- Email: [email protected]
Blunt versus penetrating trauma: Is there a resource intensity discrepancy?
The American Journal of Surgery xxx (xxxx) xxx
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
Blunt versus penetrating trauma: Is there a resource intensity discrepancy? CDR Jamie L. Fitch a, b, *, Paul T. Albini c, Anish Y. Patel d, Matthew S. Yanoff a, Christian S. McEvoy b, Chad T. Wilson a, James Suliburk a, Stephanie D. Gordy a, S. Rob Todd a a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA Department of General Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA University of California San Diego, Department of Surgery, Division of Trauma, Surgical Critical Care, Burn and Acute Care Surgery, 200 West Arbor Drive, #8896, San Diego, CA, 92103, USA d The University of Texas at Austin, 110 Inner Campus Drive, Austin, TX, 78705, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 March 2019 Received in revised form 7 July 2019 Accepted 26 August 2019
Background: The rising cost of healthcare requires responsible allocation of resources. Not all trauma centers see the same types of patients. We hypothesized that patients with blunt injuries require more resources than patients with penetrating injuries. Methods: This was a retrospective analysis of all highest-level activation trauma patients at our busy urban Level I Trauma Center over five years. Data included demographics, injuries, hospital charges, and resources used. A p value < 0.05 was significant. Results: 4578 patients were included (2037 blunt and 2541 penetrating). Blunt patients were more severely injured, more often admitted, required more radiographic studies, had longer hospital, intensive care unit, and mechanical ventilation days, and therefore, higher hospital charges. Conclusions: Within one center, patients with blunt injuries required more resources than those with penetrating injuries. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution. Published by Elsevier Inc.
1. Introduction Trauma is a leading cause of morbidity and mortality, particularly among young adults.1 Caring for critically injured patients requires significant resources. The annual cost of national inpatient trauma care in the United States is estimated to be approximately $37 billion.2 Trauma hospitalizations in high-income countries are estimated to cost a median of approximately $22,000 per patient.3 Factors associated with higher costs include injury severity score (ISS), intensive care unit (ICU) and hospital length of stay, and polytrauma.3 The rising cost of healthcare makes the responsible allocation of limited resources critical; yet, not all trauma centers receive the same distribution of blunt versus penetrating injuries. Differences
* Corresponding author. Department of General Surgery Naval Medical Center Portsmouth 620 John Paul Jones Circle Portsmouth, VA, 23703, USA. E-mail address: jamie.l.fi[email protected] (C.J.L. Fitch).
in resource utilization between blunt and penetrating injuries are not well studied, particularly in the United States (US) trauma system. Several European based studies report that blunt trauma admissions generally incur higher hospital associated costs than penetrating trauma admissions.3e6 Comparable data from the United States does not exist. In this study, resource utilization between patients with blunt and penetrating mechanisms of injury at a high-volume trauma center was compared. We hypothesized that among patients with equivalent triage, blunt trauma patients would be more resource intensive than penetrating trauma patients throughout their hospital course.
2. Materials and methods This was a retrospective review of prospectively collected data at Ben Taub Hospital, one of two American College of Surgeons verified adult Level I Trauma Centers for Trauma Service Area Q,
https://doi.org/10.1016/j.amjsurg.2019.08.018 0002-9610/Published by Elsevier Inc.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
2
C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
which includes nine counties in the upper Gulf Coast of Texas with a population of approximately 6.2 million people. All adult (>15 years of age), Code 1 (highest level activation) trauma activations from January 1, 2013eDecember 31, 2017, were included in the study cohort (Fig. 1). Patients with a primary mechanism of injury recorded as “burn” or “other” were excluded. The Trauma Registry was used to collect variables including patient demographics, mechanism of injury, injury severity, ICU and hospital lengths of stay, radiologic studies obtained, number of operating room (OR) and interventional radiology (IR) procedures performed. Charge data was captured from the hospital system's business office database to include operating room charges, radiology charges, medication charges, and total charges associated with each patient's index hospital encounter. The comparator groups were blunt versus penetrating mechanisms of injury. The validity of the assumption of normality was assessed for all continuous variables, and continuous data are presented as mean ± standard deviation and median (interquartile range) when not normally distributed. Categorical data are presented as counts and percentages. Median injury severity scores (ISS), mechanical ventilator days, ICU and hospital lengths of stay, number of radiologic studies, medications administered, and OR and IR procedures, and charges between blunt and penetrating trauma mechanism groups were compared using the Wilcoxon Rank-Sum Test. Proportions of patients admitted to the hospital were compared between the blunt trauma and penetrating trauma groups using c2 and two-sample tests of proportions. P-values were two-tailed and the statistical significance level was a 0.05. All statistical analyses were conducted using Stata/IC 13.1 (StataCorp; College Station, Texas). The collection and review of data was approved by the Institutional Review Boards of Baylor College of Medicine and Harris Health System. 3. Results Over the five-year study period, there were 4618 Code 1 trauma activations. Forty patients were excluded (14 burn patients and 26 “other” mechanism) leaving 4576 as the study cohort. There were
2035 (44.5%) patients with a blunt mechanism of injury and 2541(55.5%) patients with a penetrating mechanism of injury. Table 1 depicts the patient demographics and mechanism of injury distribution for both study groups. Blunt trauma patients were older (p < 0.0001), less likely to be male (p < 0.0001), and more severely injured (p < 0.0001). The majority of blunt injuries were due to motor vehicle crashes and most penetrating injuries were gunshot wounds. Blunt trauma patients were more likely to be admitted to the hospital (90.1% vs. 80.6%, p < 0.0001) and less likely to survive to discharge (85.1%, vs. 88.8%, p ¼ 0.0003) than penetrating trauma patients (Fig. 2). Of the study cohort, 3853 (84.2%) patients (1826 blunt trauma patients and 2027 penetrating trauma patients) were admitted to the hospital. These data are summarized in Table 2. Again, admitted blunt trauma patients were more severely injured (p < 0.0001) requiring more mechanical ventilator days, (p < 0.0001), more ICU days (p < 0.0001), and more hospital days (p < 0.0001). They also required more radiographic studies (p < 0.0001). From a charge perspective, blunt trauma patient care resulted in greater medication charges (p < 0.0001), radiology charges (p < 0.0001), and total hospital charges (p < 0.0001). When accounting for the prolonged hospital length of stay in blunt trauma patients, there were higher total hospital charges accrued per day of admission (p < 0.0001). Of the 3853 patients admitted to the hospital, 1950 (50.6%) were taken to the OR at least once. This includes 1044 (51.5%) blunt trauma patients and 906 (49.6%) penetrating trauma patients. Thirsty-six point seven percent (n ¼ 715) of these patients went to the OR more than once, ranging from 1 to 27 encounters. Twohundred-nine patients (5.4%) underwent IR procedures including 107 (5.3%) blunt trauma patients and 102 (5.6%) penetrating trauma patients. Fifty-seven blunt trauma patients and 50 penetrating trauma patients were taken to IR more than once, ranging from 1 to 7 encounters. These included both diagnostic and therapeutic procedures. As shown in Table 2, there were no significant differences between the two groups for median number or OR or IR encounters or for median OR or IR charges. Six hundred and eighty-six patients (199 blunt trauma patients and 487 penetrating trauma patients) were evaluated and
Fig. 1. Code I activation criteria.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
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Table 1 Patient demographics.
N Mean Age (years) Percent Male Median Injury Severity Score (IQR) Percent Survival Mechanism of Injury Motor Vehicle Crash Motorcycle Crash Assault Fall Auto-Pedestrian Crash Other/Unknown Gunshot Wound Stab Wound
Blunt Mechanism of Injury
Penetrating Mechanism of Injury
p value
2035 40.6 ± 16.1 79.6% 17 (8e27) 85.1%
2541 33.2 ± 12.2 89.1% 9 (1e18) 88.8%
<0.0001 <0.0001 <0.0001 0.0003
703 194 231 419 362 126
(34.5%) (9.5%) (11.4%) (20.6%) (17.8%) (6.2%)
41 (1.6%) 1872 (73.7%) 628 (24.7%)
IQR, interquartile range.
discharged from the emergency department. Similarly, blunt trauma patients discharged from the emergency department were more severely injured and received more radiologic studies. Medication charges, radiology charges, and total hospital charges were also significantly greater for blunt trauma patients (Table 3) than for penetrating trauma patients. 4. Discussion The Centers for Disease Control and Prevention (CDC) Injury Center documents trauma as a leading cause of morbidity and mortality, particularly among young adults,1 and caring for the critically injured requires significant resources. That being said, there is limited available literature on resource utilization in trauma patients, and none comparing blunt and penetrating trauma patients directly. In two separate manuscripts, Christensen et al., published data on the cost of caring for blunt and penetrating trauma patients between January 2000 and December 2005 in England and Wales.4,5 Similar to the current study, blunt trauma patients were found to be older and less likely male. Additionally, blunt trauma patients experienced longer ICU and hospital stays resulting in increased costs (£9530 for blunt trauma patients and £7983 for penetrating trauma patients). This difference was even more
profound in the severely injured. In contrast to the current study, blunt trauma patients had a decreased mortality. It is important to note that these comparisons by Christensen et al. are based on point estimates only; the differences may not be statistically significant. These were the only manuscripts identified examining “resource utilization” in blunt and penetrating trauma patients; however, they were performed independently of one another and in the United Kingdom. On further examination of the charge data, medication charges, radiology charges and total hospital charges were all statistically significantly greater in the blunt trauma subset. This can partially be explained by the increased lengths of stay of the blunt trauma patients; more days in the hospital are predictably associated with increased use of medications, radiographic studies, and other inhospital resources. When hospital charges were examined on a daily basis over the entire hospital stay, the per day hospital charges for blunt trauma patients were still significantly greater than those of penetrating trauma patients. Examining the data this way, we see that not only do blunt trauma patients require more days in the hospital, but each of those hospital days is also more expensive. The objective of the current study was to compare resource utilization in blunt and penetrating trauma patients. While charge data may serve as a proxy, it does not provide a truly granular assessment of the question at hand. The fact that blunt trauma
Fig. 2. Admission and survival by mechanism of injury.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
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C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
Table 2 Resource requirements of trauma patients admitted to the hospital.
Injury Severity Score Mechanical Ventilation Days Intensive Care Unit Days Hospital Days Radiology Studies Obtained Operating Room Visits Angiography Suite Visits Medication Charges ($) Radiology Charges ($) Operating Room Charges ($) Total Hospital Charges ($) Daily Hospital Charges ($)
Blunt Mechanism of Injury N ¼ 1826
Penetrating Mechanism of Injury N ¼ 2027
p value
17 (10e29) 1 (0e3) 2 (0e8) 7 (2e17) 15 (8e30) 1 (0e1) 0 (0e0) 1047 (392e3730) 16,365 (12,017e24,645) 15,133 (604e44,783) 63,437 (27,012e151,951) 9277 (6609e13,298)
10 (5e21) 0 (0e1) 0 (0e3) 5 (1e11) 8 (4e17) 0 (0e1) 0 (0e0) 530 (212e1493) 6784 (2543e13,265) 16,811 (607e37,728) 41,181 (18,150e87,416) 8284 (5703e12,008)
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.0686 0.7003 <0.0001 <0.0001 0.6045 <0.0001 <0.0001
(IQR), interquartile range.
patients were more severely injured based on ISS, would seem to explain the higher resource requirement; however, the data presented is insufficient to prove this assumption. We know from this analysis that blunt trauma patients received higher medication charges, but our database does not record specific medications, dosage, or frequency and so does not allow us to identify what specific medications are responsible for the higher charges. We have also shown that blunt patients in our center receive significantly more radiologic studies than penetrating patients, which is associated with increased radiology charges. For admitted patients, this may be partially explained by the increased hospital length of stay providing more time for incidental studies, such as radiographs, to add up over time. The trend is also true, though, when comparing patients who were discharged after evaluation in the emergency department. Our database does not capture what specific studies were ordered or the clinical indication or findings for each study. Given that these patients were discharged from the emergency center, it is likely that a large portion of these studies failed to identify clinically significant injuries. Further inquiry into our radiologic study ordering patterns may allow us to increase the efficiency with which we evaluate and treat both blunt and penetrating trauma patients. The current study was limited to a single center in hopes of decreasing potential confounders. All patients (blunt and penetrating) were triaged and managed by the same group of trauma surgeons within the same hospital, using extensive mutually agreed upon clinical practice management guidelines within a well-developed performance improvement and patient safety system. We therefore did not need to correct for different practice patterns that may exist between different centers. Additionally, the single center model makes our financial data more meaningful, as there is no consistency in actual charges levied by different centers for the same services. In example, Ryan et al. examined trauma alert response charges in the state of Florida in 2012e2014 and found that the flat charge levied by trauma centers for trauma activation ranged from $197 to $66,0007. This study was undertaken as a preliminary attempt to determine if, as we hypothesized, there is a predictable pattern of higher
resource utilization between the broad comparator groups of blunt and penetrating mechanism of injury. We have confirmed our hypothesis that at the highest level of trauma activation, blunt trauma patients in our center require more resources than do penetrating trauma patients. The data presented here are insufficient to extrapolate specific reasons for the increased resource utilization. The most obvious explanation, of course, is that the difference is caused directly by the fact that blunt patients are more severely injured, as is indicated by the higher median ISS. There are, however, several potential confounders for which we have not yet corrected, based on the limitations of the current data sample. Future research efforts will focus on determining what specific factors contribute to this difference in resource utilization. It is also possible that the specific organ system or body region injured, as indicated by the region-specific abbreviated injury scale (AIS) scores, may have a significant impact on overall resources required. We acknowledge a number of limitations within the current study. First, it is retrospective in nature and has all of the inherent flaws as such. Second, varying institutional practice patterns and financial systems may limit the generalizability of this study. A larger multicenter trial is needed to assess both the validity of the current findings and to extrapolate them across the clinical spectrum. Third, the financial data was obtained from the hospital billing office which poses its own set of problems. 5. Conclusions Among similarly triaged trauma patients, blunt trauma patients were more severely injured and required significantly more resources than penetrating trauma patients. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution. Disclosures 1. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
Table 3 Resource requirements of trauma patients discharged from the Emergency Center.
Injury Severity Score Radiology Studies Obtained Medication Charges ($) Radiology Charges ($) Total Hospital Charges ($)
Blunt Mechanism of Injury N ¼ 199
Penetrating Mechanism of Injury N ¼ 487
p value
1 (1e4) 5 (3e6) 17 (29e177) 9707 (4514e11,928) 11,295 (6905e15,027)
1 (1e1) 2 (2e4) 21 (2e175) 1249 (480e5444) 5266 (2920e8063)
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001
(IQR), interquartile range.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
2. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors 3. The views expressed in this article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. 4. LCDR Fitch and LT McEvoy are military service members. This work was prepared as part of their official duties. Title 17 U.S C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties.
Acknowledgements The authors thank Garrett D. Hall, BSN, RN, CAISS, and Qianzi Zhang, MPH, CPH, for significant assistance with data collection and analysis.
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References 1. Injury Center CDC. 10 leading causes of death by age group, United States e 2017. January 2019, 1-1. 2. Velopulos CG, Enwerem NY, Obirieze A, et al. National cost of trauma care by payer status. J Surg Res. 2013;184(1):444e449. https://doi.org/10.1016/ j.jss.2013.05.068. 3. Willenberg L, Curtis K, Taylor C, Jan S, Glass P, Myburgh J. The variation of acute treatment costs of trauma in high-income countries. BMC Health Serv Res. 2012;12:267. https://doi.org/10.1186/1472-6963-12-267. 4. Christensen MC, Ridley S, Lecky FE, Munro V, Morris S. Outcomes and costs of blunt trauma in England and Wales. Crit Care. 2008;12(1):R23. https://doi.org/ 10.1186/cc6797. 5. Christensen MC, Nielsen TG, Ridley S, Lecky FE, Morris S. Outcomes and costs of penetrating trauma injury in England and Wales. Injury. 2008;39(9):1013e1025. https://doi.org/10.1016/j.injury.2008.01.012. 6. Taheri PA, Butz DA, Lottenberg L, Clawson A, Flint LM. The cost of trauma center readiness. Am J Surg. 2004;187(1):7e13. https://doi.org/10.1016/S0002-9610(03) 00437-9. 7. Ryan JL, Pracht EE, Langland-Orban B. Association of trauma alert response charges with volume and hospital ownership type in Florida. Health Serv Res Manag Epidemiol. 2018;5(4). https://doi.org/10.1177/2333392818797793, 233339281879779.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
Blunt versus penetrating trauma: Is there a resource intensity discrepancy? CDR Jamie L. Fitch a, b, *, Paul T. Albini c, Anish Y. Patel d, Matthew S. Yanoff a, Christian S. McEvoy b, Chad T. Wilson a, James Suliburk a, Stephanie D. Gordy a, S. Rob Todd a a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA Department of General Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA University of California San Diego, Department of Surgery, Division of Trauma, Surgical Critical Care, Burn and Acute Care Surgery, 200 West Arbor Drive, #8896, San Diego, CA, 92103, USA d The University of Texas at Austin, 110 Inner Campus Drive, Austin, TX, 78705, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 March 2019 Received in revised form 7 July 2019 Accepted 26 August 2019
Background: The rising cost of healthcare requires responsible allocation of resources. Not all trauma centers see the same types of patients. We hypothesized that patients with blunt injuries require more resources than patients with penetrating injuries. Methods: This was a retrospective analysis of all highest-level activation trauma patients at our busy urban Level I Trauma Center over five years. Data included demographics, injuries, hospital charges, and resources used. A p value < 0.05 was significant. Results: 4578 patients were included (2037 blunt and 2541 penetrating). Blunt patients were more severely injured, more often admitted, required more radiographic studies, had longer hospital, intensive care unit, and mechanical ventilation days, and therefore, higher hospital charges. Conclusions: Within one center, patients with blunt injuries required more resources than those with penetrating injuries. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution. Published by Elsevier Inc.
1. Introduction Trauma is a leading cause of morbidity and mortality, particularly among young adults.1 Caring for critically injured patients requires significant resources. The annual cost of national inpatient trauma care in the United States is estimated to be approximately $37 billion.2 Trauma hospitalizations in high-income countries are estimated to cost a median of approximately $22,000 per patient.3 Factors associated with higher costs include injury severity score (ISS), intensive care unit (ICU) and hospital length of stay, and polytrauma.3 The rising cost of healthcare makes the responsible allocation of limited resources critical; yet, not all trauma centers receive the same distribution of blunt versus penetrating injuries. Differences
* Corresponding author. Department of General Surgery Naval Medical Center Portsmouth 620 John Paul Jones Circle Portsmouth, VA, 23703, USA. E-mail address: jamie.l.fi[email protected] (C.J.L. Fitch).
in resource utilization between blunt and penetrating injuries are not well studied, particularly in the United States (US) trauma system. Several European based studies report that blunt trauma admissions generally incur higher hospital associated costs than penetrating trauma admissions.3e6 Comparable data from the United States does not exist. In this study, resource utilization between patients with blunt and penetrating mechanisms of injury at a high-volume trauma center was compared. We hypothesized that among patients with equivalent triage, blunt trauma patients would be more resource intensive than penetrating trauma patients throughout their hospital course.
2. Materials and methods This was a retrospective review of prospectively collected data at Ben Taub Hospital, one of two American College of Surgeons verified adult Level I Trauma Centers for Trauma Service Area Q,
https://doi.org/10.1016/j.amjsurg.2019.08.018 0002-9610/Published by Elsevier Inc.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
2
C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
which includes nine counties in the upper Gulf Coast of Texas with a population of approximately 6.2 million people. All adult (>15 years of age), Code 1 (highest level activation) trauma activations from January 1, 2013eDecember 31, 2017, were included in the study cohort (Fig. 1). Patients with a primary mechanism of injury recorded as “burn” or “other” were excluded. The Trauma Registry was used to collect variables including patient demographics, mechanism of injury, injury severity, ICU and hospital lengths of stay, radiologic studies obtained, number of operating room (OR) and interventional radiology (IR) procedures performed. Charge data was captured from the hospital system's business office database to include operating room charges, radiology charges, medication charges, and total charges associated with each patient's index hospital encounter. The comparator groups were blunt versus penetrating mechanisms of injury. The validity of the assumption of normality was assessed for all continuous variables, and continuous data are presented as mean ± standard deviation and median (interquartile range) when not normally distributed. Categorical data are presented as counts and percentages. Median injury severity scores (ISS), mechanical ventilator days, ICU and hospital lengths of stay, number of radiologic studies, medications administered, and OR and IR procedures, and charges between blunt and penetrating trauma mechanism groups were compared using the Wilcoxon Rank-Sum Test. Proportions of patients admitted to the hospital were compared between the blunt trauma and penetrating trauma groups using c2 and two-sample tests of proportions. P-values were two-tailed and the statistical significance level was a 0.05. All statistical analyses were conducted using Stata/IC 13.1 (StataCorp; College Station, Texas). The collection and review of data was approved by the Institutional Review Boards of Baylor College of Medicine and Harris Health System. 3. Results Over the five-year study period, there were 4618 Code 1 trauma activations. Forty patients were excluded (14 burn patients and 26 “other” mechanism) leaving 4576 as the study cohort. There were
2035 (44.5%) patients with a blunt mechanism of injury and 2541(55.5%) patients with a penetrating mechanism of injury. Table 1 depicts the patient demographics and mechanism of injury distribution for both study groups. Blunt trauma patients were older (p < 0.0001), less likely to be male (p < 0.0001), and more severely injured (p < 0.0001). The majority of blunt injuries were due to motor vehicle crashes and most penetrating injuries were gunshot wounds. Blunt trauma patients were more likely to be admitted to the hospital (90.1% vs. 80.6%, p < 0.0001) and less likely to survive to discharge (85.1%, vs. 88.8%, p ¼ 0.0003) than penetrating trauma patients (Fig. 2). Of the study cohort, 3853 (84.2%) patients (1826 blunt trauma patients and 2027 penetrating trauma patients) were admitted to the hospital. These data are summarized in Table 2. Again, admitted blunt trauma patients were more severely injured (p < 0.0001) requiring more mechanical ventilator days, (p < 0.0001), more ICU days (p < 0.0001), and more hospital days (p < 0.0001). They also required more radiographic studies (p < 0.0001). From a charge perspective, blunt trauma patient care resulted in greater medication charges (p < 0.0001), radiology charges (p < 0.0001), and total hospital charges (p < 0.0001). When accounting for the prolonged hospital length of stay in blunt trauma patients, there were higher total hospital charges accrued per day of admission (p < 0.0001). Of the 3853 patients admitted to the hospital, 1950 (50.6%) were taken to the OR at least once. This includes 1044 (51.5%) blunt trauma patients and 906 (49.6%) penetrating trauma patients. Thirsty-six point seven percent (n ¼ 715) of these patients went to the OR more than once, ranging from 1 to 27 encounters. Twohundred-nine patients (5.4%) underwent IR procedures including 107 (5.3%) blunt trauma patients and 102 (5.6%) penetrating trauma patients. Fifty-seven blunt trauma patients and 50 penetrating trauma patients were taken to IR more than once, ranging from 1 to 7 encounters. These included both diagnostic and therapeutic procedures. As shown in Table 2, there were no significant differences between the two groups for median number or OR or IR encounters or for median OR or IR charges. Six hundred and eighty-six patients (199 blunt trauma patients and 487 penetrating trauma patients) were evaluated and
Fig. 1. Code I activation criteria.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
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Table 1 Patient demographics.
N Mean Age (years) Percent Male Median Injury Severity Score (IQR) Percent Survival Mechanism of Injury Motor Vehicle Crash Motorcycle Crash Assault Fall Auto-Pedestrian Crash Other/Unknown Gunshot Wound Stab Wound
Blunt Mechanism of Injury
Penetrating Mechanism of Injury
p value
2035 40.6 ± 16.1 79.6% 17 (8e27) 85.1%
2541 33.2 ± 12.2 89.1% 9 (1e18) 88.8%
<0.0001 <0.0001 <0.0001 0.0003
703 194 231 419 362 126
(34.5%) (9.5%) (11.4%) (20.6%) (17.8%) (6.2%)
41 (1.6%) 1872 (73.7%) 628 (24.7%)
IQR, interquartile range.
discharged from the emergency department. Similarly, blunt trauma patients discharged from the emergency department were more severely injured and received more radiologic studies. Medication charges, radiology charges, and total hospital charges were also significantly greater for blunt trauma patients (Table 3) than for penetrating trauma patients. 4. Discussion The Centers for Disease Control and Prevention (CDC) Injury Center documents trauma as a leading cause of morbidity and mortality, particularly among young adults,1 and caring for the critically injured requires significant resources. That being said, there is limited available literature on resource utilization in trauma patients, and none comparing blunt and penetrating trauma patients directly. In two separate manuscripts, Christensen et al., published data on the cost of caring for blunt and penetrating trauma patients between January 2000 and December 2005 in England and Wales.4,5 Similar to the current study, blunt trauma patients were found to be older and less likely male. Additionally, blunt trauma patients experienced longer ICU and hospital stays resulting in increased costs (£9530 for blunt trauma patients and £7983 for penetrating trauma patients). This difference was even more
profound in the severely injured. In contrast to the current study, blunt trauma patients had a decreased mortality. It is important to note that these comparisons by Christensen et al. are based on point estimates only; the differences may not be statistically significant. These were the only manuscripts identified examining “resource utilization” in blunt and penetrating trauma patients; however, they were performed independently of one another and in the United Kingdom. On further examination of the charge data, medication charges, radiology charges and total hospital charges were all statistically significantly greater in the blunt trauma subset. This can partially be explained by the increased lengths of stay of the blunt trauma patients; more days in the hospital are predictably associated with increased use of medications, radiographic studies, and other inhospital resources. When hospital charges were examined on a daily basis over the entire hospital stay, the per day hospital charges for blunt trauma patients were still significantly greater than those of penetrating trauma patients. Examining the data this way, we see that not only do blunt trauma patients require more days in the hospital, but each of those hospital days is also more expensive. The objective of the current study was to compare resource utilization in blunt and penetrating trauma patients. While charge data may serve as a proxy, it does not provide a truly granular assessment of the question at hand. The fact that blunt trauma
Fig. 2. Admission and survival by mechanism of injury.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
4
C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
Table 2 Resource requirements of trauma patients admitted to the hospital.
Injury Severity Score Mechanical Ventilation Days Intensive Care Unit Days Hospital Days Radiology Studies Obtained Operating Room Visits Angiography Suite Visits Medication Charges ($) Radiology Charges ($) Operating Room Charges ($) Total Hospital Charges ($) Daily Hospital Charges ($)
Blunt Mechanism of Injury N ¼ 1826
Penetrating Mechanism of Injury N ¼ 2027
p value
17 (10e29) 1 (0e3) 2 (0e8) 7 (2e17) 15 (8e30) 1 (0e1) 0 (0e0) 1047 (392e3730) 16,365 (12,017e24,645) 15,133 (604e44,783) 63,437 (27,012e151,951) 9277 (6609e13,298)
10 (5e21) 0 (0e1) 0 (0e3) 5 (1e11) 8 (4e17) 0 (0e1) 0 (0e0) 530 (212e1493) 6784 (2543e13,265) 16,811 (607e37,728) 41,181 (18,150e87,416) 8284 (5703e12,008)
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.0686 0.7003 <0.0001 <0.0001 0.6045 <0.0001 <0.0001
(IQR), interquartile range.
patients were more severely injured based on ISS, would seem to explain the higher resource requirement; however, the data presented is insufficient to prove this assumption. We know from this analysis that blunt trauma patients received higher medication charges, but our database does not record specific medications, dosage, or frequency and so does not allow us to identify what specific medications are responsible for the higher charges. We have also shown that blunt patients in our center receive significantly more radiologic studies than penetrating patients, which is associated with increased radiology charges. For admitted patients, this may be partially explained by the increased hospital length of stay providing more time for incidental studies, such as radiographs, to add up over time. The trend is also true, though, when comparing patients who were discharged after evaluation in the emergency department. Our database does not capture what specific studies were ordered or the clinical indication or findings for each study. Given that these patients were discharged from the emergency center, it is likely that a large portion of these studies failed to identify clinically significant injuries. Further inquiry into our radiologic study ordering patterns may allow us to increase the efficiency with which we evaluate and treat both blunt and penetrating trauma patients. The current study was limited to a single center in hopes of decreasing potential confounders. All patients (blunt and penetrating) were triaged and managed by the same group of trauma surgeons within the same hospital, using extensive mutually agreed upon clinical practice management guidelines within a well-developed performance improvement and patient safety system. We therefore did not need to correct for different practice patterns that may exist between different centers. Additionally, the single center model makes our financial data more meaningful, as there is no consistency in actual charges levied by different centers for the same services. In example, Ryan et al. examined trauma alert response charges in the state of Florida in 2012e2014 and found that the flat charge levied by trauma centers for trauma activation ranged from $197 to $66,0007. This study was undertaken as a preliminary attempt to determine if, as we hypothesized, there is a predictable pattern of higher
resource utilization between the broad comparator groups of blunt and penetrating mechanism of injury. We have confirmed our hypothesis that at the highest level of trauma activation, blunt trauma patients in our center require more resources than do penetrating trauma patients. The data presented here are insufficient to extrapolate specific reasons for the increased resource utilization. The most obvious explanation, of course, is that the difference is caused directly by the fact that blunt patients are more severely injured, as is indicated by the higher median ISS. There are, however, several potential confounders for which we have not yet corrected, based on the limitations of the current data sample. Future research efforts will focus on determining what specific factors contribute to this difference in resource utilization. It is also possible that the specific organ system or body region injured, as indicated by the region-specific abbreviated injury scale (AIS) scores, may have a significant impact on overall resources required. We acknowledge a number of limitations within the current study. First, it is retrospective in nature and has all of the inherent flaws as such. Second, varying institutional practice patterns and financial systems may limit the generalizability of this study. A larger multicenter trial is needed to assess both the validity of the current findings and to extrapolate them across the clinical spectrum. Third, the financial data was obtained from the hospital billing office which poses its own set of problems. 5. Conclusions Among similarly triaged trauma patients, blunt trauma patients were more severely injured and required significantly more resources than penetrating trauma patients. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution. Disclosures 1. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
Table 3 Resource requirements of trauma patients discharged from the Emergency Center.
Injury Severity Score Radiology Studies Obtained Medication Charges ($) Radiology Charges ($) Total Hospital Charges ($)
Blunt Mechanism of Injury N ¼ 199
Penetrating Mechanism of Injury N ¼ 487
p value
1 (1e4) 5 (3e6) 17 (29e177) 9707 (4514e11,928) 11,295 (6905e15,027)
1 (1e1) 2 (2e4) 21 (2e175) 1249 (480e5444) 5266 (2920e8063)
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001
(IQR), interquartile range.
Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018
C.J.L. Fitch et al. / The American Journal of Surgery xxx (xxxx) xxx
2. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors 3. The views expressed in this article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. 4. LCDR Fitch and LT McEvoy are military service members. This work was prepared as part of their official duties. Title 17 U.S C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties.
Acknowledgements The authors thank Garrett D. Hall, BSN, RN, CAISS, and Qianzi Zhang, MPH, CPH, for significant assistance with data collection and analysis.
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Please cite this article as: Fitch CJL et al., Blunt versus penetrating trauma: Is there a resource intensity discrepancy?, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.08.018