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Biomedical subjects

G J Jurkovich

Publications and source records attributed to G J Jurkovich.

At least 19 recordsLinked to original sources
PubMed2001

Relationship between trauma center volume and outcomes.

CONTEXT: The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown. OBJECTIVE: To evaluate the association between trauma center volume and outcomes of trauma patients. DESIGN: Retrospective cohort study. SETTING: Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study. PATIENTS: Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998. MAIN OUTCOME MEASURES: Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (</=650 admissions/y) centers. RESULTS: After multivariate adjustment for patient characteristics and injury severity, the relative odds of death was 0.02 (95% confidence interval [CI], 0.002-0.25) for patients with PAI admitted with shock to high-volume centers compared with low-volume centers. No benefit was evident in patients without shock (P =.50). The adjusted odds of death in patients with multisystem blunt trauma who presented with coma to a high-volume center was 0.49 (95% CI, 0.26-0.93) vs low-volume centers. No benefit was observed in patients without coma (P =.05). Additionally, a shorter LOS was observed in patients with PAI and New Injury Severity Scores of 16 or higher (difference in adjusted mean LOS, 1.6 days [95% CI, -1.5 to 4.7 days]) and in all patients with multisystem blunt trauma admitted to higher-volume centers (difference in adjusted mean LOS, 3.3 days [95% CI, 0.91-5.70 days]). CONCLUSIONS: Our results indicate that a strong association exists between trauma center volume and outcomes, with significant improvements in mortality and LOS when volume exceeds 650 cases per year. These benefits are only evident in patients at high risk for adverse outcomes.

Academic Medical Centers↗
PubMed2001

Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study.

HYPOTHESIS: It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality. DESIGN: A retrospective case series. SETTING: Five urban trauma centers. STUDY SELECTION: Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy). DATA EXTRACTION: Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated. MAIN OUTCOME MEASURE: Death. RESULTS: One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001). CONCLUSIONS: The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.

Adult↗
PubMed2001

Payer status: the unspoken triage criterion.

BACKGROUND: The cost of uncompensated trauma care is a significant barrier to trauma system development. Trauma center designation may burden an institution with an unprofitable mix of underinsured, severely injured patients. Concerns about inadequate reimbursement may motivate interhospital transfers on the basis of insurance status rather than medical necessity, potentially undermining the effectiveness of the system. We set out to explore whether this phenomenon exists in a mature trauma system. METHODS: Trauma patients receiving definitive care at Level III or IV trauma centers were compared with patients transferred from these centers to the only Level I regional center. Insurance status was classified as either commercial or noncommercial. Logistic regression was used to determine the independent predictors of transfer after adjusting for differences in injury severity. RESULTS: Only 12% of 2,008 patients initially evaluated at Level III/IV centers were transferred to the Level I center, an indicator of the effectiveness of prehospital triage protocols in the region. The presence of specific complex injuries, younger age, male gender, and insurance status were all associated with an increased likelihood of transfer. Insurance status was an independent predictor of transfer: patients without commercial insurance were 2.4 (95% confidence interval, 1.6-3.6) times more likely to be transferred to a Level I facility than patients with commercial insurance after adjusting for differences in injury severity. CONCLUSION: Insurance status influences the decision to transfer to higher levels of care. These findings suggest that the financial burden of a trauma system may be inequitably distributed. This inequitable distribution may be necessary for trauma system sustainability and calls for the development of disproportionate reimbursement strategies to support regional referral centers.

Adolescent↗
PubMed2001

Survival among injured geriatric patients during construction of a statewide trauma system.

BACKGROUND: Patient outcomes are presumed to vary during early implementation of a trauma system because of fluctuations in processes of care. This study estimates risk-adjusted survival for injured geriatric patients during implementation of the Washington State trauma system. METHODS: A presystem (1988-1992) versus early construction phase (1993-1995) retrospective cohort analysis of hospitalized geriatric injured patients in Washington State was conducted. Hospital data were cross-linked to death certificates, providing patient follow-up. A Cox proportional hazards model assessed survival to 60 days from hospital admission. RESULTS: A total of 77,136 geriatric patients were assessed. No difference in survival was observed (before vs. after) for all geriatric injured patients. However, among severely injured patients (Injury Severity Score > 15), survival during the implementation phase increased by 5.1% compared with patients admitted during the presystem years (p = 0.03). CONCLUSION: This study demonstrates improved survival for seriously injured geriatric trauma patients during construction of the Washington State trauma system.

Aged↗
PubMed2001

Priorities for improving hospital-based trauma care in an African city.

BACKGROUND: This study sought to identify potential cost-effective methods to improve trauma care in hospitals in the developing world. METHODS: Injured patients admitted to an urban hospital in Ghana over a 1-year period were analyzed prospectively for mechanism of injury, mode of transport to the hospital, injury severity, region of principal injury, operations performed, and mortality. In addition, time from injury until arrival at the hospital and time from arrival at the hospital until emergency surgery were evaluated. RESULTS: Mortality was 9.4%. Most deaths (65%) occurred within 24 hours of admission. Sixty percent of emergency operations were performed over 6 hours after arrival. Tube thoracostomy was performed on only 13 patients (0.6%). Only 58% of patients received intravenous crystalloid and only 3.6% received 1 or more units of blood. CONCLUSION: We identified several specific interventions as potential low-cost measures to improve hospital-based trauma care in this setting, including shorter times to emergency surgery and improvements in initial resuscitation. In addition to addressing each of these aspects of trauma care individually, quality improvement programs may represent a feasible and sustainable method to improve trauma care in hospitals in the developing world.

Adolescent↗
PubMed2001

Management of traumatic lung injury: a Western Trauma Association Multicenter review.

BACKGROUND: Improved outcomes following lung injury have been reported using "lung sparing" techniques. METHODS: A retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as "minor" (suture, wedge resection, tractotomy) or "major" (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded. RESULTS: One hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores "minor" 3.8 +/- 0.9 vs. "major" 4.3 +/- 0.7, p = 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4-2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality. CONCLUSION: Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.

Adult↗
PubMed2001

Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial.

BACKGROUND: Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries. METHODS: Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed. RESULTS: A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08-infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96-7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89-4.86, p = 0.076). CONCLUSION: Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.

Adolescent↗
PubMed2000

The effect of organized systems of trauma care on motor vehicle crash mortality.

CONTEXT: Despite calls for wider national implementation of an integrated approach to trauma care, the effectiveness of this approach at a regional or state level remains unproven. OBJECTIVE: To determine whether implementation of an organized system of trauma care reduces mortality due to motor vehicle crashes. DESIGN: Cross-sectional time-series analysis of crash mortality data collected for 1979 through 1995 from the Fatality Analysis Reporting System. SETTING: All 50 US states and the District of Columbia. SUBJECTS: All front-seat passenger vehicle occupants aged 15 to 74 years. MAIN OUTCOME MEASURES: Rates of death due to motor vehicle crashes compared before and after implementation of an organized trauma care system. Estimates are based on within-state comparisons adjusted for national trends in crash mortality. RESULTS: Ten years following initial trauma system implementation, mortality due to traffic crashes began to decline; about 15 years following trauma system implementation, mortality was reduced by 8% (95% confidence interval [CI], 3%-12%) after adjusting for secular trends in crash mortality, age, and the introduction of traffic safety laws. Implementation of primary enforcement of restraint laws and laws deterring drunk driving resulted in reductions in crash mortality of 13% (95% CI, 11%-16%) and 5% (95% CI, 3%-7%), respectively, while relaxation of state speed limits increased mortality by 7% (95% CI, 3%-10%). CONCLUSIONS: Our data indicate that implementation of an organized system of trauma care reduces crash mortality. The effect does not appear for 10 years, a finding consistent with the maturation and development of trauma triage protocols, interhospital transfer agreements, organization of trauma centers, and ongoing quality assurance.

Accidents, Traffic↗
PubMed2000

Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation.

BACKGROUND: Regional trauma systems were proposed 2 decades ago to reduce injury mortality rates. Because of the difficulties in evaluating their effectiveness and the methodologic limitations of previously published studies, the relative benefits of establishing an organized system of trauma care remains controversial. METHODS: Data on trauma systems were obtained from a survey of state emergency medical service directors, review of state statutes and a previously published trauma system inventory. Injury mortality rates were obtained from national vital statistics data, whereas motor vehicle crash (MVC) mortality rates were obtained from the Fatality Analysis Reporting System. Mortality rates were compared between states with and without trauma systems. RESULTS: As of 1995, 22 states had regional trauma systems. States with trauma systems had a 9% lower crude injury mortality rate than those without. When MVC-related mortality was evaluated separately, there was a 17% reduction in deaths. After controlling for age, state speed laws, restraint laws, and population distribution, there remained a 9% reduction in MVC-related mortality rate in states with a trauma system. CONCLUSION: These data demonstrate that a state trauma system is associated with a reduction in the risk of death caused by injury. The effect is most evident on analysis of MVC deaths.

Accidents, Traffic↗
PubMed2000

Low-cost improvements in prehospital trauma care in a Latin American city.

OBJECTIVE: Prehospital care is a critical component of efforts to lower trauma mortality. In less-developed countries, scarce resources dictate that any improvements in prehospital care must be low in cost. In one Latin American city, recent efforts to improve prehospital care have included an increase in the number of sites of ambulance dispatch from two to four and introduction of the Prehospital Trauma Life Support (PHTLS) course. METHODS: The effect of increased dispatch sites was evaluated by comparing response times before and after completion of the change. The effect of PHTLS was evaluated by comparing prehospital treatment for the 3 months before initiation of the course (n = 361 trauma patients) and the 6 months after (n = 505). RESULTS: Response time decreased from a mean of 15.5 +/- 5.1 minutes, when there were two sites of dispatch, to 9.5 +/- 2.7 minutes, when there were four sites. Prehospital trauma care improved after initiation of the PHTLS course. For all trauma patients, use of cervical immobilization increased from 39 to 67%. For patients in respiratory distress, there were increases in the use of oropharyngeal airways (16-39%), in the use of suction (10-38%), and in the administration of oxygen (64-87%). For hypotensive patients, there was an increase in use of large-bore intravenous lines from 26 to 58%. The improved prehospital treatment did not increase the mean scene time (5.7 +/- 4.4 minutes before vs. 5.9 +/- 6.8 minutes after). The percent of patients transported who died in route decreased from 8.2% before the course to 4.7% after. These improvements required a minimal increase (16%) in the ambulance service budget. CONCLUSION: Increase in sites of dispatch and increased training in the form of the PHTLS course improved the process of pre-hospital care in this Latin American city and resulted in a decrease in prehospital deaths. These improvements were low cost and should be considered for use in other less developed countries.

Adult↗
PubMed2000

Giving bad news: the family perspective.

BACKGROUND: Death from trauma frequently comes without forewarning. Relating the news of death to the family is often the responsibility of trauma surgeons. The purpose of this study was to investigate the key characteristics and methods of delivering bad news from the perspective of surviving family members. METHODS: We designed and administered a survey tool to surviving family members of trauma patients dying in the emergency department or intensive care unit. The tool consisted of 14 elements that surviving family members graded in importance when receiving bad news (1, least; 6, most). Respondents also judged the attention given to these elements (good, fair, or poor) by the person giving the bad news of death. RESULTS: Fifty-four family members of 48 patients who died completed the survey (44 intensive care unit deaths, 4 emergency room deaths). Deceased patients ranged in age from 12 to 91 years (mean, 53 years). Death occurred within 2 days of injury in 69% of the patients and within 1 week in 83%. The most important features of delivering bad news were judged to be attitude of the news-giver (ranked most important by 72%), clarity of the message (70%), privacy (65%), and knowledge/ ability to answer questions (57%). The attire of the news-giver ranked as least important (3%). Sympathy, time for questions, and location of the conversation were ranked of intermediate importance. Touching was unwanted by 30% of the respondents, but encouraged or acceptable in 24%. CONCLUSION: The attitude of the news-giver, combined with clarity of the message and the time, privacy, and knowledge to answer questions are the most important aspects of giving bad news. This information should be incorporated into resident training.

Adolescent↗
PubMed2000

Rib fractures in the elderly.

BACKGROUND: We sought to ascertain the extent to which advanced age influences the morbidity and mortality after rib fractures (fxs), to define the relationship between number of rib fractures and morbidity and mortality, and to evaluate the influence of analgesic technique on outcome. METHODS: A retrospective cohort study involving all 277 patients > or = 65 years old with rib fxs admitted to a Level I trauma center over 10 years was undertaken. The control group consisted of 187 randomly selected patients, 18 to 64 years old, with rib fxs admitted over the same time period. Outcomes included pulmonary complications, number of ventilator days, length of intensive care unit and hospital stay (LOS), disposition, and mortality. The specific analgesic technique used was also examined. RESULTS: The two groups had similar mean number of rib fxs (3.6 elderly vs. 4.0 young), mean chest Abbreviated Injury Scores (3.0 vs. 3.0), and mean Injury Severity Score (20.7 vs. 21.4). However, mean number of ventilator days (4.3 vs. 3.1), intensive care unit days (6.1 vs. 4.0), and LOS (15.4 vs. 10.7 days) were longer for the elderly patients. Pneumonia occurred in 31% of elderly versus 17% of young (p < 0.01) and mortality was 22% for the elderly versus 10% for the young (p < 0.01). Mortality and pneumonia rates increased as the number of rib fxs increased with and odds ratio for death of 1.19 and for pneumonia of 1.16 per each additional rib fracture (p < 0.001). The use of epidural analgesia in the elderly (LOS >2 days) was associated with a 10% mortality versus 16% without the use of an epidural (p = 0.28). In the younger group (LOS >2 days), mortality with and without the use of an epidural was 0% and 5%, respectively. CONCLUSION: Elderly patients who sustain blunt chest trauma with rib fxs have twice the mortality and thoracic morbidity of younger patients with similar injuries. For each additional rib fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27%. As the number of rib fractures increases, there is a significant increase in morbidity and mortality in both groups, but with different patterns for each group. Further prospective study is needed to determine the utility of epidural analgesia in this population.

Abbreviated Injury Scale↗
PubMed2000

Harborview assessment for risk of mortality: an improved measure of injury severity on the basis of ICD-9-CM.

BACKGROUND: There have been several attempts to develop a scoring system that can accurately reflect the severity of a trauma patient's injuries, particularly with respect to the effect of the injury on survival. Current methodologies require unreliable physiologic data for the assignment of a survival probability and fail to account for the potential synergism of different injury combinations. The purpose of this study was to develop a scoring system to better estimate probability of mortality on the basis of information that is readily available from the hospital discharge sheet and does not rely on physiologic data. METHODS: Records from the trauma registry from an urban Level I trauma center were analyzed using logistic regression. Included in the regression were Internation Classification of Diseases-9th Rev (ICD-9CM) codes for anatomic injury, mechanism, intent, and preexisting medical conditions, as well as age. Two-way interaction terms for several combinations of injuries were also included in the regression model. The resulting Harborview Assessment for Risk of Mortality (HARM) score was then applied to an independent test data set and compared with Trauma and Injury Severity Score (TRISS) probability of survival and ICD-9-CM Injury Severity Score (ICISS) for ability to predict mortality using the area under the receiver operator characteristic curve. RESULTS: The HARM score was based on analysis of 16,042 records (design set). When applied to an independent validation set of 15,957 records, the area under the receiver operator characteristic curve (AUC) for HARM was 0.9592. This represented significantly better discrimination than both TRISS probability of survival (AUC = 0.9473, p = 0.005) and ICISS (AUC = 0.9402, p = 0.001). HARM also had a better calibration (Hosmer-Lemeshow statistic [HL] = 19.74) than TRISS (HL = 55.71) and ICISS (HL = 709.19). Physiologic data were incomplete for 6,124 records (38%) of the validation set; TRISS could not be calculated at all for these records. CONCLUSION: The HARM score is an effective tool for predicting probability of in-hospital mortality for trauma patients. It outperforms both the TRISS and ICD9-CM Injury Severity Score (ICISS) methodologies with respect to both discrimination and calibration, using information that is readily available from hospital discharge coding, and without requiring emergency department physiologic data.

Adolescent↗
PubMed1999

Ten-year trend in survival and resource utilization at a level I trauma center.

OBJECTIVE: To determine the impact of increasing trauma center experience over time on survival and resource utilization. METHODS: The authors studied a retrospective cohort at a single level I trauma center over a 10-year period, from 1986 to 1995. Patients included all hospital admissions and emergency department deaths. The main outcome measures were the case-fatality rate adjusted for injury severity, hospital length of stay, and costs. RESULTS: A total of 25,979 patients were admitted or died. The number of patients per year increased, from 2063 in 1986 to 3313 in 1995. The proportion of patients transferred from another institution increased from 16.2% to 34.4%. Although mean length of stay declined by 28.4%, from 9.5 to 6.8 days, costs increased by 16.7%, from $14,174 to $16,547. The use of specific radiologic investigations increased; the frequency of operative procedures either remained unchanged (craniotomy, fracture fixation) or decreased (celiotomy). After adjusting for injury severity and demographic factors, the mortality rate decreased over 10 years. The improvement in survival was confined to patients with an injury severity score > or =16. CONCLUSION: Over a 10-year period, the case-fatality rate declined in patients with severe injuries. Overall acute care costs increased, partially because of the increased use of radiologic investigations. Even in otherwise established trauma centers, increasing cumulative experience results in improved survival rates in the most severely injured patients. These data suggest that experience contributes to a decrease in mortality rate after severe trauma and that developing trauma systems should consider this factor and limit the number of designated centers to maximize cumulative experience at individual centers.

Adult↗