Pain management on a trauma service: a crisis reveals opportunities.

Objectives: The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). Methods: Retrospective analysis of pain management at a level II trauma center for January-November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. Results: 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. Conclusions: Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. Level of evidence: IV.

Self-inflicted injury and the older trauma patient: a 20 year review of suicide attempts and outcomes.

PURPOSE: Older patients (Older) have complex health management needs often requiring additional resources. Mental health disorders are common among trauma patients, yet minimal information on older suicidal related injury and outcomes exists. A review of trauma patients with intentional self-inflicted injury at one trauma center was done to describe and identify unique elements of this cohort of patients. METHODS: Trauma registry data from 2000 to 2019 were reviewed for intentional injury and data abstracted included demographics, injury severity, diagnoses, comorbidities and outcomes. Cohorts by age were compared: Older (65 +) vs Younger (< 65). Values considered significant at p ≤ 0.05. RESULTS: 557 suicide attempts were identified with 9% among Older patients. Most patients were male with median age of 75 years for Older and 35 years for Younger cohort, with similar length of stay (LOS) and injury severity scores (ISS). Penetrating injury was more common among Older patients with firearm used most often, 34% vs 14% for Younger. Differences were evident between male and female Older patients with ISS 16.7 vs 5, p < 0.01 and mortality, p = 0.03. The outcome of discharge to home was significantly different between Older and Younger, 6% vs 20% (p < 0.05). A difference in mortality was evident, Older 38% vs Younger 18% (p < 0.05). CONCLUSION: With the growing aging population, it is important to acknowledge the resultant increase in concomitant mental health issues and suicidality among older patients, where depression may be undiagnosed and untreated. Providing care within this cohort may reduce future attempts and lessen the burden on the health care system.

Improving length of stay on a trauma service.

BACKGROUND: Reducing length of stay (LOS) is a major healthcare initiative. While LOS is closely linked to the diagnosis and procedure in elective surgery, many additional factors influence LOS on a trauma service. We hypothesized that more standardized patient management would lead to decreased LOS. METHODS: Retrospective analysis of Trauma Registry data compared LOS before (PRE) and after (POST) implementation of standardized processes on a trauma service. Patients were subdivided by age (over and under 65 years). Data were compared using unpaired t-test, χ2 test and analysis of variance tests, where appropriate. RESULTS: 1613 PRE and 1590 POST patients were compared. Although age and Injury Severity Score were similar, median LOS decreased by 1 day for the group overall (p<0.0001), and for subgroups over and under the age of 65 years (p<0.0001). Older patients were discharged home 13% more often in POST, compared with 4% more for younger patients. CONCLUSIONS: Improved standardization of processes on a trauma service reduced LOS in patients of all ages. A prospective study may identify specific factors associated with prolonged LOS, to allow further improvement. LEVEL OF EVIDENCE: III. STUDY TYPE: Therapeutic/Care management.