41.10 Predictors of Delayed Emergency Department Throughput among Blunt Trauma Patients.

Posted on January 31, 2019

B. Steren2, M. Fleming1, H. Zhuo3, Y. Zhang3, K. Pei1,4  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,New Haven, CT, USA 3Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology,New Haven, CT, USA 4Texas Tech University of Health Sciences Center, School of Medicine,Department Of Surgery,Lubbock, TX, USA

Introduction:  Delayed emergency department (ED) throughput has been associated with increased mortality and increased length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, work up, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED remain unclear.

Methods:  The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of prolonged ED length of stay, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS level, geographic region) and injury severity score and abbreviated injury severity score (ISS and AIS).

Results: 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 year resulted in 0.78 increased minutes in the ED (p<0.0001).  On multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status and northeast region were associated with increased ED dwell time. Black and Hispanic patients spent on average 41.76 and 40.06 more minutes respectively in the ED room when compared to white patients (p <.0001). Patients seen at University hospitals spent 52.50 more minutes in the ED when compared to community hospitals whereas patients at non-teaching hospitals spent 32.32 fewer minutes (p <.0001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 44.87, 36.02 and 89.41 more minutes respectively (p <.0001). Non-Medicaid patients at Level 1 trauma centers and those requiring intensive care admission had significantly decreased ED dwell time. Medicaid patients took the longest to move through the ED with Medicare, BlueCross and Private insurance outpacing them by 17.69, 26.67 and 27.11 minutes respectively (p <.0001). Level 1 trauma centers moved patients through the ED fastest, with level II centers experiencing 49.56-minute delays and level III centers experiencing 130.34-minute delays (p <.0001). Not surprisingly, patients admitted to the ICU spent the least amount of time in the ED when compared to those admitted to floor or other (p <.0001).

Conclusion: ED length of stay varied significantly by patient and hospital characteristics.  Medicaid patients and university status were associated with significantly higher ED dwell time, while ACS level verification status had strong correlation with ED throughput. These results may allow targeted quality improvement programs to enhance ED throughput.  

 

41.09 Joint Forces Multi-Theater Spinal Fixation Study

Posted on January 31, 2019

M. Lee2, J. Miner2, C. Micallef2, A. Drury2, J. Whitis2, J. Bini1  1Wright State Physicians,Department Of Surgery,Dayton, OH, USA 2Wright State University,Department Of Surgery,Dayton, OH, USA

Introduction: Many soldiers in support of Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn sustained unstable spinal injuries requiring placement of spinal hardware. It was most customary to defer fixations of unstable spine injuries to Role 4 and Role 5 military treatment facilities due to concerns for infection risk and related complications; though after an extensive literature search, it was found that there are no current clinical practice guidelines to direct surgeons in the decision to delay fixation. Our objective was to evaluate the practice of placing spinal instrumentation and examine the differences between those patients instrumented in theater versus those with delayed instrumentation.

Methods: Data was gathered from the beginning of Operation Iraqi Freedom/Operation Enduring Freedom with record review from the Armed Forces Health Longitudinal Health Joint Theater Trauma Registry (JTTR), Application (AHLTA), Patient Administration and Biostatisitics Activity (PASBA), and Joint Patient Tracking Application (JPTA). Soldiers with spinal injuries requiring fixation were selected and separated based on spinal instrumentation placed in theater or out of theater. Each group was assessed for development of complications and need for re-operation.

Results:344 soldiers were found to receive spinal fixation; 116 underwent instrumentation in theater while 235 were deferred for out of theater fixation. Those with fixations in theater had a lower overall complication rate in comparison to the out of theater population. In analysis of each individual complication, soldiers who underwent delayed fixation out of theater had higher incidence of PE, DVT, stage 3 and 4 ulcers along with increased rate of infectious processes. Early fixation in theater was related to greater incidence of loss of operative reduction/fixation in comparison to the out of theater counterparts. When comparing complication percentages between both groups, an overall p value for all accounting for all examined complications was found to be 0.9825.

Conclusion:In theater fixation was not associated with greater risk of infection as previously assumed along with lower rates of several other complications. Given these outcomes, early fixation may be favored while understanding these benefits are attenuated by the increase of loss of fixation. In the decision to proceed with early fixation, the instrumentation available along with the training and experience of the surgeon should be other considered factors. 

 

41.08 Can Tracheostomies Be Safely Performed on High Ventiltaor Settings? An Assessment of 690 patients

Posted on January 31, 2019

L. Toelle1, M. Zaza1, S. Leonard1, E. A. Taub1, B. A. Cotton1  1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TEXAS, USA

Introduction: Early tracheostomy is associated with a reduction in ventilator-associated pneumonia, tracheal stenosis, time spent on ventilator and mortality. Despite these benefits, early tracheostomy is often not performed due to high ventilatory requirements. We hypothesized that patients who undergo tracheostomy under high ventilator settings would have similar complication rates compared to those performed under standard ventilator settings.

Methods:  We performed retrospective review of all tracheostomies performed by Acute Care Surgery Faculty between 01/2015 and 12/2017. Patient demographics, ventilator settings, type (open or closed) and location of tracheostomy (operating room or ICU), and complications were recorded. Patients were divided into HIGH-SETTING and LOW-SETTING. HIGH-SETTING tracheostomies were defined as those on FiO2 >50%, PEEP >10, on PRVC mode, on APRV mode, or on nitric oxide. Complications were defined as: loss of airway, hypoxia requiring intervention, intra-operative ACLS, bleeding requiring return to OR, and death related to procedure. Hypoxia requiring intervention was defined as the need for bagging greater than one minute, any need for chest compressions, or need for emergent bronchoscopy post-procedure. Statistical analysis was performed using STATA 12.1. Continuous data are presented as medians (25th-75th percentile interquartile range, IQR) with comparisons performed using Wilcoxon ranksum. Categorical data are reported as proportions and tested for significance using Fisher’s exact test. 

Results: 690 tracheostomies were performed during this time frame. 154 were HIGH-SETTING tracheostomies, while 536 were LOW-SETTNG. HIGH-SETTING patients were younger (median 53 vs. 57; p=0.028) and more likely to be male (76 vs. 66%; p=0.012). While there was no difference in intra-operative vasopressors drips (2.6 vs. 2.5%; p=0.992), HIGH-RISK tracheostomies were more likely to have a cervical spine fracture with spine immobilization (27 vs. 17%; p=0.008). HIGH-SETTING tracheostomies were more likely to be done through a percutaneous approach than LOW-SETTING tracheostomies (40 vs. 32%; p=0.082). However, there was no difference in whether the procedure was performed in the ICU setting (23 vs. 20%; 0.362). HIGH-SETTING patients were on higher PEEP, had higher FiO2, were more likely to be on advanced ventilator modes, and to have been on inhaled NO2. While there was a trend towards more ACLS interventions with HIGH-SETTING patients, there was no difference in complications overall or individually (TABLE). 

Conclusion: Tracheostomies can be performed safely on high ventilator settings without increased complications. Careful pateint selection and hightened pre-procedure planning, however, is warranted.
 

41.07 A Simple and Accurate Score to Quantify Injury Severity in Resource-Poor Settings

Posted on January 31, 2019

A. Laytin1, D. Clarke2, M. Gerdin Wärnberg3, V. Kong2, J. Bruce2, G. Laing2, C. Juillard4  3Karolinska Institutet,Solna, STOCKHOLM, Sweden 4University Of California – San Francisco,San Francisco, CA, USA 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA 2University of KwaZulu-Natal,Pietermaritzburg, KWAZULU-NATAL, South Africa

Introduction: Injury care is a global health priority with 5 million deaths due to injury per year worldwide, and the burden of injury is especially high in low- and middle-income countries (LMIC). Efforts to strengthen injury care in LMIC benefit from accurate injury scores to quantify injury severity and predict a patient’s likelihood of mortality. The Injury Severity Score (ISS) and Trauma Score-Injury Severity Score (TRISS) are widely used in the US, but require comprehensive anatomic injury data collection that is often impractical in LMIC. We hypothesized that a simple injury score appropriate for resource-limited settings could achieve discrimination and strength of association with in-hospital mortality similar to resource-intensive injury scores.

 

Methods: This study uses data collected in a regional trauma registry in KwaZulu-Natal, South Africa. Data from 2012-2017 were used to compare the discrimination and strength of association with in-hospital mortality of two comprehensive anatomic injury scores—ISS and TRISS—with those of four relatively simple injury scores that rely primarily on physiologic data—Shock Index (SI), Glasgow Coma Score (GCS), Revised Trauma Score (RTS) and Kampala Trauma Score (KTS). Discrimination was assessed with ROC curve analysis. Strength of association with in-hospital mortality was assessed with standardized regression coefficients (β). KTS was developed in Kampala, Uganda in 2000. While uncommon in the US, it has been used as an injury score in several sub-Saharan African countries.

 

Results: Trauma registry data were reviewed for 4,179 patients, disclosing a median age of 30 years, a male preponderance of 84% and a 48% prevalence of penetrating injury mechanisms. Median time from injury to presentation was 13 hours, with an in-hospital mortality rate of 2.5%. TRISS, ISS and KTS had similar discrimination and strength of association with in-hospital mortality, while the other injury scores demonstrated weaker discrimination and strength of association, especially among patients presenting more than 6 hours post-injury.

 

Conclusion: In searching for a robust injury score to deploy in LMIC, KTS evidenced discrimination and strength of association with in-hospital mortality similar to the gold-standard injury scores ISS and TRISS. Using KTS can help to measure changes in outcomes over time, to compare outcomes between LMIC medical centers and to evaluate the impact of performance improvement efforts when calculating ISS or TRISS is not feasible. Presentation delay degraded the utility of the other injury scores that principally rely on physiologic data and may reflect survival bias in that patient population.

 

41.06 Early Imaging Improves Survival for Elderly Patients with Mild Traumatic Brain Injuries

Posted on January 31, 2019

K. M. Techar1, A. Nguyen1, R. M. Lorenzo1, S. Yang1, B. Thielen1, A. Cain-Nielsen2, M. R. Hemmila3, C. J. Tignanelli4,5,6  4University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA 5North Memorial Medical Center,Department Of Surgery,Robbinsdale, MN, USA 6University Of Minnesota,Institute For Health Informatics,Minneapolis, MN, USA 1University Of Minnesota,Medical School,Minneapolis, MN, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:

Traumatic Brain Injury (TBI) is responsible for 30% of trauma related deaths each year and is a major cause of permanent disability. Head computed tomography (CT) imaging is the gold standard for diagnosis of intracranial bleeding in TBI, however institutional time to imaging varies significantly, especially in patients without signs of acute distress. Studies have shown earlier clinical intervention is associated with improved outcomes. The objective of this study was to identify the optimal imaging time and its impact on outcomes for elderly patients with head trauma who present to the emergency department (ED) without signs of acute distress.

Methods:

Data from a state-wide quality collaborative was used from 2011-2017 at 29 level 1 and 2 trauma centers. Inclusion criteria were: ICD-9/10 codes for head trauma, age≥50, Glasgow Coma Scale (GCS) ≥14, Injury Severity Score (ISS) ≤20, non-full trauma activation, and head CT imaging time within 1.5 hours of arrival, excluding the initial 5 minutes. Direct admissions and patients who arrived with no signs of life were excluded. Lowess plots were generated to evaluate the association of time to head CT on in-hospital mortality. Data was dichotomized based on these findings into early and late CT cohorts. Logistic regression and negative binomial models were fit to the data to evaluate early vs late CT. Models were risk adjusted for age, gender, race, insurance status, pre-injury anticoagulant use, ED blood pressure, Abbreviated Injury Scale, GCS, and ISS. The primary outcome was in-hospital mortality. Hospital-level factors associated with early CT use were evaluated using logistic regression.

Results:

6,336 patients were included in this study. There was significant variation in time to head CT (μ-45 minutes(m), SD-22m). Mortality nadired at 35 minutes on lowess. Each one minute delay in time to head CT was associated with a 2% increase in mortality (OR 1.02, 95% CI 1.01-1.03, p=0.002). Data was dichotomized into early (≤35m, n=2,535) and late (>35m, n=3,801) cohorts. Early patients had significantly reduced in-hospital mortality (OR 0.58 95% CI 0.35-0.95,p=0.03). Early patients on anticoagulant medications were more likely to receive FFP within 4 hours (OR 1.5,p=0.03). Early patients did not have significantly faster times to neurosurgical intervention (IRR 0.76, 95% CI 0.48-1.2, p=0.2) but did have significantly shorter ED length of stay (IRR 0.89, 95% CI 0.87-0.92, p<0.001). Level 2 (OR 0.46, p<0.001), teaching (OR 0.74, p<0.001), and high-volume trauma centers (OR 0.80, p=0.001), were all less likely to provide early head CTs.

Conclusion:

Each one minute delay in head CT for elderly patients with head trauma is associated with a 2% increase in mortality. This may be due to slower delivery of therapeutic interventions such as anticoagulation reversal. Head CT within 35 minutes for elderly patients with head trauma should be evaluated as a potential quality metric.

41.05 Prior Opioid Use as a Predictor of Continued Dependence After Major Orthopedic Trauma

Posted on January 31, 2019

M. A. Chaudhary1, N. K. Kwon1, N. Bhulani1, E. D. Jager1, T. P. Koehlmoos2, A. H. Haider1, A. J. Schoenfeld1  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Uniformed Services University Of The Health Sciences,Bethesda, MD, USA

Introduction:
Prior opioid use is known to be associated with adverse clinical outcomes in surgical and trauma patients. The impact of such use on post-discharge opioid patterns following trauma has not been evaluated. In this context, we sought to determine the association of prior opioid use on continued opioid dependence following major orthopedic trauma.

Methods:
We queried TRICARE insurance claims data (2006-2014) for records of adult (18-64 years) patients who sustained major orthopedic injuries defined using ICD-9 code. Patients that died during hospitalization were excluded. Prior opioid use was categorized as unexposed, exposed (any use within 6-month prior to trauma) and sustained use (6-month continuous use before trauma). Multivariable Cox Proportional Hazards models adjusting for socio-demographic and clinical factors, as well as the environment of care  were utilized to determine  association with opioid discontinuation following hospitalization. Missing demographic information was accounted for using re-weighted estimating equations.

Results:
We were able to include 11,752 patient records. Among these, 29.4% (n=3,456) had some prior opioid use while 5% (n=586) met criteria for sustained use. After discharge, 10.2% (n=1,194) continued opioid use beyond 6 months. In multivariable models prior opioid exposure [Hazards Ration (HR): 0.78, Confidence Interval (CI): 0.74-0.82] and sustained use at the time of injury [HR: 0.40, CI: 0.35-0.47] were associated with a lower likelihood of opioid discontinuation (Figure). Additionally, advanced age [(55-64 vs. 18-24) HR: 0.75, CI: 0.66-0.86], lower socio-economic status [(Enlisted vs. Officers) HR: 0.71, CI: 0.65-0.78], depression (HR: 0.81, CI: 0.72-0.91), anxiety (HR: 0.80, CI: 0.68-0.94), injury severity score (ISS) [(>25 vs. <9) HR: 0.68, CI: 0.60-0.76] and longer ICU length of stay (HR: 0.71, CI: 0.66-0.76) depression (HR: 0.81, CI: 0.72-0.91) and anxiety (HR: 0.80, CI: 0.68-0.94) were also associated with a lower likelihood of opioid discontinuation.

Conclusion:
Our results indicate that prior opioid use is strongly associated with continued dependence among major orthopedic trauma patients after discharge. Appropriate discharge planning, cautious prescription practices and engaging outpatient care service in patients with factors associated with sustained use may reduce the likelihood of this outcome post-discharge.
 

41.04 Incidence of Non-therapeutic Administration of Tranexamic Acid in Trauma Patients

Posted on January 31, 2019

T. Kheirbek1, N. Jikaria1, B. Murray2, S. N. Leuckel1, S. F. Monaghan1, A. H. Stephen1, D. T. Harrington1, C. A. Adams1  1Brown University School Of Medicine,Surgery,Providence, RI, USA 2Brown University School Of Medicine,Emergency Medicine,Providence, RI, USA

Introduction: Early administration of tranexamic acid (TXA) has been widely implemented to prevent fibrinolysis in hemorrhagic shock. Prehospital use of emergency medical services (EMS) has become popular for suspected hemorrhage. We aimed to assess the rate of liberal use of TXA, and whether non-therapeutic administration was associated with increased thrombotic events.

Methods: We identified injured patients who received TXA between 1/2016-1/2018 by querying our level 1 trauma center's registry. We excluded patients who received TXA in the operating room for orthopedic procedures. We retrospectively reviewed medical records and radiologic images to classify whether patients had a hemorrhagic injury that would have benefited from TXA (Therapeutic Administration, TA), or not (Non-Therapeutic Administration, NTA). Demographics, injury patterns, physiologic data, as well as venous thrombotic events (VTE) and mortality rates were compared between the two groups. VTE was diagnosed by duplex ultrasound or computed tomography.

Results: Ninety-five patients received TXA for traumatic injuries, and 42% were given by EMS. TXA was considered non-therapeutic in 34/95 patients retrospectively (NTA group, 35.8%), and in 52% of the patients when given by EMS. Compared to those in NTA group, patients in TA group were younger (47.6 vs. 58.4, p=0.02) and more hypotensive in the field (systolic blood pressure, SBP: 107?31 vs. 137?32 mmHg, p<0.001) and in the emergency department (ED – SBP:  97?27 vs 128 ? 27, p<0.001). They were more tachycardic in ED (heart rate: 99?29 vs. 88?19, p=0.04). TA group had higher injury severity score (ISS – median 24 v 11, p<0.001), was transfused more often (81.7% vs 20.6%, p<0.001), and had higher in-hospital mortality (39.3% vs 2.9%, p<0.001), but there was no difference in the rate of VTE (8.2% vs 5.9%, NS). There was a higher rate of non-therapeutic use when TXA was given by Basic Life Support (BLS) units compared to Advanced Life Support (ALS) units (91.7% vs 42%).

Conclusion: Our results highlight a significantly high rate of non-therapeutic administration, especially by EMS. Hypotension and tachycardia were indications of correct use. There was no difference in VTE rates between the groups, but the low incidence rate limits our conclusion and a larger study is warranted. Cautious implementation of TXA in resuscitation protocols is encouraged in the meantime. 

 

41.03 Redefining the Trauma Triage Matrix: the Role of Emergent Interventions

Posted on January 31, 2019

C. J. Tignanelli1,2, N. J. Davis2, A. Koestner3, L. M. Napolitano4, M. R. Hemmila4  1University Of Minnesota,Surgery,Minneapolis, MN, USA 2North Memorial Health Hospital,Surgery,Robbinsdale, MN, USA 3Spectrum Health Medical Group,Surgery,Grand Rapids, MI, USA 4University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  A tiered trauma team activation (TTA) system aims to generate a provider response and allocation of resources proportional to the patient’s need based upon injury burden. The quality metric used to evaluate appropriateness of TTA criteria is the trauma triage matrix (TTM), typically with a cut-off of an injury severity score (ISS) of >15 used to identify a major trauma patient. The selection of an ISS>15 has been acknowledged as arbitrary and may not represent the optimal gauge of a patient’s need for TTA. Two additional methods have been proposed, the need for trauma intervention (NFTI) and the secondary triage assessment tool (STAT). In this study, we compare the effectiveness of the need for an emergent intervention within 6 hours (NEI-6) with these existing definitions for major trauma on activation appropriateness and trauma mortality.  

Methods:  Data from a state-wide collaborative quality initiative for trauma was utilized. The dataset contains information from 29 level 1 and 2 trauma centers from 2011–2017. Inclusion criteria were: adult patients (≥16 years) and ISS ≥5. Patients directly admitted, missing data, or with no signs of life were excluded. NEI-6 was defined as: receiving ≥5 units of packed red blood cells within the first 4 hours, any operation, angiography, chest tube, or central line placement within 6 hours of arrival, emergent intubation, or placement of an intracranial pressure monitor. Early mortality was defined as any death occurring within 48 hours of ED arrival.

Results: 73,818 patients were included in the study. 30% of trauma patients met criteria for STAT, 21% for NFTI, 20% for TTM, and 13% for NEI-6. NEI-6 was associated with the lowest rate of undertriage at 6.5% (STAT 22.3%, NFTI 14.0%, TTM 14.3%). NEI-6 best predicted undertriage mortality, early mortality, in-hospital mortality, and late (> 60 hour) mortality compared with the other methods (Table 1). Most patients who met criteria for TTM (58%), NFTI (51%), and STAT (62%) did not require emergent intervention. All four methods had similar rates of early mortality for patients who did not meet criteria (0.3% – 0.5%). 

Conclusion: NEI-6 better predicted undertriage, early, and late mortality, and need for resource utilization than TTM, NFTI, and STAT. Additionally, TTM, NFTI, and STAT resulted in significantly more full TTA’s than NEI-6 without the added benefit of identifying additional patients at risk for early mortality. NEI-6 represents a novel and effective tool for determine trauma triage and activation appropriateness. This method should be considered in future iterations of the TTM.

 

41.02 State firearm laws and their association with the need for surgical intervention

Posted on January 31, 2019

E. De Jager1, A. H. Haider1, T. Uribe-Leitz1, J. C. McCarty1, E. Goralnick1,2, G. Ortega1  1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery, Harvard Medical School,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Emergency Medicine,Boston, MA, USA

Introduction:
The relationship between various United States (US) state firearm legislative policies and firearm injuries is a source of ongoing public controversy. Prior work has shown that state level legislation is associated with firearms pediatric injuries, suicides, non-fatal injury hospital discharge rates and mortality. The relationship, however, between these policies and the need for operative intervention for firearm victims is unknown. Our objective was to examine firearm related surgical volume between states with and without strict firearm legislation. 

Methods:
States were dichotomized based on the strength of their firearm legislation policies using scores from the 2014 Brady Campaign State Scorecard (strict = state score >0) and the 2014 Gifford’s Law Center to Prevent Gun Violence scorecard (strict = state grade above F). We then extracted firearm inpatient data from the 2014 State Inpatient Database (SID) for 28 available states. States were classified into those with (13) and without (15) strict firearm legislation polices. The surgical volume per population was calculated using the mean grouped firearm surgical prevalence, using ICD-9-CM Ecodes and the 2014 state population according to the US Census Bureau. Negative binomial regression was used to calculate the incident rate ratio (IRR) for surgical volume between strict and non-strict states adjusted for age, race/ethnicity, insurance status, income, injury severity score and Charlson comorbidity index.

Results:
10,920 patients hospitalized with firearm related injuries were identified.  Overall 65.6% (American n=7,161) of these patients underwent a surgical procedure. These firearm related injuries were further classified as assault (59.3%, n=4,249), unintentional (29.6%, n=2,122) and self-harm (7.8%, n=556). The mean age of the patients was 33 years (SD 13.9). Other patient demographics are shown in the table. The unadjusted rate of firearm surgical procedures per 100,000 people was higher in non-strict states 1.11 (95% CI, 1.01-1.20) compared to strict states 0.32 (95% CI, 0.27-0.37) (<0.001). The adjusted incidence rate of firearm related surgical procedures was 2.57 (95% CI; 2.25 -2.93, p<0.001) times higher in non-strict states compared to strict states. 

Conclusion:
Residents in non-strict firearm legislation policy states were 2.57 times more likely to require a firearm related surgical intervention compared to states with strict firearm legislation policies. States could reevaluate their firearm legislation policies to reduce the burden of firearm surgical intervention. 
 

41.01 Prescription Opioid Fills Following Discharge for Trauma-Related Care

Posted on January 31, 2019

R. C. Baker1, B. C. Kenney1, J. S. Lee1, M. P. Klueh1, H. M. Hu1, M. J. Englesbe1, C. M. Brummett2, J. F. Waljee1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Anesthesiology,Ann Arbor, MI, USA

Introduction:  Although opioid analgesics are effective for acute pain, data suggest that prolonged use can occur following elective surgery. To date, the occurrence of new persistent use and the coordination of care for patients with emergency and trauma-related conditions is not well understood. Our objective was to describe the occurrence of new persistent opioid use and transitions of care for patients discharged with trauma-related conditions.

Methods:  We examined a national sample of insurance claims for inpatients with a primary diagnosis of a trauma-related condition from 2004 to 2017 drawn from OptumInsight. We included patients ages 18-64 who did not fill an opioid prescription in the 12 months prior to their admission. Our primary outcome was the occurrence of new persistent opioid use, defined as 1 or more opioid refills in the 91-180 days following discharge. We used logistic regression to identify factors associated with new persistent use. The secondary outcomes included the change in prescriber specialties of opioids following trauma-related discharge among new persistent opioid use patients. Unadjusted rates of prescribing by specialty were compared across several post-discharge periods; 0-14 days to capture the initial discharge prescription, 15-90 days, and 91-180 days.

Results: In this cohort of 41,691 opioid naïve patients discharged with a trauma-related diagnosis, 12.7% (n=5,314) developed new persistent opioid use. Logistic regression produced the following associations to new persistent opioid use: female gender (OR, 1.31; CI, 1.07-1.20), increased Charlson Comorbidity Index (OR, 1.12; CI, 1.09-1.13), history of substance abuse (OR, 1.35; CI, 1.18-1.55), and history of mental health conditions (OR, 1.32; CI, 1.23-1.43). Among new persistent opioid use patients, the majority of prescriptions filled in the initial hospital discharge period were provided by surgeons, 45.6%, and 23.7% were provided by primary care physicians. For refills provided within 15-90 days following discharge, 52.2% were provided by surgeons and 25.4% were provided by primary care physicians. For fills provided between 91-180 days following discharge, 38.5% were provided by surgeons and 31.0% were provided by primary care physicians. All other provider groups increased prescribing by 2-4% between the 15-90 and 91-180 days following discharge.

Conclusion: Among opioid-naïve patients discharged with trauma-related diagnoses, 12.7% develop new persistent opioid use. Although the majority of initial fills and refills are provided by surgeons, subsequent fills are frequently provided by other specialties. Efforts to curb new persistent use should focus on these transitions of care to identify vulnerable patients early on in their recovery.

40.10 ISOLATED LOW-GRADE BLUNT SOLID ORGAN INJURY IN ADULT TRAUMA PATIENTS: TRANSFER TO A LEVEL I TRAUMA CENTER?

Posted on January 31, 2019

A. Azim1, K. Prabhakaran1, M. Khan1, G. Lombardo1, J. Con1, R. Latifi1  1Westchester Medical Center,Surgery,Valhalla, NEW YORK, USA

Background:The management of low grade (I-III) solid organ (spleen, liver, kidney) injury has evolved to a predominantly conservative management approach with few of these patients requiring procedural intervention. Nonetheless, transfer of these patients from non-trauma centers or lower level trauma centers to Level I trauma centers is common. The objective of this study was to determine the difference in outcomes between patients transferred to and managed at a higher-level trauma center and those managed at a lower level trauma center (Level II/III).

Methods: A two-year retrospective analysis of the National Trauma Data Bank was performed. All trauma patients greater than 18 years of age with isolated low grade solid organ injury were identified. Patients were identified using ICD-10 codes and the following data points were obtained: age, gender race, admission vitals, transfer status, trauma center (TC) designation, and procedures performed. Patients were divided between 2 groups; those directly admitted to Lower Level TC or those transferred to higher Level TC Outcome measures were intervention (angioembolization or surgery) and mortality. A Chi square analysis was performed.

Results: A total of 917865 trauma patients with blunt mechanism of injury were analyzed of which 25, 619 patients had solid organ injury. A total of 1256 patients with isolated low grade solid organ injury were identified. Mean age was 43 ± 25 years, 75.2% were male, and 79.7% were white. Of these, 53.5% were transferred to Level-I trauma center and 46.4% were admitted to lower Level TC. Overall mortality rate was 1.4% and need for intervention was 4.7%.  For low grade isolated splenic injuries, 47.7% were admitted to Low Level TC compared to 52.3% transferred to Level I TC. For low grade isolated liver injuries, 44.5% were admitted to Level II/III TC compared 55.5% to transferred to Level I TC. For low grade isolated kidney injuries, 41.2% were admitted to Low Level TC compared to 59.8% transferred to Level-1 TC. The overall rate of intervention at Lower level TC was 4.6% versus 4.8% for transferred patients (p=0.11) (Table 1.). Mortality rate was similar between the two groups (1.41% vs 1.38%) (p=0.08).

Conclusion:Few adult patients with low grade solid organ injury require intervention, even when transferred to a Level I Trauma Center. Patient with low grade solid organ injury can be safely managed at lower level trauma centers.

40.09 Geographic Variation in Under Triage of Severely Injured Older Adults: A National Analysis

Posted on January 31, 2019

M. P. Jarman1, T. Uribe-Leitz1, D. Sturgeon1, C. D. Newgard4, E. Goralnick1,3, Z. Cooper1,2, A. Salim1,2, A. Haider1,2  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Trauma, Burns, And Critical Care Surgery,Boston, MA, USA 3Brigham And Women’s Hospital,Department Of Emergency Medicine,Boston, MA, USA 4Oregon Health And Science University,Department Of Emergency Medicine,Portland, OR, USA

Introduction:  Despite CDC guidelines recommending triage of significantly injured older adults (age ≥ 65) to trauma center (TC) care, less than 50% of injured older adults in the US are treated at designated Level I or II trauma centers. We sought to determine potential variation in under triage patterns across the US and understand contributory factors.

Methods: Using 2012-2014 Medicare claims data, we identified all patients age ≥ 65 with inpatient or emergency department encounters for traumatic injury and an injury severity score ≥ 16, and classified patients as under triaged if they were treated at a non-TC without subsequent transfer to a TC. Incidence of traumatic injury and under triage were aggregated to the hospital referral region (HRR) level and linked with their Dartmouth Atlas characteristics and the American Hospital Association annual survey. We then used hierarchical logistic regression to estimate odds of under triage for each region and identify associated HRR-level factors (e.g. distribution of income, race, age).

Results: Odds of under triage increased by 6% for every 100,000-person increase in population per TC at the HRR level (OR: 1.06, 95% CI: 1.02, 1.09), and by 8% for every 1-percentage point increase in the proportion of HRR residents with income at/below the federal poverty line (OR: 1.08, 95% CI: 1.03, 1.13). HRR-level factors accounted for 71% of variation in odds of under triage. Population per TC alone accounted for 41% of variation in odds of under triage. No other HRR-level factors examined were associated with odds of under triage after adjusting for the population per TC. Figure 1 illustrates the geographic distribution of under triage by HRR.

Conclusion: Under triage for injured older adults varies substantially across the US. System-level factors account for most of this variation, particularly population size relative to TC capacity, and characteristics of the population each TC serves (i.e. income distribution). Efforts to reduce under triage of older adults should consider both the capacity of trauma systems, and population characteristics.
 

40.08 Vulnerability to Financial Hardship After Severe Traumatic Injury: The Impact of Socioeconomic Status

Posted on January 31, 2019

K. M. O’Neill3, R. A. Jean3, C. P. Gross2, R. D. Becher3, R. Khera4, J. V. Elizondo5, K. Nasir2  2Yale University School Of Medicine,Internal Medicine,New Haven, CT, USA 3Yale University School Of Medicine,General Surgery,New Haven, CT, USA 4University Of Texas Southwestern Medical Center,Cardiology,Dallas, TX, USA 5Yale University School Of Medicine,New Haven, CT, USA

Introduction: Trauma-related disorders rank among the top-five most costly medical conditions to the healthcare system. However, the impact of healthcare expenses on the families of patients suffering traumatic injury is not well studied. To address this gap in knowledge, we used nationally representative data to investigate the burden of financial hardship from out-of-pocket (OOP) health expenses for families with one or more members suffering from a traumatic injury, specifically evaluating the role of socioeconomic status and injury severity on financial burden.

Methods: This retrospective cross-sectional study used nationally representative Medical Expenditure Panel Survey data from 2010 through 2015. We identified families in which at least one member had a traumatic injury and classified this injury based on severity; socioeconomic status was based on family income. Percent of annual family income used for OOP health expenses was used to assess for the risk of excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income) adjusting for demographic, socioeconomic, and healthcare utilization factors in a multivariable logistic regression model.

Results: We identified 7,538 individuals with injuries, represented in 7,102 families of the total 90,964 families in the cohort. Of these, 668 families were classified as severe. Families with a severe traumatic injury experienced increased OOP medical expenses, spending on average $2,784 (95% CI: $2,106-$2833). Increased severity of injury was also associated with increased proportion of excess final burden. Overall 4.4% in the uninjured cohort experienced excess financial burden, compared to 5.6% of families with a minor injury and 12.6% of families with severe injury (see Figure). In a risk-adjusted logistic regression model, families with a severe injury were significantly more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). Families below the federal poverty line had increased odds of excess financial burden (OR: 18.1, 95% CI: 15.3-21.4) and catastrophic medical expenses (OR: 47.8, 95%CI: 35.5-64.7). 

Conclusions: Approximately 1 in 8 households with a severely injured family member experience financial hardship. These families are significantly more vulnerable to incurring catastrophic OOP health expenses than the non-injured population. This effect was most pronounced for families living below the poverty line. These results highlight the vulnerability of poor families to financial hardship from OOP expenses and reinforce the importance of injury prevention strategies.

40.07 Does CT Scanning at a Referring Hospital Increase Mortality After Reaching a Level One Trauma Center?

Posted on January 31, 2019

K. C. Gallagher1, A. J. Medvecz1, B. T. Craig1, O. C. Guillamondegui1, B. M. Dennis1  1Vanderbilt University Medical Center,Division Of Trauma & Critical Care,Nashville, TN, USA

Introduction:
With advancing technology and rapidly increasing availability, computed tomography (CT) has become a standard radiologic adjunct in the evaluation of a trauma patient. However, the appropriate timing of initial cross-sectional imaging has not yet been established and the utility of imaging at the referring hospital (RH) remains controversial. The American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) course emphasizes that imaging should never interrupt or delay resuscitation of the injured patient. Despite these guidelines, several studies have identified delays of 60-90 minutes when patients are scanned at referring hospitals prior to arriving at the treating facility. We study the effect of CT scans at referring hospitals on in-hospital mortality at a receiving trauma center.

Methods:
A retrospective cohort study was performed with adult patients transferred to a level one trauma center from non-trauma center regional hospitals between 2012 and 2017. Inpatient-to-inpatient transfers, transfers from other state-designated level one or level two trauma centers, and patients with transfer times over 10 hours were excluded from analysis. Demographics and baseline characteristics were compared with Student’s t-test and Pearson’s Chi-squared testing. The primary endpoint was in-hospital mortality. Cox regression, controlling for transfer time, was used to evaluate the effect of CT scanning on mortality.

Results:

3415 adult trauma patients were included in the analysis: 1135 (33.2%) received a CT scan at the RH prior to transfer while 2280 (66.8%) did not. Patients who received a CT scan at the RH were more likely to be older, female, white, with a higher Charlson comorbidity index, less severely injured (lower ISS and intubation rate; higher systolic blood pressure and GCS), have a blunt mechanism, and be transferred by ground. There was no difference in “as the crow flies” distance (58.3 miles versus 57.0 miles, P = 0.34), but there were significantly longer times at RH and transport times for those that did receive a CT scan (288 minutes versus 213 minutes, P < 0.005).  The unadjusted hazard ratio (HR) for mortality after receiving a CT scan at the RH is 0.32 (95% CI 0.26-0.39, P < 0.005). The adjusted model controlling for age, sex, race, mechanism of injury, transport method, ISS, heart rate, intubation status, comorbidity index, GCS, and transport time, has a hazard ratio of 0.533 (95% CI 0.42-0.68, P < 0.005).

Conclusion:
There is a survival advantage for patients that receive CT scan prior to transfer to level one trauma center despite having significantly longer transport times. This finding contradicts both current ATLS recommendations and previous data, necessitating further investigation and discussion.
 

40.06 Rates and Correlates of Risky Firearm Behaviors among Youth Treated in an Urban Emergency Department

Posted on January 31, 2019

C. A. Mouch1, J. Goldstick3, M. A. Walton3,4, M. A. Zimmerman5, R. M. Cunningham2,3, P. M. Carter2,3  1Michigan Medicine,Department Of Surgery,Ann Arbor, MI, USA 2Michigan Medicine,Department Of Emergency Medicine,Ann Arbor, MI, USA 3University of Michigan,Injury Prevention Center,Ann Arbor, MI, USA 4Michigan Medicine,Department Of Psychiatry,Ann Arbor, MI, USA 5University of Michigan,School Of Public Health,Ann Arbor, MI, USA

Introduction: Firearms are the leading cause of trauma-related mortality among urban youth and emerging adults (EAs). However, little is known about patterns of risky firearm behaviors (i.e., firearm carriage in high-risk situations; firearm discharge in high-risk situations; firearm threats or use against another person) that may increase the likelihood of subsequent injury or death. This analysis examines rates and correlates of risky firearm behaviors (RFBs) to inform future prevention efforts, including current hospital-based violence prevention programs.

Methods: Youth/EAs (age 16-29) seeking ED treatment in an urban Level-1 trauma center completed a computerized survey. Validated measures assessed past 3-month risky firearm behaviors (RFBs), including firearm carriage in high-risk situations (i.e. carriage under the influence of alcohol/drugs, during a drug deal, while commiting a crime, or while hanging with friends), firearm discharge in high-risk situations (i.e. firearm discharge under the influence of alcohol/drugs, during a drug deal, while committing a crime, during a fight, while fleeing police, to scare someone, or while hanging with friends), and/or partner/non-partner firearm aggression (i.e., threats or use of firearm against another person). Sociodemographics, substance use, mental health, prior violence involvement, peer delinquency, and community violence exposure were also assessed. Descriptive statistics, bivariate analyses, and multivariate logistic regression identified rates and correlates of RFBs.

Results: 1,312 youth/EAs completed the survey (mean age 22; 30% Male; 51% Black; 56% receiving public assistance), with 136 (10%) youth/EAs reporting RFBs during the past 3-months. Of those reporting RFBs, 51% endorsed firearm ownership, 74% reported firearm carriage in high-risk situations, 40% endorsed firearm discharge in high-risk situations, and 31% reported partner/non-partner firearm aggression. Of note, while only 9% of youth/EAs reported either carriage or discharge for self-defense in the prior 3-months, 79% also engaged in RFBs. Multivariate logistic regression identified significant correlates of RFBs, including older age (AOR=1.08), male sex (AOR=1.84), Black race/ethnicity (AOR=1.62), full-time employment (AOR=1.88), substance misuse (AOR=2.34), ED visit for violent injury (AOR=2.29), attitudes favoring retaliation with a firearm (AOR=1.46), friends who own or carry firearms (AOR=4.73), higher levels of neighborhood collective efficacy (AOR=1.05), and higher levels of perceived community violence exposure (AOR=1.04).

Conclusion: Youth/EAs seeking treatment within an urban trauma center report elevated rates of RFBs that potentially increase their risk for subsequent injury and/or death. Prevention efforts should focus on enhancing elements of hospital and community violence prevention programs that address risky firearm behaviors among high-risk populations.

Financial Support: NIH/NIDA K23DA039341; NIH/NCATS UL1TR000433.

40.05 Racial and Socioeconomic Disparities In Prehospital Pediatric Firearm Injury Mortality

Posted on January 31, 2019

M. Hoof1, J. Friedman1, A. A. Smith1, K. Ibraheem1, D. Tatum2, J. Duchesne1, R. Schroll1, C. Guidry1, P. McGrew1  1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA 2Our Lady of The Lake,Surgery,Baton Rouge, LA, USA

Introduction: Prior studies have shown that African American (AA) and uninsured patients have worse outcomes among pediatric victims of firearm injury. However, whether racial and socioeconomic disparities exist in prehospital mortality in pediatric firearm injury (PFI) is unknown. The objective of this study was to determine if the disparities that exist in overall mortality are already present on-scene.

Methods: The National Emergency Medical Services Information Systems (NEMSIS) database was queried for all pediatric (age 0-18) firearm incidents from 2010-2015. A linear regression was carried out using variables associated with mortality on univariate analysis to identify factors associated with prehospital mortality.

Results: 16,808 firearm injuries met study criterion, though information on race and insurance status was only available for 12,268 and 3,080 events, respectively. Victims were more likely to be AA and uninsured. White (CA) children made up a higher proportion of suicide attempts and accidental injuries, whereas most assault victims were AA. CA children had a higher mortality on both univariate and multivariate analysis (MVA). Uninsured children had higher mortality on univariate analysis. On MVA, the odds ratio (OR) of death for uninsured children was 2.169, though this was not significant (p = 0.051). Other factors associated with mortality included anatomic location of injury and intention of injury, with suicide attempts having the highest mortality.

Conclusion: To our knowledge this is the largest study of prehospital mortality in pediatric firearm injury. Uninsured children had higher on-scene mortality on univariate analysis. On MVA, uninsured victims were twice as likely to die as their insured counterparts, though this only approached significance (p = 0.051), perhaps due to insufficient sample size. This trend supports the idea that poor preinjury health status may affect outcome following trauma. However, we did not see higher prehospital mortality in AA children, which has been observed in studies on overall PFI mortality. Therefore, it is possible that the outcomes disparities noted in those studies are related to in-hospital factors. Further studies are needed to examine this topic.

40.04 Medicaid Expansion Has No Effect on Mortality but May Improve In-hospital Outcomes

Posted on January 31, 2019

D. Tatum1, S. Taghavi1,2, A. Smith2, S. Baker2, R. Schroll2, C. Guidry2, P. McGrew2, C. McGinness2, T. Jacome1, J. Duchesne2  1Our Lady of the Lake Regional Medical Center,Trauma Specialist Program,Baton Rouge, LA, USA 2Tulane University School Of Medicine,Department Of Surgery,New Orleans, LA, USA

Introduction:
As part of the Affordable Care Act (ACA), Medicaid in Louisiana was expanded to include non-disabled, low income, non-elderly adults, providing a unique opportunity to examine the effect of insurance status on trauma patients in a historically low socioeconomic status (SES) region. How Medicaid expansion has influenced outcomes in an urban population with a high volume of uninsured patients has yet to be examined on the local level in Louisiana. We hypothesized that there would be a significant decrease in uninsured patients without a concomitant decrease in mortality.

Methods:
All patients aged 18 – 64 were identified in the trauma registries at two major regional trauma centers. Medicaid expansion in Louisiana began July 1, 2016. As such, the pre-expansion study period was July 1, 2015 – June 30, 2016. The post-expansion period was July 1, 2016 – June 30, 2017. Chi Square and Mann-Whitney U test were used for statistical analysis. Significance was set at P < 0.05.

Results:
A total of 8,088 patients met study criteria. Of these, 3,607 (45%) were pre-expansion, 4,481 (55%) were post-expansion. After expansion, Medicaid rates doubled from 22% to 44% (P< 0.001), and the uninsured rate decreased from 40% to 21% (P<0.001). Though number of patients increased post-expansion, median (IQR) ISS decreased significantly (see table). There was no difference in race (P = 0.782), injury type (66% blunt pre-expansion vs 66% blunt post expansion; P =0.757), or overall mortality (4.7% pre vs 3.7% post; P = 0.194); however, patients in the post-expansion cohort had shorter hospital and ICU length of stay.

Conclusion:
While Medicaid expansion in Louisiana has not reduced mortality in nonelderly trauma patients, it may have resulted in better in-hospital outcomes. In addition, expansion may explain increased patient volume and decreased ISS, as formerly uninsured patients with mild injuries may have refused care in the past. Future studies are needed to further delineate the impact of Medicaid expansion in the trauma population.

40.03 Post-Discharge Outcomes in Penetrating Pediatric Trauma at an Urban Level-one Trauma Center

Posted on January 31, 2019

G. M. Siegel3, T. Lee3, C. Wakefield3, A. Katrikh3, D. Webster3, J. Poirier1, J. Mis2, A. Shah1, M. Kaminsky2  1Rush University Medical Center,Pediatric Surgery,Chicago, IL, USA 2John H. Stroger, Jr. Hospital of Cook County,Trauma,Chicago, IL, USA 3Rush Medical College,Chicago, IL, USA

Introduction: In Chicago, gun violence significantly impacts individuals younger than eighteen. In 2017, 16% of shootings involved individuals younger than eighteen years of age with 115 resulting in a fatality. It is well-established that pediatric patients are at greater risk for failure to follow-up (FTF) after a penetrating trauma. Existing literature on trauma follow-up does not explicitly examine FTF among pediatric trauma patients at a safety net, level one trauma center that serves an area with high incidence of gun violence. A better understanding of how to serve this complex population may aid in reducing recidivism, adverse outcomes post-discharge, and the perpetuation of violent crime. We sought to assess patterns and rates of FTF across specialties, emergency department (ED) utilization, and re-hospitalization for surgical pediatric patients post-penetrating trauma at a publicly funded level-one trauma center in Chicago.

Methods: A retrospective cohort study was conducted on surgical patients (ages 0-18) with penetrating trauma admitted from 2008-2016. To examine potential predictors of FTF, nested linear models were created and compared from EMR data and U.S. Census Bureau data. 

Results: We reviewed the records of 216 patients (average age of 15.8 ± 3.6) that suffered a penetrating traumatic injury (73.1% assault with a firearm) with an injury severity score (ISS) of 11.6 ± 13.9. These individuals reside in ZIP Codes with a median household income of $37,372, which was significantly below the city of Chicago median of $66,020 in 2016. Overall follow-up compliance rate was 65.9% with a 16% post-discharge ED visit and 9.3% re-hospitalization rate within 12 months. Ethnicity (p=0.01) and ethnicity, sex, and race (p=0.04) in combination were found to be independent predictors of follow-up compliance. ICU length of stay, hospital length of stay, and ISS did not predict follow-up compliance (p-values 0.09 to 0.78).

Conclusion: We found marked differences in overall patterns and rates among the pediatric trauma population in terms of ED recidivism and FTF than cited in previous literature. Further study is necessary to expand our sample population and determine characteristics driving follow-up, ED utilization, and re-hospitalization among pediatric trauma patients in low-socioeconomic communities with a high burden of gun violence. Additionally, decreasing FTF and improving the quality of post-discharge care is a potential mechanism for cost-containment and reducing long-term recidivism. Establishing benchmarks for pediatric trauma follow-up and assessing post-discharge outcomes for pediatric patients should be a priority for all trauma centers.

 

40.02 Point of Care Ultrasound by EMS in Rural Settings can Identify Injuries and Change Triage

Posted on January 31, 2019

M. Helm2, E. Villegas2, P. Mammen2, N. Ellis2, S. Joseph1  1Valley Health System,Las Vegas, NV, USA 2Texas Tech University Health Sciences,Department Of Surgery,Odessa, TX, USA

Introduction:

In rural settings, timely access to medical care is the main contributor to complications. In West Texas, the average time from injury to EMS arrival is approximately 80 min and arrival to the definitive site of care is over 167 min. 

Early identification of injury reduces triage time, enhances appropriate utilization of resources, and improves outcomes. Point of Care Ultrasound (POCUS) is used to visualize major injuries and identify sources of shock. However, image acquisition and interpretation in the prehospital setting is difficult, requires extensive training, and may be time consuming. We set out to see if first responders could acquire adequate images with minimal training and quantify the added triage time needed for POCUS. 

Methods:

EMS from rural counties were trained using a 2-hour hands-on course in the use of POCUS. Images included neck, pulmonary, cardiac, abdomen, and pelvic windows. Surveys of first responders were used to assess skill acquisition and usefulness of training sessions.   

EMS were then given POCUS for a 3 month field test. Images were saved for evaluation. Surgeons reviewed images to assess image quality and identification of target structures.

After completion of the field test, first responders were surveyed to assess ease of use, technical complications, and total added time.  

Results:

63 first responders were trained on POCUS. All trainees felt that POCUS would be beneficial in triage. 82.5% (52/63) trainees wished to have further training. 30% (19/63) had difficulty with the pulmonary images.

57 patients were recorded by the trained EMS, with 19 patients for trauma.  

Cardiac and abdominal images were good quality and target structures were identified in 93% of all patients. 2 patients had images concerning for free intraperitoneal fluid. Tracheal imaging was done on only 6 patients.

39 EMS completed follow up surveys. All reported the POCUS was easy to use. The average time to complete POCUS was 3 minutes. Technical difficulties included the length of the probe cord, charging of the devise on an ambulance, and ambient lighting within the ambulance. Interest in expanded use included transfer of images, vascular access, imaging for other conditions, and interpretation of images while in transit.       

Conclusion:

EMS can perform POCUS after a short hands-on session. Images obtained appear to be adequate to identify major injuries. Triage decisions and field resources can be maximized using POCUS. We believe the cost of adding POCUS to rural EMS is offset by improved triage time, reduction of wasted resources, and improved survival.

We note the expanded use of POCUS by EMS for patients with other conditions may further reduce the upfront cost of this program. Finally, we noted great interest from the rural hospital emergency room to have access and training to this tool.   

We recommend Wifi capabilities to allow image interpretation while in transit and direct communication between EMS and trauma surgeons in rural areas.

40.01 National Application of the ACS NBATS Tool: Geographic Distribution of Trauma Center Need

Posted on January 31, 2019

M. P. Jarman1, T. Uribe-Leitz1, Z. G. Hashmi1, A. Salim1,2, A. H. Haider1,2  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Trauma, Burns, And Critical Care Surgery,Boston, MA, USA

Introduction: Trauma centers (TCs) in the US are geographically concentrated in urban regions and are not distributed according to population needs. This unequal distribution has created barriers in access to trauma care for large segments of the population. The objective of this study is to identify geographic regions in need of additional trauma centers in the US and demonstrate national application of the American College of surgeons (ACS) Needs Based Assessment of Trauma Systems (NBATS) areas using readily available secondary data.

Methods:  Using 20 State Inpatient Datasets from the 2014 Healthcare Cost and Utilization Project, we identified severely injured patients (Injury Severity Score ≥ 16) treated at TCs (Level I/II/III) and non-TCs. We then aggregated injury incidence to the Hospital Referral Regions (HRR) level, and linked incidence with data from the American Hospital Association Annual Survey, the Dartmouth Atlas of Health Care, and the American Trauma Association Trauma Information Exchange Program. We then used multinomial logistic regression models to estimate HRR-level injury incidence in the remaining 30 states. We applied the ACS NBATS tools to the 306 HRRs in the 48 Contiguous United States and identified the number of additional Level I/II TCs needed in each region to care for the expected volume of severely injured patients.

Results: Of the 306 HRRs examined, we identified 115 (37.6%) as needing additional TCs (Figure), including 18 (5.9%) without existing Level I/II TCs. Of the HRRs in need of additional resources, 43 (37.4%) needed one additional TC to meet projected demand for trauma care, 51 (44.3%) needed two additional TCs, 15 (13.0%) needed three additional TCs, and 6 (5.2%) needed four additional TCs. HRRs in need of additional TCs were often geographically clustered, indicating the presence of complex trauma service areas with substantial geographic barriers to TC care. HRRs in need of additional trauma resources were found in all regions of the US, and included both large population centers with multiple existing TCs and rural regions with small patient populations.

Conclusion: This is the first study to demonstrate the feasibility of using public data sources to apply the ACS NBATS tool at a national level. We identified several regions in the US where increased trauma care resources are essential to meet population-based demand for trauma care. By examining the national distribution of trauma care needs, we can identify regional patterns in the distribution of TC resources, and support trauma system organizational decisions that optimize access to care. Based on our findings, we propose the use of HRRs to standardize projections of trauma service need when using the ACS NBATS tool.

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