Major Trauma and the Elder West Virginian: A Six Year Review at a Level I Trauma Center.

BACKGROUND: Trauma was the seventh leading cause of death for persons 65 and older in West Virginia (WV) in 2010. In 2007, fatality rates for both accidental falls and motor vehicle crashes were higher in West Virginia than the nation as a whole. US Census Data from 2010 showed WV to have one of the oldest median ages in the nation (surpassed by Maine and Vermont) and currently 16% of the population of WV is over 65 years of age. METHODS: This is a retrospective observational study of data extracted from the John Michael Moore Trauma Center (JMMTC) trauma registry for the time period of January 1, 2009 to December 31, 2014. RESULTS: There were 3,895 patients, aged 65 years or older, treated at the Jon Michael Moore Trauma Center in Morgantown, WV during the study time period. Accidents accounted for 98.6% of the injuries. The elderly were most commonly injured in their place of residence (59.8%). The top two mechanisms of injury were falls (75.2%) and motor vehicular crashes (13.9%). Frequently, disposition from the Emergency Department was to a higher level of care: Intensive Care Unit (32.3%) and Step-down Unit (21.2%). The most common serious injuries were intracranial hemorrhage (40.0%), lower extremity fractures (38.1%), and spine fracture (26.0%). The average hospital stay was 5.6 days and the average ICU stay was 3.2 days. Hospital discharge dispositions frequently resulted in care out of the home; skilled nursing facility (22.0%), rehabilitation facility (15.5%), morgue/funeral home (6.6%), and long-term residential care facility (5.7%). The most common pre-existing medical conditions were hypertension (71.9%), diabetes mellitus (29.3%), chronic obstructive pulmonary disease (19.5%), and dementia (18.8%). CONCLUSION: Elder West Virginians most frequently are injured in falls and motor vehicular crashes. Pre-existing medical conditions are very common. Trauma in the elderly creates a significant burden on the patient, their families, and on the health care system in West Virginia. Injury prevention interventions have the potential to diminish the impact of trauma on elder West Virginians.

Advice on stroke provided by pharmacies in the United States: implications for treatment and care.

OBJECTIVES: Studies have found that some health lines and physician's offices have provided treatment advice other than "call 9-1-1 for an ambulance" to patients who present with a stroke scenario. We assessed the treatment advice given by selected pharmacies in the United States regarding stroke. METHODS: The investigators called 73 randomly selected pharmacies and informed respondents that the caller's mother had experienced stroke-like symptoms several days earlier. Respondents were asked what should be done if the symptoms returned in the future and then debriefed on the deception afterward. RESULTS: Seventy-one of the 73 pharmacies participated and only 20% (95% confidence interval 12-30) of respondents gave the ideal advice "call 9-1-1 for an ambulance." CONCLUSIONS: One out of every five pharmacy respondents across the United States recommended advice other than calling emergency medical services for a potential stroke scenario.

The use of technology to reduce radiation exposure in trauma patients transferred to a level I trauma center.

BACKGROUND: Patients with traumatic injuries transferred from rural hospitals to tertiary centers in West Virginia frequently undergo repeat computed axial tomography (CT) imaging upon arrival. The traditional method of sending images on a compact disc (CD) with EMS can be unreliable due to software incompatibility, CD malfunction, or misplacement of the CD. Given the known risks associated with ionizing radiation, physicians are increasingly aware of the need to avoid unnecessary CT imaging. Image storage applications such as ImageGrid provide a means to store images securely without the issues and inherent problems of a CD. These images can be uploaded at the referring hospital and may be viewed from any computer at the receiving facility, by multiple providers--even prior to patient arrival. The goal of this study was to determine if utilizing ImageGrid compared to traditional data transfer by CD resulted in a decrease in the amount and type of images obtained in the initial Emergency Department (ED) evaluation at the tertiary center. METHODS: We analyzed data from the Jon Michael Moore Trauma Registry for patients transferred to the Emergency Department at WVU Hospitals from an outside facility. Two study periods were reviewed; prior to ImageGrid implementation and after implementation of the system. Medical records of all patients admitted to the Trauma Surgery Service after a trauma system activation in the ED were reviewed during these time periods. Number and type of CT studies obtained in the Emergency Department were recorded for analysis. RESULTS: In the month of July 2010, 183 patients were admitted to the Trauma Surgery service after trauma team activation. Transfers from referring hospitals accounted for 77 of the 108 (42.1%). WVU Hospitals implemented ImageGrid during 2011. In July 2012, 243 patients were admitted to the Trauma Service, of which 105 (41.1%) were transfer patients. After implementation of ImageGridTM there was a significant decrease in the number of repeat CT Scans of the brain (19/27 [70.4%] vs. 18/40 [45.0%], p < .05), as well as CT scans of the chest, abdomen or chest/ abdomen/pelvis (9/18 [50.0%] vs. 2/23 [8.7%], p < .05). CT of the face showed a decreasing trend (5/9 [55.6%] vs. 1/9 [11%], p > .05 [p = 0.06]), but did not achieve statistical significance. After implementation of ImageGrid there was a marked decrease in total CT scans repeated (46/79 [58.2%] vs. 28/107 [26.2%], p < .05). CONCLUSION: In West Virginia, the use of image archival systems such as ImageGrid appears to result in less repeat CT imaging upon arrival at a tertiary trauma center. Given risks associated with ionizing radiation and costs of repeat imaging the benefits have important implications for patient safety and cost containment.

Trauma patient access: the role of the emergency medical services system in North-Central West Virginia.

UNLABELLED: Trauma patients face many obstacles as they access the healthcare system in North-Central West Virginia. This study highlights some of these barriers and discusses administrative and legislative initiatives that could help mitigate the disparities that rural trauma patients face. METHODS: This is a retrospective, observational study utilizing information from the West Virginia University (WVU) MedCom Database. Trauma related Emergency Medical Services (EMS) calls from 2002 to 2011 were reviewed to determine many of the parameters of the care provided by EMS in the WVU MedCom catchment area. These 54,952 trauma related EMS contacts were reviewed to determine estimated time of arrival (ETA) at the receiving facility, level of EMS response, trauma activation criteria, time of day, and day of week of the transport. RESULTS: The mean ETA for all transports was 11.7 minutes with mean transport ETA from the most rural county, Pendleton County, being 28.4 minutes. Emergency Medical Technician-B (BLS) providers covered 23% of the calls. Emergency Medical Technician-P (ALS) providers covered 76% of the calls. West Virginia State Trauma activation criteria were met for 30% of the transports. BLS providers transported 19% of these trauma activation criteria patients and ALS providers transported 78% of these transports. CONCLUSIONS: In north-central West Virginia, there are many barriers facing the trauma patient as they access the healthcare system. Among these are extended transport times, the capabilities of the EMS provider responding, and the limitation that approximately 50% of counties have either no hospital at all or only a hospital with limited treatment capability for the trauma patient transported by EMS.

Falls and dilemmas in injury prevention in older West Virginians.

UNLABELLED: Falls are the number one cause of injury-related morbidity and mortality in West Virginia senior citizens. Poor outcomes following falls are exacerbated by numerous comorbidities which are prevalent in the elderly population in West Virginia. This study describes the injury patterns, resource utilization and dispositions of WV seniors injured in a fall. METHODS: This is a descriptive retrospective cohort study utilizing the West Virginia State Trauma System registry; which collects trauma data from 33 acute care facilities in West Virginia. RESULTS: Data from 5498 cases were reviewed for patients enrolled in the Registry in 2010. Fall victims aged 65 and older were included. Most falls occurred in the home (75.2%) or in a residential institution (11.3%). Femur fractures (36.3%) and intracranial hemorrhages (8.2%) were the most common injury diagnoses. Disposition back home declined from 58.6% in the 60-65 age group to 20.9% returning home following falls in the age 90-94 group. Conversely, disposition to a skilled nursing facility rose from 20.1% in the age 60-65 group to 49.1% in the age 90-94 group. The case fatality rate for all the seniors enrolled in the trauma system was 3.3%. DISCUSSION: Fall was the mechanism of injury for 83.3% of traumatic injuries in persons over the age of 65 enrolled in the WV trauma system. Older West Virginians suffer from numerous comorbidities that increase the risk of fall as well as the severity of injuries from a fall. CONCLUSION: In West Virginia, there is a correlation between increasing age and less desirable outcomes and dispositions from trauma centers for senior citizens after a fall. West Virginia patients, families and care providers must frequently face complicated treatment dilemmas, especially as the related risk of falling and the co-morbid conditions are commonly seen in older West Virginians. Multi-modal fall prevention programs can reduce the risk of falls in senior citizens.

Injury prevention and recreational all-terrain vehicle use: the impact of helmet use in West Virginia.

UNLABELLED: All-terrain vehicles (ATVs) are a popular source of outdoor activity in the United States, particularly in West Virginia. During the period of time from 1999 to 2007, deaths associated with ATVs in West Virginia increased by 28%. Helmet use among bicycle and motorcycle riders has been shown to decrease morbidity and mortality following trauma. METHODS: We performed a retrospective observational study to compare injury patterns, hospital course, and resource utilization of non-helmeted and helmeted riders involved in ATV accidents using data from the West Virginia Trauma Center System. Descriptive statistics were calculated for all study variables and comparisons were made between helmeted and non-helmeted riders. RESULTS: In 2010, there were 1,059 patients aged 18 and over with traumas resulting from ATV accidents within the System. Riders involved in ATV trauma occurring on farms and streets were significantly more likely to be non-helmeted, while those using ATVs for recreational purposes were more likely to be helmeted. Non-helmeted riders were significantly more likely to arrive to the hospital via helicopter than helmeted riders, and were less likely to be discharged home from the ED compared to helmeted riders. Non-helmeted riders sustained significantly more head, neck, soft tissue injuries, concussions, intracranial hemorrhages, facial fractures, skull fractures, and thoracic spine fractures than helmeted riders. DISCUSSION: The findings of the current study support previous studies documenting that helmet use is protective against intracranial injury and other injuries of the head and neck. ATV use continues to be a significant contribution to trauma morbidity and mortality in West Virginia. CONCLUSION: Efforts that focus on increased helmet use have the potential to significantly reduce morbidity and mortality following ATV trauma. Enforcement of the current West Virginia ATV Law should be encouraged. Legislation expanding the mandatory use of safety equipment and rider training should be enacted in West Virginia.

Pediatric bicycle injury prevention and the effect of helmet use: the West Virginia experience.

OBJECTIVES: The primary objective was evaluation of the injury pattern of children 14 years old or less involved in bicycle accidents and comparison of the differences between those wearing a helmet and not wearing a helmet. METHODS: This was a retrospective cohort study of all pediatric patients involved in bicycle crashes from 2008 through 2010 who were treated within the West Virginia Trauma System. A case was selected for further analysis if "bicycle" and "blunt cause of injury" were present in the Mechanism of Injury field and if age was 14 years old or less. Descriptive statistics were calculated on all variables. Differences between the helmeted and un-helmeted cohorts were tested using the Wilcoxon test or Fisher's exact test as appropriate. In all cases an alpha of 0.05 was selected as the threshold for statistical significance. RESULTS: The helmeted group had a concussion rate of 19.4% while concussions were noted in 37.4% of the un-helmeted group (p = 0.0509). Additionally, there was a significant difference in the rate of skull fractures seen. Skull fractures occurred in 3.2% of the helmeted and 17.4% of the un-helmeted (p = 0.0408) riders. The rate of intra-cranial hemorrhage was 0% in helmeted riders and 17.4% in un-helmeted riders (p = 0.0079). Finally, perhaps the largest indicator of the effectiveness of helmets in the pediatric bicycle population is the mortality rate. While not statistically different, 100% (n = 2) of the deaths occurred in the un-helmeted group. CONCLUSION: This study of the West Virginia pediatric population demonstrates findings similar to prior studies looking at the effectiveness of helmets in preventing injuries during a bicycle crash. Bicycle helmets were shown to significantly reduce the rates of both skull fractures and intracranial hemorrhage. Based on this, the expanded use of helmets within the pediatric population should continue to be encouraged both from an educational and legislative standpoint.

Major trauma in West Virginia dementia patients injury patterns, discharge dispositions and implications for treatment and injury prevention.

Our study examines injury patterns, treatment implications, discharge disposition, and injury prevention for trauma patients with dementia. It is a retrospective observational study of trauma patients at the Jon Michael Moore Trauma Center at West Virginia University Hospitals. Causes of injury, injuries sustained, and discharge disposition were examined in 286 trauma patients with a pre-existing diagnosis of dementia and 5,865 trauma patients without dementia. All patients included in this study were 40 years of age or older. Injury data were compiled for patients with dementia. Causes of injury and discharge disposition were compared for the two groups.

Primary care office responses to a stroke scenario.

PURPOSE: One previous study found that healthlines affiliated with academic neurology programs recommended non-emergent treatment for a hypothetical stroke scenario almost one quarter of the time, which could contribute to patients presenting too late for time dependent stroke therapies. We assessed the treatment advice given in a hypothetical stroke scenario by primary care physician offices across the United States. METHODS: We obtained a national listing of United States primary care physician offices from Yellowpages.com, and selected a systematic random sample of numbers to call. The respondent answering the phone was presented with a standardized, scripted stroke patient scenario, and asked to choose one of four responses that could be provided (wait for symptom resolution, attempt to schedule an office appointment later in the day, schedule an office visit within two days, call 911 for ambulance transport to a hospital). RESULTS: Forty-two respondents completed the survey (average age = 43 years; 88% female), with 29% (95% CI 17%-44%) recommending scheduling an appointment later in the day if symptoms do not resolve. The remaining respondents recommended calling 911. When presented with a heart attack scenario, 100% of respondents recommended calling 911. CONCLUSIONS: Almost one third of the primary care physician offices recommended scheduling an appointment later in the day for a hypothetical stroke case, despite always giving the correct answer of call 911 for a classic heart attack scenario. These results suggest that stroke education with specific emphasis on the need to call 911 may be needed for primary care physician office receptionists.

National healthline responses to a stroke scenario: implications for early intervention.

BACKGROUND AND PURPOSE: Acute stroke is a time-dependent emergency in which patients often arrive outside of the therapeutic treatment windows. To determine the role that healthlines may have in promoting early presentation, this study evaluated patterns of healthline triage of potential stroke patients. METHODS: Phone numbers of healthlines at 82 United States hospitals with neurology residencies were acquired. Each healthline was called and the operator was presented with a standardized scripted stroke patient scenario. The operator was asked to choose 1 of 4 responses that could be given to the patient (wait for symptom resolution, contact a primary care physician, drive to a local urgent care center, call 911 for ambulance transport). The operator was then asked to name common signs and symptoms of stroke. If the operator transferred the call, the process was repeated. RESULTS: Forty-six healthlines participated, with 22% recommending that the patient contact a primary care physician. The remaining 78% recommended calling 911. Calls were transferred at least once in 18 cases, and 24% of the operators could not name 1 sign or symptom of stroke. CONCLUSIONS: Nearly one-quarter of potential stroke patients were routed away from emergent treatment for the described scenario. By diverting patients away from emergency therapy, patients are in jeopardy of "falling" out of the windows for therapy. Improved stroke education for healthline personnel may result in stroke patients arriving at an emergency department more urgently.