A mixed psychiatric and somatic care unit for trauma patients: 10 years of experience in an urban level I trauma center in the Netherlands.

BACKGROUND: A medical-psychiatric unit (MPU) is a special ward where staff is trained in caring for patients with psychiatric or behavioural problems that need hospitalisation for physical health problems. It is well known that these patients are at higher risk of complications and have a longer length of stay resulting in higher costs than patients without psychiatric comorbidity. The objective of this study was to analyse the trauma patient population of the first 10 years of existence of the MPU in a level I trauma center. PATIENTS AND METHODS: A retrospective analysis was performed in 2-year cohorts from 2006 to 2016. All trauma patients admitted to the MPU were compared with the overall trauma patient population in VUmc. Data (psychiatric diagnosis, substance abuse, trauma scores, surgical interventions, complications, mortality) were extracted from individual patient notes and the Regional Trauma Registry. RESULTS: 258 patients were identified. 36% of all patients had a history of previous psychiatric admission and 30% had attempted suicide at least once in their lifetime. Substance abuse was the most common psychiatric diagnosis (39%), with psychotic disorder (28%) in second place. The median hospital stay was 21 days. Median MPU length of stay was 10 days (range 1-160). Injuries were self-inflicted in 57%. The most common mechanism of injury was fall from height with intentional jumping in second place. Penetrating injury rate was 24% and 33% had an ISS ≥ 16, compared to 5% and 15%, respectively, in the overall trauma patient population. The most common injuries were those of the head and neck. Complication rate was 49%. CONCLUSION: Trauma patients that were admitted to the MPU of an urban level I trauma center had serious psychiatric comorbidity as well as high injury severity. Penetrating injury was much more common than in the overall trauma patient population. A high complication rate was noted. The high psychiatric comorbidity and the complicated care warrants combined psychiatric and somatic (nursing) care for this subpopulation of trauma patients. This should be taken into account in the prehospital triage to a trauma center. The institution of a MPU in level I trauma centers is recommended.

Effect of secondary prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma care.

BACKGROUND: Prevention of secondary prehospital risk factors such as hypoxia and hypotension is likely to improve patient prognosis in severe traumatic brain injury (TBI). Because the Dutch trauma care organization is characterized by fast access to specialized trauma care due to the geographical situation, we investigated whether and to what extend secondary risk factors, such as hypoxia and hypotension, and measures, such as endotracheal intubation, affect outcome in severe TBI in the context of a region with fast access to trauma care. METHODS: The medical records of 339 subsequent computed tomography-confirmed patients with TBI with a Glasgow coma scale (GCS) score≤8 who were primarily referred to a Level I trauma center in Amsterdam or Nijmegen in the Netherlands were retrospectively analyzed. RESULTS: Multinomial logistic regression revealed that the strongest outcome predictors in our population were a disturbed pupillary reflex (odds ratio [OR], 5.8), a GCS score of 3 (OR, 4.9), and arterial hypotension (OR, 3.5). Interestingly, we observed no differences between intubated and nonintubated patients with respect to metabolic and respiratory parameters or mortality whereby the injury severity score was slightly higher in endotracheally intubated patients (32 [25-41]) versus nonintubated patients (25 [22-29]). CONCLUSION: In agreement with others, GCS, a disturbed pupil reflex, and arterial hypotension were predictive for the prognosis of primarily referred patients with severe TBI in the Netherlands. In contrast, in the perspective of slightly higher injury scores in intubated patients, prehospital endotracheal intubation was not predictive for patient outcome.