Mortality benefit of transfer to level I versus level II trauma centers for head-injured patients.
(57/488)
OBJECTIVE: To determine whether head-injured patients transferred to level I trauma centers have reduced mortality relative to transfers to level II trauma centers. DATA SOURCE/STUDY SETTING: Retrospective cohort study of 542 patients with head injury who initially presented to 1 of 31 rural trauma centers in Oregon and Washington, and were transferred from the emergency department to 1 of 15 level I or level II trauma centers, between 1991 and 1994. STUDY DESIGN: A bivariate probit, instrumental variables model was used to estimate the effect of transfer to level I versus level II trauma centers on 30-day postdischarge mortality. Independent variables included age, gender, Injury Severity Scale (ISS), other indicators of injury severity, and a dichotomous variable indicating transfer to a level I trauma center. The differential distance between the nearest level I and level II trauma centers was used as an instrument. PRINCIPAL FINDINGS: Patients transferred to level I trauma centers differ in unmeasured ways from patients transferred to level II trauma centers, biasing estimates based on standard statistical methods. Transfer to a level I trauma center reduced absolute mortality risk by 10.1% (95% confidence interval 0.3%, 22.2%) compared with transfer to level II trauma centers. CONCLUSIONS: Patients with severe head injuries transferred from rural trauma centers to level I centers are likely to have improved survival relative to transfer to level II centers. (+info)
Trends, risk factors, and prevention of falls in older adults in Wisconsin.
(58/488)
Wisconsin's death rate due to falls among adults 65 years and older is more than twice the national average. The hospitalization rate due to falls-related injuries in Wisconsin increased slightly from 1995 to 2002, with an injury rate of 2159 per 100,000 in 1995, and 2263 per 100,000 in 2002. Emergency department (ED) utilization and hospitalization rates for falls-related injury are higher for women than for men in Wisconsin. In 2002, the total statewide charges for hospitalizations and ED visits for falls-related injuries were more than $96 million. Two thirds of those admitted to the hospital for a falls-related injury were discharged to a nursing home or rehabilitation facility. Multifactorial intervention strategies have been shown to decrease the rate of falls in randomized, controlled trials. The purpose of this paper is to describe trends in falls-related injury fatalities, hospitalizations, and ED visits in Wisconsin. Also included are cost data related to falls, identification of risk factors, and descriptions of the possible role of physicians and other health care professionals in interdisciplinary, multifocal programs to prevent falls-related injuries in high-risk older adults. (+info)
Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis.
(59/488)
OBJECTIVE: To determine if brief alcohol interventions in trauma centers reduce health care costs. SUMMARY BACKGROUND DATA: Alcohol-use disorders are the leading cause of injury. Brief interventions in trauma patients reduce subsequent alcohol intake and injury recidivism but have not yet been widely implemented. METHODS: This was a cost-benefit analysis. The study population consisted of injured patients treated in an emergency department or admitted to a hospital. The analysis was restricted to direct injury-related medical costs only so that it would be most meaningful to hospitals, insurers, and government agencies responsible for health care costs. Underlying assumptions used to arrive at future benefits, including costs, injury rates, and intervention effectiveness, were derived from published nationwide databases, epidemiologic, and clinical trial data. Model parameters were examined with 1-way sensitivity analyses, and the cost-benefit ratio was calculated. Monte Carlo analysis was used to determine the strategy-selection confidence intervals. RESULTS: An estimated 27% of all injured adult patients are candidates for a brief alcohol intervention. The net cost savings of the intervention was 89 US dollars per patient screened, or 330 US dollars for each patient offered an intervention. The benefit in reduced health expenditures resulted in savings of 3.81 US dollars for every 1.00 US dollar spent on screening and intervention. This finding was robust to various assumptions regarding probability of accepting an intervention, cost of screening and intervention, and risk of injury recidivism. Monte Carlo simulations found that offering a brief intervention would save health care costs in 91.5% of simulated runs. If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach 1.82 billion US dollars annually. CONCLUSIONS: Screening and brief intervention for alcohol problems in trauma patients is cost-effective and should be routinely implemented. (+info)
The severity of injury in children resulting from acts against civilian populations.
(60/488)
OBJECTIVE: To characterize the injuries to children by acts against civilian populations (AACP). SUMMARY BACKGROUND DATA: Only 2 articles have focused on the spectrum and severity of injuries to children by AACP. METHODS: A retrospective case study of children 0 to 18 years old who were entered into the Israel National Trauma Registry as a result of AACP between September 29, 2000, and June 30, 2002. RESULTS: A total of 158 children were hospitalized for injuries caused by AACP, accounting for 1.4% of all hospitalized injured children but for 10.9% of all in-hospital deaths for trauma. Explosions injured 114 (72.2%); shootings, 34 (21.5%); and other mechanisms such as stoning or stabbing, 10 (6.3%). Older children were injured by explosions more frequently than younger children (86.1% of 15- to 18-year-olds, 73.7% of 10- to 14-year-olds, 63.2% of 0- to 9-year-olds, P = 0.02). A higher percentage of children injured by explosions rather than by shootings were severely or critically injured (33.9% versus 18.8%, P = 0.10). The most frequently injured body regions were extremities (62.8%), head/face (47.3%), chest and abdomen (37.2%), and brain (18.2%). More than 1 body region was injured in 63.0%. Children injured by explosions as compared with shootings had a lower incidence of abdominal trauma (14.9% versus 20.6%), a similar incidence of chest trauma (16.7% versus 14.7%), but a higher incidence of extremity trauma (65.8% versus 53.0%). There were 7 in-hospital deaths, 6 due to severe head injury and 1 due to severe abdominal trauma; 6 of the 7 deaths were caused by explosions, and all but 1 occurred in children 15 to 18 years old. CONCLUSIONS: AACP cause significant morbidity and mortality in children, especially adolescents. Injury severity is significantly higher among children who are injured by explosions rather than by shootings. (+info)
Alcohol intake and the pattern of trauma in young adults and working aged people admitted after trauma.
(61/488)
AIMS: To investigate the relationship of different patterns of alcohol intake to various types of trauma. METHODS: We examined the associations of alcohol consumption in a series of 385 consecutive trauma admissions (278 men, 107 women, age range 16-49 years). Patients underwent clinical examinations, structured interviews on the amount and pattern of alcohol intake, and measurements of blood alcohol concentration (BAC). RESULTS: On admission, 51% of the patients had alcohol in their blood. Binge drinking was the predominant (78%) drinking pattern of alcohol intake. Assaults, falls and biking accidents were the most frequent causes of trauma. Dependent alcohol drinking and binge drinking were found to be significantly more common among patients with head trauma than in those with other types of trauma (77% vs 59%, OR=2.38; 95% CI 1.50 to 3.77). The OR for sustaining head injury increased sharply with increasing BAC: 1-99 mg/dl (1.24; 95% CI 0.55-2.01), 100-149 mg/dl 1.64; 95% CI 0.71-3.77), 150-199 mg/dl (3.20; 95% CI 1.57-6.53) and >199 mg/dl (9.23; 95% CI 4.79-17.79). CONCLUSIONS: Binge drinking is a major risk factor for head trauma among trauma patients. Assaults, falls and biking accidents are the commonest causes for such injuries. The relative risk for head injury markedly increases with increasing blood alcohol levels. Alcohol control measures should feature in policies aiming at the prevention of trauma-related morbidity and mortality. (+info)
Transfer times to definitive care facilities are too long: a consequence of an immature trauma system.
(62/488)
OBJECTIVE: The purpose of this study was to review our experience with interfacility transfers to identify problems that could be addressed in the development of a statewide trauma system. BACKGROUND: The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. This hinges on well-defined prehospital destination criteria, interfacility transfer protocols, and education of caregivers. Patients arriving at local community hospitals (LOCs) benefit from stabilization and transfer to trauma centers (TCs) for definitive care. However, in the absence of a formalized trauma system, patients may not reach the TC in a timely fashion and may not be appropriately treated or stabilized at LOCs prior to transfer. METHODS: Our facility is a level I TC and regional referral center for a compact geographic area without a formal trauma system. The Trauma Registry was queried for adult patients admitted to the trauma service between January 1, 2001 and March 30, 2003. Patients were divided into 2 groups: those received directly from the scene (DIR) and those transferred from another institution (TRAN). Medical records were reviewed to elucidate details of the early care. Data are presented as mean +/- SEM. Continuous data were compared using Student t test, and categorical data using chi2. Transfer times were analyzed by one-way ANOVA. RESULTS: A total of 3507 patients were analyzed. The TRAN group had a higher Injury Severity Score (ISS) (17.5 versus 11.0, P < 0.05), lower Glasgow Coma Score (GCS) (13.3 versus 14.1, P < 0.05), lower initial systolic blood pressure (SBP) (130 versus 140, P< 0.05), and higher mortality (10% versus 79%, P < 0.05) than the DIR group. The average time spent at the LOC was 162 +/- 8 minutes. The subgroup of patients with hypotension spent an average of 134 minutes at the LOC, often receiving numerous diagnostic tests despite unavailability of surgeons to provide definitive care. Severe head injury (GCS = 3) triggered more prompt transfer, but high ISS was underappreciated and did not result in a prompt transfer in all but the most severely injured group (ISS > 40). Some therapeutic interventions were initiated at the LOCs, but many were required at the TC. A total of 23 (8%) TRAN patients required critical interventions within 15 minutes of arrival; mortality in this group was 52%. Mortality among those requiring laparotomy after transfer was 33%. CONCLUSIONS: All but the most severely injured patients spend prolonged periods of time in LOCs, and many require critical interventions upon arrival at the TC. It is unreasonable to expect immediate availability of surgeons or operating rooms in LOCs. Thus, trauma system planning efforts should focus on 1) prehospital destination protocols that allow direct transport to the TC; and 2) education of caregivers in LOCs to enhance intervention skill sets and expedite transfer to definitive care. (+info)
Trauma systems in Japan: history, present status and future perspectives.
(63/488)
As trauma is the leading cause of death for persons 1 to 24 years in Japan, the trauma system must be established to save lives and to reduce serious sequelae. However, the trauma system has not been evaluated since 2000. In May 2002, it revealed that the deaths of about 40% of expired trauma patients who arrived at emergency centers with some vital signs were probably preventable. This result increased the awareness of the need for establishing the trauma system. Then, the Japan Prehospital Trauma Evaluation and Care program for emergency medical technicians was developed, the doctor helicopter system was promoted, the Japan Advanced Trauma Evaluation and Care program for physicians was developed, and the trauma registry program was started. The extension of the procedures that can be performed by Japanese paramedics should be extended with the establishment of a medical control system. However, the key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients there as rapidly as possible. (+info)
Neurosurgical coverage: essential, desired, or irrelevant for good patient care and trauma center status.
(64/488)
SUMMARY AND BACKGROUND DATA: As a result of many factors, the availability of neurosurgeons (NS) to care for trauma patients (TP) is increasingly sparse. This has precipitated a crisis in access to neurosurgical support in many trauma systems, often placing undue burden on level I centers. This study examines the profile of head-injured (HI) trauma patients and their actual need for the specific expertise of a neurosurgeon. METHODS: The National Trauma Data Bank (NTDB) was queried for specific information relating to the volume, nature, timeliness, and outcome of HI TP. Study patients were identified by reported International Classification of Diseases, 9th Edition (ICD-9) codes denoting open (OHI) or closed head injury (CHI) in isolation or in combination with other injuries. RESULTS: Total number of NTDB patients studied was 731,823, of which 213,357 (29%) had a reported HI. CHI represented 22% of all TP and 74% of HI. OHI was reported in 8% of all TP and was 26% of HI. Craniotomy (crani) was performed in 3.6% of all HI (1% of all TP). This was in 2.8% of OHI and 2.6% of CHI. Mean Glasgow Coma Scale score (GCS) of crani patients was 9, and 13 for the noncrani group. Subdural hematoma occurred in 18% of HI (5% of TP), with 13% undergoing crani. Epidural hematoma occurred in 10% of HI (3% of all TP), with 17% undergoing crani. Median time to OR for all cranis was 195 minutes (195 for CHI; 183 for OHI). Of all cranis, 6.5% were performed within 1 hour of hospital admission. Intracranial pressure (ICP) monitoring was reportedly used in 0.7% of TP and 2.2% of HI. CONCLUSIONS: Care of TP with HI rarely requires the explicit expertise and immediate presence of a neurosurgeon due to volume and nature of care. HI was diagnosed in <30% of TP reported to the NTDB. Over 95% required nonoperative management alone, with only 1% of all TP and 2%-4% of HI TP requiring crani and/or ICP monitoring. Immediate availability of NS is not essential if a properly trained and credentialed trauma surgeon or other health care provider can appropriately monitor patients for neurologic demise and effect early transfer to a center capable of, and committed to, operative and postoperative neurosurgical care. A subgroup of patients known to have a high propensity for the specific expertise of a neurosurgeon may be able to be identified for direct transport to these committed centers. (+info)