scholarly journals Predictors of Undertriage after Major Trauma in a Physician-led Prehospital System: Insights of a French Registry

2020 ◽  
Author(s):  
Axel BENHAMED ◽  
Laurie FRATICELLI ◽  
Clément CLAUSTRE ◽  
Marion DOUPLAT ◽  
Guillaume MARCOTTE ◽  
...  
Keyword(s):  
Trauma Center ◽  
Major Trauma ◽  
Injury Severity ◽  
Ultrasound Examination ◽  
Trauma System ◽  
Trauma Patients ◽  
Medical Systems ◽  
Aged Patients ◽  
Increased Risk ◽  
French Registry

Abstract BackgroundThe proper prehospital triage and transportation of patients suffering major trauma to lever 1 trauma centers is associated with better outcomes. Hence, emergency medical systems (EMS) aim is to avoid undertriage in these patients. The main objective of this study was to assess the rate and predictors of undertriage in a physician-led prehospital system.MethodsWe conducted an observational multicentric, region-wide, retrospective study based on the RESUVal Trauma-System registry, Rhône-Alpes region, France. All adults assessed by physician-led EMS units, from January 2011 to December 2017 with major trauma (Injury Severity Score (ISS) ≥ 16) were included. We defined the correct-triage group as major trauma patients admitted to a level I trauma center. We performed univariate then multivariate logistic regressions with undertriage as outcome.ResultsA total of 7,110 patients were included in the registry, of whom 2,591 patients with an ISS≥ 16. Among these patients, 320 (12.35%) were undertriaged. Median ISS was 25. In-hospital mortality was 16.45% (n=351/2134). Mid-aged patients (51-65 years old) were associated with a higher risk of undertriage than the others (OR=1.62, 95%CI 1.15-2.28, p=0.01). Factors associated with a lower risk of undertriage were: mechanism (fall or gunshot/stabbing wounds, 0.62, [0.45-0.86], p=0.01 and 0.44, [0.22-0.9], p=0.02, respectively), time on-scene (over 60 minutes, 0.61, [0.38-0.95], p=0.03), prehospital need for endotracheal intubation and ultrasound examination (0.53, [0.39-0.72], p<0.001 and 0.15, [0.08-0.29], p<0.001 respectively). After adjusting for severity, undertriage showed a non-significant tendency toward an increased risk of mortality (1.22, [0.8-1.89], p=0.36).ConclusionsIn our region-wide, physician-led prehospital system, undertriage of major trauma was not rare. The typical profile of undertriaged patients was a mid-aged male suffering from a blunt trauma, without respiratory distress or neurologic impairment, not benefiting from prehospital ultrasound examination and located close to a non-trauma center hospital.

scholarly journals Predictors of Undertriage after Major Trauma in a Physician-led Prehospital System: Insights of a French Registry

2020 ◽  
Author(s):  
Axel BENHAMED ◽  
Laurie FRATICELLI ◽  
Clément CLAUSTRE ◽  
Marion DOUPLAT ◽  
Guillaume MARCOTTE ◽  
...  
Keyword(s):  
Trauma Center ◽  
Major Trauma ◽  
Injury Severity ◽  
Ultrasound Examination ◽  
Trauma System ◽  
Trauma Patients ◽  
Medical Systems ◽  
Aged Patients ◽  
Increased Risk ◽  
French Registry

Abstract BackgroundThe proper prehospital triage and transportation of patients suffering major trauma to lever 1 trauma centers is associated with better outcomes. Hence, emergency medical systems (EMS) aim is to avoid undertriage in these patients. The main objective of this study was to assess the rate and predictors of undertriage in a physician-led prehospital system.MethodsWe conducted an observational multicentric, region-wide, retrospective study based on the RESUVal Trauma-System registry, Rhône-Alpes region, France. All adults assessed by physician-led EMS units, from January 2011 to December 2017 with major trauma (Injury Severity Score (ISS) ≥ 16) were included. We defined the correct-triage group as major trauma patients admitted to a level I trauma center. We performed univariate then multivariate logistic regressions with undertriage as outcome.ResultsA total of 7,110 patients were included in the registry, of whom 2,591 patients with an ISS≥ 16. Among these patients, 320 (12.35%) were undertriaged. Median ISS was 25. In-hospital mortality was 16.45% (n=351/2134). Mid-aged patients (51-65 years old) were associated with a higher risk of undertriage than the others (OR=1.62, 95%CI 1.15-2.28, p=0.01). Factors associated with a lower risk of undertriage were: mechanism (fall or gunshot/stabbing wounds, 0.62, [0.45-0.86], p=0.01 and 0.44, [0.22-0.9], p=0.02, respectively), time on-scene (over 60 minutes, 0.61, [0.38-0.95], p=0.03), prehospital need for endotracheal intubation and ultrasound examination (0.53, [0.39-0.72], p<0.001 and 0.15, [0.08-0.29], p<0.001 respectively). After adjusting for severity, undertriage showed a non-significant tendency toward an increased risk of mortality (1.22, [0.8-1.89], p=0.36).ConclusionsIn our region-wide, physician-led prehospital system, undertriage of major trauma was not rare. The typical profile of undertriaged patients was a mid-aged male suffering from a blunt trauma, without respiratory distress or neurologic impairment, not benefiting from prehospital ultrasound examination and located close to a non-trauma center hospital.

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

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.

Right Patient, Right Place, Right Time

2020 ◽  
pp. 000313482094738
Author(s):  
Benjamin L. Gough ◽  
Matthew D. Painter ◽  
Autumn L. Hoffman ◽  
Richard J. Caplan ◽  
Cynthia A. Peters ◽  
...  
Keyword(s):  
Propensity Score ◽  
Trauma Center ◽  
Injury Severity ◽  
Linear Regression Analysis ◽  
Trauma System ◽  
Hospital Length Of Stay ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
Level I ◽  
Transferred Patients

Introduction This study sought to compare outcomes of trauma patients taken directly from the field to a Level I trauma center (direct) versus patients that were first brought to a Level III trauma center prior to being transferred to a Level I (transfer) within our inclusive Delaware trauma system. Methods A retrospective review of the Level I center’s trauma registry was performed using data from 2013 to 2017 for patients brought to a single Level I trauma center from 2 surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. Results When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared with direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (odds ratio [OR] 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality ( P < .001). ISS was predictive of increased risk of mortality ( P < .001), increased LOS ( P < .001), and craniotomy ( P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred ( P < .001). Discussion Delays in the presentation to our Level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

scholarly journals Early experience of a regional trauma center in Gangwon province: First step toward organizing a regional trauma system

2019 ◽  
Vol 27 (4) ◽  
pp. 202-210
Author(s):  
Kwangmin Kim ◽  
Hongjin Shim ◽  
Pil Young Jung ◽  
Seongyup Kim ◽  
Hui-Jae Bang ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Injury Severity Score ◽  
Severity Score ◽  
Trauma Center ◽  
Injury Severity ◽  
Trauma System ◽  
Mortality Rates ◽  
Trauma Patients ◽  
Before And After ◽  
The Impact

Background: The Korean Ministry of Health and Welfare decided to establish a trauma medical service system to reduce preventable deaths. OO hospital in Gangwon Province was selected as a regional trauma center and was inaugurated in 2015. Objectives: This study examines the impact of this center, comparing mortality and other variables before and after inaugurating the center. Methods: Severely injured patients (injury severity score > 15) presenting to OO hospital between January 2014 and December 2016 were enrolled and categorized into two groups: before trauma center (n = 365) and after trauma center (n = 904). Patient characteristics, variables, and patient outcomes (including mortality rate) before and after the establishment of trauma centers were compared accordingly for both groups. Risk factors for in-hospital mortality were also identified. Results: Probability of survival using trauma and injury severity score (%) method was significantly lower in the after trauma center group (81.3 ± 26.1) than in the before trauma center group (84.7 ± 21.0) (p = 0.014). In-hospital mortality rates were similar in both groups (before vs after trauma center group: 13.2% vs 14.2%; p = 0.638). The Z and W statistics revealed higher scores in the after trauma center group than in the before trauma center group (Z statistic, 4.69 vs 1.37; W statistic, 4.52 vs 2.10); 2.42 more patients (per 100 patients) survived after trauma center establishment. Conclusion: Although the mortality rates of trauma patients remained unchanged after the trauma center establishment, the Z and W statistics revealed improvements in the quality of care.

National temporal variation in major trauma in England, Wales and Northern Ireland

Trauma ◽  
2021 ◽  
pp. 146040862098226
Author(s):  
Will Kieffer ◽  
Daniel Michalik ◽  
Jason Bernard ◽  
Omar Bouamra ◽  
Benedict Rogers
Keyword(s):  
Northern Ireland ◽  
Temporal Variation ◽  
Major Trauma ◽  
Injury Severity ◽  
Research Network ◽  
Trauma Patients ◽  
Trauma Outcomes ◽  
Causes Of Mortality ◽  
Injured Patients ◽  
Time Of Admission

Introduction Trauma is one of the leading causes of mortality worldwide, but little is known of the temporal variation in major trauma across England, Wales and Northern Ireland. Proper workforce and infrastructure planning requires identification of the caseload burden and its temporal variation. Materials and Methods The Trauma Audit Research Network (TARN) database for admissions attending Major Trauma Centres (MTCs) between 1st April 2011 and 31st March 2018 was analysed. TARN records data on all trauma patients admitted to hospital who are alive at the time of admission to hospital. Major trauma was classified as an Injury Severity Score (ISS) >15. Results A total of 158,440 cases were analysed. Case ascertainment was over 95% for 2013 onwards. There was a statistically significant variation in caseload by year (p < 0.0001), times of admissions (p < 0.0001), caseload admitted during weekends vs weekdays, 53% vs 47% (p < 0.0001), caseload by season with most patients admitted during summer (p < 0.0001). The ISS varied by time of admission with most patients admitted between 1800 and 0559 (p < 0.0001), weekend vs weekday with more severely injured patients admitted during the weekend (p < 0.0001) and by season p < 0.0001). Discussion and Conclusion: There is a significant national temporal variation in major trauma workload. The reasons are complex and there are multiple theories and confounding factors to explain it. This is the largest dataset for hospitals submitting to TARN which can help guide workforce and resource allocation to further improve trauma outcomes.

scholarly journals Independent Predictors of Mortality in Torso Trauma Injuries

2020 ◽  
Vol 9 (10) ◽  
pp. 3202
Author(s):  
Roberto Bini ◽  
Caterina Accardo ◽  
Stefano Granieri ◽  
Fabrizio Sammartano ◽  
Stefania Cimbanassi ◽  
...  
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Demographic Data ◽  
Trauma Patients ◽  
Related Condition ◽  
Predictors Of Mortality ◽  
Risk Of Death ◽  
Therapeutic Procedures ◽  
Torso Trauma ◽  
Enhanced Computed Tomography

Noncompressible torso injuries (NCTIs) represent a trauma-related condition with high lethality. This study’s aim was to identify potential prediction factors of mortality in this group of trauma patients at a Level 1 trauma center in Italy. Materials and Methods: A total of 777 patients who had sustained a noncompressible torso injury (NCTI) and were admitted to the Niguarda Trauma Center in Milan from 2010 to 2019 were included. Of these, 166 patients with a systolic blood pressure (SBP) <90 mmHg were considered to have a noncompressible torso hemorrhage (NCTH). Demographic data, mechanism of trauma, pre-hospital and in-hospital clinical conditions, diagnostic/therapeutic procedures, and survival outcome were retrospectively recorded. Results: Among the 777 patients, 69% were male and 90.2% sustained a blunt trauma with a median age of 43 years. The comparison between survivors and non-survivors pointed out a significantly lower pre-hospital Glasgow coma scale (GCS) and SBP (p < 0.001) in the latter group. The multivariate backward regression model identified age, pre-hospital GCS and injury severity score (ISS) (p < 0.001), pre-hospital SBP (p = 0.03), emergency department SBP (p = 0.039), performance of torso contrast enhanced computed tomography (CeCT) (p = 0.029), and base excess (BE) (p = 0.008) as independent predictors of mortality. Conclusions: Torso trauma patients who were hemodynamically unstable in both pre- and in-hospital phases with impaired GCS and BE had a greater risk of death. The detection of independent predictors of mortality allows for the timely identification of a subgroup of patients whose chances of survival are reduced.

Predictors of blunt diaphragm injury in Australia

Trauma ◽  
2021 ◽  
pp. 146040862110418
Author(s):  
Annelise M Cocco ◽  
Vignesh Ratnaraj ◽  
Benjamin PT Loveday ◽  
Kellie Gumm ◽  
Phillip Antippa ◽  
...  
Keyword(s):  
Injury Severity Score ◽  
Severity Score ◽  
Major Trauma ◽  
Injury Severity ◽  
Rib Fractures ◽  
Organ Injury ◽  
Trauma Patients ◽  
Missed Injury ◽  
Diaphragm Injury ◽  
Trauma Service

Introduction Blunt diaphragm injury (BDI) is an uncommon, potentially fatal consequence of blunt torso injury. While associations between BDI and other factors such as mechanism of injury or other injuries have been described elsewhere, little recent research has been done in Australia into BDI. The aims of this study were to determine the incidence rate of BDI in our centre, identify how it was diagnosed, determine rates of missed injury and identify predictive factors for BDI. The hypothesis was that patients with BDI would significantly differ to those without BDI. Methods All major trauma patients with blunt torso injuries at our Level 1 major trauma service from 2010 to 2018 were included. Data for patient demographics, other injuries, diagnosis and treatment of BDI were extracted. Patients with BDI were compared with patients without BDI in order to identify differences that could be used to predict BDI in future patients. Results Of 5190 patients with a blunt torso injury, 51 (0.98%) had a BDI at a mean age of 53 ± 19.6 years, and median Injury Severity Score (ISS) of 27(IQR 21–38.5) compared with 5139 patients with a mean age of 48.2 ± 20.7 years and median ISS of 21.9(IQR 14–26) who did not have a BDI. The diagnosis of BDI was made at CT ( n = 35), surgery ( n = 14) or autopsy ( n = 2). Blunt diaphragm injury was missed on index imaging for 11 of 43 patients (25.6%). On multivariate analysis, each point increase in ISS (OR 1.03, p = 0.02); rib fractures (OR 4.65, p = 0.004); splenic injury (OR 2.60, p = 0.004); and liver injury (OR 2.78, p = 0.003) were independently associated with BDI. Conclusion Injury Severity Score, rib fractures and solid abdominal organ injury increase the likelihood of BDI. In patients with these injuries, BDI should be considered even in the presence of normal CT findings.

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

2015 ◽  
Vol 4 (5) ◽  
pp. 1 ◽  
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.

Abstract 183: Outcomes for Major Trauma Patients in Counties Without Trauma Centers Are Worse: Nationwide Population-Based Research in Taiwan

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Dorji Harnod ◽  
Chu Hui Chang ◽  
Ray E Chang
Keyword(s):  
Major Trauma ◽  
Injury Severity ◽  
Total Mortality ◽  
Data Bank ◽  
Claim Data ◽  
Population Based ◽  
Trauma Patients ◽  
Direct Transfer ◽  
Trauma Centers ◽  
Icu Admission

Background: Some articles proved indirect-transfer the major trauma patients to the trauma centers had non-significant different outcomes with the patients direct-transfer to the centers. But the outcomes for the major trauma patients in the counties without trauma centers still can be worse. So we did a population based research by using the NHIRD data for the results. Methods: From the claim data of one million beneficiaries of Taiwan National Health Insurance during the year of 2006 to 2008, all of the trauma patients were identified from the database by the ICD-9-CM system. ICDMAP-90 was used for calculating the Injury Severity Score (ISS) as the variable controlling the disease severity. The patients of major trauma were defined as ISS more than fifteen. We used the diagnosis one year before the trauma admission for calculating Charlson Comorbidity Index (CCI). The first hospitals and the second transferred hospitals that the major trauma patients admitted, and the areas of the first hospitals were recognized in our data bank. The condition of transfer, age, genders, intubation, ICU admission, ISS, CCI, and the triage classifications were adjusted in a logistic regression model for further analysis. Results: There were 2497 major trauma patients (ISS more then 15). The total mortality rate was 12.49%. The variables like age, intubation, ICU admission, ISS and CCI were significant for mortality, but the condition of transfer was not significant in our model. After controlling all the factors, the major trauma patients that first admitted in the areas with no trauma centers have a significant higher risk of mortality (OR=1.73, P=0.005). Conclusions: Our results hint that, although indirect-transfer for the major trauma patients have insignificant difference in mortality with the direct transfer patients, the counties with no trauma centers have significant higher mortality rates in major trauma patients. Further researches are needed for investigating the possible reasons.

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