Variations in pediatric trauma transfer patterns in Northern California pediatric trauma centers (2001-2009).

BACKGROUND: Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles. A significant proportion of children with trauma is initially triaged to nontrauma hospitals and may require subsequent transfer to a specialty center. Trauma transfer patterns to a pediatric trauma center may provide insight into regional primary triage practices. Transfers from hospitals in close proximity to pediatric trauma centers might suggest that some children could have avoided transfer with minimal additional transport time. While pediatric trauma centers are scarce and serve as regional resources, transfers from beyond the regular catchment area of a trauma center could be an indication of clinical need. OBJECTIVES: The objective of this study was to gain an understanding of patterns of pediatric trauma transfer to all pediatric trauma centers within the region as a first step in assessing the efficacy and efficiency of trauma triage. The authors examined three groups of transfer patients: transfers from within the same county as the pediatric trauma center (near transfers), transfers from counties adjacent to the pediatric trauma center (catchment transfers), and transfers from more distant counties (far transfers). The hypothesis was that catchment transfers would form the bulk of transfers, near transfers would compose < 10% of total transfers, and far transfers would be younger and more severely injured than catchment transfers. METHODS: This was a retrospective analysis of institutional trauma registry data of children < 18 years from all pediatric trauma centers in Northern California from 2001 through 2009. Transfers were characterized by the location of the transfer hospital relative to the location of the pediatric trauma center. Characteristics associated with near transfer compared to primary triage to a pediatric trauma center were identified, as well as characteristics associated with far transfer compared to catchment transfer. RESULTS: A total of 2,852 of 11,952 (23.9%) pediatric trauma patients were transfers. Near transfers comprised 24.5% of cases, catchment transfers were 37.4%, and far transfers were 38.2%. After controlling for demographic, clinical, and geographic factors, younger age, higher Injury Severity Score (ISS), public versus private insurance, and an injury mechanism of "fall" were associated with near transfer rather than direct triage. Older age, higher ISS, and mechanism of "motor vehicle crash" were associated with far rather than catchment transfer. CONCLUSIONS: This analysis of patterns of transfer to all pediatric trauma centers within Northern California gives the most comprehensive population view of pediatric trauma triage to date, to the authors' knowledge. Trauma transfers comprise an important minority of patients cared for at pediatric trauma centers. The number of near transfers documented indicates the potential to improve the primary triage process of patients to pediatric trauma centers. The frequency of far transfers substantiates the well-known shortage of pediatric trauma expertise. Development of regionwide standardized transfer protocols and agreements between hospitals, as well as standardized monitoring of the process and outcomes, could increase efficiency of care.

Trauma Center-Based Surveillance of Nontraffic Pedestrian Injury among California Children.

INTRODUCTION: Every year in the United States, thousands of young children are injured by passenger vehicles in driveways or parking areas. Little is known about risk factors, and incidence rates are difficult to estimate because ascertainment using police collision reports or media sources is incomplete. This study used surveillance at trauma centers to identify incidents and parent interviews to obtain detailed information on incidents, vehicles, and children. METHODS: Eight California trauma centers conducted surveillance of nontraffic pedestrian collision injury to children aged 14 years or younger from January 2005 to July 2007. Three of these centers conducted follow-up interviews with family members. RESULTS: Ninety-four injured children were identified. Nine children (10%) suffered fatal injury. Seventy children (74%) were 4 years old or younger. Family members of 21 victims from this study (23%) completed an interview. Of these 21 interviewed victims, 17 (81%) were male and 13 (62%) were 1 or 2 years old. In 13 cases (62%), the child was backed over, and the driver was the mother or father in 11 cases (52%). Fifteen cases (71%) involved a sport utility vehicle, pickup truck, or van. Most collisions occurred in a residential driveway. CONCLUSION: Trauma center surveillance can be used for case ascertainment and for collecting information on circumstances of nontraffic pedestrian injuries. Adoption of a specific external cause-of-injury code would allow passive surveillance of these injuries. Research is needed to understand the contributions of family, vehicular, and environmental characteristics and injury risk to inform prevention efforts.

Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: a multisite, mixed methods assessment.

BACKGROUND: "Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons. METHODS: We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008. We used logistic regression models to evaluate the independent predictive value of EMS provider judgment for Injury Severity Score ≥ 16. EMS narratives were analyzed using qualitative methods to assess and compare common themes for each step in the triage algorithm, plus EMS provider judgment. RESULTS: 213,869 injured patients were evaluated and transported by EMS over the 3-year period, of whom 41,191 (19.3%) met at least one of the field triage criteria. EMS provider judgment was the most commonly used triage criterion (40.0% of all triage-positive patients; sole criterion in 21.4%). After accounting for other triage criteria and confounders, the adjusted odds ratio of Injury Severity Score ≥ 16 for EMS provider judgment was 1.23 (95% confidence interval, 1.03-1.47), although there was variability in predictive value across sites. Patients meeting EMS provider judgment had concerning clinical presentations qualitatively similar to those meeting mechanistic and other special considerations criteria. CONCLUSIONS: Among this multisite cohort of trauma patients, EMS provider judgment was the most commonly used field trauma triage criterion, independently associated with serious injury, and useful in identifying high-risk patients missed by other criteria. However, there was variability in predictive value between sites.

The forgotten trauma patient: outcomes for injured patients evaluated by emergency medical services but not transported to the hospital.

BACKGROUND: Injured patients who are not transported by an ambulance to the hospital are often not included in trauma registries. The outcomes of these patients have until now been unknown. Understanding what happens to nontransports is necessary to better understand triage validity, patient outcomes, and costs associated with injury. We hypothesized that a subset of patients who were not transported from the scene would later present for evaluation and that these patients would have a nonzero mortality rate. METHODS: This is a population-based, retrospective cohort study of injured adults and children for three counties in California from 2006 to 2008. Prehospital data for injured patients for whom an ambulance was dispatched were probabilistically linked to trauma registry data from four trauma centers, state-level discharge data, emergency department records, and death files (1-year mortality). RESULTS: A total of 69,413 injured persons who were evaluated at the scene by emergency medical services were included in the analysis. Of them, 5,865 (8.5%) were not transported. Of those not transported, 1,616 (28%) were later seen in an emergency department and discharged and 92 (2%) were admitted. Seven (0.2%) patients later died. CONCLUSION: Patients evaluated by emergency medical services, but not initially transported from the field after injury, often present later to the hospital. The mortality rate in this population was not zero, and these patients may represent preventable deaths. LEVEL OF EVIDENCE: III, therapeutic study.

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined. METHODS: A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed. RESULTS: Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy. CONCLUSION: No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

Evidence-based practice strategy: increasing timely nutrition in mechanically ventilated trauma surgical patients.

Malnutrition is common in the intensive care unit (ICU) and is related to higher incidence of morbidity and mortality among seriously ill patients. Achieving a quality nutritional care plan is a challenge to critical care practitioners and dietitians worldwide. The multifaceted and advanced therapies in the ICU historically take priority over nutritional assessments and interventions and may cause delay in achieving quality nutritional care. The initiation of nutrition in mechanically ventilated adult trauma patients is inconsistent in some hospitals. The implementation plan in this early nutrition project involved an algorithm, physicians order set, and nurse advocacy plan. Early nutritional support will likely be associated with improved clinical outcomes.

Blunt traumatic occult pneumothorax: is observation safe?--results of a prospective, AAST multicenter study.

BACKGROUND: An occult pneumothorax (OPTX) is found incidentally in 2% to 10% of all blunt trauma patients. Indications for intervention remain controversial. We sought to determine which factors predicted failed observation in blunt trauma patients. METHODS: A prospective, observational, multicenter study was undertaken to identify patients with OPTX. Successfully observed patients and patients who failed observation were compared. Multivariate logistic regression was used to identify predictors of failure of observation. OPTX size was calculated by measuring the largest air collection along a line perpendicular from the chest wall to the lung or mediastinum. RESULTS: Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%) were observed. Twenty-seven patients (6%) failed observation and required tube thoracostomy for OPTX progression, respiratory distress, or subsequent hemothorax. Fourteen percent (10 of 73) failed observation during positive pressure ventilation. Hospital and intensive care unit lengths of stay, and ventilator days were longer in the failed observation group. OPTX progression and respiratory distress were significant predictors of failed observation. Most patient deaths were from traumatic brain injury. Fifteen percentage of patients in the failed observation group developed complications. No patient who failed observation developed a tension PTX, or experienced adverse events by delaying tube thoracostomy. CONCLUSION: Most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure.

The efficacy of a two-tiered trauma activation system at a level I trauma center.

BACKGROUND: By using current American College of Surgeons trauma center triage criteria, 52% of patients transported to our level I trauma center are discharged home from the emergency department (ED). Because the majority of our trauma transports were based solely on mechanism of injury, we instituted, in 1990, a two-tiered trauma team activation system. Patients are triaged into major and minor trauma alert categories based on prehospital provider information. For minor trauma patients, respiratory therapy, operating room staff, and blood bank do not respond. The current study evaluated this triage system. METHODS: Trauma registry data on all trauma activations from 1998 to 2007 were analyzed. RESULTS: There were 20,332 trauma activations: 5,881 were major trauma, 14,451 minor trauma. The mean Injury Severity Score in major versus minor patients was significantly different (11.7 vs. 3.6, p < 0.0001). Significant differences (p < 0.0001) were also noted for all other markers of serious injury: Injury Severity Score >16, ED blood pressure <90, Glasgow Coma Score

Validation of a prehospital trauma triage tool: a 10-year perspective.

BACKGROUND: Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication. The rural county adjacent to our developed trauma system uses standardized triage criteria to identify patients for direct transport to our TCs. We hypothesized these criteria accurately identify major trauma victims (MTV) and further that communication could be simplified to expedite transport. METHODS: Prehospital personnel use a MAP (mechanism, anatomy, and physiology) scoring system to triage trauma patients. Patients with > or = 2 "hits" are defined as MTV. In 2004, the triage policy was changed so that MTV would be transported directly to a TC without base hospital consultation (previously required). The Emergency Medical Services (EMS) Medical Director reviewed cases transported to the TC to determine the appropriateness of triage decisions (over- and under-triage using the American College of Surgeons Committee on Trauma definitions). Data were compared before and after this policy change. RESULTS: For 2004 to 2006, we evaluated 676 air transports to TC and compared them to 468 in the prior 56 months. The overall transport rate increased slightly 7% to 10%. During the study period the over-triage rate was 31% compared with 21%, before the policy change. The MAP triage tool yielded a 93.8% sensitivity and a 99.5% specificity. Therefore, it determined the need for air-medical transport out of a rural environment into an established trauma system with > 90% accuracy. CONCLUSIONS: Prehospital personnel can accurately use a trauma triage tool to identify MTV. Eliminating base station contact, a potential for introducing communication error, did increase over-triage but still well within accepted limits. The system change also resulted in the transport of a greater proportion of minor trauma patients who later proved to have major injuries.

A county hospital surgical practice: a model for acute care surgery.

BACKGROUND: Trauma surgery has changed significantly over the past decade. Nonoperative evidence-based algorithms have become common and surgical trauma volume has become increasingly difficult to maintain. The acute care surgery (ACS) model, which integrates trauma, critical care, and emergency surgery, has been proposed as a future model of trauma practice. METHODS: Database information from an academic, county-based, trauma center was reviewed. A performance improvement surgical procedure database and level I trauma registry from 2005 were used to evaluate one center's ACS practice. RESULTS: There were 2,276 cases performed by 7 full-time and 5 part-time surgeons. Elective cases accounted for 64% (1,480) of caseload, emergency/urgent general surgery accounted for 32% (719) of cases, and emergency trauma surgeries accounted for 4% (96 procedures in 77 patients). In all, 23% were performed after hours. The ACS model supported controllable hours, adequate surgical volume, excellent patient care, and an appealing clinical practice. CONCLUSION: Surgical practice in a county-run trauma hospital can be similar to the ACS model, with positive results in terms of clinical volume and physician satisfaction. As clinical practices shift to the ACS model, there are lessons to be learned from currently existing, thriving, long-standing similar prototypes.

Barriers to screening for domestic violence in the emergency department.

The identification of victims of domestic violence is important to prevent further abuse and injury. The purposes of this pilot project were to identify potential barriers emergency department registered nurses encounter in screening patients for domestic violence and to assess nurses' educational backgrounds for continuing education and training needs. The most significant potential barriers to screening identified were a lack of education and instruction on how to ask questions about abuse, language barriers between nurses and patients, a personal or family history of abuse, and time issues. These findings may benefit other researchers who are trying to determine the continuing education needs of emergency department staffs.

The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system.

BACKGROUND: Continuing controversy surrounding the value of scene helicopter evacuation of urban trauma victims led to the present study. METHODS: A retrospective review was performed of all patients brought to our trauma center from the injury scene by helicopter from 1990 to 2001. RESULTS: The study included 947 consecutive patients, 911 with blunt trauma and 36 with penetrating injuries. The mean Injury Severity Score (ISS) was 8.9. Fifteen patients died in the emergency department, 312 patients (33.5%) were discharged home from the emergency department (mean ISS, 2.7), and 620 patients were hospitalized (mean ISS, 11.4). Three hundred thirty-nine of the hospitalized patients (54.7%) had an ISS < or = 9; 148 patients had an ISS > or = 16. Eighty-four patients (8.9%) required early operation, mostly for open extremity fractures; only 17 patients (1.8%) underwent surgery for immediately life-threatening injuries. For 54.7% of the patients, the helicopter was judged to be clearly faster than would have been possible by ground transport. In 140 additional patients (14.8%) with prolonged scene time, the helicopter was probably faster than ground ambulance. Considering faster transport time and either the need for early operation or hospitalization with an ISS > or = 9 as advantageous, a maximum of 22.8% of the study population possibly benefited from helicopter transport. CONCLUSION: The helicopter is used excessively for scene transport of trauma victims in our metropolitan trauma system. New criteria should be developed for helicopter deployment in the urban trauma environment.

Blunt trauma patients with prehospital pulseless electrical activity (PEA): poor ending assured.

BACKGROUND: The paucity of information on the outcome of patients experiencing prehospital pulseless electrical activity (PEA) after blunt injury led to the present study. METHODS: A retrospective review was performed of all blunt trauma victims with prehospital PEA from 1997 to 2001 in an urban county trauma system. RESULTS: One hundred ten patients, 78 men and 32 women, met study criteria. Seventy-nine patients had PEA at the scene, and 31 experienced PEA en route to a trauma center. All patients were transported in advanced life support ambulances. Cardiopulmonary resuscitation was initiated when PEA was detected. Vital signs were regained en route or at the trauma center by 25 patients (23%). The incidence of pupillary reactivity at the scene was higher in patients who regained vital signs (48% vs. 16%). Only one patient, who has significant residual neurologic impairment, survived. The mean Injury Severity Score of this population was 45.1. CONCLUSION: If these grim results are corroborated by other investigators, consideration should be given to allowing paramedics to declare blunt trauma victims with PEA dead at the scene.

A new operation with inadequate Brescia fistulae for preservation of more proximal veins.

PURPOSE: The purpose of this study was to test the hypothesis that venous outflow of a Brescia fistula that is patent but unusable for one of a variety of reasons can provide adequate drainage to sustain a prosthetic arteriovenous graft based on the brachial artery, thus sparing more proximal veins for future access procedures. METHODS: The operation consists of placement of a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. RESULTS: Between December 1998 and November 1999, 14 patients (eight male and six female; age range, 34 to 73 years; mean age, 51 years) underwent the operation. The original fistulae had been in place for 5 to 27 months (mean, 13 months). Thirteen grafts were patent at 30 days; the one early failure (24 days) was caused by infection. As of May 31, 2001, four grafts were being used (18 (1/2), 20, 23, and 28 months after placement) and four had been withdrawn in a functional state because of death (n = 3) or transplantation (n = 1). Primary functional patency rate with life-table analysis was 71%, 57%, 41%, and 41% at 3, 6, 9, and 12 months; secondary functional patency rate was 86%, 78%, 52%, and 52% at these same intervals. Three grafts had primary functional patencies greater than 18 months. CONCLUSION: Patent but unusable Brescia fistulae can provide adequate outflow to sustain arteriovenous grafts, thus sparing more proximal veins for future access procedures. The operation can extend by months or years the time during which satisfactory vascular access can be maintained in these patients, potentially increasing survival in some cases. We hope that the availability of this salvage option will encourage vascular surgeons to attempt arteriovenous fistulae at the wrist even in patients with suboptimal venous anatomy.