Biomedical subjects

E J MacKenzie

Publications and source records attributed to E J MacKenzie.

At least 37 records · Page 2Linked to original sources

PubMed1999

Systematic review of published evidence regarding trauma system effectiveness.

OBJECTIVE: Provide a systematic review of the published literature assessing the affect of trauma center/system implementation on patient outcomes. DATA SOURCES: A bibliographic search of MEDLINE (1966-May of 1998), HealthSTAR (1995-May of 1998), and CINAHL (1982-May of 1998). Additional manuscripts were identified in the references of reviewed manuscripts. Literature was limited to English language reports on trauma systems in the United States and Canada. STUDY SELECTION: Initial inclusion criteria were based on methodologic criteria (i.e., a comparative [controlled] study). Authors independently assessed the strength of evidence demonstrated by each article. DATA EXTRACTION: Included articles were classified into three groups based on study design: panel review studies, trauma registry comparison studies, and population-based studies. Key demographic, sampling frame, study design, and outcome variables were tabulated for each included study. Potential sources of bias were also identified and tabled. DATA SYNTHESIS: A total of 12, 11, and 17 studies were incorporated into individual evidence tables for panel review, registry comparison, and population-based studies, respectively. Included studies rely on weak evidence (Class III) to assess the impact of trauma systems on patient care and outcome. CONCLUSIONS: To date, studies assessing trauma system efficacy rely on hospital deaths as the primary indicator of effectiveness. Future research should use more sophisticated study designs (Class II) and expand available outcome measures to assess the entire continuum of care, including prehospital, rehabilitation outcomes, and long-term quality of life.

Data Collection↗

PubMed1999

Review of evidence regarding trauma system effectiveness resulting from panel studies.

OBJECTIVE: The objectives this study are to elucidate the advantages and disadvantages of the panel method for evaluating the quality of trauma care and to review the individual and collective evidence in support of regionalized trauma care derived from these studies. METHOD: A review of the published literature was conducted and identified 10 panel studies that compared appropriateness of care and/or the preventability of deaths occurring either across hospitals in a trauma system versus non-trauma system, in a defined region before and after implementation of a trauma system, between trauma center and non-trauma center hospitals within a defined region, or across hospitals of varying levels of care presystem. RESULTS: Panel studies vary widely in the approaches used to elicit judgments; low rates of inter-rater reliability have been reported. The strength of the evidence derived from panel studies in support of trauma system effectiveness must be reviewed in this context. CONCLUSION: All panel studies are classified as providing weak, Class III evidence. Yet, collectively they provide some face validity in support of the hypothesis that treatment at a trauma versus non-trauma center may be associated with less inappropriate care and fewer preventable deaths among the seriously injured.

California↗

PubMed1998

Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study.

OBJECTIVE: To examine patterns of trauma-related amputations over time by age and gender of the patient and by level and type of amputation, and to explore factors affecting acute care length of stay and discharge to inpatient rehabilitation. DESIGN: Population-based hospital discharge data for Maryland from 1979 through 1993. PARTICIPANTS: Patients (N = 6,069) discharged with either (1) a principal or secondary diagnosis of a trauma-related amputation to the upper or lower extremity or (2) a procedure code for a lower or upper limb amputation in combination with a principal diagnosis of an extremity injury or injury-related complication. RESULTS: Incidence of major amputations declined 3.4% (p < .05) annually from 1.88 per 100,000 in 1979 to 1.07 per 100,000 in 1993. Incidence of minor amputations declined 4.8% (p < .05) annually from 10.8 per 100,000 in 1979 to 4.7 per 100,000 in 1993. Acute care length of stay for trauma-related amputations declined 40% over the study period and was significantly affected by the patient's payer source, amputation level, and injury characteristics. Of the patients with a major amputation, 15% were discharged to inpatient rehabilitation; 60% were discharged directly home. More proximal amputation levels, presence of severe injuries to other body systems, and acute care at a designated trauma center significantly increased the likelihood of disposition to inpatient rehabilitation. The leading causes of trauma-related amputation were injuries involving machinery (40.1%), powered tools and appliances (27.8%), firearms (8.5%), and motor vehicle crashes (8%). CONCLUSIONS: Findings suggest a substantial decline in incidence rates of both major and minor amputations over the 15-year study period, a low rate of disposition to inpatient rehabilitation services of patients sustaining major amputations, and an apparent role of firearms as a cause of trauma-related amputations in patients younger than 25 years of age. The consequences of increasingly shorter acute care hospital stays and low rates of discharge to inpatient rehabilitation on the long-term outcomes of persons who have had traumatic amputation should be examined.

Adolescent↗

PubMed1998

Return to work following injury: the role of economic, social, and job-related factors.

OBJECTIVES: This study examined factors influencing return to work (RTW) following severe fracture to a lower extremity. METHODS: This prospective cohort study followed 312 individuals treated for a lower extremity fracture at 3 level-1 trauma centers. Kaplan-Meier estimates of the proportion of RTW were computed, and a Cox proportional hazards model was used to examine the contribution of multiple risk factors on RTW. RESULTS: Cumulative proportions of RTW at 3, 6, 9, and 12 months post-injury were 0.26, 0.49, 0.60, and 0.72. After accounting for the extent of impairment, characteristics of the patient that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW. CONCLUSIONS: Despite relatively high rates of recovery, one quarter of persons with lower extremity fractures did not return to work by the end of 1 year. The analysis points to subgroups of individuals who are at high risk of delayed RTW, with implications for interventions at the patient, employer, and policy levels.

Absenteeism↗

PubMed1998

Correlation between the measures of impairment, according to the modified system of the American Medical Association, and function.

We performed a prospective study of 302 patients who had a fracture of the lower extremity. Our purpose was to determine whether there was any association between impairment ratings of the lower extremity, derived with use of the Guides to the Evaluation of Permanent Impairment by the American Medical Association, and measurements of task performance based on direct observation as well as the patient's own assessment of activity limitation and disability as recorded on the Sickness Impact Profile. The mean residual impairment of the lower extremity according to the Guides was 27 per cent one year after the injury. Only 130 subjects (43 per cent) could perform all five functional tasks without difficulty. Eighty-four subjects (28 per cent) reported functional limitations that resulted in a score on the Sickness Impact Profile that was more than one standard deviation from the preinjury norm for the sample. Impairment ratings according to a modification of the system of the American Medical Association correlated strongly with the performance of functional tasks (r = 0.57) as well as the patients' reported activity limitations as recorded on the Sickness Impact Profile (r = 0.55). Correlations were highest when measures of impairment were based on strength rather than on range of motion. The relationship between the impairment rating and function (as observed by an examiner and as reported by the patient) was not influenced by the location of the fracture or the receipt of disability compensation. Our results suggest that the American Medical Association developed a valid approach for the measurement of physical impairment after a fracture of the lower extremity. In our study, the anatomical approach of evaluation based on muscle strength that was described in the Guides to the Evaluation of Permanent Impairment was the most sensitive measure of impairment compared with the anatomical measure based on range of motion and compared with the functional and diagnostic methods for the rating of impairment. Until the diagnostic and functional approaches for the measurement of musculoskeletal impairment are refined, we recommend use of the anatomical approach when evaluating impairment after a fracture of the lower extremity.

Activities of Daily Living↗

PubMed1997

Geographic variation in serious nonfatal firearm injuries in Pennsylvania.

OBJECTIVE: The purpose of this study was to characterize the geographic epidemiology of serious nonfatal firearm injuries (NFFI) within Pennsylvania during a 6-year period. METHODS: A historical review of data from the Pennsylvania Trauma System Foundation trauma registry was completed using county-level data. Based on a format adapted from the United States Department of Agriculture, NFFI in Pennsylvania were classified by their county of occurrence: central city counties, metropolitan counties, nonmetropolitan counties, or rural counties. Population-based rates of NFFI were then calculated, as were NFFI as a proportion of the number of injuries within each region. These rates were stratified by intent of injury, scene of injury, and type of firearm. RESULTS: A total of 100,703 trauma cases were reported to the Pennsylvania Trauma System Foundation from 1988 through 1993, of which 5,847 were serious NFFI. Nonfatal firearm assaults increased from rural counties to central city counties, whereas unintentional NFFI decreased (p < 0.05). A 225% increase in the number of NFFI, from 445 cases in 1988 to 1,004 cases in 1993, was noted in the central city counties. Comparatively, the increase in the noncity regions was 145%, from 182 cases in 1988 to 263 in 1993. Nonfatal firearm injuries occurred most often at home in noncity counties (rural, nonmetropolitan, and metropolitan counties) (47.9%). This is in contrast to central city counties, where NFFI occurred significantly more often in the street (53.5%) (p < 0.05). Handgun NFFI increased, whereas rifle NFFI decreased, from rural counties to central city counties (p < 0.05). Relative to population size, the risk of shotgun injuries was greatest in central city counties and lowest in rural counties. Shotgun injuries also accounted for a significantly longer hospital stay (15.06 days) compared with handgun injuries (10.38 days) and rifle injuries (11.81 days) (p < 0.05). CONCLUSION: Significant variation in NFFI was observed across population-based regions in Pennsylvania. Rural areas demonstrated relatively high risks of NFFI committed unintentionally, in the home, and with rifles. As regional populations increase, relatively high risks of NFFI, committed as assaults, in the street, and by handguns, are highlighted. Although handguns were the most prominent firearm associated with NFFI, nonfatal shotgun injuries produced substantially longer hospital stays and may be an underappreciated cause of nonfatal firearm assaults in the urban setting.

Humans↗

PubMed1997

Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study.

Multiply injured patients (an Injury Severity Score of 17 points or more) who were admitted to one of two level-I regional trauma centers between 1983 and 1994 because of a fracture of the femoral shaft with a thoracic injury (an Abbreviated Injury Scale score of 2 points or more) or without a thoracic injury were studied retrospectively. The patient populations and the protocols for the treatment of trauma were similar at the two centers; however, the centers differed with regard to the technique that was used for acute stabilization of the fracture of the femoral shaft. At Center I intramedullary nailing with reaming was used in 217 (95 per cent) of the 229 patients, whereas at Center II a plate was used in 206 (92 per cent) of the 224 patients. This difference was used to investigate the effect of acute femoral reaming on the occurrence of adult respiratory distress syndrome in multiply injured patients who had a chest injury. Three groups of patients were evaluated: those who had both a fracture of the femur and a thoracic injury, those who had a fracture of the femur but no thoracic injury, and those who had a thoracic injury without a fracture of the femur or the tibia. The third group was studied at each center to determine if there was a difference between the institutions with regard to the rate of adult respiratory distress syndrome. Patients who had diabetes, chronic obstructive pulmonary disease, asthma, hepatic or renal failure, or an immunosuppressive condition were excluded from the study. The records were abstracted to determine the Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Score for each patient. Requirements for fluid resuscitation were calculated for the first twenty-four hours; these included the number of units of packed red blood cells, fresh-frozen plasma, and platelets that were transfused and the volume of crystalloid that was used. The duration of intubation, the duration of hospitalization, and the occurence of adverse outcomes (death, multiple organ failure, adult respiratory distress syndrome, pneumonia, and pulmonary embolism) were determined for each patient. The groups of patients were analyzed as a whole and then were stratified into subgroups (according to whether or not they had a thoracic injury and whether the Injury Severity Score was less than 30 points or 30 points or more) to determine if the type of fixation of the femoral fracture affected the rate of adult respiratory distress syndrome or mortality. Logistic regression models were used to analyze the data. The over-all occurrence of adult respiratory distress syndrome in the 453 patients who had a femoral fracture was only 2 per cent (ten patients). The rates of adult respiratory distress syndrome for the patients who had a thoracic injury but no femoral fracture (eight [6 per cent] of 129 patients at Center I, compared with ten [8 per cent] of 125 patients at Center II) did not differ between centers, suggesting that the institutions were comparable in their treatment of multiply injured patients. The occurrence of adult respiratory distress syndrome in the patients who had a femoral fracture without a thoracic injury did not differ substantially according to whether the fracture had been treated with a nail (118 patients) or a plate (114 patients). Likewise, the frequency of adult respiratory distress syndrome, pneumonia, pulmonary embolism, failure of multiple organs, or death for the patients who had a femoral fracture and a thoracic injury was similar regardless of whether nailing with reaming (117 patients) or a plate (104 patients) had been used. The use of intramedullary nailing with reaming for acute stabilization of fractures of the femur in multiply injured patients who have a thoracic injury without a major comorbid disease does not appear to increase the occurrence of adult respiratory distress syndrome, pulmonary embolism, failure of multiple organs, pneumonia, or death.

Abbreviated Injury Scale↗

PubMed1996

Long-term outcomes after lower extremity trauma.

Previous studies have shown that over one-quarter of patients who were working before a severe lower extremity fracture had not returned to work by 12 months after injury. Disabilities also persisted in household management, recreation, and social interaction. The objective of this study was to determine whether recovery extended beyond 12 months. Three hundred nineteen patients who were previously working and were treated at three level I trauma centers for a severe lower extremity fracture were prospectively followed at 3, 6, and 12 months after injury. Patients were queried at each follow-up about their work status and completed the Sickness Impact Profile (SIP) at 6 and 12 months. The SIP is a widely used and well validated measure of general health status; it was used in this study to measure functional recovery across several domains of daily living. Patients who had not recovered by 12 months (i.e., 204 who were not working, working with limitations, or had limitations in performing other daily activities as measured by elevated scores on the SIP) were contacted again at 30 months and asked to complete an interview and the SIP. At 30 months, an estimated 82% of the study patients had returned to work (compared to 72% at 12 months). SIP scores improved only slightly from 6.4 at 12 months to 5.7 at 30 months. At 30 months, 64% of the patients had no disability (SIP scores less than 4), 17% had mild disability (SIP scores of 4 to 9), 12% had moderate disability (SIP scores of 10 to 19), and 7% had severe disability (SIP scores of 20 or higher). Although the majority of patients with persistent disabilities at 30 months had residual physical impairments at 12 months, the extent of impairment did not fully explain why some people had and had not recovered at 30 months after injury. The results confirm those of other studies that conclude that overall, outcomes after serious trauma are good when appropriate trauma and rehabilitation care are rendered. However, a minority of patients still report limitations at 30 months after injury, with one-fifth not returning to work.

Adolescent↗

PubMed1996

The development of the Functional Capacity Index.

OBJECTIVE: This paper describes the development of the Functional Capacity Index (FCI) and compares it to the Abbreviated Injury Scale (AIS) and the Injury Impairment Scale (IIS). METHODS: The FCI maps 1990 AIS injury descriptions into scores that reflect expected levels of reduced functional capacity at 1 year after injury. Its development involved three steps. First, an expert clinical panel identified 10 relevant dimensions of function and defined levels of capacity within each dimension. A group of 114 individuals then rated the relative severity of different levels of function in terms of their impact on daily living. The third step involved clinical experts assigning FCI scores to AIS '90 injury descriptions based on their knowledge of the likely 1-year consequences associated with each injury. As a first step in validating the FCI, 1 year postinjury levels of impairment (based on range of motion and strength) were correlated with FCI, IIS, and AIS scores derived for 301 patients with severe lower extremity fractures. RESULTS: Consistency of FCI scores derived within and across dimensions of function argue for the conceptual integrity of the index. Non-zero FCI scores were assigned to only 26% of the 1,272 AIS injury descriptions, indicating that, for most of the injuries in the AIS dictionary, very little or no residual impairment is expected for the average person at 1 year. FCI scores derived for 301 patients with lower extremity fractures ranged from 0 to 63 (out of a possible 100 points). A modest correlation was found between FCI scores and actual levels of impairment observed at 1 year. Compared with the AIS and the IIS, the FCI appeared to discriminate somewhat better among different levels of function. CONCLUSIONS: Although further empirical validation of the FCI is essential before it can be broadly applied, its development represents an important first step in the generation of an AIS-based measure of expected functional outcome. Its validation is encouraged across a variety of settings and injury types.

Abbreviated Injury Scale↗

PubMed1995

Progress in the development of trauma systems in the United States. Results of a national survey.

OBJECTIVE: To examine the status of trauma system development and key structural and operational characteristics of these systems. DESIGN AND SETTING: National survey of trauma systems with enabling state statute, regulation, or executive orders and for which designated trauma centers were present. PARTICIPANTS: Trauma system administrators and directors of 37 state and regional organizations that had legal authority to administer trauma systems, which represented a response rate of 90.2%. MAIN OUTCOME MEASURES: Trauma system components that had been implemented or were under development. RESULTS: From 1988 to 1993, the number of states meeting one set of criteria for a complete trauma system criteria increased from two to five. The most common deficiency in establishing trauma systems was failure to limit the number of designated trauma centers based on community need. Although most existing trauma systems have developed formal processes for designating trauma centers, prehospital triage protocols to allow hospital bypass, and centralized trauma registries, several systems lack standardized policies for interhospital transfer and systemwide evaluation. CONCLUSION: State and regional organizations have accomplished a great deal but still have substantial work ahead in developing comprehensive trauma systems. Research is needed to better understand the relationship between trauma volume and outcomes of care as well as the impact of trauma system structure and operational characteristics on care delivery. Improved measures of patient outcome are also needed so that effective system evaluation can take place.

Clinical Protocols↗

PubMed1995

Trauma centers in the United States: identification and examination of key characteristics.

OBJECTIVES: To identify all hospitals in the United States that operated a trauma center between 1980 and 1991 and to contrast their organizational, service, and medical staff characteristics. DESIGN: Trauma centers were identified through a series of surveys and follow-up discussions with state emergency medical service directors. Data on hospital characteristics were obtained through the American Hospital Association's 1990 Annual Survey of Hospitals. MATERIALS AND METHODS: Hospital characteristics were compared across: (1) hospitals with and without trauma centers; (2) operational and closed trauma centers; and (3) trauma centers-based on trauma level and source of designation. MEASUREMENTS AND MAIN RESULTS: Overall, 471 operational trauma centers and 58 hospitals that dropped this service were identified. Several differences were found in hospital operational, service, and medical staff characteristics across hospitals with and without trauma centers and across trauma centers distinguished by trauma level and by whether they continued to provide the service through 1991. Few differences were present across formally designated and self-designated centers. CONCLUSIONS: The study provides structural and organizational profiles of trauma centers that should help trauma system planners identify strong candidates for trauma center designation.

Data Collection↗

PubMed1995

Functional status following orthopedic trauma in young women.

OBJECTIVE: To evaluate the general health status and sexual function of women following serious orthopedic injury. METHODS: Women aged 16-44 who were treated at a level I trauma center between 1986 and 1992 for a fracture to the pelvis or lower extremity were interviewed by telephone. The interview included the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) supplemented by questions about sexual function. The SF-36 is a measure of outcome from the respondent's point of view and consists of 36 items representing eight health concepts. RESULTS: Of 289 eligible women, 233 (81%) were interviewed (123 pelvic fracture; 110 lower extremity fracture). Their mean Injury Severity Score was 17.9. Compared to age- and gender-standardized norms, study patients as a group scored significantly worse (lower scores) on all dimensions of the SF-36 except mental health (p < 0.05). Of the women interviewed, 45% reported feeling less sexually attractive due to their injury, and 39% reported a decrease in sexual pleasure. Women who reported arthritis that was attributed to their fracture had significantly poorer health outcomes than study subjects who did not. The most significant predictor of deviations from SF-36 norms was the presence of one or more comorbid chronic conditions. CONCLUSION: The results underscore the importance of considering comorbidities when evaluating health outcomes following major trauma. In addition, the relatively high rates of reported change in sexual function after injury argue for more attention to these issues in both clinical practice and outcomes research.

Activities of Daily Living↗

PubMed1994

Functional outcome after pediatric head injury.

OBJECTIVES: To examine the consequences of head injury and the medical, economic, and sociodemographic factors affecting functional status 1 year after injury. METHODS: A follow-up was conducted on 95 children (aged 5 to 15) 1 year after they were hospitalized for head injury. Parents were interviewed by phone concerning their child's preinjury and current health status, and the family's economic and social resources during the 1 year postinjury. Inpatient medical records were reviewed to obtain information regarding the characteristics of the injury. RESULTS: We found that study children were more likely than children from the general population to have limitations in physical health, behavioral problems, and to be enrolled in a special education program. These findings were true for all levels of head injury severity, although children with severe head injuries (Abbreviated Injury Scale 5) were more likely to demonstrate these functional limitations than were children with less severe injuries (Abbreviated Injury Scale 2, 3, 4). After controlling for head injury severity, we found that the poorer outcomes were associated with poverty, preinjury chronic health problems, and lower extremity injuries. CONCLUSIONS: The large proportion of children who demonstrated functional limitations underscores the importance of evaluating all children hospitalized with head injuries for functional limitations and providing rehabilitation and social services when needed.

Abbreviated Injury Scale↗

PubMed1993

Patient-oriented functional outcome after unilateral lower extremity fracture.

To determine patient-perceived functional outcome after lower extremity fracture (LEF), a prospective, follow-up study of patients managed at three level I trauma centers was conducted. Patients with unilateral LEF involving the acetabulum and distally were eligible for the study. A total of 444 patients were enrolled. Of these, 363 (82%) were interviewed at 6 months postdischarge. Study patients were predominantly young (mean age 34 years), white (72%) men (71%) who had been working preinjury (78%). Their injuries resulted primarily from motor vehicle crashes (73%); 30% had more than one fracture to the same extremity. Functional status was measured using the Sickness Impact Profile (SIP), a well-validated, general health status instrument. Mean 6-month SIP scores were significantly worse (higher) than those based on preinjury activities (9.8 vs. 2.5) (p < 0.01). Overall disability levels were moderate compared with other health conditions. Analysis of the 12 subscores comprising the SIP indicated particularly high scores in ambulation (16.2 postdischarge vs. 1.1 preinjury), sleep/rest (13.1 vs. 5.1), household management (14.5 vs. 2.6), recreation (17.6 vs. 4.2), emotional well-being (9.9 vs. 2.1), and most significantly work (33.2 vs. 8.8). Of those working preinjury, only 49% had returned by 6 months. SIP scores were highest for persons with three or more fractures to the same extremity and for fracture patterns typical of high-energy forces.

Activities of Daily Living↗

PubMed1993

Physical impairment and functional outcomes six months after severe lower extremity fractures.

To determine functional outcomes after lower extremity fracture (LEF), a prospective follow-up study of patients admitted to three level I trauma centers for treatment of unilateral LEFs was conducted. In this paper we describe outcomes at 6 months after discharge from the initial hospitalization and examine the relationship between impairment and disability. A total of 444 patients met the entry criteria for the study. Of these 376 (85%) were successfully located and interviewed at 6 months; 302 (68%) returned to the trauma center at 6 months for a clinical assessment by a physical therapist. Study patients were predominantly young (mean age = 32.4), white (72%) men (70%) who were working before the injury (77%). The fractures resulted primarily from motor vehicle crashes (71%); mean hospital LOS was 12 days. Disability was measured using the Sickness Impact Profile (SIP), a well validated patient assessment of health status. The overall SIP score averaged for all patients was 10.2, denoting a moderate level of dysfunction or disability. Analysis of the 12 subscores that constitute the SIP indicate particularly high scores for ambulation (16.7 postdischarge vs. 1.2 preinjury), sleep and rest (14.0 vs. 5.1), emotional behavior (10.5 vs. 2.2), home management (15.1 vs. 2.6), recreation and pastimes (19.0 vs. 4.4), and most notably, work (33.2 vs. 8.3). Further analysis of the subgroup of patients working before the injury shows that 48% had returned to work at 6 months. Correlations between lower extremity impairment (range of motion, muscle strength, and pain) and the ambulation subscore of the SIP were high. However, correlations between impairment and more global areas of activity such as home management, work, and recreation were considerably lower. These results suggest that other factors, over and above the extent of physical impairment, significantly influence broader disability outcomes such as return to work. Further research is needed to define these factors so that effective interventions after acute care can be identified and appropriately targeted.

Activities of Daily Living↗

PubMed1993

Effect of preinjury illness on trauma patient survival outcome.

UNLABELLED: Data from 11,156 patients treated at the four Major Trauma Outcome Study controlled sites were used to estimate the effect on survival of each APACHE II preinjury illness condition (PIC). A case-control methodology was applied; 544 patients (4.8%) had one or more PICs. For each patient with a specific PIC we identified a set of matching patients with no PICs. A patient matches a PIC patient if both have the same mechanism of injury, the same coding of Revised Trauma Score variables (Glascow Coma Scale score, systolic blood pressure, respiratory rate), the same coded age per A Severity Characterization of Trauma) (ASCOT), and if they differ by no more than 0.5 for A, B, and C (the ASCOT components for serious injuries). The estimated survival probability for a PIC patient is either the survival rate for the patient's matched set or, if there are no matches, the patient's ASCOT survival probability. The survival probabilities were used to compare the actual and predicted numbers of survivors for each PIC, using z and W statistics. Computations of z and W were also made using ASCOT survival probabilities for each PIC patient. The results indicate profound effects of five PICs (hepatic, cardiovascular, respiratory, renal, diabetes) on trauma patient outcomes. CONCLUSION: Pre-existing organ dysfunction has a profound effect on patient outcome even after controlling for age, anatomic and physiologic severity, and mechanism of injury. But, because of their relatively low incidence in this sample, PICs did not strongly influence institutional outcome performance as measured by z and W values.

Adolescent↗

PubMed1992

Inter-rater reliability of preventable death judgments. The Preventable Death Study Group.

This study examined the inter-rater reliability of preventable death judgments for trauma. A total of 130 deaths were reviewed for potential preventability by multiple panels of nationally chosen experts. Deaths involving a central nervous system (CNS) injury were reviewed by three panels, each consisting of a trauma surgeon, a neurosurgeon, and an emergency physician. Deaths not involving the CNS were reviewed by three panels, each consisting of two trauma surgeons and an emergency physician. Cases for review were sampled from all hospital trauma deaths occurring in Maryland during 1986. Panels were given prehospital and hospital records, medical examiner reports, and autopsy reports, and asked to independently classify deaths as not preventable (NP), possibly preventable (POSS), probably preventable (PROB), or definitely preventable (DEF). Cases in which there was disagreement about preventability were discussed by the panel as a group (via conference call). Results indicated that overall reliability was low. All three panels reviewing non-CNS deaths agreed in only 36% of the cases (kappa = 0.21). Agreement among panels reviewing CNS deaths was somewhat higher at 56% (kappa = 0.40). Most of the disagreements, however, were in judging whether deaths were NP or POSS. Agreement was higher for early deaths and less severely injured patients. For non-CNS deaths agreement was also higher for younger patients. When both autopsy results and prehospital care reports were available reliability increased across panels. A variety of approaches have been used to elicit judgments of preventability. This study provides information to guide recommendations for future studies involving implicit judgments of preventable death.

Central Nervous System↗

PubMed1992

Hospitalizations for traumatic injuries among children in Maryland: trends in incidence and severity: 1979 through 1988.

Trends in incidence and severity of hospitalized injury among children aged 0 through 13 years in the state of Maryland from 1979 through 1988 (n = 35,746) were examined using routinely reported hospital discharge data. Hospital discharge rates declined over the study period from 509 per 100,000 population in 1979 to 320 in 1988. There was a decline in incidence trends for both races. However, the decrease in the nonwhite population was smaller than in whites. Analysis of incidence rates for specific Injury Severity Score groups revealed a declining trend in all Injury Severity Score groups, although the mildest group (Injury Severity Score 1 through 4) had the most notable decline of 44% compared with an average decline of 20% in the other severity groups. These data suggest a change in admission practices of mildly injured children as a major cause for the observed overall decline in hospitalization rates. The smaller decrease in the hospitalization rates of non-white children compared with white children requires further study to determine the cause.

Adolescent↗