No abstract

No abstract

BackgroundEffective triage of injured patients is often a balancing act for trauma systems. As healthcare reimbursements continue to decline, 1 innovative programs to effectively use hospital resources are essential in maintaining a viable trauma system. The objective of this pilot intervention was to evaluate a new triage model using ‘trauma resource’ (TR) as a new category in our existing Tiered Trauma Team Activation (TA) approach with hopes of decreasing charges without adversely affecting patient outcome.MethodsPatients at one Level II Trauma Center (TC) over seven months were studied. Patients not meeting American College of Surgeons criteria for TA were assigned as TR and transported to a designated TC for expedited emergency department (ED) evaluation. Such patients were immediately assessed by a trauma nurse, ED nurse, and board-certified ED physician. Diagnostic studies were ordered, and the trauma surgeon (TS) was consulted as needed. Demographics, injury mechanism, time to physician evaluation, time to CT scan, time to disposition, hospital length of stay (LOS), and in-hospital mortality were analyzed.ResultsFifty-two of the 318 TR patients were admitted by the TS and were similar to TA patients (N=684) with regard to gender, mean Injury Severity Score, mean LOS and in-hospital mortality, but were older (60.4 vs 47.2 years, p<0.0001) and often involved in a fall injury (52% vs 35%, p=0.0170). TR patients had increased door to physician evaluation times (11.5 vs 0.4 minutes, p<0.0001) and increased door to CT times (76.2 vs 25.9 minutes, p<0.0001). Of the 313 TR patients, 52 incurred charges totaling US$253 708 compared with US$1 041 612 if patients had been classified as TA.ConclusionsDesignating patients as TR prehospital with expedited evaluation by an ED physician and early TS consultation resulted in reduced use of resources and lower hospital charges without increase in LOS, time to disposition or in-hospital mortality.Level of evidenceLevel II

BackgroundThe Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI) include intracranial pressure monitoring (ICPM), yet very little is known about ICPM in older adults. Our objectives were to characterize the utilization of ICPM in older adults and identify factors associated with ICPM in those who met the BTF guidelines.MethodsWe analyzed data from the American Association for the Surgery of Trauma Geriatric TBI Study, a registry study conducted among individuals with isolated, CT-confirmed TBI across 45 trauma centers. The analysis was restricted to those aged ≥60. Independent factors associated with ICPM for those who did and did not meet the BTF guidelines were identified using logistic regression.ResultsOur sample was composed of 2303 patients, of whom 66 (2.9%) underwent ICPM. Relative to Glasgow Coma Scale (GCS) score of 13 to 15, GCS score of 9 to 12 (OR 10.2; 95% CI 4.3 to 24.4) and GCS score of <9 (OR 15.0; 95% CI 7.2 to 31.1), intraventricular hemorrhage (OR 2.4; 95% CI 1.2 to 4.83), skull fractures (OR 3.6; 95% CI 2.0 to 6.6), CT worsening (OR 3.3; 95% CI 1.8 to 5.9), and neurosurgical interventions (OR 3.8; 95% CI 2.1 to 7.0) were significantly associated with ICPM. Restricting to those who met the BTF guidelines, only 43 of 240 (18%) underwent ICPM. Factors independently associated with ICPM included intraparenchymal hemorrhage (OR 2.2; 95% CI 1.0 to 4.7), skull fractures (OR 3.9; 95% CI 1.9 to 8.2), and neurosurgical interventions (OR 3.5; 95% CI 1.7 to 7.2).DiscussionWorsening GCS, intraparenchymal/intraventricular hemorrhage, and skull fractures were associated with ICPM among older adults with TBI, yet utilization of ICPM remains low, especially among those meeting the BTF guidelines, and potential benefits remain unclear. This study highlights the need for better understanding of factors that influence compliance with BTF guidelines and the risks versus benefits of ICPM in this population.Level of evidencePrognostic and epidemiological, level III.

Background Unintentional falls from heights, including balconies, result in life threatening traumatic injury. Alcohol, when combined with environmental factors and poor judgement, can potentially lead to fatal outcomes. One trauma center’s registry identified a group of young adults falling from balconies and we investigated the role of alcohol. Methods Hospital trauma service admissions from 2010 through 2017 were reviewed for unintentional falls from heights. Suicide attempts and unintentional falls off ladders or roofs were excluded. Data were obtained from trauma registry and medical record review, as well as social work service interviews. Results Falls from heights comprised 4.8% of injuries treated at our trauma center during the eight-year study period with 98.5% admitted. Of patients admitted because of falls, 10.3% (55/532) were from a balcony. The majority of this group of patients was male and 19–29 years old (67%). Of patients with a blood alcohol concentration (BAC) determination, 62% had a positive BAC upon hospital admission with an average of 0.20 g/dL among those 34 patients. No gender differences were evident for alcohol use. Seven of the eight patients under the legal drinking age of 21 years were a subgroup with high alcohol use as compared with patients 21 years and older ( p = 0.099). Ninety-four percent of falls occurred at residential locations such as dormitories or apartment complexes, often during a social event. Backward falls off railings and attempts to jump to adjoining balconies were common. Head, thorax/abdomen, and extremity fractures were common, with an average injury severity score (ISS) of 16. Average length of hospital stay was 8 days. Most patients (67%) were discharged home after hospital stay, but 21% were transferred to inpatient rehabilitation or skilled nursing facilities. There were two deaths. Conclusions Falls from balconies among young adults occur in our area yet the true frequency of these events remain unknown. Occurrence was most common among underage drinkers. Generalization is difficult with this small sample, yet high risk behaviors and environmental factors were evident. It is imperative that educational programs focus on this population with collaborative prevention efforts focused on the dangers of, and increased risk of injury associated with the balcony environment.