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Severity-adjusted mortality in trauma patients transported by police.

ABSTRACT: Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia.This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index.Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police.We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.

SUBMITTER: Band RA

PROVIDER: S-EPMC5912155 | biostudies-literature | 2014 May

REPOSITORIES: biostudies-literature

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Severity-adjusted mortality in trauma patients transported by police.

Band Roger A RA Salhi Rama A RA Holena Daniel N DN Powell Elizabeth E Branas Charles C CC Carr Brendan G BG

Annals of emergency medicine 20140102 5

<h4>Study objective</h4>Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia.<h4>Methods</h4>This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal ...[more]

PMID: 24387925

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Project description:ObjectivesRecent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) versus ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting.MethodsThe ascertainment of trauma patients age ? 15 years (n = 469 cases) by HT and (n = 580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time, and injury severity. The PS matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in the emergency department, the need for urgent surgery, intensive care unit admission, and mechanical ventilation.ResultsUnadjusted mortalities for HT compared to GT were 7.7 and 5.3%, respectively (p > 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well-matched data set, HT was associated with a 2.69-fold increase in odds of survival compared to GT patients (adjusted odds ratio = 2.69; 95% CI = 1.21-5.97).ConclusionsIn a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified Level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed. We recommend larger studies with multiple trauma systems need to be repeated using similar study methodology to substantiate our findings.

Project description:ImportancePolice in Philadelphia, Pennsylvania, routinely transport patients with penetrating trauma to nearby trauma centers. During the past decade, this practice has gained increased acceptance, but outcomes resulting from police transport of these patients have not been recently evaluated.ObjectiveTo assess mortality among patients with penetrating trauma who are transported to trauma centers by police vs by emergency medical services (EMS).Design, setting, and participantsThis cohort study used the Pennsylvania Trauma Outcomes Study registry and included 3313 adult patients with penetrating trauma from January 1, 2014, to December 31, 2018. Outcomes were compared between patients transported by police (n = 1970) and patients transported by EMS (n = 1343) to adult level I and II trauma centers in Philadelphia.ExposuresPolice vs EMS transport.Main outcomes and measuresThe primary end point was 24-hour mortality. Secondary end points included death at multiple other time points. After whole-cohort regression analysis, coarsened exact matching was used to control for confounding differences between groups. Matching criteria included patient age, injury mechanism and location, Injury Severity Score (ISS), presenting systolic blood pressure, and Glasgow Coma Scale score. Subgroup analysis was performed among patients with low, moderate, or high ISS.ResultsOf the 3313 patients (median age, 29 years [interquartile range, 23-40 years]) in the study, 3013 (90.9%) were men. During the course of the study, the number of police transports increased significantly (from 328 patients in 2014 to 489 patients in 2018; P = .04), while EMS transport remained unchanged (from 246 patients in 2014 to 281 patients in 2018; P = .44). On unadjusted analysis, compared with patients transported by EMS, patients transported by police were younger (median age, 27 years [interquartile range, 22-36 years] vs 32 years [interquartile range, 24-46 years]), more often injured by a firearm (1741 of 1970 [88.4%] vs 681 of 1343 [50.7%]), and had a higher median ISS (14 [interquartile range, 9-26] vs 10 [interquartile range, 5-17]). Patients transported by police had higher mortality at 24 hours than those transported by EMS (560 of 1970 [28.4%] vs 246 of 1343 [18.3%]; odds ratio, 1.86; 95% CI, 1.57-2.21; P < .001) and at all other time points. After coarsened exact matching (870 patients in each transport cohort), there was no difference in mortality at 24 hours (210 [24.1%] vs 212 [24.4%]; odds ratio, 0.95; 95% CI, 0.59-1.52; P = .91) or at any other time point. On subgroup analysis, patients with severe injuries transported by police were less likely to be dead on arrival compared with matched patients transported by EMS (64 of 194 [33.0%] vs 79 of 194 [40.7%]; odds ratio, 0.48; 95% CI, 0.24-0.94; P = .03).Conclusions and relevanceFor patients with penetrating trauma in an urban setting, 24-hour mortality was not different for those transported by police vs EMS to a trauma center. Timely transport to definitive trauma care should be emphasized over medical capability in the prehospital management of patients with penetrating trauma.

Project description:BACKGROUND:Hyperoxemia has been associated with increased mortality in critically ill patients, but little is known about its effect in trauma patients. The objective of this study was to assess the association between early hyperoxemia and in-hospital mortality after severe trauma. We hypothesized that a PaO2???150?mmHg on admission was associated with increased in-hospital mortality. METHODS:Using data issued from a multicenter prospective trauma registry in France, we included trauma patients managed by the emergency medical services between May 2016 and March 2019 and admitted to a level I trauma center. Early hyperoxemia was defined as an arterial oxygen tension (PaO2) above 150?mmHg measured on hospital admission. In-hospital mortality was compared between normoxemic (150?>?PaO2???60?mmHg) and hyperoxemic patients using a propensity-score model with predetermined variables (gender, age, prehospital heart rate and systolic blood pressure, temperature, hemoglobin and arterial lactate, use of mechanical ventilation, presence of traumatic brain injury (TBI), initial Glasgow Coma Scale score, Injury Severity Score (ISS), American Society of Anesthesiologists physical health class > I, and presence of hemorrhagic shock). RESULTS:A total of 5912 patients were analyzed. The median age was 39 [26-55] years and 78% were male. More than half (53%) of the patients had an ISS above 15, and 32% had traumatic brain injury. On univariate analysis, the in-hospital mortality was higher in hyperoxemic patients compared to normoxemic patients (12% versus 9%, p?<?0.0001). However, after propensity score matching, we found a significantly lower in-hospital mortality in hyperoxemic patients compared to normoxemic patients (OR 0.59 [0.50-0.70], p <?0.0001). CONCLUSION:In this large observational study, early hyperoxemia in trauma patients was associated with reduced adjusted in-hospital mortality. This result contrasts the unadjusted in-hospital mortality as well as numerous other findings reported in acutely and critically ill patients. The study calls for a randomized clinical trial to further investigate this association.

Project description:BACKGROUND:An accurate injury severity measurement is essential for the evaluation of pediatric trauma care and outcome research. The traditional Injury Severity Score (ISS) does not consider the differential risks of the Abbreviated Injury Scale (AIS) from different body regions nor is it pediatric specific. The objective of this study was to develop a weighted ISS (wISS) system for pediatric blunt trauma patients with better predictive power than ISS. METHODS:Based on the association between mortality and AIS from each of the six ISS body regions, we generated different weights for the component AIS scores used in the calculation of ISS. The weights and wISS were generated using the National Trauma Data Bank. The Nationwide Emergency Department Sample (NEDS) was used to validate our main results. Pediatric blunt trauma patients younger than 16 years were included, and mortality was the outcome. Discrimination (areas under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, concordance) and calibration (Hosmer-Lemeshow statistic) were compared between the wISS and ISS. RESULTS:The areas under the receiver operating characteristic curves from the wISS and ISS are 0.88 versus 0.86 in ISS of 1 to 74 and 0.77 versus 0.64 in ISS of 25 to 74 (p < 0.0001). The wISS showed higher specificity, positive predictive value, negative predictive value, and concordance when they were compared at similar levels of sensitivity. The wISS had better calibration (smaller Hosmer-Lemeshow statistic) than the ISS (11.6 vs. 19.7 for ISS = 1-74 and 10.9 vs. 12.6 for ISS = 25-74). The wISS showed even better discrimination with the Nationwide Emergency Department Sample. CONCLUSION:By weighting the AIS from different body regions, the wISS had significantly better predictive power for mortality than the ISS, especially in critically injured children. LEVEL OF EVIDENCE AND STUDY TYPE:Prognostic/epidemiological, level IV.

Project description:To determine the relationship between PICU volume and severity-adjusted mortality in a large, national dataset.Retrospective cohort study.The VPS database (VPS, LLC, Los Angeles, CA), a national multicenter clinical PICU database.All patients with discharge dates between September 2009 and March 2012 and valid Pediatric Index of Mortality 2 and Pediatric Risk of Mortality III scores, who were not transferred to another ICU and were seen in an ICU that collected at least three quarters of data.None.Anonymized data received included ICU mortality, hospital and patient demographics, and Pediatric Index of Mortality 2 and Pediatric Risk of Mortality III scores. PICU volume/quarter was determined (VPS sites submit data quarterly) per PICU and was divided by 100 to assess the impact per 100 discharges per quarter (volume). A mixed-effects logistic regression model accounting for repeated measures of patients within ICUs was performed to assess the association of volume on severity-adjusted mortality, adjusting for patient and unit characteristics. Multiplicative interactions between volume and severity of illness were also modeled. We analyzed 186,643 patients from 92 PICUs, with an overall ICU mortality rate of 2.6%. Volume ranged from 0.24 to 8.89 per ICU per quarter; the mean volume was 2.61. The mixed-effects logistic regression model found a small but nonlinear relationship between volume and mortality that varied based on the severity of illness. When severity of illness is low, there is no clear relationship between volume and mortality up to a Pediatric Index of Mortality 2 risk of mortality of 10%; for patients with a higher severity of illness, severity of illness-adjusted mortality is directly proportional to a unit's volume.For patients with low severity of illness, ICU volume is not associated with mortality. As patient severity of illness rises, higher volume units have higher severity of illness-adjusted mortality. This may be related to differences in quality of care, issues with unmeasured confounding, or calibration of existing severity of illness scores.

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Severity-adjusted mortality in trauma patients transported by police.

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Severity-adjusted mortality in trauma patients transported by police.

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