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332 Pediatric Thoracotomy: Heroic or Futile?
Research Forum Abstracts season, and 2/7th - or 28.57% - of ED visits would occur on weekends. We define a surge as any increase above this assumption of randomness. All statistical analyses were performed using SPSS. Results: There were 247 million weighted ED visits in the study period. For all weighted ED visits, seasonal and weekend variations were modest. Each season contained between 24.54% and 25.32% of all visits, and weekends contained 28.95% of all ED visits. When parsed by season, weekend visits ranged from 28.70% and 29.30% of all ED visits. There were 64 million weighted ED visits linked to an ECode, representing 25.90% of all ED visits. By season: 22.63% (95% CI: 22.61% 22.65%) of ED ECode visits occurred in the winter, 26.19% (95% CI: 26.17% 26.21%) occurred in the spring, 27.44% (95% CI: 27.42% - 27.46%) occurred in the summer, and 23.75% (95% CI: 23.73% - 23.77%) occurred in the fall. By day of week: 30.30% (95% CI: 30.27% - 30.32%) of ECode visits occurred on the weekend. Summer ECode visits were 3.1 million greater than winter ECode visits - a relative 21% increase in counts. Additionally, there were 1.1 million more Ecode visits on summer weekends than on winter weekends - a relative 26% increase in counts. Although the total number of ECode visits was highest in the summer, the weekend/weekday mix of ECode visits only subtlety changed by season. The proportion of ECode visits occurring on the weekend ranged from 30.87% (95% CI: 30.85% - 30.89%) in the summer, 30.62% (95% CI: 30.60% - 30.64%) in the spring, 29.96% (95% CI: 29.94% - 29.98%) in the fall, and 29.78% (95% CI: 29.76% - 29.81%) in the winter. Conclusions: Our analysis supports the belief that trauma is a disease of the summer. We found a 21% relative increase in trauma related visits in the summer months. Our study, however, found only a small surge in trauma-related visits on the weekends. ED managers need to be ready to handle large volumes of traumatic illness on both weekends and weekdays, especially during the summer.
331
Increased Risk of Inpatient Mortality Among Uninsured Traumatic Injury Patients in a Rural State Trauma Registry
Sullivan RP, Buresh C, Young T, Peek-Asa C, Hoffman B, Torner J/University of Iowa Carver College of Medicine, Iowa City, IA; University of Iowa, Iowa City, IA; University of Iowa Injury Prevention Research Center, Iowa City, IA; University of Iowa College of Public Health, Iowa City, IA
Study Objectives: Recent research has demonstrated an increase in mortality for uninsured patients following traumatic injury independent of likely contributing factors such as age, race, injury severity, co-morbidities, mechanism of injury, and treating hospital. Previous studies have focused on patients in a national trauma database with a large proportion of urban trauma centers, leading some to hypothesize that the increase in mortality is related to characteristics of injuries sustained in an urban environment. To determine whether an increased risk of mortality exists among uninsured trauma patients in a rural setting, we analyzed a state trauma registry from a predominantly rural state with markedly different patient demographics and injury characteristics relative to urban centers. Methods: This study was a retrospective review of the Iowa State Trauma Registry for the years 2002-2009 (N⫽80;,716). The State Trauma Registry contains records from all traumatically injured patients in the state of Iowa, including demographics, injury mechanism, hospital, and insurance data, as well as disposition at discharge. Exclusion criteria for this analysis included burns and age ⬍18 years old. We used multivariate logistic regression analysis to estimate the risk of inpatient mortality by insurance status at the time of injury. Several characteristics of the traumatic injury event including emergency department disposition, length of hospital and intensive care unit stay (days), transfer to a tertiary trauma center, hospital charges, and hospital discharge disposition were examined for their potential confounding effects on mortality. Results: A total of 63,702 patient records met inclusion criteria. Uninsured trauma patients were more likely to be male, non-white, 18-30 years old, have a penetrating injury and an intentional injury than those with commercial insurance. In unadjusted analyses, uninsured patients had a 50% (OR ⫽ 1.5 [CI: 1.21 - 1.77]) increased risk of mortality compared to insured patients. Furthermore, a higher percentage of uninsured patients died in the emergency department (1.8%) than did those with commercial insurance (0.8%). After controlling for likely confounders (age, sex, injury severity score, mechanism and intent of injury, co-morbidities, and traumatic brain injury) the odds of mortality were largely unchanged (adjusted OR ⫽ 1.5 [CI: 1.19 - 1.82]) suggesting that being uninsured, or an unknown mechanism for which being uninsured is a proxy, is strongly related to risk of mortality.
Volume , . : October
Conclusion: In a predominantly rural setting, uninsured patients were more likely to die following traumatic injury than their insured counterparts. This is in agreement with prior research findings showing increased mortality rates for uninsured patients in a predominantly urban national trauma registry. This finding suggests that insurance status and not the characteristics of an urban or rural environment contributes to increased risk of death from traumatic injuries. Further research is needed to identify the causative factors that contribute to increased mortality for the uninsured following traumatic injury, and to develop effective policies to address this healthcare inequity.
332
Pediatric Thoracotomy: Heroic or Futile? Easter J, Haukoos J/Denver Health, Denver, CO
Study Objectives: While studies have clarified the value of thoracotomy in adult trauma patients with rates of survival of 4-8%, in children poorer rates of survival have been observed (0-4%). It is unclear if this lower rate of pediatric survival arises from inherent differences in children or from the small sample sizes (⬍12 patients) of pediatric analyses. We aimed to assess the clinical characteristics and survival of pediatric thoracotomy in a larger cohort. Methods: A retrospective review of all consecutive emergent thoracotomies performed in children (⬍18 years) following traumatic arrest, presenting to an urban Level I trauma center emergency department between 1995 and 2009 was performed. Indications for thoracotomy were loss of vital signs following acute trauma. Patients undergoing thoracotomy at an outside hospital and then transferred to our institution were excluded. Patient demographics, out-of-hospital and emergency department presentation, outcome, and autopsy results were reviewed. Results: Twenty-nine pediatric thoracotomies were performed during the study period. Patients had a mean age of 13.9 years (range 2 - 17 years) and 25/29 (83%) were male. 16/29 (55%) patients sustained penetrating injuries (9 gun shot wounds, 7 stab wounds). 3/16 (19%) of these patients survived to hospital discharge. 5/13 (38%) of patients with blunt trauma had return of spontaneous circulation following thoracotomy but 0/13 (0%) survived to discharge. All children who survived had loss of vital signs ⱕ10 minutes. All surviving children had signs of life on EMS arrival; 2 arrested en route to the hospital with transit times ⱕ5 minutes and 1 arrested in the emergency department. All survivors had penetrating wounds to their heart, and 1 had cardiac tamponade. Conclusions: This represents the largest cohort of emergent thoracotomy in children in 20 years and suggests pediatric thoracotomy is associated with higher survival rates than previously estimated. Similar to adults, emergency department thoracotomy appears most beneficial in children sustaining penetrating trauma with loss of vital signs in the field or the emergency department.
333
Undertriage in Trauma: Differences in Outcome Among Trauma Patients With Delayed Trauma Service Activation at a Level I Trauma Center
Rogen C, Shiuh T, Veneri P, Campbell B, Hoon CJ, Reed III JF, Rosenbaum R/ Christiana Care Health System, Newark, DE
Study Objectives: Much attention has been placed on the timely identification and treatment of trauma patients in the out-of-hospital setting. The major focus of established guidelines has been to prevent the undertriage of trauma patients, that is, ensuring severely injured patients are transported to trauma centers designated to handle such injuries. Little is known, however, about the undertriage that may occur after a trauma patient arrives at a trauma center and does not receive immediate activation of the trauma system. The objective of this study is to identify whether undertriage of trauma patients after arrival at a Level I trauma center leads to worsened outcomes. Methods: A retrospective cohort analysis was performed using data derived from the trauma database of a single Level I trauma center. In this institution, a 3-tiered trauma system is used (code, alert, consult), with codes or alerts defined using hospital-based criteria derived from the American College of Surgeons/CDC Field Triage Guidelines. All trauma codes and alerts receive immediate activation of the trauma system upon identification. As trauma consults never receive full activation of the trauma system by design, these patients were excluded from analysis. Adult trauma patients (⬎12 years old) with an Injury Severity Score (ISS) ⱖ 16 transported by EMS to the trauma center between 01 January 2007 and 31 December 2009 were included in the study. Trauma patients classified as codes or alerts in the out-ofhospital setting or upon initial ED arrival were considered on-time activations (OTA), while those who had trauma system activation after initial ED arrival were considered delayed activation (DA) and undertriaged. Main outcomes collected were
Annals of Emergency Medicine S289
331
Increased Risk of Inpatient Mortality Among Uninsured Traumatic Injury Patients in a Rural State Trauma Registry
Sullivan RP, Buresh C, Young T, Peek-Asa C, Hoffman B, Torner J/University of Iowa Carver College of Medicine, Iowa City, IA; University of Iowa, Iowa City, IA; University of Iowa Injury Prevention Research Center, Iowa City, IA; University of Iowa College of Public Health, Iowa City, IA
Study Objectives: Recent research has demonstrated an increase in mortality for uninsured patients following traumatic injury independent of likely contributing factors such as age, race, injury severity, co-morbidities, mechanism of injury, and treating hospital. Previous studies have focused on patients in a national trauma database with a large proportion of urban trauma centers, leading some to hypothesize that the increase in mortality is related to characteristics of injuries sustained in an urban environment. To determine whether an increased risk of mortality exists among uninsured trauma patients in a rural setting, we analyzed a state trauma registry from a predominantly rural state with markedly different patient demographics and injury characteristics relative to urban centers. Methods: This study was a retrospective review of the Iowa State Trauma Registry for the years 2002-2009 (N⫽80;,716). The State Trauma Registry contains records from all traumatically injured patients in the state of Iowa, including demographics, injury mechanism, hospital, and insurance data, as well as disposition at discharge. Exclusion criteria for this analysis included burns and age ⬍18 years old. We used multivariate logistic regression analysis to estimate the risk of inpatient mortality by insurance status at the time of injury. Several characteristics of the traumatic injury event including emergency department disposition, length of hospital and intensive care unit stay (days), transfer to a tertiary trauma center, hospital charges, and hospital discharge disposition were examined for their potential confounding effects on mortality. Results: A total of 63,702 patient records met inclusion criteria. Uninsured trauma patients were more likely to be male, non-white, 18-30 years old, have a penetrating injury and an intentional injury than those with commercial insurance. In unadjusted analyses, uninsured patients had a 50% (OR ⫽ 1.5 [CI: 1.21 - 1.77]) increased risk of mortality compared to insured patients. Furthermore, a higher percentage of uninsured patients died in the emergency department (1.8%) than did those with commercial insurance (0.8%). After controlling for likely confounders (age, sex, injury severity score, mechanism and intent of injury, co-morbidities, and traumatic brain injury) the odds of mortality were largely unchanged (adjusted OR ⫽ 1.5 [CI: 1.19 - 1.82]) suggesting that being uninsured, or an unknown mechanism for which being uninsured is a proxy, is strongly related to risk of mortality.
Volume , . : October
Conclusion: In a predominantly rural setting, uninsured patients were more likely to die following traumatic injury than their insured counterparts. This is in agreement with prior research findings showing increased mortality rates for uninsured patients in a predominantly urban national trauma registry. This finding suggests that insurance status and not the characteristics of an urban or rural environment contributes to increased risk of death from traumatic injuries. Further research is needed to identify the causative factors that contribute to increased mortality for the uninsured following traumatic injury, and to develop effective policies to address this healthcare inequity.
332
Pediatric Thoracotomy: Heroic or Futile? Easter J, Haukoos J/Denver Health, Denver, CO
Study Objectives: While studies have clarified the value of thoracotomy in adult trauma patients with rates of survival of 4-8%, in children poorer rates of survival have been observed (0-4%). It is unclear if this lower rate of pediatric survival arises from inherent differences in children or from the small sample sizes (⬍12 patients) of pediatric analyses. We aimed to assess the clinical characteristics and survival of pediatric thoracotomy in a larger cohort. Methods: A retrospective review of all consecutive emergent thoracotomies performed in children (⬍18 years) following traumatic arrest, presenting to an urban Level I trauma center emergency department between 1995 and 2009 was performed. Indications for thoracotomy were loss of vital signs following acute trauma. Patients undergoing thoracotomy at an outside hospital and then transferred to our institution were excluded. Patient demographics, out-of-hospital and emergency department presentation, outcome, and autopsy results were reviewed. Results: Twenty-nine pediatric thoracotomies were performed during the study period. Patients had a mean age of 13.9 years (range 2 - 17 years) and 25/29 (83%) were male. 16/29 (55%) patients sustained penetrating injuries (9 gun shot wounds, 7 stab wounds). 3/16 (19%) of these patients survived to hospital discharge. 5/13 (38%) of patients with blunt trauma had return of spontaneous circulation following thoracotomy but 0/13 (0%) survived to discharge. All children who survived had loss of vital signs ⱕ10 minutes. All surviving children had signs of life on EMS arrival; 2 arrested en route to the hospital with transit times ⱕ5 minutes and 1 arrested in the emergency department. All survivors had penetrating wounds to their heart, and 1 had cardiac tamponade. Conclusions: This represents the largest cohort of emergent thoracotomy in children in 20 years and suggests pediatric thoracotomy is associated with higher survival rates than previously estimated. Similar to adults, emergency department thoracotomy appears most beneficial in children sustaining penetrating trauma with loss of vital signs in the field or the emergency department.
333
Undertriage in Trauma: Differences in Outcome Among Trauma Patients With Delayed Trauma Service Activation at a Level I Trauma Center
Rogen C, Shiuh T, Veneri P, Campbell B, Hoon CJ, Reed III JF, Rosenbaum R/ Christiana Care Health System, Newark, DE
Study Objectives: Much attention has been placed on the timely identification and treatment of trauma patients in the out-of-hospital setting. The major focus of established guidelines has been to prevent the undertriage of trauma patients, that is, ensuring severely injured patients are transported to trauma centers designated to handle such injuries. Little is known, however, about the undertriage that may occur after a trauma patient arrives at a trauma center and does not receive immediate activation of the trauma system. The objective of this study is to identify whether undertriage of trauma patients after arrival at a Level I trauma center leads to worsened outcomes. Methods: A retrospective cohort analysis was performed using data derived from the trauma database of a single Level I trauma center. In this institution, a 3-tiered trauma system is used (code, alert, consult), with codes or alerts defined using hospital-based criteria derived from the American College of Surgeons/CDC Field Triage Guidelines. All trauma codes and alerts receive immediate activation of the trauma system upon identification. As trauma consults never receive full activation of the trauma system by design, these patients were excluded from analysis. Adult trauma patients (⬎12 years old) with an Injury Severity Score (ISS) ⱖ 16 transported by EMS to the trauma center between 01 January 2007 and 31 December 2009 were included in the study. Trauma patients classified as codes or alerts in the out-ofhospital setting or upon initial ED arrival were considered on-time activations (OTA), while those who had trauma system activation after initial ED arrival were considered delayed activation (DA) and undertriaged. Main outcomes collected were
Annals of Emergency Medicine S289