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Background: "Failure to rescue" patients with complications is a factor contributing to high mortality rates after elective surgery. In trauma, where early deaths are the primary contributors to a trauma center's mortality rate, the rescue of patients with complications might not be related to overall trauma center mortality. We assessed the extent to which trauma center mortality was reflected by the center's ability to rescue patients with major complications. Methods: Data were derived from the National Trauma Databank, and limited to adults with an Injury Severity Score ≥9 and to centers with adequate complication reporting. Regression models were used to produce center-level adjusted rates for mortality and complications. Centers were ranked on their adjusted mortality rate and divided into quintiles. Results: Of 76,048 patients, 9.6% had a major complication and 7.9% died. The mean complication rate in the quintile of centers with the highest mortality rates was 11.1%, compared with 7.7% in the quintile of centers with the lowest mortality rates (p = 0.03). In addition, mortality among patients with complications differed significantly across quintiles. The mean mortality among patients with complications was 20.3% in the quintile of centers with the highest overall mortality rates, compared with 11.1% in the quintile of centers with the lowest overall mortality rates (p < 0.001). Conclusions: Unlike reports from elective surgery, complication rates after severe injury differ across centers and parallel mortality rates. Centers with low overall mortality are more successful at rescuing patients who experience complications. A lower risk of complications and better care of those with complications are both at play in high-performing trauma centers.

Background: Many national agencies have suggested that deep vein thrombosis (DVT) rates measure quality of hospital care. However, none provide recommendations for standardized screening. If screening practices vary among clinicians or hospitals, DVT rates could be biased—centers which perform more duplex ultrasounds report more DVTs. We hypothesized that trauma surgeons have varying opinions regarding duplex ultrasound screening for DVT in asymptomatic trauma patients, which result in varying practice patterns. Methods: We conducted two web-based surveys regarding the use of duplex ultrasound screening for DVT in asymptomatic trauma patients. The first (individual provider level) surveyed members of two national trauma surgery organizations (American Association for the Surgery of Trauma and Eastern Association for the Surgery of Trauma). The second (trauma center level) surveyed practice patterns of National Trauma Data Bank hospitals. Results: Three hundred seventeen individual surgeons completed surveys. There was wide variation in individual opinions regarding DVT screening in asymptomatic trauma patients (53% agree, 36% disagree, and 11% neither agree nor disagree). Two hundred thirteen National Trauma Data Bank hospitals completed surveys of which 28% (n = 60) have a written guideline regarding DVT screening in asymptomatic trauma patients. The proportion of centers with a written protocol varied significantly by trauma center level (p < 0.001) but not by teaching status. Opinions and practice patterns suggest that screening should start early and be performed weekly. The main risk factors used to suggest DVT screening are spinal cord injury and pelvic fracture. Conclusions: There are wide variations in trauma surgeons' opinions and trauma centers' practices regarding duplex ultrasound screening for DVT in asymptomatic trauma patients. This variability combined with the fact that performing more duplex ultrasounds finds more DVTs may influence reported DVT rates. DVT rates alone are biased and not reflective of true quality of trauma care.

The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications.The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity.Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS.Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

Background: Currently used Trauma and Injury Severity Score (TRISS) coefficients, which measure probability of survival (PS), were derived from the Major Trauma Outcome Study (MTOS) in 1995 and are now unlikely to be optimal. This study aims to estimate new TRISS coefficients using a contemporary database of injured patients presenting to emergency departments in the United States; and to compare these against the MTOS coefficients. Methods: Data were obtained from the National Trauma Data Bank (NTDB) and the NTDB National Sample Project (NSP). TRISS coefficients were estimated using logistic regression. Separate coefficients were derived from complete case and multistage multiple imputation analyses for each NTDB and NSP dataset. Associated PS over Injury Severity Score values were graphed and compared by age (adult 15 years; pediatric 15 years) and injury mechanism (blunt; penetrating) groups. Area under the Receiver Operating Characteristic curves was used to assess coefficients' predictive performance. Results: Overall 1,072,033 NTDB and 1,278,563 weighted NSP injury events were included, compared with 23,177 used in the original MTOS analyses. Large differences were seen between results from complete case and imputed analyses. For blunt mechanism and adult penetrating mechanism injuries, there were similarities between coefficients estimated on imputed samples, and marked divergences between associated PS estimates and those from the MTOS. However, negligible differences existed between area under the receiver operating characteristic curves estimates because the overwhelming majority of patients had minor trauma and survived. For pediatric penetrating mechanism injuries, variability in coefficients was large and PS estimates unreliable. Conclusions: Imputed NTDB coefficients are recommended as the TRISS coefficients 2009 revision for blunt mechanism and adult penetrating mechanism injuries. Coefficients for pediatric penetrating mechanism injuries could not be reliably estimated.

BACKGROUND:: Rural environments have consistently been characterized by high injury mortality rates. Although injury prevention efforts might be directed to reduce the frequency or severity of injury in rural environments, it is plausible that interventions directed to improve injury care in the rural settings might also play a significant role in reducing mortality. To test this hypothesis, we set out to examine the relationship between rurality and the setting in which patient death was most likely to occur. METHODS:: This is a population-based retrospective cohort study evaluating all trauma deaths occurring in the province of Ontario, Canada, over the interval 2002 to 2003. Patient cohorts were defined by their potential to access trauma center care using two different approaches, rurality and timely access to trauma center care. RESULTS:: There were 3,486 deaths over the study interval, yielding an overall injury mortality rate of 14.6 per 100,000 person-years. Overall, more than half of deaths occurred before reaching an emergency department (ED). Prehospital deaths were twice as likely in the most rural locations and in those with limited access to timely trauma center care. However, among patients surviving long enough to reach hospital, there was a threefold increase in the risk of ED death among those injured in a region with limited access to trauma center care. CONCLUSIONS:: We demonstrate that a significant proportion of deaths occur in rural EDs. This study provides new insights into rural trauma deaths and suggests the potential value of targeted interventions at the policy and provider level to improve the delivery of preliminary trauma care in rural environments. Language: en

The Inflammation and Host Response to Injury Large-Scale Collaborative Research program, funded by the National Institute of General Medical Sciences of the National Institutes of Health, is the first large-scale interdisciplinary program to attempt to solve the life-threatening problem of inflammation after major trauma or burn injury. One of the main goals of the project was to develop a large clinical database with baseline patient characteristics and well-defined outcomes that pertain to the host inflammatory response after injury. To minimize the impact of practice variation between participating sites, clinical guidelines were developed at the outset of the project, based on the best available evidence in concert with expert consensus.1 The resultant standards of practice guidelines have been provided to the clinical community to ensure transparency of the research initiative, highlight the applicability of these best practices, and to promote the ongoing development of consistent, high-quality care. Recognizing the complexity and heterogeneity of the patient population, the investigators have additionally created a library of standardized diagnostic criteria for complications after traumatic injury. The method used to define these complications incorporated several key components. An expert panel of surgeons who were participating investigators in the Patient-Oriented Research Core was assembled to identify and enumerate the complications that arise after traumatic injury to be included in the study database. Definitions were based on the best available evidence and were clarified to attempt to unambiguously describe complications in such a manner that reliable data could be captured relative to that complication. Input into the consensus process was also obtained from trauma research nurses to modify the definitions to facilitate practical measurement of complications based on information available in the medical record. Although the primary intent was to maintain consistent reporting and quality assessment of treatment and outcomes among participating trauma centers, the compilation of these infectious and noninfectious complication definitions in a single source may serve as a useful reference for the clinician, as well as a framework for future research.

BACKGROUND:: Laboratory and clinical studies demonstrate inconsistent findings on the effect of alcohol on traumatic brain injury (TBI) outcome. The purpose of this study is to use a comprehensive trauma database to determine whether blood alcohol concentration (BAC) is associated with mortality in patients with TBI. METHODS:: DESIGN:: Cohort study. SETTING:: Eighteen trauma centers and 51 nontrauma centers in the United States. PATIENTS:: A total of 1,529 patients aged 18 years to 84 years of age admitted to hospital with TBI between July 2001 and November 2002. EXPOSURE:: BAC assessed in the index hospital emergency department. OUTCOME:: Mortality in-hospital, 90 and 365 days after injury. RESULTS:: After adjusting for confounding variables, there was no significant difference for in-hospital, 90-day, and 365-day mortality by BAC. CONCLUSIONS:: When fully adjusted for injury severity, alcohol intoxication is not associated with significantly lower mortality after TBI. The trend toward lower mortality at higher BACs prompts questions about the complex interaction of alcohol and TBI, and warrants further investigation of the possible protective effect of alcohol. Language: en

When the clinical decision to treat a critically ill patient with antibiotics has been made, one must attempt to identify the site of infection based on clinical signs and symptoms, laboratory or diagnostic radiology studies. Identification of site requires, examination of patient, inspection of all wounds, chest radiograph, and calculation of clinical pulmonary infection score if ventilated, obtaining blood cultures, urinalysis, and line change if clinical suspicion of central venous catheter (CVC) source. If it is impossible to identify site, obtain cultures from all accessible suspected sites and initiate empiric, broad spectrum antibiotics. If likely site can be identified answer these questions: Is intra-abdominal site suspected? Is pulmonary source of infection suspected? Is skin, skin structure or soft tissue site suspected? If yes, does the patient have clinical signs suspicion for necrotizing soft tissue infection (NSTI)? Is a CVC infection suspected? Risk factors for more complicated infections are discussed and specific antibiotic recommendations are provided for each type and severity of clinical infection. Decision to continue, discontinue and/or alter antibiotic/antimicrobial treatment should be based on the clinical response to treatment, diagnostic or interventional findings, and culture and sensitivity data, bearing in mind that not all patients with infections will have positive cultures because of limitations of specimen handling, microbiology laboratory variations, time between specimen acquisition and culture, or presence of effective antibiotics at the time that specimens were obtained. It should also be noted that not all patients with increased temperature/WBC have an infection. Discontinuation of antibiotics is appropriate if cultures and other diagnostic studies are negative.

Trauma center physicians need to know the patient's prognosis to make appropriate clinical decisions when they take over the care of a transferred patient. We sought to compare the survival of injured patients after transfer to a trauma center with survival from a comparable time after injury among patients who had been admitted to the trauma center directly from the scene of injury.: Study included 2,867 patients 18 years to 84 years of age with at least one Abbreviated Injury Scale score/=3 injury transferred to a trauma center and 7,570 patients admitted directly to a trauma center. The outcome was death within one year after injury. Cox proportional hazards model for death was used accounting for time since injury, adjusted for age group, gender, injury severity, injury mechanism, and comorbidities.: Overall, there was almost no increase in the adjusted risk of death for transfer patients in the year after injury [hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.78, 1.27]. The adjusted risk of death was higher in transfer patients than nontransfer patients between 50 days and 365 days after injury (HR 1.28, 95% CI 0.79, 2.07), but not within the first 50 days (HR 0.95, 95% CI 0.76, 1.18). However these modest differences in survival within each period were not statistically significant.: After accounting for key demographic and clinical characteristics, transfer status does not appear to be a significant independent predictor of survival among patients with moderate to severe injuries treated at Level I trauma centers.

Severely bleeding trauma patients requiring massive transfusion (MT) often experience poor outcomes. Our purpose was to determine the potential role of near infrared spectrometry derived tissue hemoglobin oxygen saturation (StO2) monitoring in early prediction of MT, and in the identification of those MT patients who will have poor outcomes.Data from a prospective multi-institution StO2 monitoring study were analyzed to determine the current epidemiology of MT (defined as transfusion volume/=10 units packed red blood cells in 24 hours of hospitalization). Multivariate logistic regression was used to develop prediction models.Seven US level I trauma centers (TC) enrolled 383 patients. 114 (30%) required MT. MT progressed rapidly (40% exceeded MT threshold 2 hours after TC arrival, 80% after 6 hours). One third of MT patients died. Two thirds of deaths were due to early exsanguination and two thirds of early exsanguination patients died within 6 hours. One third of the early MT survivors developed multiple organ dysfunction syndrome. MT could be predicted with standard, readily available clinical data within 30 minutes and 60 minutes of TC arrival (area under the receiver operating characteristic curve = 0.78 and 0.80). In patients who required MT, StO2 was the only consistent predictor of poor outcome (multiple organ dysfunction syndrome or death).MT progresses rapidly to significant morbidity and mortality despite level I TC care. Patients who require MT can be predicted early, and persistent low StO2 identifies those MT patients destined to have poor outcome. The ultimate goal is to identify these high risk patients as early as possible to test new strategies to improve outcome. Further validation studies are needed to analyze appropriate allocation and study appropriate use of damage control interventions.

PurpOSe: The National Surgical Quality Improvement Program has improved the quality of surgical care by tracking risk-adjusted patient outcomes. Unlike the National Surgical Quality Improvement Program, the trauma center verification program of the American College of Surgeons (ACS) focuses on availability of optimal resources, not outcomes. We hypothesized that significant variations in outcomes exist across similar level ACS-verified trauma centers despite availability of similar resources. Methods: The National Trauma Data Bank was used to identify adult patients (age 16-99 years) who were treated at ACS-verified Level I trauma centers that submitted at least 1,000 patients during the 5-year study period (264,102 patients from 58 trauma centers, excluding dead upon arrival). Multivariate logistic regression was used to analyze expected survival for each patient, adjusted for age, gender, race, injury mechanism, transfer status, and injury severity. Observed-to-expected survival ratios (O/E ratios with 95% confidence intervals) were used to rank trauma centers as high performers (O/E ratio significantly larger than 1), low performers (O/E ratio significantly less than 1), or average performers (O/E ratio overlapping 1). Results: Almost half the centers performed significantly different from their risk-adjusted expectation. Fourteen were high performers, 11 were low performers, and 33 were average performers. Conclusions: The trauma center verification process in its present form may not ensure optimal outcome across all verified centers. If further validated, these findings suggest significant room for trauma quality improvement by replicating structures and processes of high performing trauma centers.

The National Study on the Costs and Outcomes of Trauma Care (NSCOT) was designed to address the need for better information on the value of trauma center care. It is a multi-institutional, prospective study that involved the examination of costs and outcomes of care received by over 5,000 adult trauma patients 18 to 84 years of age treated at 69 hospitals located in 12 states. The study had three major objectives: (1) to examine variations in care provided to trauma patients in Level I trauma centers and nontrauma center hospitals; (2) to determine the extent to which differences in care correlate with patient outcome, where outcome is defined not just in terms of mortality and morbidity, but also in terms of major functional outcomes at 3 months and 12 months after injury; and (3) to estimate acute and 1-year treatment costs for trauma center and nontrauma center care, and to describe the relationship between costs and effectiveness for trauma centers and nontrauma centers. In this article, we describe the design of the NSCOT study and point to some of the methodological challenges faced in its implementation and in the analysis of the data. We also present a description of the study population to serve as a basis of future reports. We conclude with lessons learned and some recommendations for future research.

Objective Current trauma system performance improvement emphasizes hospital- and patient-based outcome measures such as mortality and morbidity, with little focus upon the processes of prehospital trauma care. Little data exist to suggest which prehospital criteria should serve as potential filters. This study identifies the most important filters for auditing prehospital trauma care using a Delphi technique to achieve consensus of expert opinion. Methods Experts in trauma care from the United States (n = 81) were asked to generate filters of potential utility in monitoring the prehospital aspect of the trauma system, and were then required to rank these questions in order of importance to identify those of greatest importance. Results Twenty-eight filters ranking in the highest tertile are proposed. The majority (54%) pertains to aspects of emergency medical services, which comprise 7 of the top 10 (70%) filters. Triage filters follow in priority ranking, comprising 29% of the final list. Filters concerning interfacility transfers and transportation ranked lowest. Conclusion This study identifies audit filters representing the most important aspects of prehospital trauma care that merit continued evaluation and monitoring. A subsequent trial addressing the utility of these filters could potentially enhance the sensitivity of identifying deviations in prehospital care, standardize the performance improvement process, and translate into an improvement in patient care and outcome.

Near-infrared spectroscopy (NIRS) can continuously and noninvasively monitor tissue oxygen saturation (StO2) in muscle and may be an indicator of shock severity. Our purpose was to evaluate how well StO2 predicted outcome in high-risk torso trauma patients presenting in shock.The primary outcome in this prospective study was multiple organ dysfunction syndrome (MODS). StO2 data were obtained upon hospital arrival and for 24 hours along with other known predictors of hypoperfusion and clinical outcomes. Clinicians were blinded to StO2 measurements.Seven Level I trauma centers enrolled 383 patients, 50 of whom developed MODS. Minimum StO2 performed similarly to maximum base deficit (BD) in discrimination of MODS patients. The sensitivity for both measures (StO2 cutoff = 75%; BD cutoff = 6 mEq/L) was 78%, the specificity was 34% to 39%, the positive predictive value was 18% to 20% and the negative predictive value was 88% to 91%. StO2 and BD were also comparable in predicting death.NIRS-derived muscle StO2 measurements perform similarly to BD in identifying poor perfusion and predicting the development of MODS or death after severe torso trauma, yet have the additional advantages of being continuous and noninvasive.

BACKGROUND:: Concern has been raised about the capacity of trauma centers to absorb large numbers of additional patients from mass casualty events. Our objective was to examine the capacity of current centers to handle an increased load from a mass casualty disaster. METHODS:: This was a cross-sectional study of Level I and II trauma centers. They were contacted by mail and asked to respond to questions about their surge capacity as of July 4, 2005. RESULTS:: Data were obtained from 133 centers. On July 4, 2005 there were a median of 77 beds available in Level I and 84 in Level II trauma centers. Fifteen percent of the Level I and 12.2% of the Level II centers had a census at 95% capacity or greater. In the first 6 hours, each Level I center would be able to operate on 38 patients, while each Level II center would be able to operate on 22 patients. Based on available data, there are 10 trauma centers available to an average American within 60 minutes. Given the available bed capacity, a total of 812 beds would be available within a 60-minute transport distance in a mass casualty event. CONCLUSIONS:: There is capacity to care for the number of serious non-fatally injured patients resulting from the types of mass casualties recently experienced. If there is a further continued shift of uninsured patients to and fiscally driven closure of trauma centers, the surge capacity could be severely compromised. Language: en

Background Although there is substantial evidence supporting the benefits of an intensivist model of critical care delivery, the extent to which this model has been adopted by trauma centers across the United States is unknown. We set out to evaluate how critical care is delivered in Level I and II trauma centers and the extent to which these centers implement evidence-based patient care practices known to improve outcome. Methods All Level I and Level II trauma centers in the United States were surveyed using a previously validated questionnaire pertaining to the organizational characteristics of critical care units. Questions identifying the impediments to the implementation of an intensivist model of critical care delivery were added to the original survey. An intensivist model intensive care unit (ICU) was defined as one meeting all of the following criteria: a) the physician director was board certified in critical care; b) >50% of physicians responsible for care were board certified in critical care; c) an intensivist made daily rounds on the patients; and d) an intensive care team had the authority to write orders on the patients. The survey respondents were also queried regarding the extent to which they complied with evidence-based guidelines for care in the ICU. Results The overall response rate was 65% (295 centers). Only 61% of Level I centers and 22% of Level II centers provided an intensivist model of critical care delivery. Sixty-nine percent of centers had a form of collaborative care with an intensivist, but few centers had dedicated intensivists without responsibilities outside the ICU. The most common reason cited for not involving an intensivist in the delivery of critical care services was a concern regarding a loss of continuity of care. There was limited implementation of evidence-based practices in the ICU; the model of critical care delivery had no effect on rates of implementation of these practices. Conclusion The process of trauma center verification and designation should assure a high quality of trauma care. In keeping with these expectations of quality, the delivery of critical care services in trauma centers should evolve to a model that both includes the trauma surgeon in the care of the injured and allows for collaboration with a dedicated intensivist, who may or may not be a surgeon. The benefits of an intensivist model might be distinct from the utilization of evidence-based practices, suggesting that there might be incremental benefit in using these practices as markers of quality.

Background: Transfer patients (TP) differ from patients transported directly from the field (DP) by virtue of their complexity and delays to definitive care, factors that might impact on costs and resource utilization and aggravate the adverse selection that already threatens TC reimbursement. Methods: This is a retrospective cohort study where patients admitted to a Level I trauma center were classified as a TP or DP. Crude and adjusted total costs, complications, length of stay, and proportion of DRG outliers were compared across the two cohorts. Results: Among 8,665 patients, 40% were transferred. TP were more likely to be DRG outliers (15% versus 10%, p < 0.001). Costs in 65% of the DRGs were higher in the TP. Rates of complications and length of stay were significantly greater in the TP. Conclusion: There are systematic differences in resource consumption between transferred patients and patients transported directly from the field. These differences render conventional DRG-based mechanisms of reimbursement inadequate, suggesting a need for recognition of the transfer patient as a distinct entity by payers.

Despite broad clinical use of the American Association of the Surgery of Trauma (AAST) injury scale for kidney, it has only been found to predict the need for renal surgery in single institution series. We sought to validate this scheme for morbidity and mortality in a national cohort of patients with renal injury.A retrospective cohort design was used to determine the association between increasing AAST scores and nephrectomy, dialysis, and mortality. The cohort included all patients with a renal injury in the National Trauma Data Bank (NTDB) from 1994 and 2003. Univariate and multivariate prediction models were used for analysis of data.At the time of review, a total of 742,774 patient records were registered in the NTDB. Renal injury occurred in 8465 patients (1.2%). Increasing injury grade was associated with a greater nephrectomy (RR 12-127), dialysis (RR 1.3-4.7), and mortality (RR 1.3-1.9) rate for blunt kidney injury. For penetrating injury, nephrectomy was the only outcome that was associated with higher grades of renal injury with a RR of 7.7 to 31 for grades III to V injuries.The AAST injury scale for kidney predicts for morbidity in blunt and penetrating renal injury and for mortality in blunt injury. Thus, we continue to support its use as a clinical and research tool.

Federal motor vehicle safety standards are based on crash test dummy analyses that estimate the relative risk of traumatic brain injury (TBI) and severe thoracic injury (STI) by quantifying head (Head Injury Criterion [HIC]) and chest (Chest Gravity Score [CGS]) acceleration. The New Car Assessment Program (NCAP) combines these probabilities to yield the vehicle's five-star rating. The validity of the NCAP system as it relates to an actual motor vehicle crash (MVC) remains undetermined. We therefore sought to determine whether HIC and CGS accurately predict TBI and STI in actual crashes, and compared the NCAP five-star rating system to the rates of TBI and/or STI in actual MVCs.We analyzed frontal crashes with restrained drivers from the 1994 to 1998 National Automotive Sampling System. The relationship of HIC and CGS to the probabilities of TBI and STI derived from crash tests were respectively compared with the HIC-TBI and CGS-STI risk relationships observed in actual crashes while controlling for covariates. Receiver operating characteristic curves determined the sensitivity and specificity of HIC and CGS as predictors of TBI and STI, respectively. Estimates of the likelihood of TBI and/or STI (in actual MVCs) were compared with the expected probabilities of TBI and STI (determined by crash test analysis), as they relate to NCAP ratings.The crash tests overestimate TBI likelihood at HIC scores800 and underestimate it at scores500. STI likelihood is overestimated when CGS exceeds 40 g. Receiver operating characteristic curves demonstrated poor sensitivity and specificity of HIC and CGS in predicting injury. The actual MVC injury probability estimates did not vary between vehicles of different NCAP rating.HIC and CGS are poor predictors of TBI and STI in actual MVCs. The NCAP five-star rating system is unable to differentiate vehicles of varying crashworthiness in actual MVCs. More sensitive parameters need to be developed and incorporated into vehicle crash safety testing to provide consumers and automotive manufacturers with useful tools with which to measure vehicle safety.

STUDY OBJECTIVE: Intimate partner violence (IPV) is a major cause of injury and death among women, and it is a problem with significant relevance to health care providers. In this study, we examined risk factors for IPV-related injury within 9 months of an index episode of abuse in a population of police- or court-identified victims of IPV. METHODS: This was a prospective cohort study of 354 women in abusive relationships. The outcome measured was injury within 9 months. Stepwise logistic regression was used for the statistical analysis. RESULTS: Two factors were found to be independently associated with increased risk of injury: victim's lack of full-time employment (RR 3.47, 95% CI 1.43-8.41) and physical abuse on the index incident date (RR 3.06, 95% CI 1.16-8.06). CONCLUSIONS: By questioning our patients about these issues, we can begin to identify the complex risk factors that predispose women in abusive relationships to future injury. Language: en

Background: Nonoperative management of many pediatric injuries has generated debate as to whether surgeons must be routinely involved in the early assessment and management of pediatric trauma. This study examines the frequency of operative intervention among injured children and evaluates potential predictors of emergent intervention. Methods: Pediatric (age < 18 years) patients were identified from the National Trauma Data Bank. Primary outcome measures were surgical intervention by specialty, time to intervention, and mortality. Prehospital factors were evaluated as predictors of emergent surgical intervention. Results: Thirty percent of trauma admissions underwent operative intervention, with 57% of these requiring emergent surgery. Patients needing emergent general or neurosurgical intervention were at increased risk of death. Requiring one type of emergent surgical intervention was predictive of needing a second type of emergent procedure. Predictors of emergent general surgical intervention were penetrating mechanism, increasing age, and the presence of shock or coma. Conclusion: These data support the continued routine involvement of surgeons in the initial assessment and management of the injured child.

Background Transporting all trauma patients to regional trauma centers is inefficient; however, the bypass of nearer, nondesignated hospitals in deference to regional trauma centers decreases mortality in the severely injured. One approach to improving efficiency is to allow the initial assessment of selected patients at lower level (Level III/IV) designated centers. We set out to evaluate whether patients initially assessed at these centers and then transferred to a Level I facility were adversely affected by delays to definitive care. Methods This is a retrospective cohort study in which the primary exposure being evaluated is initial assessment at a Level III or IV trauma center before transport to a Level I center in an urban setting. The outcomes in this transfer cohort were compared with outcomes in patients transported directly from the scene to a Level I center (direct cohort). The outcomes of interest were mortality, length of stay, and hospital charges. Multivariate analyses were used to adjust for differences in baseline characteristics across these two cohorts. Results Crude length of stay was comparable, whereas mortality was lower and charges were 40% higher in the transfer cohort (n = 281) compared with the direct cohort (n = 4,439). After adjusting for confounders, mortality and length of stay were similar and total charges were significantly greater in the transferred patients. Conclusion Interfacility transfers in a mature urban trauma system do not appear to impact on clinical outcome. However, transfer patients use significantly greater resources as measured by hospital charges. This effect is likely because of the nature of their injuries or, alternatively, delays in reaching definitive care.

Venous thromboembolism (VTE) is a major source of morbidity in critically ill trauma patients. Although the incidence and risk factors for VTE after trauma in adults have been well described, similar data regarding pediatric patients are lacking.Pediatric (age16 years) trauma patients with VTE were identified from a large administrative database collated from 19 states across the United States. Risk factors for VTE were identified using multivariate techniques.Risk of VTE increased with age and Injury Severity Scores. VTE was clearly associated with head, thoracic, abdominal, lower extremity, and spinal injuries. Craniotomy, laparotomy, and spinal operations were also associated with VTE. The greatest risk of VTE was in children with venous catheters.Older children with high Injury Severity Scores, major vascular injury, craniotomy, or venous catheters are at risk for VTE. These data may help guide strategies geared toward screening and prophylaxis in injured children.

Background: The cost of uncompensated trauma care is a significant barrier to trauma system development. Trauma center designation may burden an institution with an unprofitable mix of underinsured, severely injured patients. Concerns about inadequate reimbursement may motivate interhospital transfers on the basis of insurance status rather than medical necessity, potentially undermining the effectiveness of the system. We set out to explore whether this phenomenon exists in a mature trauma system. Methods: Trauma patients receiving definitive care at Level III or IV trauma centers were compared with patients transferred from these centers to the only Level I regional center. Insurance status was classified as either commercial or noncommercial. Logistic regression was used to determine the independent predictors of transfer after adjusting for differences in injury severity. Results: Only 12% of 2,008 patients initially evaluated at Level III/IV centers were transferred to the Level I center, an indicator of the effectiveness of prehospital triage protocols in the region. The presence of specific complex injuries, younger age, male gender, and insurance status were all associated with an increased likelihood of transfer. Insurance status was an independent predictor of transfer: patients without commercial insurance were 2.4 (95% confidence interval, 1.6-3.6) times more likely to be transferred to a Level I facility than patients with commercial insurance after adjusting for differences in injury severity. Conclusion: Insurance status influences the decision to transfer to higher levels of care. These findings suggest that the financial burden of a trauma system may be inequitably distributed. This inequitable distribution may be necessary for trauma system sustainability and calls for the development of disproportionate reimbursement strategies to support regional referral centers.

Background: North American trauma centers are beginning to note the limitations of emergent torso sonography. The purpose of this prospective study was to evaluate the frequency, causes, associations, and sequelae of indeterminate (IND) sonograms in blunt trauma. Methods: Among adult blunt trauma patients assessed with screening torso sonography, clinician sonographers recorded the abdominal sonogram as positive, negative, or IND for free fluid. Patients with IND sonograms were further investigated with repeat sonography, computed tomography, or diagnostic peritoneal lavage. Results: Among 417 patients with blunt trauma (mean Injury Severity Score = 21) managed with sonography, there were 28 (6.7%) IND and 389 (93.3%) non-IND sonograms. Sonograms were IND because of patient factors in 71% (20 of 28) and because of operator factors in 29% (8 of 28). None of the 28 patients were managed with repeat sonography alone. All 4 diagnostic peritoneal lavage examinations gave negative results, whereas 8 of 23 computed tomographic scans were abnormal (6 of 8 patients underwent laparotomy). The mean time required for diagnostic workup was 117 minutes in the IND group and 48 minutes in the non-IND group (p < 0.001 in both cases). Conclusion: This prospective study has demonstrated that IND sonograms are not common at our center (6.7%), are usually attributable to patient factors, and are associated with greater diagnostic time. Patients with IND sonograms require further investigation because they often have injuries requiring laparotomy.