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Background: Health care spending is driven by a very small percentage of Americans, many of whom are patients with prolonged durations of stay. The objective of this study was to characterize superusers in the trauma population., Methods: The National Trauma Data Bank for 2008-2012 was queried. Superusers were defined as those with a duration of stay in the top 0.06% of the population and were compared with the remainder of the population to determine differences in demographic characteristics, comorbidities, prehospital factors, and outcomes. Multivariate analysis was used to determine independent predictors of being classified as a superuser., Results: A total of 3,617,261 patients met inclusion criteria, with 34,728 qualifying as superusers. Mean duration of stay for superusers was 58.7 days compared with the average 4.6 days (P < .001). Superusers were more likely to be male, black, Medicaid insured, and have a higher Injury Severity Score and lower Glasgow Coma Scale score. The hospital course of superusers was likely to be complicated by pneumonia, acute respiratory distress syndrome, decubitus ulcer, and acute kidney injury., Conclusion: Age, sex, race, and insurance were associated with prolonged use of inpatient care in the trauma patient population. Specific comorbidities and complications are associated with being a superuser. This subset of the trauma population confers a disproportionate burden on the health care system and can serve as a potential target for intervention., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Achieving a higher hemoglobin (Hb) level might allow the anemic, critically ill, trauma patient to have an improved outcome during rehabilitation therapy., Methods: Patients with major blunt trauma orthopedic injuries were administered epoetin alfa or placebo weekly both in hospital and for up to 12 weeks after discharge or until the Hb level was >12.0 g/dL, whichever occurred first. The 36-question Short Form Health Assessment questionnaire (SF-36) was used to evaluate physical function (PF) outcomes at baseline, at hospital discharge, and at several time points posthospital discharge., Results: One hundred ninety-two patients were enrolled (epoetin alfa [n = 97], placebo [n = 95]). Hb increased from baseline to hospital discharge in both groups (epoetin alfa: 1.2 g/dL vs placebo: 0.9 g/dL), and transfusion requirements were similar between groups. Both groups showed improvements in SF-36 PF; there were no significant differences in the average of all posthospital discharge scores (epoetin alfa: 27.3 vs placebo 30.9; P = 0.38). Thromboembolic events were similar between groups., Conclusions: No differences were observed in physical function outcomes or safety in anemic, critically ill, trauma patients treated with epoetin alfa compared with placebo., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care., Design: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members., Methods: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM., Results: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion., Conclusions: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

Background: Adequate nutritional replacement of critically ill and injured patients is of paramount importance, as it decreases infectious morbidity and mortality. However, multiple methods of determining nutritional requirements exist, including mathematical formulas, weight based calculations, and the use of metabolic cart measurements, the latter of which is associated with significant labor and equipment costs. We hypothesized that metabolic cart measurements, despite increasing the cost of care, would more accurately determine nutritional requirements in a critically ill population than formulaic or weight-based calculations., Methods: Consecutive metabolic cart measurements were prospectively obtained on 59 critically ill surgery and trauma patients, and compared with predicted values as determined by the Harris-Benedict equation and weight-based calculations. Comparison was made to actual resting energy expenditure data acquired via indirect calorimetry data obtained from serial metabolic carts., Results: There were 59 patients who formed the study population, with 37% of the population having two or more metabolic cart readings (total number of cart readings was 106). There was no statistically significant difference between the metabolic cart results, the predicted resting energy expenditure as calculated by the Harris-Benedict equation adjusted with a factor of 1.5, and a weight based calculation at 30 kcal/kg adjusted body weight. Metabolic requirements were stable over time (4-48 days) without significant variation. Nutritional parameters, as evaluated by the visceral proteins prealbumin and transferrin significantly increased with time in injured patients., Conclusions: Either 30 kcal/kg adjusted body weight or the resting energy expenditure calculated from the Harris-Benedict equation multiplied by 1.5 adequately predicts the nutritional requirements of critically ill surgery and trauma patients. The addition of metabolic cart data does not provide any additional information in the determination of caloric needs in the critically ill and injured patient. In this population, omission of metabolic cart data would have saved 33,000 dollars without adversely affecting patient outcome.

Background: A number of forces have come together to effect a perceived change in the volume and nature of transfers to Level I trauma centers recently. These may have little to do with the actual clinical need. This study seeks to verify whether a change in the profile of trauma transfers has occurred and to characterize the nature of any changes., Methods: Retrospective review of state trauma registry data from 1999 through 2003 including day and time of transfer, Injury Severity Score (ISS), primary ICD-9, payor status, and mortality. The transfer group (TTP) was compared with the general population of trauma patients (ATP) and variables trended. Analysis employed descriptive statistics and logistic regression. Average malpractice insurance premium charges and measures of subspecialty surgeon participation in trauma care were also trended., Results: During the study period ATP increased by 6% and TTP by 34%. The majority of transfers were from Level II to Level I trauma centers. Mean ISS increased from 9.1 to 10.0 (1.2%) in ATP and from 11.3 to 12.8 (2%) in TTP. The mortality rate over time was essentially unchanged for both groups; 4% ATP versus 5% TTP. Proportion of self-pay patients in each group remained relatively static between 20% to 25%. The number of patients with head injury (HI) increased by 14%, their transfer rate increased by 44%. Orthopedic injury (OI) prevalence increased 25% whereas transfers increased by 48%. Mean ISS increased from 13.7 to 14.8 and 11.1 to 12.9, respectively. The variables most significant for predicting transfer were arrival at initial emergency department between 3:00 pm and 7:00 am and OI or HI. Concomitantly, the mean malpractice insurance premium paid by general, orthopedic, and neurosurgeons each rose by approximately 90% during the study period. Waivers of regulatory compliance were requested by 28% of trauma centers (72% Level II) with 39% of requests related to lack of neurosurgery services., Conclusion: During the study period, a disproportionate increase in TTP occurred in comparison to ATP. This finding is more pronounced in patients with HI and OI. Findings do not appear attributable to changes in severity or proportion of self payors. The ISS of TTP is below 16. Concomitantly, there was a precipitous rise in malpractice premiums and a functional decrease in neurosurgeons. This suggests a multifactorial reluctance or inability of initial hospitals to care for patients they are theoretically capable of treating, placing undo burden on Level I centers.

Background: Performance of digital rectal examination (DRE) on all trauma patients during the secondary survey has been advocated by the Advanced Trauma Life Support course. However, there is no clear evidence of its efficacy as a diagnostic test for traumatic injury. The purpose of this study is to analyze the value of a policy mandating DRE on all trauma patients as part of the initial evaluation process and to discern whether it can routinely be omitted., Methods: Prospective study of patients treated at a Level I trauma center. Clinical indicators other than DRE (OCI) denoting gastrointestinal bleeding (GIB), urethral disruption (UD), or spinal cord injury (SCI) were sought and correlated with DRE findings suggesting the same. Impression of the examining physician as to the need and value of DRE was also studied. Patients with a Glasgow Coma Scale Score (GCS) of 3 and pharmacologically paralyzed were excluded from the SCI analyses. UD analysis included only males., Results: In all, 512 cases were studied (72% male, 28% female) ranging in age from 2 months to 102 years. Thirty index injuries were identified in 29 patients (6%), 17 SCI (3%), 11 GIB (2%), and 2 UD (0.4%). DRE findings agreed positively or negatively with one or more OCI of index injuries in 93% of all cases (92% seeking SCI, 90% seeking GIB, 96% seeking UD). Overall, negative predictive value of DRE was the same as that of OCI, 99% (SCI 98% versus 99%, GIB, 97% versus 99%, UD both 100%). Positive predictive value for DRE was 27% and for OCI 24% (SCI 47% versus 44%, GIB 15% versus 18%, UD 33% versus 6%). Efficiency of DRE was 94% and OCI was 93%. For confirmed index injuries, indicative DRE findings were associated with 41% and OCI 73% (SCI 36% versus 79%, GIB 36% versus 73%, UD 50% versus 100%). OCIs were present in 81% of index injury cases. In all index injury cases where OCIs were absent, positive DRE findings were also absent. DRE was felt to give additional information in 5% of all cases and change management in 4%. In cases where the clinician felt DRE was definitely indicated (29%) it reportedly gave no additional information in 85% and changed management in 11%., Conclusion: DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.

Background: The ATLS Course advocates that injured patients have a chest x-ray (CXR) to identify potential injuries. The purpose of this study was to correlate clinical indications and clinician judgment with CXR results to ascertain if a selective policy would be beneficial., Methods: Patients treated at a Level I trauma center over 12 months were prospectively evaluated. Before obtaining a CXR, signs, symptoms, and history suggestive of thoracic injury were identified. Additionally, a trauma surgeon (TS) recorded whether in their judgment a CXR was clinically indicated. These findings were compared with final CXR diagnoses. The sensitivity of individual clinical indicators, combinations of clinical indicators, and TS judgment for CXR abnormalities were calculated with a 95% confidence interval., Results: During the twelve-month study period, data were acquired on 772 patients (age 0-102 years). Seventy percent were male and 86.0% were injured by blunt force. Only 29% (N = 222) of the patients manifested one or more of the clinical indicators (signs and symptoms). The negative predictive value for the TS judgment was 98.2% which was superior to the clinical indicators. Reliance on the opinion of the TS to determine the need for a CXR would have eliminated 49.9% of CXRs and avoided hospital and radiologist reading charges totaling $100,078.22., Conclusion: Mandatory CXR for all trauma patients has a low yield for abnormal findings. A selective policy relying on surgical judgment guided by clinical indicators is safe and efficacious while reducing cost and conserving resources.

Background: Several risk factors, including emergent intubation, severe head injury, shock, blunt trauma, and high severity of injury, have been identified as risk factors for the development of pneumonia after trauma. This study assesses the contribution of emergent intubation to the development of pneumonia after injury., Methods: A retrospective review of all trauma patients requiring intubation or cricothyroidotomy in the Emergency Department (ED) or in the pre-hospital area (field) over a 41/2 year period., Results: 571 patients comprised the study population. Of these, 80% had airways established in the ED, while 20% were intubated in the field. Field intubation was associated with a lower Glasgow Coma Scale (GCS) score (p <0.0001) and more severe injury (p <0.0001), particularly to the chest and extremities.Twenty-five percent of the population developed pneumonia. Patients diagnosed with pneumonia were older (p=0.009), and had a higher ISS (p <0.0001), lower GCS score, (p <0.008), longer ICU and hospital length of stay (p < 0.0001). Injuries to the head, thorax and extremities were more common (p < 0.05) and more severe (p <0.05) in patients developing pneumonia. The incidence of pneumonia after field airway was significantly higher (35% versus 23%, p=0.048).Multiple logistic regression analysis identified field intubation, age, AIS-head, and AIS-extremity as independent risk factors for pneumonia., Conclusion: Pre-hospital but not ED intubation is an independent risk factor for the development of post-traumatic pneumonia. Other predictors include the severity of injury, specifically head and extremity injuries.