85.01 The Impact of Trauma Centers on Statewide Organ Donation Rate

Posted on January 26, 2017

C. Santino1, K. Ibraheem1, N. Kulvatunyou1, A. Azim1, G. Vercruysse1, A. Tang1, R. Friese1, L. Gries1, T. O’Keeffe1, B. Joseph1  1University Of Arizona,Division Of Trauma, Critical Care, Burns & Emergency Surgery,Tucson, AZ, USA

Introduction:

Trauma care has evolved with several studies demonstrating that patients treated at trauma centers have better outcomes. Trauma patients also form the major pool of organ donors in the United States. However, it is unknown if the distribution of trauma centers has affected organ donation. The aim of this study was to assess the association between trauma center distribution across states and organ donation rates.

Methods:

We performed a one year analysis (2013) of the CDC WISQARS database for all injury related deaths in a state. Number of organ donors after trauma-related death were obtained from the UNOS database. Number of trauma centers and their level of verification (Level I, II, III) in each state were obtained from American College of Surgeons’ (ACS) trauma center registry. Only states with data available for organ donation were included. States were divided into two groups based on the trauma center distribution per million population: high density states (HDS) where trauma center density was greater than the national average and low density states (LDS) where trauma center density was less than the national average. Stepwise linear regression analysis was performed for the predictors of organ donors per million population and organ donors per 100,000 trauma deaths.

Results:

A total of 40 states were included in the analysis with mean trauma center distribution of 5.7 trauma centers per one million population and an organ donation rate of 16.8±12.8 organ donors per one million population. 30 states were included in LDS and 10 in HDS. HDS states had a higher number of total adult trauma centers (5 [2-11] vs. 2 [1-7]; p=0.02), a higher number of level 1 and 2 trauma centers (5 [1-10] vs. 2 [1-5]; p=0.02), and a lower area of coverage per trauma center (p=0.001). HDS states had a higher rate of organ donors per one million population (24.8±21.9 vs. 14.2±6.5;p=0.022) and a higher rate of organ donors per 100,000 trauma deaths (32.2±22.1 vs. 17.4±7.8;p=0.025). On stepwise linear regression analysis, trauma center distribution per million population was independently associated with higher rate of organ donors per one million population (β [95% CI]: 0.38 [0.01-0.49]; p=0.04) and organ donors per trauma death (β [95% CI]: 0.40 [0.03 – 0.59]; p=0.03).                 

Conclusion:

Regional variability of ACS verified trauma centers significantly impact statewide trauma-related organ donation rate. The findings of this study highlight a correlation between statewide organ donation rates and ACS verified trauma center density.

 

47.06 Geographic and Socioeconomic Distribution of Pediatric Firearm Injuries in Arizona

Posted on January 26, 2017

A. Safavi1, T. O’Keeffe1, R. S. Friese1, B. Joseph1  1University Of Arizona,Division Of Trauma, Critical Care, Emergency Surgery, And Burns, Department Of Surgery,Tucson, AZ, USA

Introduction:
Strict firearm legislation has been shown to decrease pediatric firearm injuries. However other factors may also play part, such as the effect of socioeconomic status.  The aim of this study is to identify the geographic distribution of pediatric firearm injuries in Arizona and examine the association of firearm incidence with household income of Arizonian families. 

Methods:
Patients younger than 18 years old with firearm injuries in Arizona were identified from the 2008-2012 Arizona trauma registry.  Primary outcome of interest was incidence of firearm injury per county and zip code of residence.  Secondary outcome was the socioeconomic status of the household of residence. Using US census bureau data, mean and median income for individual counties and zip codes were obtained.  Descriptive and linear regression analysis was then used to determine the association between socioeconomic status and incidence of pediatric firearm injury.

Results:
577 children with firearm injuries (male: female 493:84, mean age 15.6+3.5) were included, of which 31 (5%) were self inflicted. 279 (46%) of children were Caucasian followed by African American 68 (12%) and Native American 47 (8%).  Among counties, Pima (12.7) Yuma (10.2) and Maricopa (9.7) had the highest number of pediatric firearm injury per 100,000 populations. When analyzing by zip code of residence, 349 (60%) and 479 (83%) of injured children were residing in zip codes below 50 (53,893$) and 75 (67,843$) percentile of Arizona mean household income respectively. This was coherent with subgroup analysis of individual counties.  Residing in zip code with mean household annual income below 50 percentile was found to be predictive of higher pediatric firearm injury incidence in linear regression analysis  (β coefficient, 2.09; 95% confidence interval, 0.5-3.6; p = 0.007).

Conclusion:
Low household income is an independent predictor of pediatric firearm injury. Interventions to specifically target this high risk population may lead to more impactful intervention programs.

32.07 The Impact Of Gcs-age Prognosis (Gap) Score On Geriatric Tbi Outcomes

Posted on January 25, 2017

M. Khan1, A. Azim1, T. O’Keeffe1, L. Gries1, K. Ibraheem1, A. Tang1, G. Vercruysse1, R. Friese1, B. Joseph1  1University Of Arizona,Trauma And Surgical Critical Care/Department Of Surgery,Tucson, AZ, USA

Introduction:
As the population ages, increasing number of elderly patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information plays a crucial role in informed decision making for these patients. The aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients

Methods:
One-year (2011) retrospective analysis of geriatric TBI patients (h-AIS≥3 and age≥65) in the National Trauma Data Bank was performed and patients dead on arrival were excluded. We defined and calculated a GCS and Age Prognosis (GAP) score (Age/GCS score) for all patients. Our outcome measures were mortality and discharge disposition (Home versus Rehab/SNiF). ROC analysis was performed to determine the discriminatory power of GAP score.

Results:
A total of 8,750 geriatric patients with TBI were included. Mean age was 77.8± 7.1 years, median [IQR] GCS was 15 [14-15], and median [IQR] head-AIS was 4[3-4]. Overall mortality rate was 14.1% and 42.7% patients were discharged home. As the GAP score increased, mortality rate increased and discharge to home decreased. ROC analysis revealed excellent an discriminatory power for mortality (AUC: 0.826). Above a GAP score of 12, mortality rate was greater than 60%, more than 35% patients were discharged to Rehab/SNif and less than 5% of patients were discharged home.

Conclusion:
For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in drastic increase in mortality and adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patient families.
 

11.04 Early Thromboprophylaxis With Low Molecular Weight Heparin In Patients With Pelvic Fractures Is Safe

Posted on January 25, 2017

F. Jehan1, K. Ibraheem1, A. Azim1, A. Tang1, T. O’Keeffe1, N. Kulvatunyou1, L. Gries1, G. Vercruysse1, R. Friese1, B. Joseph1  1University Of Arizona,Trauma,critical Care, Burn And Emergency Surgery/Department Of Surgery,Tucson, AZ, USA

Introduction:
Early initiation of thromboprophylaxis is highly desired in patients with pelvic fractures but it is often delayed due to fears of re-bleeding and hemorrhage. The aim of our study was to assess the safety profile of early initiation of venous thromboprophylaxis in patients with pelvic trauma.

Methods:
Three year (2010-2012) retrospective study of trauma patients with pelvic fractures presenting at single level-I trauma center was performed. Patients who received thromboprophylaxis with low molecular weight heparin (LMWH) during their hospital stay were included. Patients were stratified in two groups based on timing of initiation of prophylaxis; early (initiation within first 24 hours) and late (initiation after 24 hours) initiation. Signs of bleeding or hemorrhage were defined as presence of pelvic hematoma, free fluid, or blush on CT scan. Decrease in hemoglobin (Hb) was defined as difference between admission Hb level and lowest post-prophylaxis Hb level. Our primary outcome measures were decrease in Hb levels, pRBC units transfused, and need for hemorrhage control (operative or angioembolization) after initiation of prophylaxis. Secondary outcome measures were hospital and ICU length of stay. Multivariate regression analysis was performed.

Results:
 

255 patients were included (158 in early and 97 in late group). Mean±SD age was 48.2±23.3 years, 50.6% were male, and mean±SD number of pRBC units was 0.62±1.59. After adjusting for confounders, there was no difference in the decrease in Hb levels (b= 0.087, 95% [CI]=[-0.253 – 1.025], p=0.23) or pRBC units transfused (b= -0.005, 95% [CI]= [-0.366 – 0.364]; p=0.75) between the two groups. Only one patient required hemorrhage control after initiation of thromboprophylaxis and belonged to the late group. There was no difference in the hospital LOS (b=0.120, 95% [CI]= -0.165 – 4.929; p=0.67). ICU length of stay was significantly shorter in early prophylaxis group (b= 0.206, 95% [CI]= 0.206 – 4.762; p=0.03).

On sub-analysis of patients with signs of bleeding or hemorrhage (n=52), there was no difference in decrease in Hb levels (b= 0.131, 95% [CI]= -1.411 – 2.586; p=0.55) or pRBC units transfused (b= -0.007, 95% [CI]= -1.588 – 1.518; p=0.96) between the two groups

Conclusion:
Our study shows no difference in pRBC transfusion requirements, drop in hemoglobin levels, or need for hemorrhage control between early and late initiation of thromboprophylaxis. We conclude that fear of hemorrhage with early thromboprophylaxis is not substantiated in patients with pelvic fractures