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Patients with Psychiatric Disorders Require Greater Health-Care Resources after Injury

Warnack, Elizabeth; Choi, Beatrix Hyemin; DiMaggio, Charles; Frangos, Spiros; Bukur, Marko; Marshall, Gary
The objective of this study was to assess whether patients with comorbid psychiatric conditions admitted after traumatic injury require greater health-care resource utilization. The trauma registry of a Level 1 trauma center was used to identify all adult trauma patients presenting from 2012 to 2015. Patients with psychiatric needs, identified as having either an ICD-9 code corresponding to a psychiatric disorder or requiring inpatient psychiatric consultation, were compared with controls, using propensity score matching. Patients with psychiatric disorders were more than three times more likely to present with penetrating injuries (odds ratio [OR] 3.5, P < 0.005). They had longer length of hospital stay (median 5 [IQR 2.5-11] vs. three days [IQR 1-7], P < 0.01), were approximately 70 per cent more likely to require ICU-level care (OR 1.68, P = 0.08), and were 80 per cent less likely to be discharged home (OR 0.18, P < 0.005). Trauma patients with psychiatric illness or need consume greater health-care resources.
PMID: 30606344
ISSN: 1555-9823
CID: 3680982

Correlation of thromboelastography with conventional coagulation testing in elderly trauma patients on pre-existing blood thinning medications

Williams, David M.; Hodge, Andrew; Catino, Joseph; DiMaggio, Charles; Marshall, Gary; Ayoung-Chee, Patricia; Frangos, Spiros; Bukur, Marko
Background: Thromboelastography (TEG) may have a role in managing injured patients on pre-existing anticoagulant/antiplatelet agents.
ISI:000448534900010
ISSN: 0002-9610
CID: 3430982

Weight-Based Enoxaparin for Venous Thromboembolic Event Prophylaxis in Adult Trauma Patients Results in Improved Prophylaxis [Meeting Abstract]

Rodier, S; Marshall, G T; Moore, S; Maggio, C D; Frangos, S G; Chee, P A; Tandon, M; Bukur, M
INTRODUCTION: Venous thromboembolism (VTE) is a common morbidity in trauma patients. Standard chemical VTE prophylaxis is often inadequate. We hypothesized that using weight-based dosing would result in appropriate prophylaxis more frequently than fixed dosing.
METHOD(S): All patients admitted to a Level I trauma service during a 6-month period were included unless contraindications for VTE prophylaxis existed. A prospective weight-based enoxa-parin dosing group was compared with a retrospective uniform-dosing group. The weight-based dosage was 0.5 mg/kg subcutaneous q12 hours rounded to the nearest 10 mg. Peak anti-factor Xa activity was measured and patients who fell outside of the prophylactic range had their dose adjusted by +/- 10 mg q12 hours. The uniform dosing group received 30 mg subcutaneous q12 hours, and did not receive dose adjustments. Data were analyzed using Pearson's correlation and Fisher's exact test, as appropriate.
RESULT(S): Eighty-three patients were included in the study. Significantly more patients in the uniform-dosing group were sub-therapeutically anti-coagulated vs the weight-based group. In the uniform dosing group, anti-Xa level correlated with body surface area (BSA) (1C = 0.24, p = 0.0010) and weight. Weight-based dosing both pre-and post-readjustment normalized the correlation of anti-Xa with BSA (ic=0.049, p = 0.18) and weight (Figure).
CONCLUSION(S): Weight-based VTE prophylaxis with anti-Xa-based dose adjustment improves the rate of appropriate prophylaxis relative to uniform dosing and eliminates variances secondary to BSA and weight in trauma patients
EMBASE:638696316
ISSN: 1879-1190
CID: 5379822

Subway-Related Trauma: An Urban Public Health Issue with a High Case-Fatality Rate

Rodier, Simon G; DiMaggio, Charles J; Wall, Stephen; Sim, Vasiliy; Frangos, Spiros G; Ayoung-Chee, Patricia; Bukur, Marko; Tandon, Manish; Todd, S Rob; Marshall, Gary T
BACKGROUND:Between 1990 and 2003, there were 668 subway-related fatalities in New York City. However, subway-related trauma remains an understudied area of injury-related morbidity and mortality. OBJECTIVE:The objective of this study was to characterize the injuries and events leading up to the injuries of all patients admitted after subway-related trauma. METHODS:We conducted a retrospective case series of subway-related trauma at a Level I trauma center from 2001 to 2016. Descriptive epidemiology of patient demographics, incident details, injuries, and outcomes were analyzed. RESULTS:Over 15 years, 254 patients were admitted for subway-related trauma. The mean (standard error of the mean) age was 41 (1.0) years, 80% were male (95% confidence interval [CI] 74-84%) and median Injury Severity Score was 14 (interquartile range [IQR] 5-24). The overall case-fatality rate was 10% (95% CI 7-15%). The most common injuries were long-bone fractures, intracranial hemorrhage, and traumatic amputations. Median length of stay was 6 days (IQR 1-18 days). Thirty-seven percent of patients required surgical intervention. At the time of injury, 55% of patients (95% CI 49-61%) had a positive urine drug or alcohol screen, 16% (95% CI 12-21%) were attempting suicide, and 39% (95% CI 33-45%) had a history of psychiatric illness. CONCLUSIONS:Subway-related trauma is associated with a high case-fatality rate. Alcohol or drug intoxication and psychiatric illness can increase the risk of this type of injury.
PMID: 29753571
ISSN: 0736-4679
CID: 3121232

Functional outcomes after inpatient rehabilitation for trauma-improved but unable to return home

Lancaster, Catherine W; DiMaggio, Charles; Marshall, Gary; Wall, Stephen; Ayoung-Chee, Patricia
BACKGROUND: Twenty-five percent of trauma patients are discharged to postacute care, indicating a loss of physical function and need for rehabilitation. The purpose of this study was to quantify the functional improvements in trauma patients discharged from inpatient rehabilitation facility (IRF) and identify predictors of improvement. MATERIALS AND METHODS: A retrospective cohort study of trauma patients aged >/= 18 years were admitted to an IRF after discharge from a level-1 trauma center. Data included demographics, injury characteristics, hospital, and IRF course. The functional independence measure (FIM) was used to measure change in physical and cognitive function. RESULTS: There were 245 patients with a mean age of 55.8 years and mean injury severity score (ISS) of 14.7. Fall was the leading mechanism of injury (45.7%). On IRF admission, 50.7% of patients required moderate or greater assistance. On discharge, the mean intraindividual change in FIM score was 29.9; 85.4% of the patients improved by >/=1 level of functioning. Before injury, 99.6% of patients were living at home, but only 56.0% were discharged home from the IRF, despite 81.8% requiring minimal assistance at most (23.5% to skilled nursing; 19.7% readmitted). Increasing age and lower ISS were associated with less FIM improvement, and increasing ISS was associated with increased FIM improvement. CONCLUSIONS: More than 80% of the trauma patients experienced meaningful functional improvements during IRF admission. However, only half were discharged home, and a quarter required further institutional care. Further research is needed to identify the additional impediments to return to preinjury functioning.
PMID: 29103674
ISSN: 1095-8673
CID: 2773342

Traumatic injury in the United States: In-patient epidemiology 2000-2011

DiMaggio, Charles; Ayoung-Chee, Patricia; Shinseki, Matthew; Wilson, Chad; Marshall, Gary; Lee, David C; Wall, Stephen; Maulana, Shale; Leon Pachter, H; Frangos, Spiros
BACKGROUND: Trauma is a leading cause of death and disability in the United States (US). This analysis describes trends and annual changes in in-hospital trauma morbidity and mortality; evaluates changes in age and gender specific outcomes, diagnoses, causes of injury, injury severity and surgical procedures performed; and examines the role of teaching hospitals and Level 1 trauma centres in the care of severely injured patients. METHODS: We conducted a retrospective descriptive and analytic epidemiologic study of an inpatient database representing 20,659,684 traumatic injury discharges from US hospitals between 2000 and 2011. The main outcomes and measures were survey-adjusted counts, proportions, means, standard errors, and 95% confidence intervals. We plotted time series of yearly data with overlying loess smoothing, created tables of proportions of common injuries and surgical procedures, and conducted survey-adjusted logistic regression analysis for the effect of year on the odds of in-hospital death with control variables for age, gender, weekday vs. weekend admission, trauma-centre status, teaching-hospital status, injury severity and Charlson index score. RESULTS: The mean age of a person discharged from a US hospital with a trauma diagnosis increased from 54.08 (s.e.=0.71) in 2000 to 59.58 (s.e.=0.79) in 2011. Persons age 45-64 were the only age group to experience increasing rates of hospital discharges for trauma. The proportion of trauma discharges with a Charlson Comorbidity Index score greater than or equal to 3 nearly tripled from 0.048 (s.e.=0.0015) of all traumatic injury discharges in 2000 to 0.139 (s.e.=0.005) in 2011. The proportion of patients with traumatic injury classified as severe increased from 22% of all trauma discharges in 2000 (95% CI 21, 24) to 28% in 2011 (95% CI 26, 30). Level 1 trauma centres accounted for approximately 3.3% of hospitals. The proportion of severely injured trauma discharges from Level 1 trauma centres was 39.4% (95% CI 36.8, 42.1). Falls, followed by motor-vehicle crashes, were the most common causes of all injuries. The total cost of trauma-related inpatient care between 2001 and 2011 in the US was $240.7 billion (95% CI 231.0, 250.5). Annual total US inpatient trauma-related hospital costs increased each year between 2001 and 2011, more than doubling from $12.0 billion (95% CI 10.5, 13.4) in 2001 to 29.1 billion (95% CI 25.2, 32.9) in 2011. CONCLUSIONS: Trauma, which has traditionally been viewed as a predicament of the young, is increasingly a disease of the old. The strain of managing the progressively complex and costly care associated with this shift rests with a small number of trauma centres. Optimal care of injured patients requires a reappraisal of the resources required to effectively provide it given a mounting burden.
PMCID:5269564
PMID: 27157986
ISSN: 1879-0267
CID: 2107442

Bicycle helmets are highly protective against traumatic brain injury within a dense urban setting

Sethi, Monica; Heidenberg, Jessica; Wall, Stephen P; Ayoung-Chee, Patricia; Slaughter, Dekeya; Levine, Deborah A; Jacko, Sally; Wilson, Chad; Marshall, Gary; Pachter, H Leon; Frangos, Spiros G
BACKGROUND: New York City (NYC) has made significant roadway infrastructure improvements, initiated a bicycle share program, and enacted Vision Zero, an action plan to reduce traffic deaths and serious injuries. The objective of this study was to examine whether bicycle helmets offer a protective advantage against traumatic brain injury (TBI) within a contemporary dense urban setting with a commitment to road safety. METHODS: A prospective observational study of injured bicyclists presenting to a Level I trauma centre was performed. All bicyclists arriving within 24h of injury were included. Data were collected between February, 2012 and August, 2014 and included demographics, imaging studies (e.g. computed tomography (CT)), injury patterns, and outcomes including Glasgow Coma Scale (GCS) and Injury Severity Score. RESULTS: Of 699 patients, 273 (39.1%) were wearing helmets at the time of injury. Helmeted bicyclists were more likely to have a GCS of 15 (96.3% [95% Confidence Interval (CI), 93.3-98.2] vs. 87.6 [95% CI, 84.1-90.6]) at presentation. Helmeted bicyclists underwent fewer head CTs (40.3% [95% CI, 34.4-46.4] vs. 52.8% [95% CI, 48.0-57.6]) and were less likely to sustain intracranial injury (6.3% [95% CI, 2.6-12.5] vs. 19.7% [14.7-25.6]), including skull fracture (0.9% [95% CI, 0.0-4.9] vs. 15.3% [95% CI, 10.8-20.7]) and subdural hematoma (0.0% [95% CI, 0.0-3.2] vs. 8.1% [95% CI, 4.9-12.5]). Helmeted bicyclists were significantly less likely to sustain significant TBI, i.e. Head AIS >/=3 (2.6% [95% CI: 0.7-4.5] vs.10.6% [7.6-12.5]). Four patients underwent craniotomy while three died; all were un-helmeted. A multivariable logistic regression model showed that helmeted bicyclists were 72% less likely to sustain TBI compared with un-helmeted bicyclists (Adjusted Odds Ratio 0.28, 95% CI 0.12-0.61). CONCLUSIONS: Despite substantial road safety measures in NYC, the protective impact of simple bicycle helmets in the event of a crash remains significant. A re-assessment of helmet laws for urban bicyclists is advisable to most effectively translate Vision Zero from a political action plan to public safety reality.
PMID: 26254573
ISSN: 1879-0267
CID: 1721522

Physical Function Recovery in Older Trauma Patients [Meeting Abstract]

Ayoung-Chee, Patricia; Sedaghatzandi, Deborah; Frangos, Spiros G; Marshall, Gary T; Wall, Stephen P
ISI:000361119700350
ISSN: 1879-1190
CID: 2544822

Communication skills training in surgical residency: a needs assessment and metacognition analysis of a difficult conversation objective structured clinical examination

Falcone, John L; Claxton, Rene N; Marshall, Gary T
BACKGROUND: The objective structured clinical examination (OSCE) can be used to evaluate the Accreditation Council for Graduate Medical Education Core Competencies of Professionalism and Interpersonal and Communication Skills. The aim of this study was to describe general surgery resident performance on a "difficult conversation" OSCE. METHODS: In this prospective study, junior and senior residents participated in a 2-station OSCE. Junior stations involved discussing operative risks and benefits and breaking bad news. Senior stations involved discussing goals of care and discussing transition to comfort measures only status. Residents completed post-OSCE checklist and Likert-based self-evaluations of experience, comfort, and confidence. Trained standardized patients (SPs) evaluated residents using communication skill-based checklists and Likert-based assessments. Pearson correlation coefficients were determined between self-assessment and SP assessment. Mann-Whitney U tests were conducted between junior and senior resident variables, using alpha = 0.05. RESULTS: There were 27 junior residents (age 28.1 +/- 1.9 years [29.6% female]) and 27 senior residents (age 32.1 +/- 2.5 years [26.9% female]). The correlation of self-assessment and SP assessment of overall communication skills by junior residents was -0.32 on the risks and benefits case and 0.07 on the breaking bad news case. The correlation of self-assessment and SP assessment of overall communication skills by senior residents was 0.30 on the goals of care case and 0.26 on the comfort measures only case. SP assessments showed that junior residents had higher overall communication skills than senior residents (p = 0.03). Senior residents perceived that having difficult conversations was more level appropriate (p < 0.001), and they were less nervous having difficult conversations (p < 0.01) than junior residents. CONCLUSIONS: We found that residents perform difficult conversations well, that subjective and objective skills are correlated, and that skills-based training is needed across all residency levels. This well-received method may be used to observe, document, and provide resident feedback for these important skills.
PMID: 24797845
ISSN: 1878-7452
CID: 1795212

A community traffic safety analysis of pedestrian and bicyclist injuries based on the catchment area of a trauma center

Slaughter, Dekeya R; Williams, Nick; Wall, Stephen P; Glass, Nina E; Simon, Ronald; Todd, S Rob; Bholat, Omar S; Jacko, Sally; Roe, Matthew; Wilson, Chad T; Levine, Deborah A; Marshall, Gary; Ayoung-Chee, Patricia; Pachter, H Leon; Frangos, Spiros G
BACKGROUND: This study was designed to examine the characteristics of pedestrian and bicyclist collisions with motor vehicles within New York City's high-density hub. The primary objectives were to map crash locations and to identify hot spots within these injury clusters. The secondary objective was to quantify differences in injury severity based on road type and user behaviors. METHODS: Between December 2008 and June 2011, data were prospectively collected from pedestrians and bicyclists struck by motor vehicles and brought to Bellevue Hospital, a Level 1 trauma center in New York City. Behaviors by cohort (i.e., crossing patterns for pedestrians, riding patterns for bicyclists), Injury Severity Score (ISS), and collision locations were extracted from the database. Analyses of mean ISS were performed using a Student's t test with a p < 0.05 considered significant. Geomaps were created to identify clusters or "hot spots," where higher volumes of crashes occurred over time. Spatial analysis was performed to demonstrate whether these were random events. RESULTS: A total of 1,457 patients (1,075 pedestrians and 382 bicyclists) were enrolled. Collision locations were known for 97.5%. Of the injured pedestrians, those crossing avenues (n = 277) had higher ISSs than those crossing streets (n = 522) (p = 0.01) and were more likely to die (p = 0.002). Pedestrians crossing midblock (n = 185) had higher mean ISSs than those crossing with the signal in the crosswalk (n = 320) (8.12 vs. 5.01, p < 0.001). Based on density mapping, hot spots of pedestrian collisions were detected in midtown Manhattan, while hot spots for bicyclists were detected at bridge and tunnel portals. Spatial analysis indicates that these are not random events (p < 0.05). CONCLUSION: Pedestrians injured on avenues sustained more serious injuries than those injured on narrower streets. A better understanding of collision locations and features may allow for tailored injury prevention strategies. Trauma centers serve an important role in public health surveillance within their local communities. LEVEL OF EVIDENCE: Epidemiologic study, level III.
PMID: 24662878
ISSN: 2163-0755
CID: 884192