Base Excess as a Predictor for Injury Severity in Pediatric Trauma Patients

Background

Base excess is considered a predictor of mortality and severity of injury in trauma patients. Base excess had been widely examined in different settings. Only few studies have examined the role of base excess in pediatric trauma patients.

Objective

To evaluate the value of admission base excess in pediatric trauma patients with respect to intensive care unit (ICU) admission rate and length of hospital stay. Methods: A retrospective study of pediatric trauma patients was conducted at a Level II trauma center. All patients aged 0–16 years for which a trauma team was activated over the years 2006–2009 were included. Study database included admission base excess, mechanism of injury, location and nature of injury, injury severity score, length of hospital stay, and ICU admission.

Results

The study group consisted of 359 patients. There was a weak linear correlation between admission base excess, length of stay in the hospital, and ICU admission. Base excess seemed to show a stronger correlation for the youngest age group (0–6 years) and no correlation for the middle age group. There was a positive but weak correlation (R Spearman = 0.26) between admission base excess and Injury Severity Score (ISS). However, 40% of the children with an ISS score >25 had normal admission base excess values. The area under the curve of the receiver operating characteristic curves of base excess for predicting ICU admission was 0.66.

Conclusions

The admission base excess in pediatric trauma patients seems to be a weak prognostic factor in our facility.     

Comparison of mortality due to severe multiple trauma in two comprehensive models of emergency care: Atlantic Pyrenees (France) and Navarra (Spain)

Background: Injury due to external causes is an important health problem in our society today. Emergency care systems based on the concept of “comprehensive care” can prevent deaths and disabilities as well as limit the severity and pain caused by trauma. Objective: To investigate the frequency and characteristics of different mechanisms of injury and to estimate mortality, comparing two comprehensive emergency systems: Atlantic Pyrenees (AP) in France and Navarra (NA) in Spain. Material and Methods: A prospective cohort study of severe multiple-injury patients attended to by the comprehensive emergency care systems of AP and NA from April 1, 2001 to March 31, 2002. Data were collected from personal patient data, the emergency coordination center “112,” pre-hospital and hospital health care levels, and discharge data. Bivariate statistical analysis and multivariate logistic regression models were employed for statistical management. Results: There were 614 severe multiple trauma patients recorded, 278 in AP and 336 in NA. Significant differences were observed in arrival time, pre-hospitalization care, pre-hospital Revised Trauma Score (RTS), Injury Severity Score (ISS) at the intensive care unit, and procedures used (intubation, administration of fluids, immobilization, and diagnostic methods). Logistic regression showed significant differences in patient death, age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01–1.03), penetrating or accidental injuries, (OR 3.85, 95% CI 1.1–13.1), RTS (OR 0.58, 95% CI 0.5–0.7), and ISS score (OR 1.05, 95% CI 1.0–1.1). Conclusion: Despite a more aggressive approach and employment of greater resources, the French comprehensive trauma system does not show greater survival rates among injured patients compared to Navarra, even when controlling for confounding factors like age, injury mechanism, RTS, ISS, and others.     

Survival Benefit of Transfer to Tertiary Trauma Centers for Major Trauma Patients Initially Presenting to Nontertiary Trauma Centers

Objectives: Recent evidence suggests a measurable reduction in mortality for patients transferred from a nontertiary trauma center (Level III or IV) to a Level I trauma center, but not for those transferred to a Level II trauma center. Whether this can be generalized to a predominantly rural region with fewer tertiary trauma care resources is uncertain. This study sought to evaluate mortality differences for patients initially presenting to nontertiary trauma centers in a predominantly rural region depending on transfer status. Methods: This was a retrospective cohort study of patients initially presenting to 104 nontertiary trauma centers in Oklahoma and meeting the state’s criteria for major trauma. Patients dying within 1 hour of emergency department (ED) arrival at the nontertiary trauma center were excluded. The exposure variable of interest was admission status, which was categorized as either transfer to a tertiary (Level I or II) trauma center within 24 hours or admission to a nontertiary trauma center. Propensity scores were used to minimize the selection bias inherent in the decision to admit or transfer a patient for higher‐level care. Multiple logistic regression was used to generate three propensity score models: probability of transfer to either a Level I or II, Level I only, and Level II only. Propensity scores were then included as a covariate in multivariable Cox regression models assessing outcome differences between admitted and transferred patients. The outcome of interest was 30‐day mortality, defined as death at either the nontertiary trauma center or the tertiary trauma center within 30 days of arrival at the initial Level III/IV center’s ED. Results: A total of 6,229 patients met study criteria, of whom 2,669 (43%) were transferred to tertiary trauma centers. Of those transferred, 1,422 patients (53%) were transferred to a Level I trauma center. Crude mortality was lower for patients transferred to tertiary trauma centers compared to those remaining at nontertiary trauma facilities (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.48 to 0.72). After adjusting for the propensity to be transferred, Injury Severity Score (ISS), presence of severe head injury, and age, transfer to a tertiary trauma center was associated with a significantly lower 30‐day mortality (HR = 0.38; 95% CI = 0.30 to 0.50) compared to admission and treatment at a nontertiary trauma center. The observed survival benefit was similar for patients transferred to a Level I trauma center (HR = 0.36; 95% CI = 0.20 to 0.4) and those transferred to a Level II center (HR = 0.45; 95% CI = 0.33 to 0.61). Conclusions: This study suggests a survival benefit among patients initially presenting to nontertiary trauma centers who are subsequently transferred to tertiary trauma centers compared to those remaining in nontertiary trauma centers, even after adjusting for variables affecting the likelihood of transfer. Although this survival benefit was larger for patients treated at a Level I trauma center, Level II trauma centers in a region with few tertiary trauma resources demonstrated a measurable benefit as well. ACADEMIC EMERGENCY MEDICINE 2010; 17:1223–1232 © 2010 by the Society for Academic Emergency Medicine     

Staffing of the ED by non–emergency medicine-trained personnel: the VA experience

Study objective

VA (Veteran's Affairs) emergency departments (EDs) are generally staffed with physicians trained in internal medicine (IM), although recently, a movement has begun toward hiring emergency medicine (EM)-trained staff. At our institution, the ED is staffed by physicians of both specialties. This study examines the frequency of unscheduled return visits to the ED in an effort to compare the quality of emergency care given by physicians trained in IM and EM.

Methods

The record of all visits to a VA hospital ED during a 90-day period were examined, and all those visits resulting in a return ED visit within the 30 subsequent days were noted.

Results

The charts of 2891 consecutive ED patients were examined. The rate of revisits was significantly higher for the IM than for the EM-trained physicians (8.9% vs 5.5%, respectively; P < .001). The IM-trained physicians had a significantly higher rate of admissions upon revisit within 30 days than did the EM-trained physicians (3.5% vs 1.9%, respectively; P = .014). The IM-trained staff had lower initial hospitalization rates than the EM physicians (20% vs 43%, respectively; P < .0001).

Conclusions

The IM-trained physicians were less likely to hospitalize patients, although this can be partially explained by the lower acuity of patients during the hours that they covered. The IM-trained physicians were significantly more likely to have a patient return after discharge and also more likely to have a patient return in need of hospitalization. This may reflect a difference in training for the rapid diagnosis and risk stratification of ED patients.     

Evaluation of a Consensus-Based Criterion Standard Definition of Trauma Center Need for Use in Field Triage Research

Research on field triage of injured patients is limited by the lack of a widely used criterion standard for defining trauma center need. Injury Severity Score (ISS) >15 has been a commonly used outcome measure in research for determining trauma center need that has never been validated. A multidisciplinary team recently published a consensus-based criterion standard definition of trauma center need, but this measure has not yet been validated. The objective was to determine if the consensus-based criterion standard can be obtained by medical record review and compare patients identified as needing a trauma center by the consensus-based criterion standard vs. ISS >15. A subanalysis of data collected during a 2-year prospective cohort study of 4,528 adult trauma patients transported by EMS to a single trauma center was conducted. These data included ICD-9-CM codes, treatment times, and other patient care data. Presence of the consensus-based criterion standard was determined for each patient. ISS was calculated based on ICD-9-CM codes assigned for billing. The consensus-based criterion standard could be applied to 4,471 (98.7%) cases. ISS could be determined for 4,506 (99.5%) cases. Based on an ISS >15, 8.9% of cases were identified as needing a trauma center. Of those, only 48.2% met the consensus-based criterion standard. Almost all patients that did not meet the consensus-based criterion standard, but had an ISS >15 were diagnosed with chest (rib fractures (100/205 cases)/pneumothorax (57/205 cases), closed head (without surgical intervention 88/205 cases), vertebral (without spinal cord injury 45/205 cases), and/or extremity injuries (39/205 cases). There were 4,053 cases with an ISS <15. 5.0% of those with an ISS <15 met the consensus-based criterion standard with the majority requiring surgery (139/203 cases) or a blood transfusion (60/203 cases). The kappa coefficient of agreement for ISS and the consensus-based criterion standard was 0.43. We determined that the consensus-based criterion standard could be identified through a medical record review. Use of the consensus-based criterion standard for field triage research will more accurately identify injured patients who need the resources of a trauma center when compared to ISS.     

A Model for an Integrated Emergency Medicine/Trauma Service

Objective: To describe a model for an integrated multidisciplinary trauma service and to compare survival outcomes for patients resuscitated by either emergency medicine (EM) or surgical housestaff assigned to the trauma service.
Methods: A prospective observational study was performed using injured patients evaluated in the trauma room at Hartford Hospital from July 1 through December 31, 1995. Inclusion criteria included an ICD-9-CM code of 800 through 959.9 and any of the following: transfer from another hospital, admission to the intensive care unit, hospitalization for ±23 hours, survival probability of ±90%, or Abbreviated Injury Score of ±3. Patients were excluded for burns necessitating transfer to a burn unit for definitive care, and for missing data elements that prevented a patient from being analyzed by the TRISS method. Data elements included mechanism of injury, Injury Severity Score, Revised Trauma Score, probability of survival, age, gender, and whether an EM resident was team leader. Patients in the EM cohort (group 1) were compared with patients for whom a surgical resident was team leader (group 2) for all data elements and for hospital survival. TRISS analysis was performed to evaluate outcomes in comparison with national norms.
Results: After exclusions, 609 patients were left for analysis. There were 141 (30%) resuscitated with an EM resident as team leader. No significant difference was found for matched variables between the groups. Both groups had good comparability with the Major Trauma Outcome Study (MTOS) database baseline, with M scores of 0.949 and 0.942, respectively. Outcomes for both groups also compared favorably with the MTOS norm for survival, with Z scores of 2.38 and 2.35 for groups 1 and 2.
Conclusions: These results suggest that in this model of integrated EW trauma service, equivalent survival outcomes occur whether EM or surgery housestaff act as team leaders.     

Rural Emergency Medicine: Patient Volume and Training Opportunities

Background: A paucity of board-certified Emergency Physicians practice in rural Emergency Departments (EDs). One proposed solution has been to train residents in rural EDs to increase the likelihood that they would continue to practice in rural EDs. Some within academic Emergency Medicine question whether rural hospital EDs can provide adequate patient volume for training an Emergency Medicine (EM) resident. Study Objectives: To compare per-physician patient-volumes in rural vs. urban hospital EDs in Oklahoma (OK) and the proportion of board-certified EM physicians in these two ED settings. Methods: A 21-question survey was distributed to all OK hospital ED directors. Analysis was limited to non-military hospitals with EDs having an annual census > 15,000 patient visits. Comparisons were made between rural and urban EDs. Results: There were 37 hospitals included in the analysis. Urban EDs had a higher proportion of board-certified EM physicians than rural EDs (80% vs. 28%). There were 4359 vs. 4470 patients seen per physician FTE (full-time equivalent) in the rural vs. urban ED settings, respectively (p = 0.84). Conclusions: Patient volumes per physician FTE do not differ in rural vs. urban OK hospital EDs, suggesting that an adequate volume of patients exists in rural EDs to support EM resident education. Proportionately fewer board-certified Emergency Physicians staff rural EDs. Opportunities to increase rural ED-based EM resident training should be explored.     

Regionalization Patterns for Children with Serious Trauma in California (2005–2015): A Retrospective Cohort Study

Abstract

Objective

Trauma centers provide coordinated specialty care and have been demonstrated to save lives. Many states do not have a comprehensive statewide trauma system. Variable geography, resources, and population distributions present significant challenges to establishing an effective uniform system for pediatric trauma care. We aimed to identify patterns of primary (field) triage and transfer of serious pediatric trauma throughout California. We hypothesized that pediatric primary triage to trauma center care would be positively associated with younger age, increased injury severity, and local emergency medical service (EMS) regions with increased resources. We hypothesized that pediatric trauma transfer would be associated with younger age, increased injury severity, and rural regions with decreased resources. Methods: We conducted a retrospective cohort study of the California Office of Statewide Health Planning and Development emergency department and inpatient discharge data (2005–2015). All patients with serious injury, defined as Injury Severity Score (ISS) >9 were included. Demographic, injury, hospital, and regional characteristics such as distances between patient residence and destination hospitals were tabulated. Univariate and multinomial logit analyses were conducted to analyze individual, hospital, and regional characteristics associated with the outcomes of location of primary triage and transfer. Estimates were converted into predicted probabilities for ease of data interpretation. Results: Primary triage to was to either a pediatric trauma center (37.8%), adult level I/II trauma center (35.0%), adult level III/IV trauma center (1.9%), pediatric non-trauma hospital (3.4%), or an adult non-trauma hospital (21.9%).Younger age, private non-HMO insurance, motor vehicle mechanism, and rural areas were the major factors influencing primary triage to any trauma hospital. Younger age, private non-HMO insurance, higher ISS, fall mechanism, <200 bed hospital, and rural areas were the major factors influencing transfer from a non-trauma hospital to any trauma center. Conclusions: We demonstrate statewide primary triage and transfer patterns for pediatric trauma in a large and varied state. Specifically we identified previously unrecognized individual, hospital, and EMS system associations with pediatric trauma regionalization. Knowledge of these de facto trauma care access patterns has policy and process implications that could improve care for all injured children in need.     

Helicopter use in rural trauma

Objective: To profile a helicopter emergency medical service in rural Australia. To assess patient injury severities and outcomes. To compare missions involving ambulance officers with physicians. To determine any time advantage of the aircraft over ground transfer. Methods: Intention‐to‐treat analysis using retrospective case note review of all helicopter emergency medical service trauma patients from January 2004 to November 2006. Global positioning system mapping technology was used to compare one‐way road transfer times with two‐way helicopter retrieval. Results: Two hundred and twenty‐two missions were identified from the helicopter log. Forty missions were aborted in flight. Of 182 patients transported, 11 records were incomplete, leaving 171 for analysis. Fifty (29%) patients transported had an Injury Severity Score (ISS) > 15; the average ISS was 12.30 (standard error of the mean 0.82). The average calculated distance flown was 160.4 nautical miles (standard error of the mean 5.29; range 28–360 nautical miles). There was no significant difference in ISS between ambulance officers and physician groups (t = ?1.17, P = 0.25, 95% CI ?7.37–1.91). There was no difference in the incidence of severe injury (ISS > 15, P = 0.39) or mortality (P = 0.33) when the groups were compared. Air transport was significantly faster beyond 100 km, with a mean difference of 48 min (P = 0.00). Conclusion: We could not identify a significant survival benefit attributable to the addition of a doctor, although numbers for this comparison were small. Predicting missions where flight physicians might provide benefit remain imprecise and should be a priority area for prospective evaluation. We have demonstrated that in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care.     

Level I Trauma Certification and Emergency Medicine Resident Major Trauma Experience

Objective: American College of Surgeons (ACS) and Residency Review Committee for Emergency Medicine (RRC–EM) guidelines conflict regarding the role of emergency physicians in directing major trauma resuscitations. This article describes the impact of ACS level I trauma certification on emergency medicine (EM) resident trauma experience.
Methods: A written survey and a follow–up letter were sent to all 101 EM program directors as of August 16, 1994. The survey addressed demographics and trauma experience at hospitals designated by the RRC–EM as primary training sites.
Results: There were 95 (94%) survey respondents. Estimates of the percentage of trauma resuscitations directed by EM residents were significantly lower at level I centers (52% X 27%, 95% CI 45–59%) than they were at non–level I centers (70% X 30%, 95% CI 58–82%) (p < 0.01). There was no significant difference in trauma census between level I and non–level I centers. Of 14 respondents who said they were cited by the RRC–EM for inadequate trauma experience, ten (71%) were in ACS level I trauma centers (p = 1.0). Twelve of the 14 respondents cited for inadequate trauma experience were in either the Northeast or the Midwest.
Conclusions: EM residents direct a smaller percentage of major trauma resuscitations at ACS level I hospitals than they do at non–level I facilities. This finding is not offset by an increased trauma census at level I facilities and may be more pronounced in the Northeast and the Midwest.     

A Comparison of Trauma Intubations Managed by Anesthesiologists and Emergency Physicians

Although airway management by emergency physicians has become standard for general emergency department (ED) patients, many believe that anesthesiologists should manage the airways of trauma victims. OBJECTIVES: To compare the success and failure rates of trauma intubations performed under the supervision of anesthesiologists and emergency physicians. METHODS: This was a prospective, observational study of consecutive endotracheal intubations (ETIs) of adult trauma patients in a single ED over a 46-month period. All ETIs before November 26, 2000, were supervised by anesthesiologists (34 months), and all ETIs from November 26, 2000, onward were supervised by emergency physicians (12 months). Data regarding clinical presentation, personnel involved, medications used, number of attempts required, and need for cricothyrotomy were collected. Study outcomes were: 1) successful intubation within two attempts, and 2) failure of intubation. Failure was defined as inability to intubate, resulting in successful intubation by another specialist, or cricothyrotomy. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to compare results between groups. RESULTS: There were 673 intubations during the study period. Intubation within two attempts was accomplished in 442 of 467 patients (94.6%) managed by anesthesiologists, and in 196 of 206 of patients (95.2%) managed by emergency physicians (OR = 1.109, 95% CI = 0.498 to 2.522). Failure of intubation occurred in 16 of 467 (3.4%) patients managed by anesthesiologists, and in four of 206 (1.9%) patients managed by emergency physicians (OR = 0.558, 95% CI = 0.156 to 1.806). CONCLUSIONS: Emergency physicians can safely manage the airways of trauma patients. Success and failure rates are similar to those of anesthesiologists.     

Supply and Demand of Board-certified Emergency Physicians by U.S. State, 2005

Objectives:  The objective was to estimate the emergency medicine (EM) board-certified emergency physician (EP) workforce supply and demand by U.S. state.
Methods:  The 2005 National Emergency Department Inventories-USA provided annual visit volumes for U.S. emergency departments (EDs). We estimated full-time equivalent (FTE) EP demand at each ED by dividing the actual number of visits by the estimated average EP visit volume (3,548 visits/year) and then summing FTEs by state. Our model assumed that at least one EP should be present 24/7 in each ED. The number of EM board-certified EPs per state was provided by the American Board of Medical Specialties (American Board of Emergency Medicine, American Board of Pediatrics) and the American Osteopathic Board of Emergency Medicine. We used U.S. Census Bureau civilian population estimates to calculate EP population density by state.
Results:  The supply of EM board-certified EPs was 58% of required FTEs to staff all EDs nationally and ranged from 10% in South Dakota to 104% in Hawai'i (i.e., there were more EPs than the estimated need). Texas and Florida had the largest absolute shortages of EM board-certified EPs (2,069 and 1,146, respectively). The number of EM board-certified EPs per 100,000 U.S. civilian population ranged from 3.6 in South Dakota to 13.8 in Washington, DC. States with a higher population density of EM board-certified EPs had higher percent high school graduates and a lower percent rural population and whites.
Conclusions:  The supply and demand of EM board-certified EPs varies by state. Only one state had an adequate supply of EM board-certified EPs to fully staff its EDs.     

ATLS P RACTICES AND S URVIVAL AT R URAL L EVEL III T RAUMA H OSPITALS , 1995-1999

Objective: To determine whether Advanced Trauma Life Support (ATLS) practices characterizing initial resuscitation and interfacility transfer at rural trauma hospitals are associated with risk-adjusted survival. Methods: Retrospective, observational analysis of rural injured patient survival. Process-of-care variables were associated with TRISS (trauma and injury severity score)-derived Z-statistics (95% confidence intervals) for high-risk population subsets (defined below). Inclusion criteria: all patients ≥12 years of age entered into a statewide trauma system, January 1, 1995, to December 31, 1999, and initially presenting to Level III trauma centers (N = 4,961). Exclusion criteria: pronounced dead on arrival (n = 26), directly admitted to hospital (n = 3), and unknown disposition at first hospital (n = 2). Process variables include: intubation in emergency department (ED) given Glasgow Coma Scale (GCS) score < 9 [ INTUB ], administration of blood products in ED given systolic blood pressure (SBP) < 90?mm Hg [ BLOOD ], trauma surgeon presence within 5 minutes of patient arrival given GCS < 9?mm Hg or SBP < 90?mm Hg [ UNSTABLE-TS ], trauma surgeon presence within 5 minutes of patient arrival given injury severity score (ISS) > 15 [ ISS-TS ], transfer to higher level of care given ISS > 20 and no hypotension [ TRAN ], transfer to higher level of care given GCS < 9 [ TRAN-GCS ]. Results: For the high-risk subpopulations, the following Z-scores (with and without an intervention) were found: Conclusions: Some ATLS interventions ( BLOOD , TRAN , and TRAN-GCS ) are associated with improved survival for selected high-risk subgroups in these 21 rural Level III trauma hospitals.     

A Survey of Academic Emergency Medicine Department Chairs on Hiring New Attending Physicians

Background

For graduating emergency medicine (EM) residents, little information exists as to what attributes department chairs are seeking in hiring new attendings. Study Objectives: To determine which qualities academic EM department chairs are looking for when hiring a new physician directly out of residency or fellowship.

Methods

An anonymous 15-item Web-based survey was sent to the department chairs of all accredited civilian EM residency programs in March of 2011. The questions assessed the desirability of different candidate attributes and the difficulty in recruiting EM-trained physicians. Respondents were also asked to give the current number of available job openings.

Results

Fifty-five percent of eligible department chairs responded. On a 5-point scale, the most important parts of a candidate's application were the interview (4.8 ± 0.4), another employee's recommendation (4.7 ± 0.5), and the program director's recommendation (4.5 ± 0.7). The single most important attribute possessed by a candidate was identified as “Ability to work in a team,” with 58% of respondents listing it as their top choice. Advanced training in ultrasound was listed as the most sought-after fellowship by 55% of the chairs. Overall, department chairs did not have a difficult time in recruiting EM-trained physicians, with 56% of respondents stating that they had no current job openings.

Conclusion

How a physician relates to others was consistently rated as the most important part of the candidate's application. However, finding a job in academic EM is difficult, with graduates having limited job prospects.     

Emergency Physician Practices and Requirements Regarding the Medical Screening Examination of Psychiatric Patients

OBJECTIVE: To describe the testing requirements and practices of emergency physicians (EPs) when conducting a medical screening examination of psychiatric patients. METHODS: An anonymous survey was developed and mailed to 500 EPs randomly selected through American College of Emergency Physicians membership rolls. RESULTS: Two hundred ninety surveys were returned (58%). Eighty-five percent of the respondents were male, 70% practiced in a community setting and 28% in an academic setting, 58% were emergency medicine (EM) residency-trained, and 88% were EM board-certified or board-eligible. Ninety-eight percent stated they were actively involved with the psychiatric medical screening exam (PMSE). Routine testing was required by 35% of the respondents, with 16% being required by ED protocol, and 84% by the psychiatrist/psychiatric institute. Of those with required testing, tests required were: complete blood cell count (56%), electrolytes (56%), serum alcohol (85%), serum toxicology screen (31%), urine toxicology screen (86%), electrocardiogram (18%), liver function test (16%), blood urea nitrogen (45%), and creatinine (40%). Many clinicians believed that certain tests were unnecessary as part of a PMSE. There was no statistical difference between the opinions of the physicians required to test and those not required to test in terms of which tests they thought were a necessary part of a PMSE regardless of the patient's clinical presentation. The EM-trained physicians were also found to be significantly less likely to think certain tests were necessary for the PMSE when compared with the non-EM-trained physicians. CONCLUSIONS: Routine testing was required as part of the medical screening examination of psychiatric patients for only one-third of the respondents. Few respondents believed that any of these tests were necessary. Emergency medicine-trained physicians were less likely to feel that routine testing was necessary.     

Does a Category II Trauma Activation Warrant the Initial Presence of an Attending Trauma Surgeon?

Background: Previous studies have examined the impact of the immediate presence of attending trauma surgeons on category I trauma alert activation outcomes. Study Objectives: This study sought to determine if the initial presence of an attending surgeon influences category II trauma activation outcomes. Methods: This 2-year retrospective review of category II alert activations involved a trauma database query to identify patients and extract pertinent variables. Results: The attending and non-attending groups were comprised of 2192 (67.6%) and 1051 (32.4%) patients, respectively. There was no significant difference in gender, age, emergency department (ED) duration, Intensive Care Unit (ICU) duration, ED disposition, or ICU admission between groups. No significant differences in outcomes, including patient mortality, complication rates, length of stay, and Injury Severity Score, were calculated between groups. Conclusion: These results lend strength to our category II trauma alert activation criteria and suggest that non-critically injured patients in need of trauma care are receiving appropriate treatment, regardless of who performs the initial evaluation. Comparable successful outcomes support the contention that the mandatory initial presence of an attending trauma surgeon is not necessary for category II activations. Initial evaluation may be performed by an emergency physician alone or by a non-attending surgeon (senior surgical resident or fellow) in conjunction with an emergency physician. Management of category II trauma alert activations should be determined by individual institutions after a thorough evaluation of resources and outcomes.     

Characteristics of Pediatric Trauma Transfers to a Level I Trauma Center: Implications for Developing a Regionalized Pediatric Trauma System in California

Background: Since California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children. Objectives: This study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out‐of‐catchment transfers would come from hospitals in close geographic proximity to the study center. Methods: This was a retrospective observational analysis of trauma patients ≤ 18 years of age in the institutional trauma database (2000–2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD‐9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight‐line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers. Results: Of 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ≤ 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15–18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS) > 18 (RR = 0.26; p < 0.01). The out‐of‐catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight‐line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0–136.4), compared to 33.6 miles (IQR = 13.9–61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out‐of‐catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15–18 (RR = 1.28; p < 0.001) were predictive of out‐of‐catchment patients bypassing other pediatric‐capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity. Conclusions: From the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols. ACADEMIC EMERGENCY MEDICINE 2010; 17:1364–1373 © 2010 by the Society for Academic Emergency Medicine     

Prospective analysis of the effect of physician experience with the FAST examination in reducing the use of CT scans

Objective: The objective of this study was to examine the effect of ultrasound experience level on emergency physicians’ Focused Assessment with Sonography for Trauma (FAST) exam accuracy and emergency physicians’ confidence in using FAST findings to assist in managing patients with blunt trauma. Methods: This prospective, consecutive enrolment study evaluated adult trauma team activation blunt trauma patients. Based on the number of post‐training FAST exams carried out, 11 attending emergency physicians were grouped into A (<25 exams, n = 4), B (26–50 exams, n = 4) or C (>50 exams, n = 3). The FAST exam was carried out prior to other diagnostic studies. The emergency physicians were asked to prospectively judge their perception of the need for surgery, abdominal CT or no further tests. All study patients ultimately underwent CT, diagnostic peritoneal lavage or laparotomy. Among each physician group, the number of subsequent CT scans deemed necessary by the emergency physician after a ‘normal’ FAST was calculated and compared. Results: Accuracy was greatest in group C. Sixty‐nine of 80 patients in group A had a normal FAST exam; emergency physicians deemed CT necessary in 68/69 cases (99%; confidence interval [CI] 92–100%). Eighty‐two of 98 patients in group C had a normal FAST exam; emergency physicians deemed CT necessary in 19/82 cases (23%; CI 15–34%). Physicians in groups B and C were less likely to order CT after a normal FAST than group A (P < 0.001). Conclusions: FAST accuracy was greatest among more experienced emergency physicians. A normal FAST exam assisted more experienced emergency physicians with the perceived need to order significantly fewer CT scans than less experienced emergency physicians.