A statewide teleradiology system reduces radiation exposure and charges in transferred trauma patients.

BACKGROUND: Trauma transfer patients routinely undergo repeat imaging because of inefficiencies within the radiology system. In 2009, the virtual private network (VPN) telemedicine system was adopted throughout Oregon allowing virtual image transfer between hospitals. The startup cost was a nominal $3,000 per hospital. METHODS: A retrospective review from 2007 to 2012 included 400 randomly selected adult trauma transfer patients based on a power analysis (200 pre/200 post). The primary outcome evaluated was reduction in repeat computed tomography (CT) scans. Secondary outcomes included cost savings, emergency department (ED) length of stay (LOS), and spared radiation. All data were analyzed using Mann-Whitney U and chi-square tests. P less than .05 indicated significance. Spared radiation was calculated as a weighted average per body region, and savings was calculated using charges obtained from Oregon Health and Science University radiology current procedural terminology codes. RESULTS: Four-hundred patients were included. Injury Severity Score, age, ED and overall LOS, mortality, trauma type, and gender were not statistically different between groups. The percentage of patients with repeat CT scans decreased after VPN implementation: CT abdomen (13.2% vs 2.8%, P < .01) and cervical spine (34.4% vs 18.2%, P < .01). Post-VPN, the total charges saved in 2012 for trauma transfer patients was $333,500, whereas the average radiation dose spared per person was 1.8 mSV. Length of stay in the ED for patients with Injury Severity Score less than 15 transferring to the ICU was decreased (P < .05). CONCLUSIONS: Implementation of a statewide teleradiology network resulted in fewer total repeat CT scans, significant savings, decrease in radiation exposure, and decreased LOS in the ED for patients with less complex injuries. The potential for health care savings by widespread adoption of a VPN is significant.

Statewide assessment of injury and death rates among riders of off-road vehicles treated at trauma centers.

BACKGROUND: Injuries and deaths among riders of off-road motorized all-terrain vehicles are increasing in the US. We hypothesized that serious injuries in Oregon have increased among riders of both four-wheel and two-wheel vehicles. STUDY DESIGN: We analyzed the Oregon Trauma Registry. Seriously injured patients treated in the state's designated urban and rural trauma centers were identified using E-codes (821.0 to 821.9), which indicate whether patients were riding either an off-road all-terrain four-wheel vehicle (ATV) or off-road two-wheeled motorcycle (ORMC). Second, we performed a supplemental analysis of similar patients in the trauma registry of Oregon's University-based tertiary care trauma center. Patients in earlier time periods were compared with those in later time periods. RESULTS: Patients injured riding off-road vehicles and needing treatment in Oregon's trauma centers increased 76%. Sixty percent of patients were injured riding an ATV, and 35% were injured riding an ORMC. Children (aged younger than 15 years) were 20% and 23% of patients in the earlier and later years. At Oregon's University-based Level I trauma center, in the years 2002 to 2005, more than twice as many patients needed tertiary care for severe injuries caused by off-road vehicle crashes compared with the previous 4 years. CONCLUSIONS: There has been an alarming increase in the number of both ATV and ORMC riders requiring treatment in Oregon's trauma centers. Surgeons need to join a coalition of health care providers, citizens and public officials to implement a comprehensive injury-prevention response to this epidemic.

Enterocutaneous fistula and ventral hernia after absorbable mesh prosthesis closure for trauma: the plain truth.

HYPOTHESIS: The severity of abdominal injury is the determining factor for the development of enterocutaneous fistula and ventral hernia after absorbable mesh prosthesis closure (AMPC) for trauma. METHODS: We conducted a retrospective analysis of case series that included 140 consecutive trauma patients with AMPC surviving more than 48 hours from October 1, 1989, to March 31, 2000, at a Level I trauma center. The days until abdominal wall reconstruction was used as a measure of exposure of the viscera to the mesh. The abdominal trauma index (ATI) was used as the measure of injury severity. Statistical analysis included t test comparisons, logistic regression analysis, and life-table analysis for hernia development. RESULTS: Enterocutaneous fistula occurred in 10 patients (7.1%). The ATI (mean, 32.5 +/- 23.1) was the only variable independently associated with fistula formation (p = 0.01). The risk of fistula increased by 4% for each 1 unit increase in ATI (95% confidence interval [CI], 1-7%). One hundred seventeen patients (84%) survived to completion of abdominal wall reconstruction over a mean of 18.9 +/- 22.5 days and 3.6 +/- 1.9 operations. The number of days until abdominal wall reconstruction was the only variable independently associated with ventral hernia development (p < 0.001). The likelihood of fascial closure decreased by 26% (95% CI, 16-44%) per day and the risk of ventral hernia increased by 16% (95% CI, 9-23%) per day. The hernia development rate at 4 years (per life table) was 67% for the total, 13% for patients with delayed fascial closure, and 80% for patients requiring other closure techniques. CONCLUSION: Although the severity of abdominal injury is the most important factor for fistula formation, the most important factor for ventral hernia development is the duration of AMPC. Daily interventions, such as mesh tightening, may be necessary to limit ventral hernia in these high-risk patients.

Time to death of hospitalized injured patients as a measure of quality of care.

BACKGROUND: In population-based studies, the quality of care delivered to injured patients is commonly judged by hospital survival rates. Evidence suggests injured patients surviving hospitalization remain at risk for death from their injuries after discharge. Patient characteristics associated with higher risk of late death are not completely defined. METHODS: The National Death Index is a government-maintained database composed of death certificate records from all decedents in the United States. Patients in a trauma registry were cross-linked to decedents in National Death Index on the basis of Social Security number or other unique identifiers. Decedents' time from injury to death was calculated. Logistic regression models were fit to those who died at hospital discharge and those who died in the first year after injury. RESULTS: Among 4293 hospitalized injured patients recorded in a trauma registry, 157 died during hospitalization. Among the 4136 discharged alive, 91 patients were linked to death certificate records filed in the 365 days after discharge. Patients over the age of 65 had a 15-fold greater odds of death than younger patients. CONCLUSION: Trauma registry data cross-linked to vital statistics records is practicable. Patients who die in the year after injury differ from the traditional population used to evaluate quality of trauma care, and new standards are needed that evaluate long-term survival.