Tag Archives: mortality

General

Urinary Tract Infection in the Elderly Trauma Patient

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Yesterday I talked about using a medical orthopaedic trauma service to provide better care to elderly patients with fractures. Many of these patients have multiple pre-existing diseases and are quite fragile. A recent paper from the Rhode Island Hospital shows just how fragile these patients may be.

Urinary tract infection (UTI) is one of the most common nosocomial infections, accounting for about 40% of all such infections. The vast majority are related to indwelling bladder catheters. It is so much of a problem that, in order to decrease federal spending in the US, Medicare now denies payment for care related to these infections.

This study looked at the relationship between UTI and bladder catheters and how this infection relates to overall mortality in older trauma patients. It was a retrospective review of 6 years of data from a single institution. After excluding patients who entered the hospital with a UTI, they found that 12% of their patients developed this infection and 72% were indeed related to catheters. Males had a significantly increasing risk of UTI with increasing age. And the risk of death from UTI increased about 7% per year after age 55.

Bottom line: Urinary tract infections are especially bad for the elderly. As part of your daily rounds on any patient, look at every tube and line and ask yourself “is that really needed any more?” If not, get rid of it before it kills your patient!

Related post:

Reference: The development of a urinary tract infection is associated with increased mortality in trauma patients. J Trauma ePub ahead of print, doi: 10.1097/TA.0b013e31821e2b8f, July 2011.

General

Trauma Mortality vs Cancer Mortality from CT Scans for Trauma

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Trauma professionals worry about radiation exposure in our patients. A lot. There are a growing number of papers dealing with this topic in the journals every month. The risk of dying from cancer due to CT scanning is negligible compared to the risk from acute injuries in severely injured patients. However, it gets a bit fuzzier when you are looking at risk vs benefit in patients with less severe injuries. Is it possible to quantify this risk to help guide our use of CT scanning in trauma?

A nice paper from the Mayo clinic looked at their scan practices in 642 adult patients (age > 14) over a one year period. They developed dose estimates using a detailed algorithm, and combined them with data from the Biological Effects of Ionizing Radiation VII data. The risk level for injury was estimated using their trauma team activation criteria. High risk patients met their highest level activation criteria, and intermediate risk patients met their intermediate level activation criteria.

Key points in this article were:

  • Average radiation dose was fairly consistent across all age groups (~25mSv)
  • High ISS patients had a significantly higher dose
  • Cumulative risk of cancer death from CT radiation averaged 0.1%
  • This risk decreased with age. It was highest in young patients (< 20 yrs) at 0.2%, and decreased to 0.05% in the elderly (> 60 yrs)

Bottom line: Appropriate CT scan use in trauma evaluation is challenging. It’s use is widespread, and although it changes management it has not decreased trauma mortality. This paper shows that the risk of death from trauma in the elderly outweighs the risk of death from CT scan radiation. However, this gap narrows in younger patients with less serious injuries because of their very low mortality rates. Therefore, we need to focus our efforts to reduce radiation exposure on our young patients with minor injuries.

Related posts:

References:

  • Comparison of trauma mortality and estimated cancer mortality from computed tomography during initial evaluation of intermediate-risk trauma patients. J Trauma 70(6):1362-1365, 2011.
  • Health risks from low levels of ionizing Radiation: BEIR VII, Phase 2. Washington DC: The National Academies Press, 2006.
General

Helicopter Transport of Trauma Patients Saves Lives

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Helicopter EMS (HEMS) transport of trauma patients is used primarily to decrease the amount of time between injury and arrival at the trauma center. Unfortunately, efficacy studies have provided conflicting answers as to whether this is actually true. Last year, the CDC completed a large sample study of this issue using the National Trauma Data Bank (NTDB) in an attempt to determine if HEMS flights are effective.

Using almost 150,000 entries in the NTDB for 2007, they were able to isolate over 56,000 adult records with complete data points. They looked for mortality patterns based on age, injury severity, and revised trauma score, comparing patients who were transported by air vs ground.

They found the following:

  • Odds of dying in-hospital were 39% lower overall when transported by helicopter
  • This survival advantaged disappeared for patients age 55 and older, possibly because of decreased reserve, comorbidities, more complications, or medications that interfere with successful resuscitation
  • Regardless of type of transport, males always fared worse than females

Bottom line: This is a large and intriguing study. About 85% of the US population has access to a Level I or II trauma center within an hour. However, a third of those can only get there in that period of time if transported by air. This mode of transport has a significantly lower mortality rate. However, there are cost and safety considerations as well. The key now is to figure out which patients will have the best outcomes after air transport. This will require more work, looking at more than just mortality (e.g. disability, complications).

Reference: Reduced mortality in injured adults transported by helicopter emergency medical services. Prehospital Emerg Care 15(3):295-302, 2011.

General

Trauma is Deadlier Than We Think

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Everyone knows that trauma is the number one killer of anyone age 1-44. The assumption is that if you sustain major injury and survive through discharge from a trauma center, you are home free. Unfortunately, this does not appear to be the case.

Arbabi and others from Harborview in Seattle looked at long term outcomes of 124,000 adult trauma patients treated over a 14 year period at any of Washington’s designated trauma centers.

During this period of time, in-hospital deaths decreased from 8% in 1995 to 4.9% in 2008. However, deaths after discharge increased from 4.7% to 7.4% during the same time interval. It appeared that older patients and those discharged to skilled nursing facilities (SNF) did particularly poorly after discharge. The risk of death after discharge to a SNF was 1.5 to 2x higher than normal. Yet mortality after discharge to an inpatient rehab facility was similar to that of patients sent home.

Bottom Line: Higher mortality in major trauma patients sent to a skilled nursing facility is likely a reflection of their age and severity of injury, as well as the services available there. Although patients with severe injuries may be sent to a rehab center, they typically must be able to participate in therapy for several hours a day. Those with more severe injuries that do not meet rehab criteria are typically sent to a SNF. This also explains why the authors found that patients with high ISS, low GCS, poor Functional Independence Measure and Medicare insurance had a higher likelihood of dying. This association should prompt us to look more thoroughly at these facilities to determine if they need additional oversight, more money or better rehab services.

Reference: Long-term survival of adult trauma patients. JAMA 305(10):1001-1007, 2011.

General

What Is The Cost of the “Personal Freedom” Not To Wear A Motorcycle Helmet?

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The Highway Safety Act of 1966 led to a mandate that all states adopt universal helmet laws for all motorcycle riders or risk the loss of federal highway funds. By 1975, all but 3 states had enacted these laws. However, Congress then did an about-face and eliminated the helmet law requirement for receiving the funds. Many states then revisited their laws, and some repealed them. As of now, 20 states (and D.C.) have inclusive helmet laws, 27 have conditional laws, and 3 (IL, IA, NH) have no helmet requirements.

Croce and his group in Memphis looked at the impact of helmet use in motorcyclists using the National Trauma Data Bank from 2002-2007. They found:

  • Helmet use was higher in states with helmet laws (90%), vs conditional laws (61%), vs no laws (53%)
  • Helmeted riders had less severe injuries in nearly all brain and skull trauma. Glasgow Coma Scale and Injury Severity Scores were significantly lower.
  • Cervical spine fractures were less frequent in helmeted patients (3.9% vs 5.9%)
  • Hospital and ICU stays were shorter for riders who wore helmets
  • Mortality was significantly lower in helmeted motorcyclists (3.8% vs 6.7%)
  • Significantly more helmeted riders were insured

Advocacy groups continue to try to repeal or weaken helmet laws, generally based on a 1986 report (ref 2) which stated that helmets decrease peripheral vision and hearing, increase the number of cervical injuries, and have no impact on mortality. Frequently, proponents of helmet law repeal also claim that the laws infringe on personal freedom.

Helmets do decrease peripheral vision by 20 degrees, but research and a DOT report have shown that this has no impact on motorcycle safety or impact rates (refs 3,4). Helmets have been shown to have no impact on hearing at low speeds, and all riders (with or without helmets) have decreased hearing at higher speeds. Helmets do not diminish or enhance hearing at any given speed (ref 4). A number of studies, including this one, have shown that cervical injuries are less frequent in riders who survive the crash.

The insurance and hospital utilization information in this paper is most interesting. Unhelmeted riders have more significant injuries, are more likely to stay in the hospital and ICU longer, and are much less likely to have insurance to pay for it. And this is for the survivors! Deaths create an even greater societal burden, with lost lifetime earnings, tax revenues and other adverse economic effects.

Courts have repeatedly upheld mandatory helmet laws under the Constitution when challenged. A federal court once responded to one of these challenges with this quote: 

“From the moment of injury, society picks the person up off the highway, delivers him to a municipal hospital and municipal doctors; provides him with unemployment compensation if, after recovery, he cannot replace his lost job; and, if the injury causes permanent disability, may assume responsibility for his and his family’s subsistence. We do not understand a state of mind that permits plaintiff to think that only he himself is concerned.”

For a list of current helmet law status by state, click here.

References:

  1. Impact of motorcycle helmets and state laws on society’s burden. J Trauma 250(3):390-394, 2009.
  2. The effect of motorcycle helmet use on the probability of fatality and the severity of head and neck injuries: a latent variable framework. Evaluation Review 10:335-375, 1986.
  3. Motorcycle helmets – medical costs and the law. J Trauma 30:1189-1199, 1990.
  4. The effects of motorcycle helmets upon seeing and hearing. NHTSA Report number DOT HS 808-399, 1994.