Surgical Critical Care of Special Populations (Pregnant, Geriatric, Pediatric)

This review covers the specialized care of populations who present different management challenges when critically injured. The text is divided into three sections: pregnant, geriatric, and pediatric patients. For each population, the discussion focuses on the unique diagnostic and treatment algorithms that the surgical intensivist must consider. In addition to management of trauma in these special populations, other common diagnoses warranting surgical intensive care unit (ICU) admission are reviewed. Current guidelines on diagnostic imaging and medication safety are outlined. Injury prevention and outcomes improvement are an essential component of optimizing trauma care. The epidemiology of traumatic injury within each specialized population is included in this review. Outcomes are discussed in depth, particularly with respect to the geriatric ICU patient, including a section on barriers to disposition, decision-making capacity, and end-of-life care in the surgical ICU.   This review contains 2 figures, 4 tables, and 72 references. Key words: end of life in the ICU, geriatric trauma, injury prevention, pediatric trauma, pregnanc

Triage of elderly trauma patients: a population-based perspective.

BackgroundElderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes.Study designThis is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center.ResultsThere were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers.ConclusionsThis is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population

Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States

STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient\u27s lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and$50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 15% relative risk reduction in mortality (1.3 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 30$50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 15% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness. Inc. All rights reserved

The American College of Surgeons Needs-Based Assessment of Trauma Systems

BackgroundIn 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California.MethodsTrauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers.ResultsA total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results.ConclusionEstimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool.Level of evidenceEconomic, level V

The Economic Footprint of Acute Care Surgery in the United States

BackgroundAcute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics.MethodsWe queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates.ResultsOf the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25$341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US$10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients.ConclusionAcute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs.Level of evidenceEpidemiologic, level III

The American College of Surgeons Needs-Based Assessment of Trauma Systems

BackgroundIn 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California.MethodsTrauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers.ResultsA total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results.ConclusionEstimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool.Level of evidenceEconomic, level V

Triage of Elderly Trauma Patients: A Population-Based Perspective

BACKGROUND: Elderly patients are frequently under-triaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes. STUDY DESIGN: This is a population-based, retrospective cohort study of all injured adults aged ≥55 years from 3 counties in California and 4 in Utah (2006–2007). Pre-hospital data were linked to trauma registry data, state-level discharge data, emergency department (ED) records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared to those treated at non-trauma centers. Under-triage was defined as an injury severity score (ISS)>15 with transport to a non-trauma center. RESULTS: There were 6,015 patients in the analysis. Patients who were taken to non-trauma centers were on average older (79.4 vs. 70.7 years, p<0.001), more often female (68.6% vs. 50.2%, p<0.01), and less often had an ISS>15 (2.2% vs. 6.7%, p<0.01). The number of patients with an ISS>15 was 244 and the under-triage rate was 32.8% (N=80). Overall 60-day mortality for patients with an ISS>15 was 17%, with no difference between trauma and non-trauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers. CONCLUSIONS: This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of under-triage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population