Faculty Bibliography

This study evaluated the safety of early anti-factor Xa assay-guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay-guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.

BACKGROUND:Elderly patients with Traumatic Brain Injury (TBI) are frequently transferred to designated Trauma Centers (TC). We hypothesized that TC transfer is associated with improved outcomes. METHODS:Retrospective study utilizing the National Trauma Databank. Demographics, injury and outcomes data were abstracted. Patients were dichotomized by transfer to a designated level I/II TC vs. not. Multivariate regression was used to derive the adjusted primary outcome, mortality, and secondary outcomes, complications and discharge disposition. RESULTS:19,664 patients were included, with a mean age of 78.1 years. 70% were transferred to a level I/II TC. Transferred patients had a higher ISS (12 vs. 10, p < 0.001). Mortality was significantly lower in patients transferred to level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p = 0.011), as was the likelihood of discharge to skilled nursing facilities (26.4% vs. 30.2%, AOR 0.80, p < 0.001). CONCLUSIONS:Elderly patients with mild TBI transferred to level I/II TCs have improved outcomes. Which patients with mild TBI require level I/II TC care should be examined prospectively.

BACKGROUND:We sought to evaluate the role of trauma center designation in the association of race and insurance status with disposition to rehabilitation centers among elderly patients with Traumatic Brain Injury (TBI). METHODS:The National Trauma Data Bank (2014-2015) was used to identify elderly (age ≥ 65) patients with isolated moderate to severe blunt TBI who survived to discharge. Race, insurance status, and outcomes were stratified by trauma center designation and compared. RESULTS:3,292 patients met the inclusion criteria. Black patients were 1.5 times less likely (AOR 0.64, p = 0.01) and Latino patients were 1.7 times less likely (AOR 0.58, p = 0 0.007) to be discharged to rehabilitation centers as compared with White patients. Asian patients at Level I hospitals were more likely to be discharged to rehabilitation centers if they had private vs. non-private insurance (42.9% versus 12.7%, p = 0.01). CONCLUSION/CONCLUSIONS:Black and Latino patients were less likely to be discharged to rehabilitation centers compared to White patients. The etiology of these disparities deserves further study.

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally accepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospi-tal received multiple injured patients within minutes; lessons learned included the need for a formalized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for hmultiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in organizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.

BACKGROUND:The mangled extremity (ME) is a limb with a multisystem injury (soft tissue, bone, nerves, or vessels). We hypothesized that trauma patients who present with mangled lower extremities (ME) experience a higher rate of venous thromboembolism when matched against trauma patients of similar injury burden without ME. MATERIALS AND METHODS/METHODS:Data were abstracted from the Trauma Quality Improvement Program database from 2013 to 2016. Baseline comparisons were made between patients with and without ME. Propensity score matching with logistic regression modeling on the matched sample was performed controlling for patient gender, race, insurance status, age, injury severity score, Charlson comorbidity index, presence of significant other non-ME trauma, use of and time to prophylactic anticoagulation, placement of an inferior vena cava filter, and if immediate operative intervention was performed. RESULTS:A total of 1060 patients presented with an ME. Compared with other trauma patients, those with ME tended to be younger and male. They were more likely to receive prophylactic anticoagulation and an inferior vena cava filter. After propensity score matching, ME was statistically significantly associated with pulmonary embolism (PE) but not deep venous thrombosis (average treatment effect on the treated 1.7%, P = 0.04; and 1.4%, P = 0.22, respectively). These results were confirmed in a logistic regression on the matched sample (odds ratios 1.6, P = 0.11 for deep venous thrombosis, and odds ratio 3.2, P = 0.006 for PE). CONCLUSIONS:Patients with mangled lower extremities experience higher rates of PE. Based on these findings, institutions may consider evaluating their own VTE rates and chemoprophylaxis protocols in those with MEs.

BACKGROUND:Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection. OBJECTIVES/OBJECTIVE:The objective of this study was to assess whether ETs performed at Level I trauma centers (TC) are associated with improved survival. METHODS:This was a retrospective study utilizing the National Trauma Databank 2014-2015. We included all thoracotomies performed within 1 h of hospital arrival. Patients were stratified according to TC designation level. Patient demographics, outcomes, and center characteristics were compared. We conducted multivariable regression with survival as the outcome. RESULTS:There were 3183 ETs included in this study; 2131 (66.9%) were performed at Level I TCs. Patients treated at Level I and non-Level I TCs had similar median injury severity scores, as well as signs of life and systolic blood pressures on admission. Patients treated at Level I TCs had significantly higher survival rates (21.6% vs. 16.3%, p < 0.001), with 40% greater odds of survival after controlling for injury-specific factors and emergency medical services transportation time (adjusted odds ratio 1.40, 95% confidence interval 1.04-1.89, p = 0.03). Penetrating injuries had 23.1% survival after ET vs. 12.9% for blunt injuries (adjusted odds ratio 1.86, 95% confidence interval 1.37-2.53, p < 0.001). CONCLUSIONS:ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients.

Introduction: Venous thromboembolism (VTE) represents a significant source of morbidity after traumatic brain injury (TBI). The safety and timing of VTE chemoprophylaxis after TBI remain a concern, given the risk of intracranial hemorrhage progression. We evaluated the safety of anti-factor Xa assay-guided dosing for chemoprophylaxis in adult TBI patients. We hypothesized that Xa assay-guided chemoprophylaxis would be safe compared with fixed-dosing.
Method(s): An observational analysis of adult TBI patients was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group received an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured 4 hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with dose adjustment of +/-10 mg based on the assay result. The assay-guided group compared with historical fixed-dose controls, and a TBI cohort from the most recent Trauma Quality Improvement Program data set.
Result(s): Of the 179 patients included in the study, 85 patients were in the assay-guided group and 94 were in the fixed-dose group. Relative to the fixed-dose group, the assay-guided group had a lower Glasgow Coma Scale score and higher Injury Severity Score (Table). The proportion of severe (Abbreviated Injury Scale head >=4) TBI, intracranial hemorrhage progression, and VTE rates were similar between groups. However, the assay-guided group had chemoprophylaxis initiated earlier and had a higher percentage of low molecular weight heparin use relative to the Trauma Quality Improvement Program sample.
Conclusion(s): Early initiation of low molecular weight heparin anti-factor Xa assay-guided VTE prophylaxis is safe in TBI patients. These findings should be validated prospectively in a multicenter study. [Figure presented]
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Introduction: Increasing evidence suggests that disparities in outcomes exist among patients with traumatic brain injury (TBI), but much less is known about such disparities in the elderly. The objective of this study was to determine if race and insurance status are associated with mortality among elderly patients with isolated moderate and severe TBI.
Method(s): A 4-year retrospective analysis of the Trauma Quality Improvement Program database (2013-2016) was performed to identify patients aged 60 and older with isolated moderate or severe TBI. Patients were stratified by race and insurance status comparing demographic characteristics and outcomes. A logistic regression analysis was performed to determine the relationship between race, insurance status, and mortality among elderly patients with isolated moderate and severe TBI.
Result(s): A total of 27,951 patients with isolated TBI were identified. Of those, 7.8% were black with 50.2% having insurance and 79.5% were white with 45.3% having insurance. The overall mortality rate was 9.22% with no significant differences in Head AIS. Black patients with insurance were significantly older (73 vs 63, p<0.001) and had more comorbidities (1 [0,2] vs 0 [0,1], p=0.002) when compared with black patients without insurance. With the exception of age, no significant differences were found among white patients. After adjusting for confounding variables, black race was independently associated with decreased mortality (AOR 0.69, 95% CI 0.5-0.96, p= 0.016).
Conclusion(s): Black race, independent of insurance, is associated with decreased mortality among older adults with isolated moderate and severe TBI. The role of race in affecting mortality following TBI warrants further investigation.
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BACKGROUND:Injury care involves the complex interaction of patient, physician, and environment that impacts patient complications, level of harm, and failure to rescue (FTR). FTR represents the likelihood of a hospital to be unable to rescue patients from death after in-hospital complications. OBJECTIVE:This study aimed to hypothesize that error type and number of errors contribute to increased level of harm and FTR. METHODS:Patient information was abstracted from weekly trauma performance improvement (PI) records (from January 1, 2016, to July 19, 2017), where trauma surgeons determined the level of harm and identified the factors associated with complications. Level of harm was determined by definitions set forth by the Agency for Healthcare Research and Quality. Logistic regression was used to determine the impact of individual factors on FTR and level of harm, controlling for age, gender, Charlson score, injury severity score (ISS), error (in diagnosis, technique, or judgment), delay (in diagnosis or intervention), and need for surgery. RESULTS:A total of 2216 trauma patients presented during the study period. Of 2216 patients, 224 (224/2216, 10.10 %) had complications reported at PI meetings; of these, 31 patients (31/224, 13.8 %) had FTR. PI patients were more likely to be older (mean age 51.3 years, SE 1.58, vs 46.5 years, SE 0.51; P=.008) and have higher ISS (median 22 vs 8; P<.001), compared with patients without complications. Physician-attributable errors (odds ratio [OR] 2.82; P=.001), most commonly errors in technique, and nature of injury (OR 1.91; P=.01) were associated with higher levels of harm, whereas delays in diagnosis or intervention were not. Each additional factor involved increased level of harm (OR 2.09; P<.001) and nearly doubled likelihood of FTR (OR 1.95; P=.01). CONCLUSIONS:Physician-attributable errors in diagnosis, technique, or judgment are more strongly correlated with harm than delays in diagnosis and intervention. Increasing number of errors identified in patient care correlates with an increasing level of harm and FTR.