score is associated with postdischarge ED utilization among hospitalized trauma patients.MethodsLevel 1 trauma patient admitted between January 2014 and June 2016 were stratified by 30-day postdischarge ED utilization (yes/no). CNI is a nationwide Zip code-based score (1.0–5.0) and was determined per patient from the CNI website. Higher scores indicate greater barriers to healthcare per aggregate socioeconomic factors. Patients with 30-day postdischarge ED visits were compared with those without, evaluating for differences in CNI score and clinical and demographic characteristics.Results309 of 3245 patients (9.5%) used the ED. The ED utilization group was older (38.3±15.7 vs. 36.3±16.4 years, p=0.034), more injured (Injury Severity Score 10.4±8.7 vs. 7.7±8.0, p<0.001), and more likely to have had in-hospital complications (17.5% vs. 5.4%, p<0.001). Adjusted for patient age, injury severity, gender, race/ethnicity, penetrating versus blunt injury, alcohol above the legal limit, illicit drug use, the presence of one or more complications and comorbidities, hospital length of stay, and insurance category, CNI score ≥4 was associated with increased utilization (OR 2.0 [95% CI 1.4 to 2.9, p<0.001]).DiscussionCNI is an easily accessible score that independently predicts postdischarge ED utilization in trauma patients. Patients with CNI score ≥4 are at significantly increased risk. Targeted intervention concerning discharge planning for these patients represents an opportunity to decrease postdischarge ED utilization.Level of evidenceIII, Prognostic and Epidemiological.

Download Full-text

Pain Assessment and Control in the Injured Elderly

The American Surgeon ◽

10.1177/000313481608201001 ◽

2016 ◽

Vol 82 (10) ◽

pp. 867-871 ◽

Cited By ~ 1

Author(s):

Ara Ko ◽

Megan Y. Harada ◽

Eric J.T. Smith ◽

Michael Scheipe ◽

Rodrigo F. Alban ◽

...

Keyword(s):

Risk Factors ◽

Length Of Stay ◽

Injury Severity ◽

Unit Length ◽

Patient Characteristics ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Increased Risk ◽

Elderly Trauma Patients

Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.

Download Full-text

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.

Download Full-text

Older trauma patients are at high risk of delirium, especially those with underlying dementia or baseline frailty

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000639 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000639

Author(s):

Danielle Ní Chróinín ◽

Nevenka Francis ◽

Pearl Wong ◽

Yewon David Kim ◽

Susan Nham ◽

...

Keyword(s):

Older Patients ◽

Multivariable Analysis ◽

Primary Outcome Measure ◽

Hospital Length ◽

Assessment Tools ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Level Of Evidence ◽

Increased Risk ◽

History Of

BackgroundGiven the increasing numbers of older patients presenting with trauma, and the potential influence of delirium on outcomes, we sought to investigate the proportion of such patients who were diagnosed with delirium during their stay—and patient factors associated therewith—and the potential associations between delirium and hospital length of stay (LOS). We hypothesized that delirium would be common, associated with certain patient characteristics, and associated with long hospital LOS (highest quartile).MethodsWe conducted a retrospective observational cohort study of all trauma patients aged ≥65 years presenting in September to October 2019, interrogating medical records and the institutional trauma database. The primary outcome measure was occurrence of delirium.ResultsAmong 99 eligible patients, delirium was common, documented in 23% (23 of 99). On multivariable analysis, adjusting for age, frailty and history of dementia, frailty (OR 4.09, 95% CI 1.08 to 15.53, p=0.04) and dementia (OR 5.23, 95% CI 1.38 to 19.90, p=0.02) were independently associated with likelihood of delirium. Standardized assessment tools were underused, with only 34% (34 of 99) screened within 4 hours of arrival. On univariate logistic regression analysis, having an episode of delirium was associated with long LOS (highest quartile), OR of 5.29 (95% CI 1.92 to 14.56, p<0.001). In the final multivariable model, adjusting for any (non-delirium) in-hospital complication, delirium was independently associated with long LOS (≥16 days; OR 4.81, p=0.005).DiscussionIn this study, delirium was common. History of dementia and baseline frailty were associated with increased risk. Delirium was independently associated with long LOS. However, many patients did not undergo standardized screening at admission. Early identification and targeted management of older patients at risk of delirium may reduce incidence and improve care of this vulnerable cohort. These data are hypothesis generating, but support the need for initiatives which improve delirium care, acknowledging the complex interplay between frailty and other geriatric syndromes in the older trauma patients.Level of evidenceIII.

Download Full-text

Outcomes of major trauma among patients with chronic kidney disease and receiving dialysis in Nova Scotia: a retrospective analysis

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000672 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000672

Author(s):

Ryan Pratt ◽

Mete Erdogan ◽

Robert Green ◽

David Clark ◽

Amanda Vinson ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Nova Scotia ◽

Kidney Disease ◽

Hospital Mortality ◽

Major Trauma ◽

Injury Severity ◽

Cox Regression ◽

Trauma Patients ◽

Risk Of Death ◽

Increased Risk

BackgroundThe risk of death and complications after major trauma in patients with chronic kidney disease (CKD) is higher than in the general population, but whether this association holds true among Canadian trauma patients is unknown.ObjectivesTo characterize patients with CKD/receiving dialysis within a regional major trauma cohort and compare their outcomes with patients without CKD.MethodsAll major traumas requiring hospitalization between 2006 and 2017 were identified from a provincial trauma registry in Nova Scotia, Canada. Trauma patients with stage ≥3 CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2) or receiving dialysis were identified by cross-referencing two regional databases for nephrology clinics and dialysis treatments. The primary outcome was in-hospital mortality; secondary outcomes included hospital/intensive care unit (ICU) length of stay (LOS) and ventilator-days. Cox regression was used to adjust for the effects of patient characteristics on in-hospital mortality.ResultsIn total, 6237 trauma patients were identified, of whom 4997 lived within the regional nephrology catchment area. CKD/dialysis trauma patients (n=101; 28 on dialysis) were older than patients without CKD (n=4896), with higher rates of hypertension, diabetes, and cardiovascular disease, and had increased risk of in-hospital mortality (31% vs 11%, p<0.001). No differences were observed in injury severity, ICU LOS, or ventilator-days. After adjustment for age, sex, and injury severity, the HR for in-hospital mortality was 1.90 (95% CI 1.33 to 2.70) for CKD/dialysis compared with patients without CKD.ConclusionIndependent of injury severity, patients without CKD/dialysis have significantly increased risk of in-hospital mortality after major trauma.

Download Full-text

186 Acute Kidney Injury in Skeletal Trauma Admissions to Intensive Care: An Under-Estimated Complication

British Journal of Surgery ◽

10.1093/bjs/znab134.537 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

O Brown ◽

T Crisp ◽

M Flatman ◽

C Hing

Keyword(s):

Acute Kidney Injury ◽

Intensive Care ◽

Injury Severity ◽

Penetrating Trauma ◽

Kidney Injury ◽

Long Bone ◽

Trauma Patients ◽

Skeletal Trauma ◽

Body Regions ◽

Intensive Care Stay

Abstract Introduction Acute kidney injury (AKI) is associated with prolonged admission and 3.5 times increased mortality for trauma patients requiring intensive care (ICU) treatment. Blunt trauma confers greater risk of AKI than penetrating trauma, potentially related to long bone fracture. The relationship between skeletal trauma and AKI in ICU has not previously been investigated. Method Retrospective data was analysed from 202 consecutive adult patients admitted to ICU with skeletal trauma from 01/06/2018 to 01/06/2019. AKI was defined by creatinine rise >1.5 times baseline. Results AKI was found in 70/202 (34.65%) patients aged 16-99 years, 138 males and 64 females. Mean limb Abbreviated Injury Scale (AIS) was significantly higher in AKI (AIS= 2.57 (SD 0.53) versus non-AKI AIS=2.38 (SD 0.61), p = 0.027). Other body regions and total Injury Severity Score (ISS) were non-significant. AKI was associated with a significantly worse Glasgow Outcome Score (AKI 3.28 (SD 1.52) versus 4.02 (SD 1.08) p < 0.001), increased intensive care stay (AKI 7.03 (SD 8.30) days versus non-AKI 3.8 (SD 4.1) days p < 0.001) and increased 30-day mortality (AKI 18/70 (25.71%) versus non-AKI 10/132 (7.58%) p < 0.001) Conclusions Skeletal trauma patients have a high incidence of AKI, which was significantly correlated with severity of skeletal limb trauma but not overall ISS.

Download Full-text

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.

Download Full-text