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Background and Objectives: Pediatric out‐of‐hospital cardiac arrest survival outcomes are dismal (<10%). Care that is provided in adherence to established guidelines has been associated with improved survival. Lower mortality rates have been reported in higher‐volume hospitals, teaching hospitals, and trauma centers. The primary objective of this article was to explore the relationship of hospital characteristics, such as annual pediatric patient volume, to adherence to pediatric cardiac arrest guidelines during an in situ simulation. Secondary objectives included comparing adherence to other team, provider, and system factors. Methods: This prospective, multicenter, observational study evaluated interprofessional teams in their native emergency department (ED) resuscitation bays caring for a simulated 5‐year‐old child presenting in cardiac arrest. The primary outcome, adherence to the American Heart Association pediatric guidelines, was assessed using a 14‐item tool including three component domains: basic life support (BLS), pulseless electrical activity (PEA), and ventricular fibrillation (VF). Provider, team, and hospital‐level data were collected as independent data. EDs were evaluated in four pediatric volume groups (low < 1,800/year; medium 1,800–4,999; medium‐high 5,000–9,999; high > 10,000). Cardiac arrest adherence and domains were evaluated by pediatric patient volume and other team and hospital‐level characteristics, and path analyses were performed to evaluate the contribution of patient volume, systems readiness, and teamwork on BLS, PEA, and VF adherence. Results: A total of 101 teams from a spectrum of 50 EDs participated including nine low pediatric volume (<1,800/year), 36 medium volume (1,800–4,999/year), 24 medium‐high (5,000–9,999/year), and 32 high volume (≥10000/year). The median total adherence score was 57.1 (interquartile range = 50.0–78.6). This was not significantly different across the four volume groups. The highest level of adherence for BLS and PEA domains was noted in the medium‐high–volume sites, while no difference was noted for the VF domain. The lowest level of BLS adherence was noted in the lowest‐volume EDs. Improved adherence was not directly associated with higher pediatric readiness survey (PRS) score provider experience, simulation teamwork performance, or more providers with Pediatric Advanced Life Support (PALS) training. EDs in teaching hospitals with a trauma center designation that served only children demonstrated higher adherence compared to nonteaching hospitals (64.3 vs 57.1), nontrauma centers (64.3 vs. 57.1), and mixed pediatric and adult departments (67.9 vs. 57.1), respectively. The overall effect sizes for total cardiac adherence score are ED type γ = 0.47 and pediatric volume (low and medium vs. medium‐high and high) γ = 0.41. A series of path analyses models was conducted that indicated that overall pediatric ED volume predicted significantly better guideline adherence, but the effect of volume on performance was only mediated by the PRS for the VF domain. Conclusions: This study demonstrated variable adherence to pediatric cardiac arrest guidelines across a spectrum of EDs. Overall adherence was not associated with ED pediatric volume. Medium‐high–volume EDs demonstrated the highest levels of adherence for BLS and PEA. Lower‐volume EDs were noted to have lower adherence to BLS guidelines. Improved adherence was not directly associated with higher PRS score provider experience, simulation teamwork performance, or more providers with PALS training. This study demonstrates that current approaches optimizing the care of children in cardiac arrest in the ED (provider training, teamwork training, environmental preparation) are insufficient. [ABSTRACT FROM AUTHOR]

Introduction: Prehospital care is the first part of the trauma treatment and care system. Diagnostic and therapeutic measures taken before these patients arrive at the hospital plays significantly reduce mortality and improve their outcomes. Therefore, the present study aimed to determine the knowledge, attitude, and clinical skill of emergency medical technicians in Tehran Emergency Center in trauma exposure. Methods: In this descriptive study, 213 participants were selected through stratified random sampling. Data were collected using a four-part questionnaire including demographic information, trauma knowledge questionnaire, trauma attitude questionnaire, and a clinical skill checklist. To compare the level of knowledge, attitude, and clinical skills on the one hand and demographic variables, on the other hand, independent samples t-test and one-way ANOVA were utilized. Then, to examine the normality of data distribution, Kolmogorov–Smirnov test with Bonferroni post hoc test was used to compare mean scores on different levels of the variables in questionnaires. Data were analyzed in SPSS/17 using descriptive and inferential statistics. Results: Results showed that the majority of participants (81.1%) had an average knowledge of trauma. Examining their attitude regarding trauma revealed that the majority (88.3%) had a positive attitude toward trauma and taking care of trauma patients. Moreover, the skill of 62.4% of technicians regarding trauma was good. Based on Pearson's correlation, significant positive correlations existed between scores of knowledge and scores of attitude (r = 0.186, P < 0.05), scores of knowledge and scores of clinical skill (r = 0.333, P < 0.05), and scores of attitude and scores of clinical skill (r = 0.258, P < 0.05). Conclusion: According to the results, emergency medical technicians in Tehran had a good level of knowledge, attitude, and clinical skills in trauma exposure. However, to maintain and enhance the level of knowledge and skills, in-service training should be continued more vigorously and periodically evaluated in the clinical practice. [ABSTRACT FROM AUTHOR]

Background: Trauma team activation (TTA) represents a considerable expenditure of trauma centre resources. It is mainly triggered by field triage criteria. The overall quality of the criteria may be evaluated based on the rate of over- and undertriage. However, there is no gold standard that defines which adult patients truly require a trauma team. The objective of this study was to develop consensus-based criteria defining the necessity for a trauma team.Methods: A consensus group was formed by trauma specialists experienced in emergency and trauma care with a specific interest in field triage and having previously participated in guideline development. A literature search was conducted to identify criteria that have already been used or suggested. The initial list of criteria was discussed in two Delphi round and two consensus conferences. The entire process of discussion and voting was highly standardized and extensively documented, resulting in a final list of criteria.Results: Initially 95 criteria were identified. This was subsequently reduced to 20 final criteria to appropriately indicate the requirement for attendance of a trauma team. The criteria address aspects related to injury severity, admission to an intensive care unit, death within 24 h, need for specified invasive procedures, need for surgical and/or interventional radiological procedures, and abnormal vital signs within a defined time period.Conclusions: The selected criteria may be applied as a tool for research and quality control concerning TTA. However, future studies are necessary to further evaluate for possible redundancy in criteria that may allow for further reduction in criteria. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH. Methods: This retrospective cohort study was approved by the institutional review board. Study subjects were patients ≥ 18 years of age with an International Classification of Diseases code corresponding to a traumatic ICH and admitted to an ED observation unit (EDOU) of an urban, academic Level I trauma center between February 1, 2015, and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record, and imaging data, from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU before and after protocol implementation as a covariate, we sought to determine the pre‐post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit, or operating room from the EDOU and the proportion of patients with worsening findings on repeat computed tomography (CT) head scan in the EDOU. Results: A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Inter‐rater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the preprotocol period and 153 after protocol implementation. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR = 0.45, 95% confidence interval [CI] = 0.25–0.82, p = 0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission before implementation of the protocol and 13% (20/153) of patients required an inpatient admission after protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p = 0.34). Conclusions: While there was no difference in EDOU LOS, implementing a low‐risk mild TBI and ICH protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol‐driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between The International Classification of Diseases, Ninth Revision, Clinical Modification-derived conscious status and mortality rates in trauma centres (TC) vs. non-trauma centres (NTC). Methods: Patients in the 2006-2011 Nationwide Emergency Department Sample meeting, The Centers for Disease Control and Prevention criteria for traumatic brain injury (TBI), with head/neck Abbreviated Injury Scale (AIS) scores ≥3 were included. Loss of consciousness (LOC) was computed for each patient. Primary outcomes included treatment at a level I/II TC vs. NTC and in-hospital mortality. We compared logistic regression models controlling for patient demographics, injury characteristics, and AIS score with identical models that also included LOC. Results: Of 66,636 patients with isolated TBI identified, 15,761 (23.6%) had missing LOC status. Among the remaining 50,875 patients, 59.0% were male, 54.0% were ≥65 years old, 56.7% were treated in TCs, and 27.3% had extended LOC. Patients with extended LOC were more likely to be treated in TCs vs. those with no/brief LOC (71.1% vs. 51.4%, p < 0.001). Among patients aged <65, TC treatment was associated with increased odds of mortality [Adjusted Odds Ratio (AOR) 1.79]; accounting for LOC substantially mitigated this relationship [AOR 1.27]. Similar findings were observed among older patients, with reduced effect size. Conclusion: Extended LOC was associated with TC treatment and mortality. Accounting for patient LOC reduced the differential odds of mortality comparing TCs vs. NTCs by 60%. Research assessing TBI outcomes using administrative data should include measures of consciousness. [ABSTRACT FROM AUTHOR]

The purpose of this study was to define the trends in fracture complexity and overall injury severity of orthopedic trauma patients at a level I trauma center. A retrospective review of a prospectively collected trauma database was performed to determine the Injury Severity Score (ISS) and AO/OTA classification of the most common fractures among all patients presenting from 1995 to 1999 and from 2008 to 2012. Inclusion criteria were lower extremity fractures of the femur and tibia and pelvic fractures within the years of interest. Exclusion criteria were age younger than 18 years, pathologic fractures, and insufficient medical records to determine ISS or AO/OTA classification. The total number of fractures increased from 4869 between 1995 and 1999 to 5902 between 2008 and 2012. There was an increase in the percentage of lower extremity periarticular fractures (20.7% to 23.4%, P<.001) and the percentage of pelvic and acetabular fractures (32.7% to 39.9%, P<.001) and a decrease in the percentage of lower extremity extra-articular fractures (46.6% to 36.7%, P<.001). The ratios of tibial pilon and plateau fractures relative to extra-articular tibial fractures increased from 0.29 to 0.60 (P<.001) and from 0.49 to 0.81 (P<.001), respectively. The average ISS had increased from 2008 to 2012 compared with from 1995 to 1999 (19.2 vs 15.1, P<.001). The complexity of certain lower extremity fractures and the severity of injury of patients treated at this referral institution are high and continue to increase. As US health care economics continue to change, with provider and hospital reimbursements shifting toward a patient outcomes basis with potential penalties for complications and readmissions, hospitals and providers must recognize these trends. Trauma centers must continue to measure the complexity of fracture care provided to properly risk-stratify their patient population. [Orthopedics. 2018; 41(2):e211–e216.] [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Recent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) versus ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting. Methods: The ascertainment of trauma patients age ≥ 15 years (n = 469 cases) by HT and (n = 580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time, and injury severity. The PS matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in the emergency department, the need for urgent surgery, intensive care unit admission, and mechanical ventilation. Results: Unadjusted mortalities for HT compared to GT were 7.7 and 5.3%, respectively (p > 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well‐matched data set, HT was associated with a 2.69‐fold increase in odds of survival compared to GT patients (adjusted odds ratio = 2.69; 95% CI = 1.21–5.97). Conclusions: In a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified Level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed. We recommend larger studies with multiple trauma systems need to be repeated using similar study methodology to substantiate our findings. [ABSTRACT FROM AUTHOR]

The primary purpose of this narrative is to elucidate the numerous significant changes that occur at the intensive care unit (ICU) level as a medical center pursues becoming a Level I trauma center. Specifically, we will focus on the following important areas: (1) leadership and strategy issues behind the decision to move forward with becoming a trauma center; (2) preparation needed to take a highly functioning surgical ICU and align it for the inevitable changes that happen as trauma go-live occurs; (3) intensivist staffing changes; (4) roles for and training of advanced practice practitioners; (5) graduate medical education issues; (6) optimizing interactions with closely related services; (7) nursing, staffing, and training issues; (8) bed allocation issues; and (9) reconciling the advantages of a "unified adult critical care service" with the realities of the central relationship between trauma and surgical critical care. [ABSTRACT FROM AUTHOR]

Background: Road traffic injuries (RTIs) are the eighth leading cause of death worldwide, with an estimated 90% of RTIs occurring in low- and middle-income countries (LMICs) like Brazil. There has been minimal research in evaluation of delays in transport of RTI patients to trauma centers in LMICs. The objective of this study is to determine specific causes of delays in prehospital transport of road traffic injury patients to designated trauma centers in Maringá, Brazil.Methods: A qualitative method was used based on the Consolidated Criteria for Reporting Qualitative Research (COREQ) approach. Eleven health care providers employed at prehospital or hospital settings were interviewed with questions specific to delays in care for RTI patients. A thematic analysis was conducted.Results: Responses to primary causes of delay in treatment to RTI patients fell into the following categories: 1) lack of public education, 2) traffic, 3) insufficient personnel/ambulances, 4) bureaucracy, and 5) poor location of stations. Suggestions for improvement in delays fell into the categories of 1) need for centralized station/avoid traffic, 2) improving public education, 3) Increase personnel, 4) increase ambulances, 5) proper extrication/rapid treatment.Conclusion: Our study found varied responses between hospital and SAMU providers regarding specific causes of delay for RTI patients; SAMU providers cited primarily traffic, bureaucracy, and poor location as primary factors while hospital employees focused more on public health aspects. These results mirror prehospital system challenges in other developing countries, but also provide solutions for improvement with better infrastructure and public health campaigns. [ABSTRACT FROM AUTHOR]

Objectives: Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low risk for neurologic decline, neurosurgical intervention, or radiographic worsening. Methods: Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and computed tomography (CT)-documented isolated SDH presenting to a university-affiliated, urban, 100,000-annual-visit ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model. Results: A total of 644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. A total 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors—SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14, and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1%, and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5%, and negative likelihood ratio was 0.127. Conclusion: Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers. [ABSTRACT FROM AUTHOR]

Objective: Timely triage and appropriate destination decision making for injured patients are central challenges faced by emergency medical services (EMS) systems. In 2010, North Carolina (NC) adopted a statewide Trauma Triage and Destination Plan (TTDP) based on the CDC's Field Triage Guidelines to better address these challenges. We sought to characterize the implementation of these guidelines by quantifying their effect on multiple metrics of patient care. Methods: We employed a retrospective pre-post study design utilizing a statewide EMS medical record database. We assessed several metrics of patient care--including changes in destination choice, appropriateness of EMS destination, transit time to first hospital, transit time to definitive care, and others--in a six-month period in the year before and after the implementation of the guidelines. Results: We evaluated a total of 190,307 EMS encounters pre- (n = 93,927) and post-implementation (n = 96,380). Among all patients, there was not a significant difference in the percentage transported to a community hospital or Level I, II, or III trauma center as their first destination. Among those patients meeting TTDP guidelines for transport to a trauma center, the number transported to a Level I or II trauma center decreased 1.0% from 30.6% (n = 2,911) to 29.6% (n = 2,954) (95% CI: -0.2%, 2.2%). Those transported to a Level I trauma center decreased 0.4% from 21.2% to 20.8% in the post-period (95% CI: -0.7%, 1.5%). There were also no significant changes in EMS scene times (14.0 pre-, 14.1 post-) and transport times (12.9 pre-, 13.0 post-). While scene distance from a Level I trauma center showed a decreased likelihood of transport to that center, there was an overall post-implementation increase of 2.5% from 18.0% to 20.5% (95% CI: -3.6%, -1.3%) in transport to a Level I trauma center among patients meeting anatomic criteria across all distance ranges. Conclusions: We found that implementation of region-specific destination plans based on the Field Triage Guidelines had little effect on selected hospital destination, scene times, transport times, and other metrics of EMS decision making and effectiveness. We suspect this is due to delays in information dissemination and adoption by field providers. [ABSTRACT FROM AUTHOR]

Background: In 2011, revised Field Triage Guidelines were released jointly by the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons – Committee on Trauma (ACS-COT). It is unknown how the modifications will affect the number of injured children identified by EMS providers as needing transport to a trauma center. Objective: To determine the change in under- and over-triage rates when the 2011 Field Triage Guidelines are compared to the 2006 and 1999 versions. Methods: EMS providers in charge of care for injured children (<15 years) transported to pediatric trauma centers in 3 mid-sized cities were interviewed immediately after completing transport. Patients were included regardless of injury severity. The interview included patient demographics and each criterion from the Field Triage Guidelines' physiologic status, anatomic injury, and mechanism of injury steps. Included patients were followed through hospital discharge. The 1999, 2006, and 2011 Guidelines were each retrospectively applied to the collected data. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics. Results: EMS interviews were conducted for 5,610 children and outcome data was available for 5,594 (99.7%). Average age was 7.6 years; 5% of children were identified as needing a trauma center using the study outcome. Applying the 1999, 2006, or 2011 Guidelines to the EMS interview data the over-triage rate was 32.6%, 27.9%, and 28.0%, respectively. The under-triage rate was 26.5%, 35.1%, and 34.8%, respectively. The 2011 Guidelines resulted in an 8.2% (95% CI 0.6–15.9%) absolute increase in under-triage and a 4.6% (95% CI 2.8–6.3%) decrease in over-triage compared to 1999 Guidelines. Conclusion: Use of the Field Triage Guidelines for children resulted in an unacceptably high rate of under-triage regardless of the version used. Use of the 2011 Guidelines increased under-triage compared to the 1999 version. Research is needed to determine how to better assist EMS providers in identifying children who need the resources of a trauma center. [ABSTRACT FROM AUTHOR]

Objective In 2006, the American College of Surgeons' Committee on Trauma and the Centers for Disease Control and Prevention released field triage guidelines with special consideration for older adults. Additional considerations for direct transport to a Level I or II trauma center ( TC) were added in 2011, reflecting perceived undertriage to TCs for older adults. We examined whether age-based disparities in TC care for severe head injury decreased following introduction of the 2011 revisions. Methods A pre-post design analyzing the 2009 and 2012 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases with multivariable logistic regressions considered changes in 1) the trauma designation of the emergency department where treatment was initiated and 2) transfer to a TC following initial treatment at a non- TC. Results Compared with adults aged 18 to 44 years, after multivariable adjustment, in both years TC care was less likely for adults aged 45 to 64 years (odds ratio [ OR] = 0.76 in 2009 and 0.74 in 2012), aged 65 to 84 years ( OR = 0.61 and 0.59), and aged 85+ years ( OR = 0.53 and 0.56). Between 2009 and 2012, the likelihood of TC care increased for all age groups, with the largest increase among those aged 85+ years ( OR = 1.18), which was statistically different (p = 0.02) from the increase among adults aged 18 to 44 years ( OR = 1.12). The analysis of transfers yielded similar results. Conclusions Although patterns of increased TC treatment for all groups with severe head trauma indicate improvements, age-based disparities persisted. [ABSTRACT FROM AUTHOR]

Background: The available information on trauma care in mixed rural-urban areas with scattered populations is limited. The aim of this study is to describe epidemiology, resource use, transfers and outcomes for trauma care within such an area, prior to implementation of a formal trauma system.Methods: A multicentre observational study including potential severely injured patients from June 2007 to May 2010. All patients received by trauma teams at seven acute care hospitals (ACH) and one major trauma centre (MTC) were included. Major trauma was defined as Injury Severity Score (ISS) > 15.Results: A total of 2323 patients were included. ACH received 1330 patients and delivered definite care to 85% of these. Only 329 (14%) patients were major trauma of which 134 (41%) were initially received at an ACH. Nine per cent of patients were transferred between hospitals. After inter-hospital transfers, 79% of all major trauma patients received definite care at the MTC. Helicopter emergency services admitted 52% of major trauma and performed 68% of inter-hospital transfers from ACH to MTC. Forty-eight patients (2%) died within 30 days.Conclusion: In a region with a dispersed network of hospitals, geographical challenges, and low rate of major trauma cases, efforts should be made to identify patients with major trauma for treatment at a MTC as early as possible. This can be done by implementing triage and transfer guidelines, maintaining competence at ACHs for initial stabilization, and sustaining an organization for effective inter-facility transfers. [ABSTRACT FROM AUTHOR]

Objective: Recent advancements in trauma resuscitation have shown a great benefit of early identification and control of hemorrhage, which is the most common cause of death in injured patients. We introduce a new analytical approach, anomaly detection (AD), as an alternative method to the traditional logistic regression (LR) method in predicting which injured patients receive transfusions, intensive care, and other interventions.Methods: We abstracted routinely collected prehospital vital sign data from patient records (adult patients who survived more than 15 minutes after being directly admitted to a level 1 trauma center). The vital signs of the study cohort were analyzed using both LR and AD methods. Predictions on blood transfusions generated by these approaches were compared with hospital records using the respective areas under the receiver operating characteristic curves (AUROC).Results: Of the patients seen at our trauma center between January 1, 2009, and December 31, 2010, 5,464 were included. AD significantly outperformed LR, identifying which patients would receive transfusions of uncrossmatched blood, transfusion of blood between the time of admission and 6 hours later, the need for intensive care, and in-hospital mortality (mean AUROC = 0.764 and 0.720, respectively). AD and LR provided similar predictions for the patients who would receive massive transfusion. Under the stratified 10 fold times 10 cross-validation test, AD also had significantly lower AUROC variance across subgroups than LR, suggesting AD is a more stable predictions model.Conclusions: AD provides enhanced predictions for clinically relevant outcomes in the trauma patient cohort studied and may assist providers in caring for acutely injured patients in the prehospital arena.Keywords: trauma; transfusion; vital signs; logistic regression; anomaly detection [ABSTRACT FROM PUBLISHER]

Background: There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center.Objective: To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center.Methods: EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion.Results: Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4–3.2). Glasgow Coma Score (GCS) < 14 had a +LR of 14.3 (95% CI 11.2–18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS < 14 had an initial ED GCS < 14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8–2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP) < 90 had a +LR of 3.5 (95% CI 2.5–5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children <1 year, 46% 1–4 years, 7% 5–9 years, and 2% 10–15 years. A total of 19% of those with an EMS SBP < 90 had an initial ED SBP < 90.Conclusions: The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria. [ABSTRACT FROM PUBLISHER]

Introduction: Studies show that pediatric trauma centers produce better outcomes and reduced mortality for injured children. Yet, most children do not have timely access to a pediatric trauma center and require stabilization locally with subsequent transfer. Investigators have demonstrated that pediatric transport teams (PTT) improve outcomes for critically ill children; however, these studies did not differentiate outcomes for injured children. It may be that moderate to severely injured children actually fare worse with PTT due to slower transport times inherent to their remote locations and thus delays in important interventions. Objective: The purpose of this study was to determine if outcomes for injured children are affected by use of PTT for inter-hospital transfer. Methods: We conducted a retrospective chart review of 1,177 children transferred to a pediatric trauma center for injury care between March 1st, 2012 and December 31st, 2013. We compared children who were transported by PTT (ground/air) to those transported by ground advanced life support (ALS) and air critical care (ACC). We described patient characteristics and transport times. For PTT vs. ALS and ACC, we compared hospital length of stay (LOS), transport interventions and adverse events. Results: 1,177 injured children were transferred by the following modes: 68% ALS, 13% ACC, 11% Ground PTT, and 9% Air PTT. Children transported by PTT were younger and had higher ISS and lower GCS scores. PTT had a longer total transport time, departure preparation time, and patient bedside time. After controlling for age, ISS, GCS, transport mode, distance, and time, we found no significant difference in LOS between PTT vs. ALS and ACC. A subgroup analysis of children with higher ISS scores demonstrated a 65% longer LOS for children transported by ACC vs. PTT. There were no differences between transport teams with regard to acidosis, hypocarbia or hypercarbia, or maintenance of tubes and lines. Conclusions: Children transported by PTT were younger and sicker (vs. ACC and ALS). Despite longer transport times, children transported by PTT did not have a longer hospital LOS or adverse events during transport. However, for those children with higher ISS, transport by ACC resulted in longer hospital LOS vs. PTT. [ABSTRACT FROM AUTHOR]

Objectives Traumatic injury is a leading cause of death in the United States, and rural populations are at increased risk of injury and death. Rural residents have limited access to trauma care, and telemedicine has been proposed as one strategy to improve the provision of trauma care locally. The objective of this study was to describe patient-level factors associated with telemedicine consultation in North Dakota critical-access hospital ( CAH) emergency departments ( EDs) and to measure the association between telemedicine consultation and interhospital transfer. Methods Observational cohort study of all adult (age ≥ 18 years) trauma patients treated in North Dakota CAH EDs with an active telemedicine subscription between 2008 and 2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine-enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and interhospital transfer, adjusting for patient, injury, and hospital factors. Results Of the 9,281 North Dakota trauma patients seen in CAHs, 2,837 were treated in an ED with an active telemedicine subscription. Telemedicine was consulted for 11% of all trauma patients in telemedicine-capable EDs. Factors associated with telemedicine consultation included higher Injury Severity Score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness, injury mechanism, and type of injury, telemedicine use was not associated with interhospital transfer (adjusted odds ratio = 1.28, 95% confidence interval = 0.94 to 1.75). Conclusion Emergency department-based telemedicine consultation is requested for the most severely injured rural trauma patients, especially with those with penetrating trauma, burns, and abnormal presenting vital signs. Telemedicine consultation was not independently associated with increased probability of transfer. Future work should evaluate how telemedicine impacts the timeliness of care and specific care interventions. [ABSTRACT FROM AUTHOR]

In a modern medical delivery system, it is very difficult to provide adequate, timely, and equitable medical care for severely injured patients. Trauma is a leading cause of deaths under the age of 40 and a source of expensive socioeconomic losses in Korea. Korean government has been making a major effort to establish a trauma system since 2000, but inadequacies of the current trauma system still result in many preventable deaths from accidental injuries. The designation and support program for regional trauma centers is the first step in a national plan for trauma system development. At present, there are 9 regional trauma centers and 7 candidates for trauma centers. Regional trauma centers must play a key role in a regionally inclusive trauma system that integrates emergency medical services systems and healthcare delivery systems to deliver optimal medical care for injured patients. [ABSTRACT FROM AUTHOR]

From 2011 to 2016, 16 regional trauma centers were designated throughout the country and 9 of the 16 centers have been operating their own trauma facilities. At present, there are some differences in treatment experiences and levels according to the type and size of the trauma centers. Treating the trauma system as a part of emergency medical service, while the field of severe trauma is clearly different from the rest of emergency medical service in particular, has become a serious problem in Korea. First of all, the role of trauma centers should have been established before they are added to the trauma care system. Beyond that, manpower is the most important factor in building a trauma center. Pusan National University Hospital offers the ideal environment for a study on the relationship between trauma centers and emergency centers. Pusan National University Hospital has 2 independent emergency rooms: one each in the trauma center and emergency center. Therefore, it is possible to compare the outcomes of 2 different emergency rooms and identify the proportion of the trauma population who is transferred from the emergency center to the trauma center due to trauma severity index. Ultimately, the government and individual hospitals must support personnel in each trauma centers administratively and financially to sustain trauma centers over the long term. The purpose of this proposal is to suggest some resolutions to the problems associated with the trauma care system in Korea. [ABSTRACT FROM AUTHOR]

Background: Fragility fractures are a major health care problem worldwide. Both hip and non-hip fractures are associated with excess mortality in the years following the fracture. Residents of long-term nursing homes represent a special high-risk group for poor outcomes. Orthogeriatric co-management models of care have shown in multiple studies to have medical as well as economic advantages, but their impact on this high-risk group has not been well studied. Objective: We studied the outcome of long-term care residents with hip and non-hip fractures admitted to a geriatric fracture center. Methods: The study design is a single center, prospective cohort study at a level-I trauma center in Austria running a geriatric fracture center. The cohort included all fragility fracture patients aged over 70 admitted from a long-term care residence from May 2009 to November 2011. The data set consisted of 265 patients; the mean age was 86.8 ± 6.7 years, and 80 % were female. The mean follow-up after the index fracture was 789 days, with a range from 1 to 1842 days. Basic clinical and demographic data were collected at hospital admission. Functional status and mobility were assessed during follow-up at 3, 6, and 12 months. Additional outcome data regarding readmissions for new fractures were obtained from the hospital information database; mortality was crosschecked with the death registry from the governmental institute of epidemiology. Results: 187 (70.6 %) patients died during the follow-up period, with 78 patients (29.4 %) dying in the first year. The mean life expectancy after the index fracture was 527 (±431) days. Differences in mortality rates between hip and non-hip fracture patients were not statistically significant. Compared to reported mortality rates in the literature, hip fracture patients in this orthogeriatric-comanaged cohort had a significantly reduced one-year mortality [OR of 0.57 (95 % CI 0.31-0.85)]. After adjustment for confounders, only older age (OR 1.091; p = 0.013; CI 1.019-1.169) and a lower Parker Mobility Scale (PMS) (OR 0.737; p = 0.022; CI 0.568-0.957) remained as independent predictors. During follow-up, 62 patients (23.4 %) sustained at least one subsequent fracture, and 10 patients (3.4 %) experienced multiple fractures; 29 patients (10.9 %) experienced an additional fracture within the first year. Nearly, half (47.1 %) regained their pre-fracture mobility based on the PMS. Conclusion: Despite the generally poor outcomes for fragility fracture patients residing in long-term care facilities, orthogeriatric co-management appears to improve the outcome of high-risk fragility fracture patients. One-year mortality was 29.4 % in this cohort, significantly lower than in comparable trials. Orthogeriatric co-management may also have positive impacts on both functional outcome and the risk of subsequent fractures. [ABSTRACT FROM AUTHOR]

Objective: Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups. Methods: Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes. Results: Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means. Conclusion: Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI. [ABSTRACT FROM AUTHOR]

Objective: A review of the literature yielded little information regarding factors associated with the decision to use ground (GEMS) or helicopter (HEMS) emergency medical services for trauma patients transferred inter-facility. Furthermore, studies evaluating the impact of inter-facility transport mode on mortality have reported mixed findings. Since HEMS transport is generally reserved for more severely injured patients, this introduces indication bias, which may explain the mixed findings. Our objective was to identify factors at referring non-tertiary trauma centers (NTC) influencing transport mode decision. Methods: This was a case-control study of trauma patients transferred from a Level III or IV NTC to a tertiary trauma center (TTC) within 24-hours reported to the Oklahoma State Trauma Registry between 2005 and 2012. Multivariable logistic regression was used to determine clinical and non-clinical factors associated with the decision to use HEMS. Results: A total of 7380 patients met the study eligibility. Of these, 2803(38%) were transported inter-facility by HEMS. Penetrating injury, prehospital EMS transport, severe torso injury, hypovolemic shock, and TBI were significant predictors (p<0.05) of HEMS use regardless of distance to a TTC. Association between HEMS use and male gender, Level IV NTC, and local ground EMS resources varied by distance from the TTC. Many HEMS transported patients had minor injuries and normal vital signs. Conclusions: Our results suggest that while distance remains the most influential factor associated with HEMS use, significant differences exist in clinical and non-clinical factors between patients transported by HEMS versus GEMS. To ensure comparability of study groups, studies evaluating outcome differences between HEMS and GEMS should take factors determining transport mode into account. The findings will be used to develop propensity scores to balance baseline risk between GEMS and HEMS patients for use in subsequent studies of outcomes. [ABSTRACT FROM AUTHOR]

Objective. The aim of the present study was to estimate the cost-effectiveness of trauma service funding enhancements at an inner city major trauma centre. Methods. The present study was a cost-effectiveness analysis using retrospective trauma registry data of all major trauma patients (injury severity score >15) presenting after road trauma between 2001 and 2012. The primary outcome was cost per life year gained associated with the intervention period (2007-12) compared with the pre-intervention period (2001-06). Incremental costs were represented by all trauma-related funding enhancements undertaken between 2007 and 2010. Risk adjustment for years of life lost was conducted using zero-inflated negative binomial regression modelling. All costs were expressed in 2012 Australian dollar values. Results. In all, 876 patients were identified during the study period. The incremental cost of trauma enhancements between 2007 and 2012 totalled $7.91 million, of which $2.86 million (36%) was attributable to road trauma patients. After adjustment for important covariates, the odds of in-hospital mortality reduced by around half (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.27, 0.82; P = 0.01). The incremental cost-effectiveness ratio was A$7600 per life year gained (95% CI A$5524, $19 333). Conclusion. Trauma service funding enhancements that enabled a quality improvement program at a single major trauma centre were found to be cost-effective based on current international and Australian standards. [ABSTRACT FROM AUTHOR]

Objectives Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes. Methods This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [ MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering. Results There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non- MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters. Conclusions Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence. [ABSTRACT FROM AUTHOR]

Objective The objective of this present study was to describe the initial destination hospital of paediatric patients transported by Ambulance Victoria paramedics within the South Western area of Victoria to determine the proportion of patients that bypassed their closest hospital. Methods All Ambulance Victoria primary ambulance transports for paediatric patients aged 1 month to 14 years in the Barwon South West region between 1 April 2008 and 28 February 2011 were reviewed. Each case was examined to determine the destination hospital location relative to the case scene location, and the overall nature of each case was grouped into one of seven categories (medical respiratory, medical cardiac, medical neurological, medical other, trauma time critical, and trauma non-time critical). Results There were 1191 cases identified, with 978 (82%) being taken to the closest hospital and 213 (18%) to a more distant facility. The average distance travelled from the scene to the destination hospital was 15.2 km, and almost 90% of patients transported to the nearest hospital were within 15 km of that hospital. Time critical trauma cases and respiratory-related medical cases had higher rates of transport to more distant hospitals as their initial destination (26% to non-closest and 23% to non-closest, respectively). Conclusion The patient's condition and their location relative to the larger medical facilities appear to influence the decision of destination hospital. Uncertainty regarding the availability of 24 h hospital services and staffing details may contribute to longer transfers. [ABSTRACT FROM AUTHOR]

Objectives: After rural injury, evaluation at local hospitals with transfer to regional trauma centres may delay definitive care. This study sought to determine the impact of such delays on outcomes in patients with TBI within a mature regional trauma system. Methods: The ETMC Level 1 Trauma registry was queried from 2008–2013 for patients with blunt TBI, aged ≥ 18 and admitted ≤ 24 hours from injury and stratified them as ‘transfer’ vs ‘direct’ admission. Demographics, transfer distance, transfer times and outcomes were compared using Chi-square,t-test and multivariable logistic regression;p< 0.05 was significant. Results: During the study period, 1845 patients met inclusion criteria: 947 ‘direct’ and 898 ‘transfers’. For transfers, median distance was 60.1 miles; mean time to initial care was 1.2 ± 2.7 hours and time to Level 1 care was 5.0 ± 2.4 hours. Transfer patients were older (56 vs 49 years;p< 0.01) and had more comorbidities, but had lower mean ISS (15.9 vs 18.8;p< 0.01) and lower mortality (7.0 vs 10.3%;p< 0.03), complications and LOS. Neurosurgical intervention was comparable (p= 0.88), as was mortality for patients with ISS ≥ 15 (12.4% vs 14.8%;p= 0.28). After regression analysis, advanced age and increasing ISS, not distance or time, predicted mortality. Conclusion: Neither transfer distance nor time independently contributed to mortality for TBI after rural injury. An established regional trauma system, with initial local stabilization using ATLS principles, may help reduce negative outcomes for injured patients in rural settings. [ABSTRACT FROM PUBLISHER]

Background: The regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status. Methods: We queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared. Results: 5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06). Conclusions: These data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated. [ABSTRACT FROM AUTHOR]

Research on field triage of injured patients is limited by the lack of a widely used criterion standard for defining trauma center need. Injury Severity Score (ISS) >15 has been a commonly used outcome measure in research for determining trauma center need that has never been validated. A multidisciplinary team recently published a consensus-based criterion standard definition of trauma center need, but this measure has not yet been validated. The objective was to determine if the consensus-based criterion standard can be obtained by medical record review and compare patients identified as needing a trauma center by the consensus-based criterion standard vs. ISS >15. A subanalysis of data collected during a 2-year prospective cohort study of 4,528 adult trauma patients transported by EMS to a single trauma center was conducted. These data included ICD-9-CM codes, treatment times, and other patient care data. Presence of the consensus-based criterion standard was determined for each patient. ISS was calculated based on ICD-9-CM codes assigned for billing. The consensus-based criterion standard could be applied to 4,471 (98.7%) cases. ISS could be determined for 4,506 (99.5%) cases. Based on an ISS >15, 8.9% of cases were identified as needing a trauma center. Of those, only 48.2% met the consensus-based criterion standard. Almost all patients that did not meet the consensus-based criterion standard, but had an ISS >15 were diagnosed with chest (rib fractures (100/205 cases)/pneumothorax (57/205 cases), closed head (without surgical intervention 88/205 cases), vertebral (without spinal cord injury 45/205 cases), and/or extremity injuries (39/205 cases). There were 4,053 cases with an ISS <15. 5.0% of those with an ISS <15 met the consensus-based criterion standard with the majority requiring surgery (139/203 cases) or a blood transfusion (60/203 cases). The kappa coefficient of agreement for ISS and the consensus-based criterion standard was 0.43. We determined that the consensus-based criterion standard could be identified through a medical record review. Use of the consensus-based criterion standard for field triage research will more accurately identify injured patients who need the resources of a trauma center when compared to ISS. [ABSTRACT FROM PUBLISHER]

Introduction: Trauma systems were developed to improve the care for the injured. The designation and elements comprising these systems vary across countries. In this study, we have compared the demographic patterns and patient outcomes of Level I trauma centers in three international trauma systems. Methods: International multicenter prospective trauma registry-based study, performed in the University Medical Center Utrecht (UMCU), Utrecht, the Netherlands, John Hunter Hospital (JHH), Newcastle, Australia, and Harborview Medical Center (HMC), Seattle, the United States. Inclusion: patients ≥18 years, admitted in 2012, registered in the institutional trauma registry. Results: In UMCU, JHH, and HMC, respectively, 955, 1146, and 4049 patients met the inclusion criteria of which 300, 412, and 1375 patients with Injury Severity Score (ISS) > 15. Mean ISS was higher in JHH (13.5; p < 0.001) and HMC (13.4; p < 0.001) compared to UMCU (11.7). Unadjusted mortality: UMCU = 6.5 %, JHH = 3.6 %, and HMC = 4.8 %. Adjusted odds of death: JHH = 0.498 [95 % confidence interval (CI) 0.303-0.818] and HMC = 0.473 (95 % CI 0.325-0.690) compared to UMCU. HMC compared to JHH was 1.002 (95 % CI 0.664-1.514). Odds of death patients ISS > 15: JHH = 0.507 (95 % CI 0.300-0.857) and HMC = 0.451 (95 % CI 0.297-0.683) compared to UMCU. HMC = 0.931 (95 % CI 0.608-1.425) compared to JHH. TRISS analysis: UMCU: Ws = 0.787, Z = 1.31, M = 0.87; JHH, Ws = 3.583, Z = 6.7, M = 0.89; HMC, Ws = 3.902, Z = 14.6, M = 0.84. Conclusion: This study demonstrated substantial differences across centers in patient characteristics and mortality, mainly of neurological cause. Future research must investigate whether the outcome differences remain with nonfatal and long-term outcomes. Furthermore, we must focus on the development of a more valid method to compare systems. [ABSTRACT FROM AUTHOR]

Background The issue of patient volume related to trauma outcomes is still under debate. This study aimed to investigate the relationship between number of severely injured patients treated and mortality in German trauma hospitals. Methods This was a retrospective analysis of the TraumaRegister DGU® (2009-2013). The inclusion criteria were patients in Germany with a severe trauma injury (defined as Injury Severity Score ( ISS) of at least 16), and with data available for calculation of Revised Injury Severity Classification ( RISC) II score. Patients transferred early were excluded. Outcome analysis (observed versus expected mortality obtained by RISC-II score) was performed by logistic regression. Results A total of 39 289 patients were included. Mean(s.d.) age was 49·9(21·8) years, 27 824 (71·3 per cent) were male, mean(s.d.) ISS was 27·2(11·6) and 10 826 (29·2 per cent) had a Glasgow Coma Scale score below 8. Of 587 hospitals, 98 were level I, 235 level II and 254 level III trauma centres. There was no significant difference between observed and expected mortality in volume subgroups with 40-59, 60-79 or 80-99 patients treated per year. In the subgroups with 1-19 and 20-39 patients per year, the observed mortality was significantly greater than the predicted mortality ( P < 0·050). High-volume hospitals had an absolute difference between observed and predicted mortality, suggesting a survival benefit of about 1 per cent compared with low-volume hospitals. Adjusted logistic regression analysis (including hospital level) identified patient volume as an independent positive predictor of survival (odds ratio 1·001 per patient per year; P = 0·038). Conclusion The hospital volume of severely injured patients was identified as an independent predictor of survival. A clear cut-off value for volume could not be established, but at least 40 patients per year per hospital appeared beneficial for survival. [ABSTRACT FROM AUTHOR]

Objective. We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. Methods. We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. Results. We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. Conclusions. Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists. Methods: We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05. Results: A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term ( p = 0.02) and a regression coefficient of −0.006 for the quadratic term ( p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline. Conclusions: The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death. [ABSTRACT FROM AUTHOR]

Background: National trauma registries have helped improve patient outcomes across the world. Recently, the idea of an International Trauma Data Bank (ITDB) has been suggested to establish global comparative assessments of trauma outcomes. The objective of this study was to determine whether global trauma data could be combined to perform international outcomes benchmarking. Methods: We used observed/expected (O/E) mortality ratios to compare two trauma centers [European high-income country (HIC) and Asian lower-middle income country (LMIC)] with centers in the North American National Trauma Data Bank (NTDB). Patients (≥16 years) with blunt/penetrating injuries were included. Multivariable logistic regression, adjusting for known predictors of trauma mortality, was performed. Estimates were used to predict the expected deaths at each center and to calculate O/E mortality ratios for benchmarking. Results: A total of 375,433 patients from 301 centers were included from the NTDB (2002-2010). The LMIC trauma center had 806 patients (2002-2010), whereas the HIC reported 1,003 patients (2002-2004). The most important known predictors of trauma mortality were adequately recorded in all datasets. Mortality benchmarking revealed that the HIC center performed similarly to the NTDB centers [O/E = 1.11 (95 % confidence interval (CI) 0.92-1.35)], whereas the LMIC center showed significantly worse survival [O/E = 1.52 (1.23-1.88)]. Subset analyses of patients with blunt or penetrating injury showed similar results. Conclusions: Using only a few key covariates, aggregated global trauma data can be used to adequately perform international trauma center benchmarking. The creation of the ITDB is feasible and recommended as it may be a pivotal step towards improving global trauma outcomes. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Care in a trauma centre is associated with significant reductions in mortality after severe injury. However, emerging evidence suggests that outcomes across similarly accredited trauma centres are not equivalent, even after adjusting for case-mix. The primary objective of this analysis was to evaluate secular trends in overall mortality at trauma centres. Secondarily, we explored trauma centre-specific mortality to determine the extent of variation between centres. Methods: Data on 26 421 adults (= 18 yr) admitted to a trauma centre between 2005 and 2011 were derived from the Ontario Trauma Registry. We used generalized estimating equations to calculate in-hospital mortality over time and hierarchical models to estimate trauma centre-specific mortality. To quantify variability between centres, we calculated median odds ratios. Adjusted odds of death were calculated for each trauma centre to identify those with higher than expected, average and lower than expected mortality. Results: Overall mortality at trauma centres decreased from 13.2% in 2005 to 11.2% in 2009. After adjusting for case mix, the odds of death decreased by approximately 3% a year (95% confidence interval 0%-5%). Trauma centre--specific mortality ranged from 11.4% to 13.1%. After adjusting for case mix, differences in trauma centre--specific mortality were observed (median odds ratio = 1.25), suggesting that the odds of dying could be 1.25-fold greater if the same patient was admitted to 1 randomly selected trauma centre as opposed to another. Differences were most pronounced for patients with isolated head injuries and among older patients as evidenced by higher median odds ratios and the number of outliers. Interpretation: We observed a significant improvement over time in the mortality of severely injured patients cared for at Ontario's trauma centres. However, considerable differences in trauma centre--specific mortality were observed. Differences were most pronounced among older injured patients and those with isolated traumatic brain injury. System-wide performance improvement initiatives should target these subgroups. [ABSTRACT FROM AUTHOR]

Purpose: To derive and internally validate a clinical prediction rule for trauma triage. Methods: Ambulance presentations requiring trauma team activation between 2007 and 2011 at a single inner city major trauma centre were analysed. The primary outcome was major trauma, defined as Injury Severity Score >15, intensive care unit admission or in-hospital death. Demographic details, vital signs on arrival at hospital, mechanism of injury and injured body regions were used in the modelling process. Multivariable logistic regression was used on a randomly selected derivation sample. Receiver operating characteristic (ROC) analysis and Hosmer-Lemeshow tests were used to assess the discrimination and calibration of the derived model. The model was further tested using bootstrapping cross-validation. Results: A total of 3027 patients were identified. Predictors selected for the prediction model were age ≥65 years (OR 1.58, 95 %CI 1.08-2.32, p = 0.02), abnormal vital signs (OR 3.72, 95 %CI 2.64-5.25), Glasgow Coma Scale score ≤13 (OR 14, 95 %CI 9.23-23.34 p < 0.001), penetrating injury (OR 5.13, 95 %CI 2.76-9.54, p < 0.001), multiregion injury (OR 4.72 95 %CI 3.45-6.46, p < 0.001), falls (OR 1.51 95 %CI 1.06-2.15, p = 0.02) and motor vehicle crashes (OR 0.56, 95 %CI 0.35-0.90, p = 0.02). The ROC area under the curve (AUC) for the final model was 0.85 (95 %CI 0.83-0.87) with a Hosmer-Lemeshow test statistic p = 0.83. Bootstrapping cross-validation demonstrated an identical AUC. Conclusion: We have derived and internally validated a trauma risk prediction rule using trauma registry data. This may assist with the formulation of revised local and regional trauma triage protocols. External validation is required before implementation. [ABSTRACT FROM AUTHOR]

Aims and objectives To systematically review the relationship of trauma centre characteristics and trauma patient outcomes. Background Numerous studies have documented the impact of trauma centre level, trauma centre verification, volume per centre and per surgeon or resource availability on outcomes among trauma patients. However, there continues to be debated about whether trauma care is comparable by these trauma centre characteristics. Design Systematic review. Methods Eligible studies were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 14 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined criteria. Results A total of 50 studies which met criteria were selected. Ten of 17 articles showed that level I trauma centres had better patient outcomes than level II centres. The achievement of trauma centre verification by American College of Surgeons or State was beneficial to decreasing mortality and length of stay in 9 of 11 studies. High trauma admission volume was beneficial in 8 of 16 studies. The volume per trauma surgeon did not contribute to better patient outcomes in 4 of 5 studies. The availability of in-house trauma surgeon was beneficial to lower mortality and shorter length of stay in only 2 of 9 studies. Conclusion This review supports that achieving the trauma centre verification by American College of Surgeons or State is definitely beneficial to patient outcomes. However, the benefit of level I centres compared with level II centres, and volume of annual trauma patients to outcomes is still debating. Further prospective study examining this relationship is required. Relevance to clinical practice Understanding which characteristics of trauma centre provides the best prospect for improved outcomes depending on patient need and resource availability would allow further appreciation of the processes that foster such enhancement. [ABSTRACT FROM AUTHOR]

Background Severe paediatric trauma is rare, and pre-hospital and local hospital personnel experience with injured children is often limited. We hypothesised that a higher proportion of paediatric trauma victims were taken to the regional trauma centre ( TC). Methods This is an observational follow-up study that involves one level I TC and seven local hospitals. We included paediatric (< 16 years) and adult (≥ 16-≤ 79 years) trauma patients with a driving distance to the TC > 30 minutes. The primary end-point was the proportion of trauma patients arriving in the TC. Results We included 1934 trauma patients, 238 children and 1696 adults. A total of 33/238 children (13.9%) vs. 304/1696 adults (17.9%) were transported to the TC post-injury ( P = 0.14). Among these, children were significantly less injured than adults [median Injury Severity Score ( ISS) 9 vs. 14, P < 0.01]. There was no significant difference between the groups in the proportion of seriously injured trauma victims ( ISS > 15) taken to the TC [8/11 (72.7%) vs. 139/182 (76.4%)]. The corresponding figures for ISS < 15 were 25/227 (11.0%) and 164/1509 (10.9%), respectively. No significant difference was found in intensive care unit length of stay or time to TC arrival. No paediatric vs. 36/1671 (2.2%) adult deaths were observed at 30-day follow-up ( P = 0.03). Conclusions There was no difference in the proportion of paediatric and adult trauma patients transported to the TC, neither overall nor among severely injured patients. Paediatric trauma patients admitted to the TC were, however, significantly less injured than adults. [ABSTRACT FROM AUTHOR]

Objective: We compared the survival of trauma patients in urban versus rural settings after the implementation of a novel rural non-trauma center alternative care model called the Model Rural Trauma Project (MRTP). Materials and Methods: We conducted an observational cohort study of all trauma patients brought to eight rural northern California hospitals and two southern California urban trauma centers over a one-year period (1995-1996). Trauma patients with an injury severity score (ISS) of >10 were included in the study. We used logistic regression to assess disparities in odds of survival while controlling for Trauma and Injury Severity Score (TRISS) parameters. Results: A total of 1,122 trauma patients met criteria for this study, with 336 (30%) from the rural setting. The urban population was more seriously injured with a higher median ISS (17 urban and 14 rural) and a lower Glasgow Coma Scale (GCS) (GCS 14 urban and 15 rural). Patients in urban trauma centers were more likely to suffer penetrating trauma (25% urban versus 9% rural). After correcting for differences in patient population, the mortality associated with being treated in a rural hospital (OR 0.73; 95% CI 0.39 to 1.39) was not significantly different than an urban trauma center. Conclusion: This study demonstrates that rural and urban trauma patients are inherently different. The rural system utilized in this study, with low volume and high blunt trauma rates, can effectively care for its population of trauma patients with an enhanced, committed trauma system, which allows for expeditious movement of patients toward definitive care. [ABSTRACT FROM AUTHOR]

Background. Recent interest has focused on reorganizing emergency medical services (EMS) for traumatic brain injury (TBI) patients, with bypass of nonspecialist hospitals and direct transportation to distant neuroscience centers. Although this could expedite neurosurgery and neurocritical care, deteriorating physiology could be deleterious. Methods. We performed a multicenter cohort study examining adult patients with significant TBI enrolled in the English National Trauma Registry. The distributions and correlation of first recorded prehospital and emergency department (ED) vital signs were compared, and the effect of time on changes in vital signs was examined in bivariate and multivariate analyses. Results. A total of 7149 eligible patients were studied. No clinically significant differences were apparent between distributions of prehospital and ED vital signs. Moderate linear correlation was observed for field and ED pulse rate ( r2 = 0.34) and GCS values (Spearman's rho = 0.76), with weak correlation apparent for systolic blood pressure ( r2 = 0.28) and respiratory rate ( r2 = 0.28). Eight percent of cases' vital signs deteriorated in the prehospital interval; however , odds of deterioration in vital sign status did not vary significantly with duration of EMS interval. Conclusion. The similarity between prehospital and ED vital signs, and lack of association between EMS interval and physiological deterioration, may support a strategy of direct transportation of TBI cases to specialist centers. Further research is necessary to identify patients at risk from deterioration during bypass and to investigate effects on mortality. [ABSTRACT FROM AUTHOR]

Background: Delayed admission to appropriate care has been shown increase mortality following traumatic brain injury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in a cohort of TBI patients in the intensive care unit (ICU). Methods: A retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was carried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed admission. Patients in the delayed admission group were initially transported to a local hospital without neurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized to identify pre-hospital factors associated with delayed admission. Results: Of 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed admission groups (median time to admission 1:07h, IQR 0:52-1:28 vs. 4:06h, IQR 2:53-5:43, p <0.001). In multivariate analysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13), incident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital physician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial injury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38). A significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion when admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was noted between the groups (p= 0.814). Conclusion: Delayed trauma center admission following TBI is common. Factors increasing likelihood of this were: male gender, incident at public place compared to home, low energy trauma, absence of pre-hospital physician involvement, stable blood pressure, no major extra cranial injuries, normal pupillary light reflex and severe alcohol intoxication. Focused educational efforts and access to physician consultation may help expedite access to appropriate care in TBI patients. [ABSTRACT FROM AUTHOR]

Objectives. We examined whether urban patients who suffered gunshot wounds (GSWs) farther from a trauma center would have longer transport times and higher mortality. Methods. We used the Illinois State Trauma Registry (1999-2009). Scene address data for Chicago-area GSWs was geocoded to calculate distance to the nearest trauma center and compare prehospital transport times. We used multivariate regression to calculate the effect on mortality of being shot more than 5 miles from a trauma center. Results. Of 11 744 GSW patients during the study period, 4782 were shot more than 5 miles from a trauma center. Mean transport time and unadjusted mortality were higher for these patients (P < .001 for both). In a multivariate model, suffering a GSW more than 5 miles from a trauma center was associated with an increased risk of death (odds ratio = 1.23; 95% confidence interval = 1.02, 1.47; P = .03). Conclusions. Relative "trauma deserts" with decreased access to immediate care were found in certain areas of Chicago and adversely affected mortality from GSWs. These results may inform decisions about trauma systems planning and funding. [ABSTRACT FROM AUTHOR]

Introduction This study aims to compare the trauma system before and after implementing a physician-staffed helicopter emergency medical service ( PS-HEMS). Our hypothesis was that PS-HEMS would reduce time from injury to definitive care for severely injured patients. Methods This was a prospective, controlled, observational study, involving seven local hospitals and one level I trauma centre using a before and after design. All patients treated by a trauma team within a 5-month period (1 December 2009-30 April 2010) prior to and a 12-month period (1 May 2010-30 April 2011) after implementing a PS-HEMS were included. We compared time from dispatch of the first ground ambulance to arrival in the trauma centre for patients with Injury Severity Score ( ISS) > 15. Secondary end points were the proportion of secondary transfers and 30-day mortality. Results We included 1788 patients, of which 204 had an ISS > 15. The PS-HEMS transported 44 severely injured directly to the trauma centre resulting in a reduction of secondary transfers from 50% before to 34% after implementation ( P = 0.04). Median delay for definitive care for severely injured patients was 218 min before and 90 min after implementation ( P < 0.01). The 30-day mortality was reduced from 29% (16/56) before to 14% (21/147) after PS-HEMS ( P = 0.02). Logistic regression showed PS-HEMS had an odds ratio ( OR) for survival of 6.9 compared with ground transport. Conclusions Implementation of a PS-HEMS was associated with significant reduction in time to the trauma centre for severely injured patients. We also observed significantly reduced proportions of secondary transfers and 30-day mortality. [ABSTRACT FROM AUTHOR]

Damage control resuscitation ( DCR) is emerging as a standard practice in civilian and military trauma care. Primary objectives include resolution of immediate life threats followed by optimization of physiological status in the perioperative period. To accomplish this, DCR employs a unique hypotensive-hemostatic resuscitation strategy that avoids traditional crystalloid intravenous fluids in favor of early blood component use in ratios mimicking whole blood. The presence of uncontrolled major hemorrhage ( UMH) coupled with a delay in access to hemostatic surgical intervention remains a primary contributor to preventable death in both combat and in many domestic settings, including rural areas and disaster sites. As a result, civilian and military emergency care leaders throughout the world have sought a means to project DCR principles forward of the traditional trauma resuscitation bay, into such remote environments as disaster scenes, rural health facilities, and the contemporary battlefield. After reflecting on experiences from past conflicts, defining current capability gaps, and examining available and potential solutions, a strategy for 'remote damage control resuscitation' ( RDCR) has been proposed. In order for RDCR to progress from concept to clinical strategy, it will be necessary to define existing gaps in knowledge and clinical capability; develop a lexicon so that investigators and operators may understand each other; establish coherent research and development agendas; and execute comprehensive investigations designed to predict, diagnose, and mitigate the consequences of hemorrhagic shock and acute traumatic coagulopathy before they become irreversible. This article seeks to introduce the concept of RDCR; to reinforce the importance of identifying and optimally managing UMH and the resulting shock state as part of a comprehensive approach to out-of-hospital stabilization and en route care; and to propose investigational strategies to enable the development and broad implementation of RDCR principles. [ABSTRACT FROM AUTHOR]

Background: Achieving definitive care within the "Golden Hour" by minimizing response times is a consistent goal of regional trauma systems. This study hypothesizes that in urban Level I Trauma Centers, shorter pre-hospital times would predict outcomes in penetrating thoracic injuries. Materials and Methods: A retrospective cohort study was performed using a statewide trauma registry for the years 1999-2003. Total pre-hospital times were measured for urban victims of penetrating thoracic trauma. Crude and adjusted mortality rates were compared by pre-hospital time using STATA statistical software. Results: During the study period, 908 patients presented to the hospital after penetrating thoracic trauma, with 79% surviving. Patients with higher injury severity scores (ISS) were transported more quickly. Injury severity scores (ISS) ≥16 and emergency department (ED) hypotension (systolic blood pressure, SBP <90) strongly predicted mortality (P < 0.05 for each). In a logistic regression model including age, race, and ISS, longer transport times for hypotensive patients were associated with higher mortality rates (all P values <0.05). This was seen most significantly when comparing patient transport times 0-15 min and 46-60 min (P < 0.001). Conclusion: In victims of penetrating thoracic trauma, more severely injured patients arrive at urban trauma centers sooner. Mortality is strongly predicted by injury severity, although shorter pre-hospital times are associated with improved survival. These results suggest that careful planning to optimize transport time-encompassing hospital capacity and existing resources, traffic patterns, and trauma incident densities may be beneficial in areas with a high burden of penetrating trauma. [ABSTRACT FROM AUTHOR]

Objectives. We estimated associations between payer status, race/ethnicity, and acceptance of nontargeted opt-out rapid HIV screening in the emergency department (ED). Methods. We analyzed data from a prospective clinical trial between 2007 and 2009 at Denver Health. Patients in the ED were offered free HIV testing. Patient demographics and payer status were collected, and we used multivariable logistic regression to estimate associations with HIV testing acceptance. Results. A total of 31 525 patients made 44 765 unique visits: 40% were White, 37% Hispanic, 14% Black, 1% Asian, and 7% unknown race/ethnicity. Of all visits, 10 237 (23%) agreed to HIV testing; 27% were self-pay, 23% state-sponsored, 18% Medicaid, 13% commercial insurance, 12% Medicare, and 8% another payer source. Compared with commercial insurance patients, self-pay patients (odds ratio [OR] = 1.63; 95% confidence interval [CI] = 1.51, 1.75), state-sponsored patients (OR = 1.64; 95% CI = 1.52, 1.77), and Medicaid patients (OR = 1.24; 95% CI = 1.14, 1.34) had increased odds of accepting testing. Compared with White patients, Black (OR = 1.29; 95% CI = 1.21, 1.38) and Hispanic (OR = 1.17; 95% CI = 1.11, 1.23) patients had increased odds of accepting testing. Conclusions. Many ED patients are uninsured or subsidized through government programs and are more likely to consent to free rapid HIV testing. [ABSTRACT FROM AUTHOR]