A Review of "First Rib Fracture: A Hallmark of Severe Trauma" (1975).

This review is submitted for inclusion in the literary festschrift in honor of J. David Richardson, MD.

The injured elderly: a rising tide.

BACKGROUND: Injury remains a public health challenge despite advances in trauma care. Periodic survey of injury epidemiology is essential to the trauma system's continuous performance improvement. We undertook this study to characterize the changes in Florida injury rates during the past 15 years. METHODS: Injured patients were identified with the use of a statewide database over 15 years ending in 2010. Population data were obtained from the U.S. Census. Severe injury was defined by International Classification Injury Severity Scores less than 0.85. Injury rates were expressed in discharges per 100,000 residents. Trends were analyzed by linear regression. RESULTS: The 1.5 million patient discharges consisted of 5.2% children, 39.7% adults, and 55.1% elderly. The overall injury rate decreased in children by 18% but increased in adults by 2% and in the elderly by 17% during the study period. The proportion of severe injuries decreased in children and the elderly but did not change in adults. Injury patterns changed in all age groups. CONCLUSION: Injury in the elderly is increasing at a rate seven times that of adults. In 2010, the elderly accounted for only 17% of the population but 55% of injury-related discharges. These trends have dramatic implications for the design of future trauma systems and health care resource use.

Fifteen-year trauma system performance analysis demonstrates optimal coverage for most severely injured patients and identifies a vulnerable population.

BACKGROUND: Trauma systems are designed to deliver timely and appropriate care. Prehospital triage regulations and interfacility transfer guidelines are the primary determinants of system efficacy. We analyzed the effectiveness of the Florida trauma system in delivering trauma patients to trauma centers over time. STUDY DESIGN: Injured patients were identified by ICD-9 codes from a statewide discharge dataset, and they were categorized as children (less than 16 years old), adult (16 to 65 years old), or elderly (over 65 years old). Severe injury was defined by International Classification Injury Severity Scores (ICISS) < 0.85. Residence ZIP codes were used as a surrogate for injury location. RESULTS: Severe injury discharges increased at designated trauma centers (DTCs) and decreased at nontrauma centers (NTCs). The proportion of patients with severe injuries discharged from DTCs increased for all age groups, capturing nearly all severely injured children and adults. Access to DTCs was dependent on proximity for severely injured elderly but not for severely injured children and adults. CONCLUSIONS: Triage improved over time, enabling near complete capture of at-risk children and adults independent of DTC proximity. Because distance from a DTC does not limit access for children and adults, existing trauma system resources are sufficient to meet the current demands. Efforts are needed to determine the trauma resource and triage needs of the severely injured elderly.

High-volume trauma centers have better outcomes treating traumatic brain injury.

BACKGROUND: Survival and discharge status from severe traumatic brain injury (TBI) patients treated during the past 11 years in seven state-designated Level I trauma centers was analyzed to test for a relationship between patient volume and outcome. METHODS: Data for patients age 16 years to 64 years were aggregated by quarter for years 2000 to 2010. TBI patients were identified using DRG International Classification of Diseases--9th Rev.--Clinical Modification codes: 800 to 804 and 850.1 to 854. Severity was defined using the International Classification Injury Severity Score (ICISS) less than 0.85 (risk of death > 15%). Using a random effects model controlling for sex, race, ethnicity, and insurance status, TBI volume was analyzed against quarterly inpatient mortality and functional recovery, defined as discharge to home or rehabilitation versus transfer to skilled nursing facilities. Hospitals were categorized into quarterly TBI volume quintiles, using the top quintile (highest-volume center) as control. To account for overall injury severity influence, ICISS was further categorized as less than 20%, 20% to 40%, and 40% to 60%. RESULTS: Two high-volume hospitals consistently treated more TBI patients (>40 patients per quarter). Four treated less than 40 patients per quarter, and one transitioned to high-volume midway through the study period. After controlling for severity, demographics, and insurance status, highest-volume centers demonstrated a 9% lower mortality risk (p < 0.001). Lower-volume hospitals discharged a significantly larger proportion of TBI patients to skilled nursing facilities and fewer patients to home or rehabilitation facilities (p < 0.01). CONCLUSION: High volume (>40 patients per quarter) is associated with improved severe TBI patient survival and, probably, improved quality of life. Efforts to identify best practices and implement educational interventions to improve compliance with best-practice standards will benefit patients with severe traumatic brain injury. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Survival advantage for elderly trauma patients treated in a designated trauma center.

BACKGROUND: This article analyzes the effectiveness of designated trauma centers (DTCs) in Florida concerning reduction in the mortality risk of severely injured elderly trauma victims. METHODS: Inpatient hospital data collected by the Agency for Health Care Administration were used to identify elderly trauma patients. An instrumental variables method was used to adjust for prehospital selection bias in addition to the influence of age, gender, race, risk of mortality, comorbidities, and type of injury. The model was estimated using a bivariate probit full information maximum likelihood model to determine the impact of triage to a trauma center as opposed to a nontrauma hospital. RESULTS: After adjusting for confounding influences, treatment at a DTC was associated with a statistically significant reduction of 0.072, 0.040, and 0.036 in the probability of mortality for patients in the age groups 65 years to 74 years, 75 years to 84 years, and ≥ 85 years, respectively. CONCLUSIONS: Treatment of severely injured elderly trauma patients in DTCs is associated with statistically significant gains in the probability of survival.

Insurance status, not race, is a determinant of outcomes from vehicular injury.

BACKGROUND: Hypothesizing that outcomes from specific injury mechanisms should not vary by race or socioeconomic status, we analyzed the relationship of race and ethnicity to fatality in motor vehicle crash victims treated during 2008 and 2009. STUDY DESIGN: Logistic regression analysis of pooled administrative data assessed the contribution of patient demographics and injury severity to outcome, defined as mortality during acute hospitalization. Demographic factors included age, sex, race, ethnicity, and insurance. Severe injury was defined using ICD-9 Injury Severity Score (survival probability) p < 0.85, presence of up to 3 comorbidities, and/or diagnosis of spinal cord injury and/or traumatic brain injury. Mortality was stratified by survival time after trauma center arrival to death within 24 hours or thereafter. Factors contributing to outcomes were tested using chi square analysis of the calculated model estimate. RESULTS: For 8,758 motor vehicle crash victims treated in state-designated trauma centers, age, sex, injury severity, and 2 or more comorbidities consistently predicted survival. Neither race nor ethnicity was associated with increased mortality risk. Being uninsured was related to death within 24 hours (p < 0.001). The majority of the uninsured who died within 24 hours had an ICD-9 Injury Severity Score p ≤ 0.5. Mortality risk after 24 hours was driven by traumatic brain injury and comorbidities. CONCLUSIONS: The results of this study indicated that higher immediate mortality of the uninsured is a behavioral and socioeconomic rather than physiologic marker. This higher mortality is driven by increased injury severity that increases cost of care in uninsured survivors. This disparity suggests that risk-taking behavior, especially relating to safety practices and licensing regulations, is an important etiologic factor. Improved outcomes require better public education and enforcement in conjunction with improvements in processes of care.

Pelvic fracture: the last 50 years.

The past 50 years have been a time of rapid progress in the control of mortality and morbidity of pelvic fracture. Early understanding of the anatomic features of the fracture and the potential for major, life-threatening arterial hemorrhage in a small proportion of patients led to multidisciplinary approaches designed to control hemorrhage and temporarily stabilize the fracture. Progress in the diagnosis and management of lower urinary tract injuries has resulted in maintenance of urinary continence and sexual function in a large proportion of patients with pelvic fracture-associated urinary tract injury. Finally, definitive open reduction and fixation of the fracture has led to permanent pelvic stability and pain-free walking in most patients. With successful combination of these approaches, survival and return to a satisfactory level of function is now the rule rather than the exception for patients with severe pelvic fracture.