Financial implication of proposed legislation on hospital reimbursement for the injured drunk driver.

The state of Michigan currently has no-fault automobile insurance with personal injury protection, providing anyone injured in motor vehicle collisions with unlimited medical and rehabilitation benefits and lost wage recovery. A new bill proposal, Michigan House Bill 5588, will eliminate hospital reimbursement for those who are found to be intoxicated at the time of a motor vehicle collision. These medical costs will be passed on to patients, which may result in a large reimbursement deficit for hospitals caring for these patients. This retrospective review examines the costs of caring for all intoxicated drivers who were admitted to a Level 1 trauma center after a motor vehicle collision over a 2-year period. Intoxicated drivers were younger (P = 0.0002), had a lower Glasgow Coma Scale (P = 0.0013), and were more likely to meet Level 1 trauma criteria (P = 0.0002). The sum of total charges for injured drunk drivers totaled $5.2 million. When taking into account fixed and variable costs of care, lost hospital net income would be $3 million (21.9%) over a 3-year span whether House Bill 5588 passes. In conclusion, the passage of House Bill 5588 will lead to a large financial burden for hospitals that treat intoxicated drivers.

Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel.

BACKGROUND: The mortality risk in elderly patients who sustained head trauma resulting in intracranial hemorrhage (ICH) while taking the antiplatelet agents aspirin (ASA) or clopidogrel or both (Plavix) was evaluated. METHODS: A retrospective review identified trauma patients, age 50 or greater, who had computed tomography (CT) evidence of ICH and were taking ASA, clopidogrel, or a combination of both. Patient demographics, type of medication, mechanism of injury, Glasgow Coma Score (GCS), grading of head CT scans, and outcomes were characterized. RESULTS: One hundred nine patients including 61 men and 48 women were identified; the mean age was 77 years +/- 10 years. Injury was due to level fall (73), fall from height (21), motor vehicle crash (11), and other (4). Twenty (18%) patients died; age, gender, type of medication, and mechanism of injury were not predictive of death. The initial GCS for survivors was 14.2 +/- 1.9 versus 11.3 +/- 4.9 for nonsurvivors (p < 0.007). Deaths based on initial CT grade were: grade 1, 5 of 70; grade 2, 4 of 17; grade 3, 5 of 10; grade 4, 6 of 12 (p = 0.002). Follow-up CT scans were performed in 81 patients who were not taken to surgery and had grade 1 or 2 hemorrhage initially. Of 4 patients with hemorrhage progression, there was 1 death (25%) versus 6 deaths in 77 patients without progression (8%; p = 0.70). CONCLUSIONS: There is high mortality rate associated with ASA or clopidogrel or both in elderly patients who have head trauma resulting in ICH. The presenting GCS and initial grade of CT scan are most predictive of death. Progression of hemorrhage after admission is unusual. The risk of brain injury, particularly from falls, should be explained to elderly patients taking these medications.

Donation after cardiac death: lessons learned.

Despite the increasingly positive outcome of organ transplantation as an accepted treatment of end-stage organ diseases, an average of 15 people die each day awaiting organ transplantation. According to the United Network for Organ Sharing, there are more than 90,000 people in the United States waiting for an organ transplant. In the United States, less than 1% of all deaths are attributed to brain death. A single brain-dead organ donor has the potential to save up to 8 individuals by donating organs and providing up to 50 people with tissue and cornea transplants. The reality is that the source of available brain-dead donors does not meet the needs of the growing waiting list. To help deal with the increasing demand for organs, donation after cardiac death has been reintroduced to families of patients with catastrophic brain injuries. Families have the right to be informed of all potential end-of-life options, including that of organ donation and the use of donation after cardiac death when appropriate. Hospitals and healthcare workers must be committed to provide the option of donation after cardiac death for both donor families and transplant recipients. The purpose of this article is to examine the process of implementing a donation after cardiac death policy in a 1,061-bed tertiary care hospital with level I trauma designation.

Treatment of trauma patients with intracranial hemorrhage on preinjury warfarin.

BACKGROUND: Preinjury warfarin anticoagulation has been shown to increase the mortality of traumatic intracranial hemorrhage. We have evaluated the impact on patient mortality of the rapid triage of patients at risk for warfarin associated traumatic intracranial hemorrhage. METHODS: A "Coumadin Protocol" was implemented in January, 2001 in the Emergency Department that expedited triage of anticoagulated trauma patients to immediate physician evaluation. Patient outcomes during a 2 year period were compared with a matched control group of similarly injured, anticoagulated patients who were treated before protocol initiation. RESULTS: Thirty-five patients were treated after implementation of the Coumadin Protocol. Mean time until warfarin reversal was 4.3 +/- 4.4 hours, and there was a 37% mortality. Twenty-two control patients had a mean time to reversal of 4.2 +/- 2.9 hours, with a 45% mortality (p = 0.610). Ten protocol patients were shown to have intracranial hemorrhage progression by computed tomography (CT) scan, with a 60% mortality rate. Seventeen patients had follow-up CT scan and showed no progression; only one of these patients (6%) died (p = 0.004). Hemorrhage severity based on the initial CT scan did not predict mortality or hemorrhagic progression. CONCLUSIONS: We conclude from these data that a trauma center protocol for rapid identification of intracranial bleeding without a concomitant therapeutic protocol does not improve survival in head injured patients on preinjury warfarin.

Improved organ procurement through implementation of evidence-based practice.

Michigan, like most other states in the nation, has a clear need for more organ donors for transplantation; at this time, there are more than 2,800 patients in the state awaiting organs. We have evaluated the effects of a process improvement program designed to increase the number of organ donors and the number of organs donated from appropriate trauma patients. In 2005, William Beaumont Hospital began working with the Michigan Hospital Association Keystone Center and more than 40 hospitals across Michigan to implement evidence-based practices in organ donation focused on 4 specific outcomes and process measures. Outcome measures were conversion rate and referral rate, whereas the process measures were timely notification rate and the rate of requests by appropriate requester. We have retrospectively reviewed our recent outcomes in regard to these measures and compared them with the outcomes for the same time period 1 year before implementation. The data for preimplementation (January-December 2004; 32 eligible donors) and postimplementation (January-December 2005; 30 eligible donors) are summarized below: [table: see text] In 2004, a total of 67 organs were made available to Gift of Life Michigan; in 2005, a total of 88 organs were made available, a 31% increase. Implementation of evidence-based practice initiatives can significantly increase the donor conversion rate. This has led to an overall increase in the number of organs available for transplant.

Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality.

BACKGROUND: A prospective cohort study at our institution demonstrated a 48% mortality rate in warfarin anticoagulated trauma patients sustaining intracranial hemorrhage (ICH) compared with a 10% mortality rate in nonanticoagulated patients. Forty percent of patients demonstrated progression of their ICH, despite anticoagulation reversal, with a resultant 65% mortality rate. Seventy-one percent of these patients initially presented with a Glasgow Coma Scale (GCS) score > or = 14 and a 'minor' ICH. We postulated that early diagnosis of ICH and rapid anticoagulation reversal would reduce ICH progression rates and mortality. METHODS: All anticoagulated patients with known or suspected head trauma were entered into the Coumadin protocol. The protocol ensured immediate triage and physician evaluation, head computed tomography (CT) scan, and fresh frozen plasma administration in patients with documented ICH. RESULTS: Eighty-two patients were entered into the protocol with ICH documented in 19 (23%). Sixteen of 19 patients (84%) presented with GCS > or = 14. Median international normalized ratio (INR) for treated patients with ICH was 2.7 versus 2.5 for patients without ICH (p = 0.546). Mean time to initiate warfarin reversal was 1.9 hours for protocol patients versus 4.3 hours for preprotocol patients (p < 0.001). Two of 19 (10%) protocol patients with ICH died. However, both patients presented >10 hours after injury with a severe ICH. This 10% mortality rate is significantly less than the 48% mortality rate seen previously (p < 0.001) and is now consistent with that observed in similarly injured patients not on anticoagulation. CONCLUSION: Neither the initial GCS nor INR in anticoagulated trauma patients reliably identifies patients with ICH. Rapid confirmation of ICH with expedited head CT scan combined with prompt reversal of warfarin anticoagulation with fresh frozen plasma decreases ICH progression and reduces mortality.

Epidural versus intravenous pain control in elderly patients with rib fractures.

BACKGROUND: Epidural catheters are used in older patients with rib fractures to improve outcome. We reviewed the efficacy of epidural analgesia (EA) compared with intravenous narcotics (IVN) in this population. METHODS: Rib fracture patients >55 years old admitted to our level I trauma center from 1999 through 2002 were reviewed for demographics, Injury Severity Score (ISS), Abbreviated Injury Score for chest, length of stay, cardiopulmonary comorbidities, complications, and type of analgesia. RESULTS: There were 187 patients: 72 men and 115 women. The mean age was 77 years. For ISS <9, length of stay for EA patients was 12 +/- 5 days versus 5 +/- 4 days for IVN patients (P < 0.001). Complications occurred in 9 of 10 EA patients versus 21 of 52 IVN patients (P < 0.001). No difference was noted in length of stay for patients with ISS > or =9. Complications in the high ISS group occurred in 29 of 43 EA patients versus 37 of 82 IVN patients (P <0.05). Stratification of patients based on low versus high Abbreviated Injury Score for chest yielded similar results. CONCLUSIONS: EA is associated with prolonged length of stay and increased complications in elderly patients, particularly those with less significant injuries, regardless of cardiopulmonary comorbidities. EA for elderly patients with rib fractures should be prospectively re-evaluated.

Spontaneous retroperitoneal hemorrhage.

BACKGROUND: We evaluated patients with spontaneous retroperitoneal hemorrhage for reliable predictors of early diagnosis and improved outcomes. METHODS: A retrospective chart review was done to determine patient demographic and laboratory findings, presenting symptoms, time to diagnosis, anticoagulant and/or antiplatelet agent use, transfusions, and patient outcome. RESULTS: One hundred nineteen patients were identified; 14 (12%) died (mean age 77 +/- 9 years vs. 74 +/- 10 years for survivors [P = 0.235]). All nonsurvivors were on anticoagulants: 8 of 89 (9%) were on heparin or warfarin alone, and 6 of 23 (26% [P = 0.028]) were on a combined anticoagulant-antiplatelet regimen. Symptom onset to computed axial tomography (CAT) scan averaged 1.3 +/- 1.3 days for nonsurvivors versus 1.5 +/- 1.9 days for survivors (P = 0.778). Hemoglobin was 9.07 +/- 3.35 for nonsurvivors versus 9.60 +/- 2.07 for survivors (P = 0.435). Eighty-eight patients were transfused, and 10 died; 31 patients had no transfusion, and 4 of these died (P = 0.821). CONCLUSIONS: A high index of clinical suspicion is necessary for diagnosis of spontaneous retroperitoneal hemorrhage because these patients present with a variety of symptoms. Prospective studies are necessary to determine whether earlier diagnosis combined with aggressive resuscitation can impact the high mortality rate seen in these patients.

Management of blunt splenic injury in patients with concurrent infectious mononucleosis.

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.

Hypothermia is an independent predictor of mortality in ruptured abdominal aortic aneurysms.

Hypothermia is known to significantly increase mortality in trauma patients, but the effect of hypothermia on outcomes in ruptured abdominal aortic aneurysms (RAAA) has not been evaluated. The authors reviewed their experience from 1990 to 1999 in 100 consecutive patients who presented with RAAA and survived at least to the operating room for surgical treatment. There were 70 men and 30 women, with a mean overall age of 74 +/-8 years. Overall mortality was 47%. Univariate ANOVA (analysis of variants) showed significant correlation with mortality for decreased intraoperative temperature, decreased intraoperative systolic blood pressure, increased intraoperative base deficit, increased blood volume transfused, increased crystalloid volume (all p < 0.001); decreased preoperative hemoglobin (p = 0.015); and increased age (p = 0.026). Patient sex, initial preoperative temperature, preoperative systolic blood pressure, and operating room time were not correlated with mortality in the univariate analysis. Using these same clinical variables, multiple logistic regression analysis showed only 2 factors independently correlated with mortality: lowest intraoperative temperature (p = 0.006) and intraoperative base deficit (p = 0.009). The mean lowest temperature for survivors was 35 +/-1 degrees C and for nonsurvivors 33 +/-2 degrees C (p < 0.001). When patients were grouped by lowest intraoperative temperature, those whose temperature was < 32 degrees C (n = 15) had a mortality rate of 91%, whereas patients with a temperature between 32 and 35 degrees C (n = 50) had a mortality rate of 60%. In the group that remained at or > 35 degrees C (n = 35) the mortality rate was only 9%. A nomogram of predicted mortality versus temperature was constructed from these data and showed that for temperatures of 36, 34, and 32 degrees C the predicted mortality was 15%, 49%, and 84%, respectively. The authors conclude that hypothermia is a strong independent contributor to mortality in patients with ruptured abdominal aortic aneurysms and that very aggressive measures to prevent hypothermia are warranted during the resuscitation and treatment of these patients.

Complications of preinjury warfarin use in the trauma patient.

BACKGROUND: The frequency of use of warfarin anticoagulation increases significantly in the elderly population. It remains controversial whether this puts these patients at increased risk for hemorrhagic complications after trauma. METHODS: We prospectively evaluated consecutive trauma patients who were taking warfarin and compared their outcomes to a group of age-matched patients with head injuries but not taking warfarin. RESULTS: One hundred fifty-nine trauma patients on warfarin were evaluated, 94 (59%) with some type of head trauma; 25 of these 94 patients (27%) had documented intracranial trauma. Fifteen patients died (9.4%); they had an international normalized ratio of 3.3 +/- 1.6 versus 3.0 +/- 2.1 for survivors in the warfarin group (p = 0.585). Twelve deaths were in the group of 25 patients with intracranial injuries (48%). Three patients without head injury died (5%) of other causes not related to warfarin or hemorrhage at a mean of 13 days after admission. Ten of 12 patients on warfarin with intracranial injuries who died had documented loss of consciousness (LOC); two patients who died secondary to an isolated intracranial injury had no LOC. Of 70 age-matched patients with head trauma not taking warfarin, 47 (67%) had intracranial injury and 5 of these died (10%) (p < 0.001 for both values compared with study patients). There were no significant differences for patients with intracranial injury comparing those on warfarin and those who were not in terms of age, gender, mechanism of injury, Injury Severity Score, or Glasgow Come Scale score. CONCLUSION: We conclude that the preinjury use of warfarin does not place the trauma patient at increased risk for fatal hemorrhagic complications in the absence of head trauma. Furthermore, the presence of a head trauma alone is not predictive of mortality. However, the presence of intracranial injury is strongly associated with a mortality rate that is significantly higher than patients with head trauma who are not taking warfarin. LOC is also associated with mortality, but the absence of loss of consciousness does not reliably indicate the absence of intracranial injury or risk of death.

Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma.

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.

High-flow venovenous rewarming for the correction of hypothermia in a canine model of hypovolemic shock.

BACKGROUND: Continuous arteriovenous rewarming (CAVR) has been shown to effectively reverse hypothermia; however, its use is limited in the setting of profound hypotension. We have evaluated the effectiveness of high-flow venovenous rewarming (HFVR) using bypass for the correction of hypothermia in a hypotensive canine model and compared these results to CAVR. METHODS: Eight dogs, randomly assigned to either HFVR or CAVR, were cooled to a core temperature of 29.5 degrees C and then bled to a mean arterial pressure of 55 mm Hg. Rewarming was then initiated and the time required for blood, liver parenchyma, and esophageal (core) temperature to reach 36 degrees C was recorded. RESULTS: Mean flow rates were 1,536 +/- 667 mL/min for HFVR and 196 +/- 35 mL/min for CAVR (p = 0.007). Time in minutes to rewarm to 36 degrees C for the HFVR versus the CAVR groups, respectively, were as follows: blood, 12 +/- 2 versus 99 +/- 19; liver, 21 +/- 3 versus 102 +/- 16; and esophageal, 25 +/- 6 versus 125 +/- 17 (all < 0.001). CONCLUSION: HFVR is an effective method for rapid rewarming in a profoundly hypothermic, hypotensive animal model and may have clinical utility in patients presenting with hypovolemia/hypotension complicated by hypothermia.

Intracranial complications of preinjury anticoagulation in trauma patients with head injury.

BACKGROUND: We have evaluated our recent experience as a Level I trauma center to test the hypothesis that preinjury anticoagulation adversely affects the morbidity and mortality of trauma patients with an intracranial injury. METHODS: Records of 380 patients admitted to the trauma service from January 1997 to December 1998 who at the time of admission were taking warfarin, low-molecular-weight heparin, aspirin, nonsteroidal anti-inflammatory drugs, clopidogrel, dipyridamole, pentoxifylline, or naproxen were reviewed. Thirty-seven patients with intracranial injuries were identified and compared with a matched (age, gender, mechanism, and severity of injury) control group of 37 patients with similar head injury but not taking any anticoagulant randomly selected from the trauma registry for that same time period. RESULTS: The control and anticoagulated groups were comparable in terms of age, 75 +/- 8 versus 74 +/- 11 years (p = 0.655); gender, 22 men/15 women versus 21 men/16 women; mechanism of injury, 30 falls/7 motor vehicle crashes versus 30 falls/7 motor vehicle crashes; and length of hospital stay, 11 +/- 14 versus 10 +/- 11 days (p = 0.853). In the anticoagulated group, the mean Injury Severity Score was 17.0 +/- 7.8 and the mean Glasgow Coma Scale score was 11.8 +/- 4.0; these were not significantly different from the control group, which had a mean Injury Severity Score of 19.8 +/- 8.1 (p = 0.143) and a Glasgow Coma Scale score of 12.5 +/- 2.6 (p = 0.378). There were 14 deaths (38%) in the anticoagulation group, versus 3 deaths in the control group (8%) (p = 0.006). In the anticoagulation group, 4 of 12 patients (33%) taking warfarin died, whereas 9 of 19 patients (47%) taking aspirin died (p = 0.285). All deaths were secondary to head injuries; all deaths in the control group and all but one in the anticoagulated group were the result of a fall; 6 of 10 anticoagulated patients who fell on stairs died, and 5 of these were taking aspirin only. CONCLUSION: These data indicate that the trauma patient with preinjury anticoagulation such as warfarin or even aspirin who has an intracranial injury has a four- to fivefold higher risk of death than the nonanticoagulated patient. The efficacy of reversing the anticoagulant effect at the time of hospital admission remains to be evaluated.