Concurrent Diagnoses of Post-Traumatic Stress Disorder and Physical Injury is Associated with Increased Emergency Department Utilization in the U.S.

Background. Every year, approximately 2.5 million individuals sustain traumatic physical injuries that require admission to an acute care facility. Several studies suggest that physical injury increases the risk for the development of Post-Traumatic Stress Disorder (PTSD). Nationally, 20% to 40% of acutely injured patients had symptoms consistent with PTSD. Most studies describe the prevalence of PTSD and other mental health conditions post-injury. However, there is limited attention to the effect of pre-existing mental health condition as pre-injury factor, and conclusions from these studies were limited by their small sample sizes, lack of population comparison group, and non-population based. The overall objective of this study was to examine the association between physical injury and PTSD and other mental health conditions in adult patients >18 years who were admitted in ED between 2009-2011. More specifically, those patients who were admitted with physical injury were compared with patients who had a concurrent diagnosis of PTSD, or concurrent diagnosis of other mental health conditions with patients who did not have these concurrent conditions. The interaction between presenting diagnoses, patient characteristics, hospital setting, location, and risk for outcomes such as mortality rates, and costs were also explored. Method. This is a cross-sectional, descriptive study that compares the prevalence of Injury (ICD-9-CM 800-999) for patients with and without PTSD (ICD-9-CM 308.91) and patients with and without other mental health diagnoses other than PTSD (ICD-9-CM 290-320) using the National Emergency Department Sample (NEDS) databases who were admitted to a US Emergency Department (ED) between January 1, 2009, through December 31, 2011. The interaction between presenting diagnoses, patient characteristics, hospital setting, location and risk for outcomes such as mortality rates, and costs were explored using univariate, bivariate, and multivariate analyses. Results. Adjusted analyses suggested that for the period 2009 to 2011, there were 308, 078,546 ED visits among adults in the US Approximately 22% (N=66,936, 140) of these ED visits had injury-related diagnoses, 0.25% (N=758,528) had PTSD diagnoses, and 25% (N=77,536,048) had mental health diagnoses other than PTSD. There were 133,243 adult patients that were diagnosed with both PTSD and Injury for this period. Adult patients with a diagnosis of PTSD had 1.03-fold higher odds of having injury diagnosis compared to those who are otherwise similar but unaffected adults. Adult patients with mental health diagnoses had iii1.30-fold higher odds of having injury-related ED visits compared to those that are unaffected.Results from a survey-adjusted multivariate logistic regression analysis indicated that PTSD diagnosis increased the odds of injury-related ED visits to 1.30-fold compared to those that are unaffected. In comparison to adults aged 45-64, those who were aged 18-44 had 1.10-fold higher odds of an injury, while aged 65-84 had 1.10-fold lesser odds. Males, compared to females, had 1.40-fold higher odds of having injury-related ED visits. Compared to patients with Medicare insurance, those that have private and other insurances had 1.50 and 2.60c-fold higher odds to have injury-related ED visits.There were significant differences in mortality rates across the studied groups. Injured adult patients compared to otherwise similar but uninjured counterparts had significantly lower mortality rates (0.79% vs. 0.37%, p<0.0001). PTSD diagnosed adults had lower mortality rates in comparison to those that were unaffected (0.20% vs. 0.56%, p<0.0001). PTSD diagnosed patients with injury diagnoses also had a slightly lower mortality rate compared to their uninjured counterparts (0.19% vs. 0.20%, p<0.001). The mortality rates among adults with other mental health diagnoses compared to those that were unaffected were also lower (0.53% vs. 0.70%, p<0.0001). Adult patients with concurrent diagnoses of other mental health and injury showed a lesser mortality rate compared to those without injuries (0.25% vs. 0.61%, p<0.0001). There were significant differences in cost across the groups. Adult patients with injury had higher mean costs compared to those without injury ($45,271 vs.$33,197, p <0.001). Uninjured PTSD diagnosed adults showed lower costs compared to those that did not have PTSD ($21,061 vs.$33,272, p<0.001). Similarly, adults with mental health conditions without injury had lower costs compared to those who did not ($30,269 vs.$35,196, p<0.001). There was incremental ivincrease in costs for ED patients with concurrent diagnoses. The mean cost for patients with a diagnosis of PTSD was $21,061. The cost increased by 26$28, 319). The costs increased by 54% when there was concurrent diagnoses of PTSD, Injury, and other mental health conditions ($45,431).Conclusion. These findings indicate that when investigating injury as an outcome, the presence of PTSD and other mental health conditions is a potential confounder and effect modifier. For example, this study showed that PTSD diagnosis didn't increase the odds of dying among those who were diagnosed with injury. Likewise, diagnoses of injury didn't increase the odds of dying among those diagnosed with PTSD. In regards to hospital costs, adult patients with injury or PTSD diagnoses incurred more hospital costs compared to similar but unaffected patients. Results also showed that there were incremental costs incurred with the increased number of diagnoses. For example, combined diagnoses of Injury and PTSD increased the cost by 23% compared to just having PTSD diagnosis alone. Having concurrent diagnoses of PTSD, Injury, and other mental health disorder increased the cost further by 54% compared to just having a diagnosis of PTSD. Based from these findings, it is suggested that mental health and PTSD screening needs to be evaluated upon entry to ED, and immediate referral to mental health services must be considered a priority for patients with an injury. Strategies for injury prevention need to include mental health evaluation and management at the primary, secondary, and tertiary care service settings

Concurrent Traumatic Brain Injury with Craniofacial Trauma: A 10-Year Analysis of a Single Institution’s Trauma Registry

Background: Craniofacial injuries are thought to be commonly associated with traumatic brain injury (TBI), but there is conflicting evidence in the literature. This retrospective cohort study aims to evaluate the incidence of TBI in patients with craniofacial trauma. Methods: The study included 2982 consecutive patients with either solitary or concurrent diagnoses of TBI and facial fractures, seen and evaluated at a single level II trauma center between 1 January 2010 and 31 December 2020. Continuous variables were compared against whether the patient had one or both diagnoses. Results: Of the target population, 55.8% had a solitary diagnosis of TBI; 30.28% had a solitary diagnosis of facial fractures; and 13.92% had concurrent diagnoses of both TBI and facial fractures. Patients with concurrent diagnoses had a significantly longer mean length of stay (LOS) compared to those with solitary diagnoses (9.92 ± 16.33 days vs. 6.21 ± 10.96 days, p p = 0.68) and ICU LOS (p = 0.09) did not differ significantly between the two groups. Conclusions: Trauma to the face should be given special attention due to the increased chance of TBI with craniofacial fractures. Patients with concurrent diagnoses of TBI and facial fractures had worse hospital outcomes than those with solitary diagnoses of either TBI or facial trauma

Electric Scooter Injury in Southern California Trauma Centers.

BACKGROUND: Electric scooters are popular in Southern California due to their ease of use, affordability, and availability. The objective of this study was to characterize how hospital admissions and outcomes varied due to electric scooter injury among Southern California trauma centers. STUDY DESIGN: Trauma registry data from 9 urban trauma centers were queried for patients sustaining injury while operating an electric scooter from January to December 2018. Data collection included patient demographics, diagnoses, interventions, and outcomes. RESULTS: During the 1-year study period, 87 patients required trauma surgeon care due to scooter-related injury, with a mean age of 35.1 years; 71.3% were male with 20.7% and 17.2% of patients requiring ICU admission and a surgical intervention, respectively. One (1.1%) patient died. The head and face were most commonly injured, followed by the extremities. Helmet use was uncommon (71.3%). High variability in patient volume was noted, with 2 centers considered high-incidence and the remaining low-incidence. CONCLUSIONS: Injuries from electric scooter crashes are primarily to the head, face, and extremities, with approximately 1 in 5 patients requiring ICU admission and/or a surgical intervention. There is significant variation in patient volume among Southern California trauma centers that could affect the delivery of care with the abrupt introduction of this technology. Targeted public health interventions and policies might better address community use of the electric scooter

Significant variation in computed tomography imaging of pregnant trauma patients: a retrospective multicenter study.

PURPOSE: Following motor vehicle collisions (MVCs), patients often undergo extensive computed tomography (CT) imaging. However, pregnant trauma patients (PTPs) represent a unique population where the risk of fetal radiation may supersede the benefits of liberal CT imaging. This study sought to evaluate imaging practices for PTPs, hypothesizing variability in CT imaging among trauma centers. If demonstrated, this might suggest the need to develop specific guidelines to standardize practice. METHODS: A multicenter retrospective study (2016-2021) was performed at 12 Level-I/II trauma centers. Adult (≥18 years old) PTPs involved in MVCs were included, with no patients excluded. The primary outcome was the frequency of CT. Chi-square tests were used to compare categorical variables, and ANOVA was used to compare the means of normally distributed continuous variables. RESULTS: A total of 729 PTPs sustained MVCs (73% at high speed of ≥ 25 miles per hour). Most patients were mildly injured but a small variation of injury severity score (range 1.1-4.6, p < 0.001) among centers was observed. There was a variation of imaging rates for CT head (range 11.8-62.5%, p < 0.001), cervical spine (11.8-75%, p < 0.001), chest (4.4-50.2%, p < 0.001), and abdomen/pelvis (0-57.3%, p < 0.001). In high-speed MVCs, there was variation for CT head (12.5-64.3%, p < 0.001), cervical spine (16.7-75%, p < 0.001), chest (5.9-83.3%, p < 0.001), and abdomen/pelvis (0-60%, p < 0.001). There was no difference in mortality (0-2.9%, p =0.19). CONCLUSION: Significant variability of CT imaging in PTPs after MVCs was demonstrated across 12 trauma centers, supporting the need for standardization of CT imaging for PTPs to reduce unnecessary radiation exposure while ensuring optimal injury identification is achieved

Decreased hospital length of stay and intensive care unit admissions for non-COVID blunt trauma patients during the COVID-19 pandemic.

BackgroundThe COVID-19 pandemic overwhelmed hospitals, forcing adjustments including discharging patients earlier and limiting intensive care unit (ICU) utilization. This study aimed to evaluate ICU admissions and length of stay (LOS) for blunt trauma patients (BTPs).MethodsA retrospective review of COVID (3/19/20-6/30/20) versus pre-COVID (3/19/19-6/30/19) BTPs at eleven trauma centers was performed. Multivariable analysis was used to identify risk factors for ICU admission.Results12,744 BTPs were included (6942 pre-COVID vs. 5802 COVID). The COVID cohort had decreased mean LOS (3.9 vs. 4.4 days, p = 0.029), ICU LOS (0.9 vs. 1.1 days, p < 0.001), and rate of ICU admission (22.3% vs. 24.9%, p = 0.001) with no increase in complications or mortality compared to the pre-COVID cohort (all p > 0.05). On multivariable analysis, the COVID period was associated with decreased risk of ICU admission (OR = 0.82, CI 0.75-0.90, p < 0.001).ConclusionsBTPs had decreased LOS and associated risk of ICU admission during COVID, with no corresponding increase in complications or mortality

Adolescent Trauma During the COVID Pandemic: Just Like Adults, Children, or Someone Else?

COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social interactions affect development. This has the potential to change adolescent trauma. A post-hoc multicenter retrospective analysis of adolescent (13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed. Patients were divided into 3 groups based on injury date: historical control (CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH (POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL groups in separate analyses. 726 ATPs were identified across the 3 time periods. POST had a similar penetrating trauma rate compared to both PRE (15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%, P = .69). POST also had a similar rate of suicide attempts compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2% vs 2.1%, P = .43). However, POST had a higher rate of drug positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but was similar in all other comparisons of alcohol and drugs to PRE and POST periods (all P > .05). Hence ATPs were affected differently than adults and children, as they had a similar rate of penetrating trauma, suicide attempts, and alcohol positivity after SAH orders. However, they had increased drug positivity compared to the CONTROL, but not PRE group

Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic

BackgroundThe COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order.MethodsA multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses.ResultsAcross all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618).ConclusionThis multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s).Level of evidenceEpidemiological, level IV

COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients.

PurposeThere is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients.MethodsA retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019-6/30/2019 and 1/1/2020-6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups.ResultsA total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients.ConclusionThis multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients

Effects of the COVID-19 pandemic on pediatric trauma in Southern California.

PurposeThe COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders.MethodsA multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019-6/30/2019 (CONTROL), 1/1/2020-3/18/2020 (PRE), 3/19/2020-6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses.Results1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05).ConclusionsThis multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS

Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic.

BackgroundThe COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order.MethodsA multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses.ResultsAcross all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618).ConclusionThis multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s).Level of evidenceEpidemiological, level IV