The paper explores the needs of trauma patients with limited English proficiency (LEP) and the drivers bringing them in the hospital.1 When the Affordable Healthcare Act was signed, a provision was ...made for covered entities to provide “meaningful access” to language assistance services for those with LEP.2 The formidable challenge that language barriers place upon patients and healthcare system has long been cited to be responsible for worse outcomes, poor quality, and a threat to patient safety.3 Flexibility remains as to the provision of these services, and a uniform standard as to what is considered adequate and equitable access still remains uncertain. In October 2022 the United States Health and Human Services (USHHS) announced steps to improve language access and $4 million in grants to develop and test methods of informing those with LEP on how to access language services.4 This topic is important as a growing number of patients with LEP regularly access care with barriers to translational services. ...differences in discharge disposition and readmission rates between the NELP and EP groups were not recorded.
Abstract There has been a spike in interest and use of telehealth, catalyzed recently by the anticipated implementation of the Affordable Care Act, which rewards efficiency in healthcare delivery. ...Advances in telehealth services are in many areas, including gap service coverage (eg, night-time radiology coverage), urgent services (eg, telestroke services and teleburn services), mandated services (eg, the delivery of health care services to prison inmates), and the proliferation of video-enabled multisite group chart rounds (eg, Extension for Community Healthcare Outcomes programs). Progress has been made in confronting traditional barriers to the proliferation of telehealth. Reimbursement by third-party payers has been addressed in 19 states that passed parity legislation to guarantee payment for telehealth services. Medicare lags behind Medicaid, in some states, in reimbursement. Interstate medical licensure rules remain problematic. Mobile health is currently undergoing explosive growth and could be a disruptive innovation that will change the face of healthcare in the future.
The need for improved methods of hemorrhage control and resuscitation has resulted in a reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA). However, there is a paucity ...of data regarding the use of REBOA on a multi-institutional level in the United States.
To evaluate the outcomes in trauma patients after REBOA placement.
A case-control retrospective analysis was performed of the 2015-2016 American College of Surgeons Trauma Quality Improvement Program data set, a national multi-institutional database of trauma patients in the United States. A total of 593 818 adult trauma patients (aged ≥18 years) were analyzed and 420 patients were matched and included in the study; patients who were dead on arrival or were transferred from other facilities were excluded. Trauma patients who underwent REBOA placement in the ED were identified and matched with a similar cohort of patients (the no-REBOA group). Both groups were matched in a 1:2 ratio using propensity score matching for demographics, vital signs, mechanism of injury, injury severity score, head abbreviated injury scale score, each body region abbreviated injury scale score, pelvic fractures, lower extremity vascular injuries and fractures, and number and grades of intra-abdominal solid organ injuries.
Outcome measures were the rates of complications and mortality.
Of 593 818 trauma patients, 420 patients (the REBOA group, 140 patients; 36 women and 104 men; mean SD age, 44 20 years; the no-REBOA group, 280 patients; 77 women and 203 men; mean SD age, 43 19 years) were matched and included in the analysis. Among the REBOA group, median injury severity score was 29 (interquartile range IQR, 18-38) and 129 patients (92.1%) had a blunt mechanism of injury. There was no significant difference between groups in median 4-hour blood transfusion (REBOA: packed red blood cells, 6 U IQR, 3-8 U; platelets, 4 U IQR, 3-9 U, and plasma, 3 U IQR, 2-5 U; and no-REBOA: packed red blood cells, 7 U IQR, 3-9 U; platelets, 4 U IQR, 3-8 U, and plasma, 3 U IQR, 2-6 U) or 24-hour blood transfusion (REBOA: packed red blood cells, 9 U IQR, 5-20 U; platelets, 7 U IQR, 3-13 U, and plasma, 9 U IQR, 6-20 U; and no-REBOA: packed red blood cells, 10 U IQR, 4-21 U; platelets, 8 U IQR, 3-12 U, and plasma, 10 U IQR, 7-20 U), median hospital length of stay (REBOA, 8 days IQR, 1-20 days; and no-REBOA, 10 days IQR, 5-22 days), or median intensive care unit length of stay (REBOA, 5 days IQR, 2-14 days; and no-REBOA, 6 days IQR, 3-15 days). The mortality rate was higher in the REBOA group as compared with the no-REBOA group (50 35.7% vs 53 18.9%; P = .01). Patients who underwent REBOA placement were also more likely to develop acute kidney injury (15 10.7% vs 9 3.2%; P = .02) and more likely to undergo lower extremity amputation (5 3.6% vs 2 0.7%; P = .04).
Placement of REBOA in severely injured trauma patients was associated with a higher mortality rate compared with a similar cohort of patients with no placement of REBOA. Patients in the REBOA group also had higher rates of acute kidney injury and lower leg amputations. There is a need for a concerted effort to clearly define when and in which patient population REBOA has benefit.
To determine the impact of the increasing aging population on trauma mortality relative to mortality from cancer and heart disease in the United States.
The population in the United States continues ...to increase as medical advancements allow people to live longer. The resulting changes in the leading causes of death have not yet been recognized.
Data were obtained (2000-2010) from the Web-based Injury Statistics Query and Reporting System database of the Centers for Disease Control and Prevention. We defined trauma deaths as unintentional injuries, suicides, and homicides.
From 2000 to 2010, the US population increased by 9.7% and the number of trauma deaths increased by 22.8%. Trauma deaths and death rates deceased in individuals younger than 25 years but increased for those 25 years and older. During this period, death rates for cancer and heart disease decreased. The largest increases in trauma deaths were in individuals in their fifth and sixth decades of life. Since 2000, the largest proportional increase (118%) in crude trauma deaths occurred in 54-year-olds. Overall, in 2010, trauma was the leading cause of death in individuals 46 years and younger. Trauma remains the leading cause of years of life lost.
Trauma is now the leading cause of death for individuals 46 years and younger. The largest increase in the number of trauma deaths and the highest crude number of trauma deaths occurred in baby boomers. Policy makers allocating resources should be made aware of the larger impact of trauma on our aging and burgeoning US population.
INTRODUCTION Anemia can result in significant hypoxia and worse outcomes in patients with a traumatic brain injury (TBI). Blood transfusion may prevent hypoxia and hypoxia-induced secondary brain ...injury. However, there is a lack of clinical evidence guiding transfusion strategies in TBI. METHODS We performed a 2014–2018 analysis of our ICU database and included all adult patients with isolated severe TBI (head-abbreviated injury severity (AIS)≥3 and other body region AIS<3) who underwent RBC transfusion after 48-hours of ICU admission. Patients were divided into two groups based on the pre-transfusion Hb level: Patients who received liberal transfusion (LT) (transfusion threshold: hemoglobin (Hb) 8–10g/dL) vs patients who received restrictive transfusion (RT) (transfusion threshold: Hb<7g/dL). Outcome measures were complications, in-hospital mortality, and neurological outcomes on Glasgow outcome scale extended (GOS-E) at discharge. Multivariate regression analysis was performed to control for confounding variables. RESULTS We analyzed 1,524 patients with isolated severe TBI admitted to the ICU. 366 patients received RBCs after 48-hrs of ICU admission and were included for analysis. Mean age was 43 years, 76% were male, and 82% were white. 30% of the patients received LT while 70% received RT. Patients in the LT group received more RBCs than patients in RT group 2 vs. 1, P = .03). Patients in LT group had lower mortality (P = .01), and higher GOS-E at discharge (P = .04). However, there was no difference between the two groups regarding in-hospital complications, transfusion reactions, ICU-length of stay or hospital LOS. On multivariate regression analysis, LT was independently associated with higher odds of survival (OR: 2.10 1.34-3.56, P = .02) and improved neurological outcomes at discharge (OR: 2.851.48-3.97, P = .01). However, there was no association with complications (P = .27), or transfusion reactions (P = .16). CONCLUSION A liberal transfusion strategy with transfusion threshold of Hb 8–10g/dL is associated with improved survival and neurological outcomes in critically injured patients with severe TBI. Further studies are required to verify this threshold for transfusion and improve outcomes in this high risk subset of trauma population.
Trauma patients admitted to critical care are at high risk of mortality because of their injuries. Our aim was to develop a machine learning-based model to predict mortality using Fahad-Liaqat-Ahmad ...Intensive Machine (FLAIM) framework. We hypothesized machine learning could be applied to critically ill patients and would outperform currently used mortality scores.
The current Deep-FLAIM model evaluates the statistically significant risk factors and then supply these risk factors to deep neural network to predict mortality in trauma patients admitted to the intensive care unit (ICU). We analyzed adult patients (≥18 years) admitted to the trauma ICU in the publicly available database Medical Information Mart for Intensive Care III version 1.4. The first phase selection of risk factor was done using Cox-regression univariate and multivariate analyses. In the second phase, we applied deep neural network and other traditional machine learning models like Linear Discriminant Analysis, Gaussian Naïve Bayes, Decision Tree Model, and k-nearest neighbor models.
We identified a total of 3,041 trauma patients admitted to the trauma surgery ICU. We observed that several clinical and laboratory-based variables were statistically significant for both univariate and multivariate analyses while others were not. With most significant being serum anion gap (hazard ratio HR, 2.46; 95% confidence interval CI, 1.94-3.11), sodium (HR, 2.11; 95% CI, 1.61-2.77), and chloride (HR, 2.11; 95% CI, 1.69-2.64) abnormalities on laboratories, while clinical variables included the diagnosis of sepsis (HR, 2.03; 95% CI, 1.23-3.37), Quick Sequential Organ Failure Assessment score (HR, 1.52; 95% CI, 1.32-3.76). And Systemic Inflammatory Response Syndrome criteria (HR. 1.41; 95% CI, 1.24-1.26). After we used these clinically significant variables and applied various machine learning models to the data, we found out that our proposed DNN outperformed all the other methods with test set accuracy of 92.25%, sensitivity of 79.13%, and specificity of 94.16%; positive predictive value, 66.42%; negative predictive value, 96.87%; and area under the curve of the receiver-operator curve of 0.91 (1.45-1.29).
Our novel Deep-FLAIM model outperformed all other machine learning models. The model is easy to implement, user friendly and with high accuracy.
Prognostic study, level II.
The timely restoration of lost blood in hemorrhaging patients with trauma, especially those who are hemodynamically unstable, is of utmost importance. While intravenous access has traditionally been ...considered the primary method for vascular access, intraosseous (IO) access is gaining popularity as an alternative for patients with unsuccessful attempts. Previous studies have highlighted the higher success rate and easier training process associated with IO access compared with peripheral intravenous (PIV) and central intravenous access. However, the effectiveness of IO access in the early aggressive resuscitation of patients remains unclear. This review article aims to comprehensively discuss various aspects of IO access, including its advantages and disadvantages, and explore the existing literature on the clinical outcomes of patients with trauma undergoing resuscitation with IO versus intravenous access.
Frailty is highly prevalent in the elderly and confers high risk for adverse outcomes. We aimed to assess the impact of frailty on critically ill older adult trauma patients.
We analyzed the ...ACS-TQIP(2010–2014) including all critically-ill trauma patients ≥65y. The modified frailty index (mFI) was calculated. Following stratified into frail and non-frail, propensity score matching was performed. Our primary outcome measure was in-hospital complications. Secondary outcome measures included mortality and discharge disposition.
We identified 88,629 patients, of which 34,854 patients (frail: 17,427, non-frail: 17,427) were matched. Overall 14% died. Frail patients had higher rates of complications (34% vs. 18%, p < 0.001), mortality (18.1% vs. 9.7%, p < 0.001), and were more likely to be discharged to rehab/SNF (58.7% vs. 21.2% p < 0.001) compared to non-frail patients.
critically-ill frail patients are more likely to have higher morbidity and mortality. Frailty can be used as an objective measure to identify high-risk patients.
•Frail ICU patients have higher rates of complications.•Infectious complications are the most common followed by respiratory.•Frail geriatric trauma patients have adverse discharge disposition.•Rates of adverse outcomes increase linearly with increasing mFI.
Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the ...Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented.
Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay.
Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel.
We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.
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