Juan Pablo Herrera-Escobar1, Arturo J Rios-Diaz, Cheryl K Zogg, Lindsey L Wolf, Alyssa Harlow, Eric B Schneider, Zara Cooper, Carlos Alberto Ordonez, Ali Salim, Adil H Haider. 1. From the Center for Surgery and Public Health (J.P.H-E., A.J.R-D., C.Z., L.L.W., A.H., E.B.S., Z.C., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School; Harvard T.H Chan School of Public Health (J.P.H-E., A.J.R-D., C.Z., L.L.W., A.H., E.B.S., Z.C., A.S., A.H.H.); Division of Trauma, Burn and Surgical Critical Care, Department of Surgery (Z.C., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School Boston, Massachusetts; and Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O.), Fundacion Valle del Lili, Universidad del Valle, Cali, Colombia.
Abstract
BACKGROUND: Severely injured trauma patients have higher in-hospital mortality at Level II versus Level I trauma centers (TCs). To better understand these differences, we sought to determine if there were any periods during which hemodynamically unstable trauma patients are at higher risk of death at Level II versus Level I TCs within the first 24 hours postadmission. STUDY DESIGN: Trauma patients aged 18 years to 64 years, with Injury Severity Score of 15 or greater, systolic blood pressure less than 90 mm Hg at admission, and treated at Level II or Level I TCs, were identified using the 2007 to 2012 National Trauma Data Bank. Burn patients, transfers, and patients dead on arrival were excluded. Log-binomial regression models, adjusted for patient- and hospital-level confounders, were used to compare mortality at Level II versus Level I TCs over the first 24 hours postadmission. RESULTS: Of 13,846 hemodynamically unstable patients, 4,212 (30.4%) were treated at 149 Level II TCs, and 9,634 (69.6%) at 116 Level I TCs. Within the first 24 hours, 3,059 (22.1%) patients died. In risk-adjusted models, mortality risk was significantly elevated at Level II versus Level I TCs during the 24 hours postadmission (relative risk, 1.08; 95% confidence interval, 1.01-1.16). Hourly mortality risk was significantly different between Level II and Level I TCs during 4 hours to 7 hours postadmission, with a maximal difference at 7 hours (relative risk, 1.70; 95% confidence interval, 1.23-2.36) and comparable mortality risk beyond 7 hours postadmission. CONCLUSION: The 4-hour to 7-hour time window postadmission is critical for hemodynamically unstable trauma patients. Variations in available treatment modalities may account for higher relative mortality at Level II TCs during this time. Further investigation to elucidate specific risk factors for mortality during this period may lead to reductions in in-hospital mortality among hemodynamically unstable trauma patients. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.
BACKGROUND: Severely injured traumapatients have higher in-hospital mortality at Level II versus Level I trauma centers (TCs). To better understand these differences, we sought to determine if there were any periods during which hemodynamically unstable traumapatients are at higher risk of death at Level II versus Level I TCs within the first 24 hours postadmission. STUDY DESIGN:Traumapatients aged 18 years to 64 years, with Injury Severity Score of 15 or greater, systolic blood pressure less than 90 mm Hg at admission, and treated at Level II or Level I TCs, were identified using the 2007 to 2012 National Trauma Data Bank. Burn patients, transfers, and patients dead on arrival were excluded. Log-binomial regression models, adjusted for patient- and hospital-level confounders, were used to compare mortality at Level II versus Level I TCs over the first 24 hours postadmission. RESULTS: Of 13,846 hemodynamically unstable patients, 4,212 (30.4%) were treated at 149 Level II TCs, and 9,634 (69.6%) at 116 Level I TCs. Within the first 24 hours, 3,059 (22.1%) patients died. In risk-adjusted models, mortality risk was significantly elevated at Level II versus Level I TCs during the 24 hours postadmission (relative risk, 1.08; 95% confidence interval, 1.01-1.16). Hourly mortality risk was significantly different between Level II and Level I TCs during 4 hours to 7 hours postadmission, with a maximal difference at 7 hours (relative risk, 1.70; 95% confidence interval, 1.23-2.36) and comparable mortality risk beyond 7 hours postadmission. CONCLUSION: The 4-hour to 7-hour time window postadmission is critical for hemodynamically unstable traumapatients. Variations in available treatment modalities may account for higher relative mortality at Level II TCs during this time. Further investigation to elucidate specific risk factors for mortality during this period may lead to reductions in in-hospital mortality among hemodynamically unstable traumapatients. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.
Authors: Claudia P Orlas; Juan Pablo Herrera-Escobar; Cheryl K Zogg; José J Serna; Juan J Meléndez; Alexandra Gómez; Diana Martínez; Michael W Parra; Alberto F García; Fernando Rosso; Luis Fernando Pino; Adolfo Gonzalez; Carlos A Ordoñez Journal: World J Surg Date: 2020-06 Impact factor: 3.352
Authors: Gabrielle E Hatton; Reginald E Du; Shuyan Wei; John A Harvin; Kevin W Finkel; Charles E Wade; Lillian S Kao Journal: J Am Coll Surg Date: 2019-11-14 Impact factor: 6.113