Implementation of a surgical intensive care unit service is associated with improved outcomes for trauma patients

Klein, Amanda; Brown, Carlos; Aydelotte, Jayson; Ali, Sádia; Clark, A. Clay; Coopwood, Ben

doi:10.1097/ta.0000000000000460

Cited by 11 publications

(7 citation statements)

References 8 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…This study illuminates the need to ensure that SCC training continues to be inclusive of non-trauma and also non-surgical conditions, for the purpose of maintaining a versatile and capable SCC workforce and sustaining the representation of surgical specialists in the world of critical care medicine. The specialty of SCC and management of patients in TICUs are geared toward the unique needs of surgical patients, and in some studies this narrow focus has demonstrated benefit in terms of lower ventilator days,3 complications,2–4 and mortality 4 5. This is consistent with evidence showing a survival benefit for patients treated in an ICU matched to their specific needs rather than boarding in another specialty unit 19.…”

Section: Discussionsupporting

confidence: 54%

Trauma ICU Prevalence Project: the diversity of surgical critical care

Michetti

Fakhry

Brasel

et al. 2019

Trauma Surg Acute Care Open

View full text Add to dashboard Cite

BackgroundSurgical critical care is crucial to the care of trauma and surgical patients. This study was designed to provide a contemporary assessment of patient types, injuries, and conditions in intensive care units (ICU) caring for trauma patients.MethodsThis was a multicenter prevalence study of the American Association for the Surgery of Trauma; data were collected on all patients present in participating centers’ trauma ICU (TICU) on November 2, 2017 and April 10, 2018.ResultsForty-nine centers submitted data on 1416 patients. Median age was 58 years (IQR 41–70). Patient types included trauma (n=665, 46.9%), non-trauma surgical (n=536, 37.8%), medical (n=204, 14.4% overall), or unspecified (n=11). Surgical intensivists managed 73.1% of patients. Of ICU-specific diagnoses, 57% were pulmonary related. Multiple high-intensity diagnoses were represented (septic shock, 10.2%; multiple organ failure, 5.58%; adult respiratory distress syndrome, 4.38%). Hemorrhagic shock was seen in 11.6% of trauma patients and 6.55% of all patients. The most common traumatic injuries were rib fractures (41.6%), brain (38.8%), hemothorax/pneumothorax (30.8%), and facial fractures (23.7%). Forty-four percent were on mechanical ventilation, and 17.6% had a tracheostomy. One-third (33%) had an infection, and over half (54.3%) were on antibiotics. Operations were performed in 70.2%, with 23.7% having abdominal surgery. At 30 days, 5.4% were still in the ICU. Median ICU length of stay was 9 days (IQR 4–20). 30-day mortality was 11.2%.ConclusionsPatient acuity in TICUs in the USA is very high, as is the breadth of pathology and the interventions provided. Non-trauma patients constitute a significant proportion of TICU care. Further assessment of the global predictors of outcome is needed to inform the education, research, clinical practice, and staffing of surgical critical care providers.Level of evidenceIV, prospective observational study.

show abstract

Section: Discussionsupporting

confidence: 54%

Trauma ICU Prevalence Project: the diversity of surgical critical care

Michetti

Fakhry

Brasel

et al. 2019

Trauma Surg Acute Care Open

View full text Add to dashboard Cite

show abstract

“…There is limited data supporting the ability of specialized care teams to reduce morbidity to the same extent as mortality, HLOS, and total costs. 9, 11, 19 Additionally, one large prospective, multicenter study found a higher incidence of complications among trauma patients treated at trauma centers as compared to non-trauma centers. 20 Its authors hypothesized that more aggressive (i.e.…”

Section: Discussionmentioning

confidence: 99%

Neuro, trauma, or med/surg intensive care unit

Lombardo

Scalea

Sperry

et al. 2017

Journal of Trauma and Acute Care Surgery

View full text Add to dashboard Cite

Introduction Patients with non-traumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without TBI fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU. Methods This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head CT scans of patients with Glasgow Coma Scale (GCS) ≤13 and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU-type and survival and calculate the probability of death for increasing ISS. Polytrauma patients (ISS > 15) with TBI and isolated TBI patients (other AIS < 3) were analyzed separately. Results There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Prior to adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit-type, age and ISS remained independent predictors of death. Unit-type modified the effect of ISS on mortality. TBI-polytrauma patients admitted to a TICU had improved survival across increasing ISS (Fig1). Survival for isolated TBI patients was similar between TICU and NICU. Med/Surg ICU carried the greatest probability of death. Conclusion Polytrauma patients with TBI have lower mortality risk when admitted to a Trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a Neuro ICU compared to a Trauma ICU. Med/Surg ICU admission carries the highest mortality risk.

show abstract

“…It is also possible that the trauma surgeon, privy to an inherent understanding of a patient's injury burden, may be at an advantage with respect to the decision to extubate. Klein et al 8 compared the outcomes of patients managed at a regional trauma center before and after the implementation of a surgical critical care service. Prior to the implementation of the service, the ICU care at their center was provided by a pulmonary medicine intensivist group.…”

Section: Discussionmentioning

confidence: 99%

Risk factors for extubation failure at a level I trauma center: does the specialty of the intensivist matter?

Weinberg

Stevens

Goslar

et al. 2016

Trauma Surg Acute Care Open

View full text Add to dashboard Cite

IntroductionExtubation failure in critically ill patients is associated with higher morbidity and mortality. Although predictors of failed extubation have been previously determined in intensive care unit (ICU) cohorts, relatively less attention has been directed toward this issue in patients with trauma. The aim of this study was to identify predictors of extubation failure among patients with trauma in a multidisciplinary ICU setting.MethodsA prospective observational study of extubation failures (EF) was conducted at an American College of Surgeons level I trauma center over 3 years (2011–2013). Case–control patients (CC) were then compared with the study group (EF) with respect to demographic/clinical characteristics and outcomes. Failure of extubation was defined as reintubation within 72 hours following planned extubation.Results7830 patients were admitted to the trauma service and 1098 (14%) underwent mechanical ventilation. 63 patients met inclusion criteria for the EF group and 63 comprised the CC group. The overall rate of extubation failure was 5.7% and mean time to reintubation was 13.0 hours. Groups (EF vs CC) were similar for Injury Severity Score (21 vs 21), Glasgow Coma Scale at extubation (11 vs 10), number of comorbidities (1.5 vs 1.7), injury mechanism (blunt 79% vs 74%), and body mass index (27.9 vs 27.2). In addition, groups were similar with respect to weaning protocol compliance (84% vs 89%, p=0.57). EF group had significantly increased ICU length of stay (LOS) (15.7 vs 7.4 days, p<0.001), ventilator days (13.3 vs 4.8, p<0.001), and mortality (9.5% vs 0%, p=0.03). Multiple regression analysis identified that EF was associated with increased odds of: (1) temperature >38°C at time of extubation (OR 5.9, 95% CI 1.7 to 20.8), and (2) non-surgeon intensivist consultation (OR 24.2, 95% CI 5.5 to 105.9).ConclusionsExtubation failure is associated with increased LOS, ventilator days, and mortality in patients with trauma. Fever at time of extubation is associated with extubation failure, and the presence of such should give pause in the decision to extubate. Non-surgeon intensivist involvement increases risk of extubation failure, and a surgical critical care service may be most appropriate for the management of ventilated patients with trauma.Level of evidenceIII, Prognostic and epidemiological.

show abstract

Implementation of a surgical intensive care unit service is associated with improved outcomes for trauma patients

Abstract: Therapeutic/care management study, level IV.

Cited by 11 publications

References 8 publications

Trauma ICU Prevalence Project: the diversity of surgical critical care

Trauma ICU Prevalence Project: the diversity of surgical critical care

Neuro, trauma, or med/surg intensive care unit

Risk factors for extubation failure at a level I trauma center: does the specialty of the intensivist matter?

Contact Info

Product

Resources

About