Publications by authors named "Kevin Sexton"

72 Publications

The Power Law in Operating Room Management.

J Med Syst 2021 Sep 8;45(10):92. Epub 2021 Sep 8.

Department of Anesthesiology, Department of Orthopaedics and Rehabilitation (By Courtesy), Department of Surgery (By Courtesy), University of Vermont Larner College of Medicine, Burlington, VT, US.

The Acute Care Surgery model has been implemented by many hospitals in the United States. As complex adaptive systems, healthcare systems are composed of many interacting elements that respond to intrinsic and extrinsic inputs. Systems level analysis may reveal the underlying organizational structure of tactical block allocations like the Acute Care Surgery model. The purpose of this study is to demonstrate one method to identify a key characteristic of complex adaptive systems in the perioperative services. Start and end times for all surgeries performed at the University of Vermont Medical Center OR1 were extracted for two years prior to the transition to an Acute Care Surgery service and two years following the transition. Histograms were plotted for the inter-event times calculated from the difference between surgical cases. A power law distribution was fit to the post-transition histogram. The Kolmogorov-Smirnov test for goodness-of-fit at 95% level of significance shows the histogram plotted from post-transition inter-event times follows a power law distribution (K-S = 0.088, p = 0.068), indicating a Complex Adaptive System. Our analysis demonstrates that the strategic decision to create an Acute Care Surgery service has direct implications on tactical and operational processes in the perioperative services. Elements of complex adaptive systems can be represented by a power law distributions and similar methods may be applied to identify other processes that operate as complex adaptive systems in perioperative care. To make sustained improvements in the perioperative services, focus on manufacturing-based interventions such as Lean Six Sigma should instead be shifted towards the complex interventions that modify system-specific behaviors described by complex adaptive system principles when power law relationships are present.
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http://dx.doi.org/10.1007/s10916-021-01764-1DOI Listing
September 2021

Using performance frontiers differentiates orthopaedic subspecialties.

J Clin Anesth 2021 Aug 22;75:110485. Epub 2021 Aug 22.

Department of Anesthesiology, Orthopaedics and Rehabilitation (by courtesy), and Surgery (by courtesy), Larner College of Medicine, University of Vermont, Burlington, VT, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.jclinane.2021.110485DOI Listing
August 2021

Does Gender Matter: A Multi-Institutional Analysis of Viscoelastic Profiles for 1565 Trauma Patients With Severe Hemorrhage.

Am Surg 2021 Jul 15:31348211033542. Epub 2021 Jul 15.

Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA.

Background: Viscoelastic tests including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are being used in patients with severe hemorrhage at trauma centers to guide resuscitation. Several recent studies demonstrated hypercoagulability in female trauma patients that was associated with a survival advantage. The objective of our study was to elucidate the effects of gender differences in TEG/ROTEM values on survival in trauma patients with severe hemorrhage.

Methods: A retrospective review of consecutive adult patients receiving massive transfusion protocol (MTP) at 7 Level I trauma centers was performed from 2013 to 2018. Data were stratified by gender and then further examined by TEG or ROTEM parameters. Results were analyzed using univariate and multi-variate analyses.

Results: A total of 1565 patients were included with 70.9% male gender (n = 1110/1565). Female trauma patients were older than male patients (43.5 ± .9 vs 41.1 ± .6 years, = .01). On TEG, females had longer reaction times (6.1 ± .9 min vs 4.8 ± .2 min, = .03), increased alpha angle (68.6 ± .8 vs 65.7 ± .4, < .001), and higher maximum amplitude (59.8 ± .8 vs 56.3 ± .4, < .001). On ROTEM, females had significantly longer clot time (99.2 ± 13.7 vs 75.1 ± 2.6 sec, = .09) and clot formation time (153.6 ± 10.6 sec vs 106.9 ± 3.8 sec, < .001). When comparing by gender, no difference for in-hospital mortality was found for patients in the TEG or ROTEM group ( > .05). Multivariate analysis showed no survival difference for female patients (OR 1.11, 95% CI .83-1.50, = .48).

Conclusions: Although a difference between male and females was found on TEG/ROTEM for certain clotting parameters, no difference in mortality was observed. Prospective multi-institutional studies are needed.
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http://dx.doi.org/10.1177/00031348211033542DOI Listing
July 2021

Retrospective study on rib fractures: smoking and alcohol matter for mortality and complications.

Trauma Surg Acute Care Open 2021 15;6(1):e000732. Epub 2021 Jun 15.

Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Background: Rib fractures and substance use are both common in trauma patients, but there is little data on how smoking and alcohol use may be associated with outcomes in these patients. We assessed the association between smoking or alcohol use disorder (AUD) and outcomes in patients with rib fractures.

Methods: We used institutional databases to conduct a retrospective review of patients with rib fractures at the only American College of Surgeons-verified adult level 1 trauma center in a rural state between 2015 and 2019. The key exposure variables were smoking and AUD. The key outcome variables were mortality and pulmonary complications (pneumonia, adult respiratory distress syndrome, and pneumothorax). We used multivariable regression for analysis and directed acyclic graphs to identify variables for adjustment.

Results: We identified 1880 eligible patients with rib fractures, including 693 (37%) who were smokers and 204 (11%) who had AUD. Compared with non-smokers, smokers were younger, more often male, and had lower mortality rates. Regression showed that smokers had a lower likelihood of mortality (OR 0.48; 95% CI 0.27 to 0.87; p=014). Likelihood of pneumonia, ARDS, and pneumothorax was not different between smokers and non-smokers. Compared with patients without AUD, patients with AUD were older, more often male, and had higher likelihood of pneumonia and lower likelihood of pneumothorax. Regression showed that patients with AUD had higher likelihood of pneumonia (OR 1.82; 95% CI 1.24 to 2.68; p=0.002) and lower likelihood of pneumothorax (OR 0.51; 95% CI 0.33 to 0.75; p=0.002).

Discussion: In trauma patients with rib fractures treated at a level 1 trauma center over 5 years, smoking was associated with decreased risk of mortality. These findings have implications for risk stratification and clinical decision-making for patients with rib fractures.

Level Of Evidence: III.
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http://dx.doi.org/10.1136/tsaco-2021-000732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207992PMC
June 2021

Preoperative nutritional counselling in patients undergoing oesophagectomy.

J Perioper Pract 2021 Jul 1:17504589211006026. Epub 2021 Jul 1.

Department of Surgery, Division of Thoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Background: Patients undergoing surgery for oesophageal cancer are at high risk of malnutrition due to pathology and neoadjuvent therapy. This study sought to determine if oesophageal cancer patients undergoing oesophagectomy achieve superior clinical outcomes when preoperative nutritional counselling is performed.

Methods: Oesophageal cancer patients undergoing oesophagectomy were retrospectively divided into cohorts based on those who received ( = 48) and did not receive ( = 58) preoperative nutritional counselling. We compared weight loss, length of stay, 30-day readmission related to nutrition or feeding tube problems, and 90-day mortality.

Results: Per cent weight loss was less in patients who received preoperative nutritional counselling. There was a trend toward decreased mean length of stay and there were fewer readmissions for feeding tube-related complications in patients who received counselling.

Conclusions: Nutritional counselling before surgery may lead to decreased weight loss and reduced readmissions for feeding tube-related complications in patients with oesophageal cancer undergoing oesophagectomy.
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http://dx.doi.org/10.1177/17504589211006026DOI Listing
July 2021

DeIDNER Corpus: Annotation of Clinical Discharge Summary Notes for Named Entity Recognition Using BRAT Tool.

Stud Health Technol Inform 2021 May;281:432-436

Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Named Entity Recognition (NER) aims to identify and classify entities into predefined categories is a critical pre-processing task in Natural Language Processing (NLP) pipeline. Readily available off-the-shelf NER algorithms or programs are trained on a general corpus and often need to be retrained when applied on a different domain. The end model's performance depends on the quality of named entities generated by these NER models used in the NLP task. To improve NER model accuracy, researchers build domain-specific corpora for both model training and evaluation. However, in the clinical domain, there is a dearth of training data because of privacy reasons, forcing many studies to use NER models that are trained in the non-clinical domain to generate NER feature-set. Thus, influencing the performance of the downstream NLP tasks like information extraction and de-identification. In this paper, our objective is to create a high quality annotated clinical corpus for training NER models that can be easily generalizable and can be used in a downstream de-identification task to generate named entities feature-set.
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http://dx.doi.org/10.3233/SHTI210195DOI Listing
May 2021

COVID-19 Is Connected with Lower Health Literacy in Rural Areas.

Stud Health Technol Inform 2021 May;281:804-808

COM Surgery Trauma Surgery, University of Arkansas for Medical Sciences.

The relationship between social determinants of health (SDoH) and health outcomes is established and extends to a higher risk of contracting COVID-19. Given the factors included in SDoH, such as education level, race, rurality, and socioeconomic status are interconnected, it is unclear how individual SDoH factors may uniquely impact risk. Lower socioeconomic status often occurs in concert with lower educational attainment, for example. Because literacy provides access to information needed to avoid infection and content can be made more accessible, it is essential to determine to what extent health literacy contributes to successful containment of a pandemic. By incorporating this information into clinical data, we have isolated literacy and geographic location as SDoH factors uniquely related to the risk of COVID-19 infection. For patients with comorbidities linked to higher illness severity, residents of rural areas associated with lower health literacy at the zip code level had a greater likelihood of positive COVID-19 results unrelated to their economic status.
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http://dx.doi.org/10.3233/SHTI210286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8290347PMC
May 2021

Deep Learning Methods to Predict Mortality in COVID-19 Patients: A Rapid Scoping Review.

Stud Health Technol Inform 2021 May;281:799-803

Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

The ongoing COVID-19 pandemic has become the most impactful pandemic of the past century. The SARS-CoV-2 virus has spread rapidly across the globe affecting and straining global health systems. More than 2 million people have died from COVID-19 (as of 30 January 2021). To lessen the pandemic's impact, advanced methods such as Artificial Intelligence models are proposed to predict mortality, morbidity, disease severity, and other outcomes and sequelae. We performed a rapid scoping literature review to identify the deep learning techniques that have been applied to predict hospital mortality in COVID-19 patients. Our review findings provide insights on the important deep learning models, data types, and features that have been reported in the literature. These summary findings will help scientists build reliable and accurate models for better intervention strategies for predicting mortality in current and future pandemic situations.
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http://dx.doi.org/10.3233/SHTI210285DOI Listing
May 2021

Using performance frontiers to differentiate elective and capacity-based surgical services.

J Trauma Acute Care Surg 2021 06;90(6):935-941

From the Department of Surgery (S.E.R., A.K.M.) and Department of Anesthesia (M.H.T., M.W.B.), Larner College of Medicine, Burlington, Vermont; and University of Arkansas for Medical Sciences (K.W.S.), Little Rock, Arkansas.

Background: Acute care surgery (ACS) model of care delivery has many benefits. However, since the ACS surgeon has limited control over the volume, timing, and complexity of cases, traditional metrics of operating room (OR) efficiency almost always measure ACS service as "inefficient." The current study examines an alternative method-performance fronts-of evaluating changes in efficiency and tests the following hypotheses: (1) in an institution with a robust ACS service, performance front methodology is superior to traditional metrics in evaluating OR throughput/efficiency, and (2) introduction of an ACS service with block time allocation will improve OR throughput/efficiency.

Methods: Operating room metrics 1-year pre-ACS implementation and post-ACS implementation were collected. Overall OR efficiency was calculated by mean case volumes for the entire OR and ACS and general surgery (GS) services individually. Detailed analysis of these two specific services was performed by gathering median monthly minutes-in block, out of block, after hours, and opportunity unused. The two services were examined using a traditional measure of efficiency and the "fronts" method. Services were compared with each other and also pre-ACS implementation and post-ACS implementation.

Results: Overall OR case volumes increased by 5% (999 ± 50 to 1,043 ± 46: p < 0.05) with almost all of the increase coming through ACS (27 ± 4 to 68 ± 16: p < 0.05). By traditional metrics, ACS had significantly worse median efficiency versus GS in both periods: pre (0.67 [0.66-0.71] vs. 0.80 [0.78-0.81]) and post (0.75 [0.53-0.77] vs. 0.83 [0.84-0.85]) (p < 0.05). As compared with the pre, GS efficiency improved significantly in post (p < 0.05), but ACS efficiency remained unchanged (p > 0.05). The alternative fronts chart demonstrated the more accurate picture with improved efficiency observed for GS, ACS, and combined.

Conclusion: In an institution with a busy ACS service, the alternative fronts methodology offers a more accurate evaluation of OR efficiency. The provision of an OR for the ACS service improves overall throughput/efficiency.
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http://dx.doi.org/10.1097/TA.0000000000003137DOI Listing
June 2021

Application of Machine Learning in Intensive Care Unit (ICU) Settings Using MIMIC Dataset: Systematic Review.

Informatics (MDPI) 2021 Mar 3;8(1). Epub 2021 Mar 3.

Department of Biomedical Informatics, University of Arkansas for Medical Sciences (UAMS), Little Rock, Arkansas 72205, USA.

Modern Intensive Care Units (ICUs) provide continuous monitoring of critically ill patients susceptible to many complications affecting morbidity and mortality. ICU settings require a high staff-to-patient ratio and generates a sheer volume of data. For clinicians, the real-time interpretation of data and decision-making is a challenging task. Machine Learning (ML) techniques in ICUs are making headway in the early detection of high-risk events due to increased processing power and freely available datasets such as the Medical Information Mart for Intensive Care (MIMIC). We conducted a systematic literature review to evaluate the effectiveness of applying ML in the ICU settings using the MIMIC dataset. A total of 322 articles were reviewed and a quantitative descriptive analysis was performed on 61 qualified articles that applied ML techniques in ICU settings using MIMIC data. We assembled the qualified articles to provide insights into the areas of application, clinical variables used, and treatment outcomes that can pave the way for further adoption of this promising technology and possible use in routine clinical decision-making. The lessons learned from our review can provide guidance to researchers on application of ML techniques to increase their rate of adoption in healthcare.
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http://dx.doi.org/10.3390/informatics8010016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112729PMC
March 2021

Anesthetics affect peripheral venous pressure waveforms and the cross-talk with arterial pressure.

J Clin Monit Comput 2021 Feb 19. Epub 2021 Feb 19.

Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, USA.

Analysis of peripheral venous pressure (PVP) waveforms is a novel method of monitoring intravascular volume. Two pediatric cohorts were studied to test the effect of anesthetic agents on the PVP waveform and cross-talk between peripheral veins and arteries: (1) dehydration setting in a pyloromyotomy using the infused anesthetic propofol and (2) hemorrhage setting during elective surgery for craniosynostosis with the inhaled anesthetic isoflurane. PVP waveforms were collected from 39 patients that received propofol and 9 that received isoflurane. A multiple analysis of variance test determined if anesthetics influence the PVP waveform. A prediction system was built using k-nearest neighbor (k-NN) to distinguish between: (1) PVP waveforms with and without propofol and (2) different minimum alveolar concentration (MAC) groups of isoflurane. 52 porcine, 5 propofol, and 7 isoflurane subjects were used to determine the cross-talk between veins and arteries at the heart and respiratory rate frequency during: (a) during and after bleeding with constant anesthesia, (b) before and after propofol, and (c) at each MAC value. PVP waveforms are influenced by anesthetics, determined by MANOVA: p value < 0.01, η = 0.478 for hypovolemic, and η = 0.388 for euvolemic conditions. The k-NN prediction models had 82% and 77% accuracy for detecting propofol and MAC, respectively. The cross-talk relationship at each stage was: (a) ρ = 0.95, (b) ρ = 0.96, and (c) could not be evaluated using this cohort. Future research should consider anesthetic agents when analyzing PVP waveforms developing future clinical monitoring technology that uses PVP.
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http://dx.doi.org/10.1007/s10877-020-00632-6DOI Listing
February 2021

The clinical impact and safety profile of high-dose intra-arterial verapamil treatment for cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

Clin Neurol Neurosurg 2021 Mar 6;202:106546. Epub 2021 Feb 6.

Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA, 15212, United States.

Background: Cerebral vasospasm (CVS) leads to delayed cerebral ischemia (DCI) and cerebral infarction, a potential cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). The objective of this study was to evaluate the clinical efficacy and safety profile of high-dose IA verapamil for aSAH in a large series of patients.

Methods: Between 2011-2019, a retrospective cohort of 188 consecutive patients presenting with aSAH were reviewed. High-dose IA verapamil (> 20 mg per vascular territory on each side) was intermittently used for appropriate patients to manage symptomatic CVS. Of the 188 patients reviewed, 86 were treated with high-dose IA verapamil. The clinical efficacy and safety profile of our ruptured aneurysm patient cohort were compared to historical literature controls. The primary endpoints studied included radiographic stroke corresponding to cerebral vasospasm, clinical outcome at discharge and subsequent follow-up, and overall functional status as defined by the modified Rankin scale (mRS). The safety profile of high dose IA verapamil was a secondary endpoint.

Results: IA verapamil was delivered between 2-16 days after ictus (median post-bleed day 6) and 74 % of patients had documented clinical improvement after therapy, with 61.5 % achieving good functional outcomes (mRS < 2). 25.5 % of all patients had evidence of vasospasm-related DCI. 3 patients sustained transient hemodynamic changes after verapamil treatment and 10 patients developed post-procedural seizures successfully managed with intravenous lorazepam.

Conclusion: High-dose IA verapamil treatment is well-tolerated in the high-risk aneurysmal subarachnoid hemorrhage population that experience severe, symptomatic CVS with good functional outcomes at follow-up.
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http://dx.doi.org/10.1016/j.clineuro.2021.106546DOI Listing
March 2021

Role of Machine Learning Techniques to Tackle the COVID-19 Crisis: Systematic Review.

JMIR Med Inform 2021 Jan 11;9(1):e23811. Epub 2021 Jan 11.

Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, United States.

Background: SARS-CoV-2, the novel coronavirus responsible for COVID-19, has caused havoc worldwide, with patients presenting a spectrum of complications that have pushed health care experts to explore new technological solutions and treatment plans. Artificial Intelligence (AI)-based technologies have played a substantial role in solving complex problems, and several organizations have been swift to adopt and customize these technologies in response to the challenges posed by the COVID-19 pandemic.

Objective: The objective of this study was to conduct a systematic review of the literature on the role of AI as a comprehensive and decisive technology to fight the COVID-19 crisis in the fields of epidemiology, diagnosis, and disease progression.

Methods: A systematic search of PubMed, Web of Science, and CINAHL databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines to identify all potentially relevant studies published and made available online between December 1, 2019, and June 27, 2020. The search syntax was built using keywords specific to COVID-19 and AI.

Results: The search strategy resulted in 419 articles published and made available online during the aforementioned period. Of these, 130 publications were selected for further analyses. These publications were classified into 3 themes based on AI applications employed to combat the COVID-19 crisis: Computational Epidemiology, Early Detection and Diagnosis, and Disease Progression. Of the 130 studies, 71 (54.6%) focused on predicting the COVID-19 outbreak, the impact of containment policies, and potential drug discoveries, which were classified under the Computational Epidemiology theme. Next, 40 of 130 (30.8%) studies that applied AI techniques to detect COVID-19 by using patients' radiological images or laboratory test results were classified under the Early Detection and Diagnosis theme. Finally, 19 of the 130 studies (14.6%) that focused on predicting disease progression, outcomes (ie, recovery and mortality), length of hospital stay, and number of days spent in the intensive care unit for patients with COVID-19 were classified under the Disease Progression theme.

Conclusions: In this systematic review, we assembled studies in the current COVID-19 literature that utilized AI-based methods to provide insights into different COVID-19 themes. Our findings highlight important variables, data types, and available COVID-19 resources that can assist in facilitating clinical and translational research.
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http://dx.doi.org/10.2196/23811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7806275PMC
January 2021

Characterization of Acidosis in Trauma Patient.

J Emerg Trauma Shock 2020 Jul-Sep;13(3):213-218. Epub 2020 Sep 18.

Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Background: Recent data suggest that acidosis alone is not a good predictor of mortality in trauma patients. Little data are currently available regarding factors associated with survival in trauma patients presenting with acidosis.

Aims: The aims were to characterize the outcomes of trauma patients presenting with acidosis and to identify modifiable risk factors associated with mortality in these patients.

Settings And Design: This is a retrospective observational study of University of Arkansas for Medical Sciences (UAMS) trauma patients between November 23, 2013, and May 21, 2017.

Methods: Data were collected from the UAMS trauma registry. The primary outcome was hospital mortality. Analyses were performed using t-test and Pearson's Chi-squared test. Simple and multiple logistic regressions were performed to determine crude and adjusted odds ratios.

Results: There were 532 patients identified and 64.7% were acidotic (pH < 7.35) on presentation: 75.9% pH 7.2-7.35; 18.5% pH 7.0-7.2; and 5.6% pH ≤ 7.0. The total hospital mortality was 23.7%. Nonsurvivors were older and more acidotic, with a base deficit >-8, Glasgow Coma Scale (GCS) ≤ 8, systolic blood pressure ≤ 90, International Normalized Ratio (INR) >1.6, and Injury Severity Score (ISS) >15. Mortality was significantly higher with a pH ≤ 7.2 but mortality with a pH 7.2-7.35 was comparable to pH > 7.35. In the adjusted model, pH ≤ 7.0, pH 7.0-7.2, INR > 1.6, GCS ≤ 8, and ISS > 15 were associated with increased mortality. For patients with a pH ≤ 7.2, only INR was associated with increase in mortality.

Conclusions: A pH ≤ 7.2 is associated with increased mortality. For patients in this range, only the presence of coagulopathy is associated with increased mortality. A pH > 7.2 may be an appropriate treatment goal for acidosis. Further work is needed to identify and target potentially modifiable factors in patients with acidosis such as coagulopathy.
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http://dx.doi.org/10.4103/JETS.JETS_45_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717465PMC
September 2020

Hemorrhage-Control Training in Medical Education.

J Med Educ Curric Dev 2020 Jan-Dec;7:2382120520973214. Epub 2020 Nov 19.

Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Objectives: To evaluate and analyze the efficacy of implementation of hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of students with controlling major hemorrhage and they will find this a valuable skill set for medical and other healthcare professional students.

Methods: After IRB and institutional approval was obtained, hemorrhage-control education was incorporated into the surgery clerkship curriculum for 96 third-year medical students at the University of Arkansas for Medical Sciences using the national Stop The Bleed program. Using a prospective study design, participants completed pre- and post-training surveys to gauge prior experiences and comfort levels with controlling hemorrhage and confidence levels with the techniques taught. Course participation was mandatory; survey completion was optional. The investigators were blinded as to the individual student's survey responses. A knowledge quiz was completed following the training.

Results: Implementation of STB training resulted in a significant increase in comfort and confidence among students with all hemorrhage-control techniques. There was also a significant difference in students' perceptions of the importance of this training for physicians and other allied health professionals.

Conclusion: Hemorrhage-control training can be effectively incorporated into the formal medical school curriculum via a single 2-hour Stop The Bleed course, increasing students' comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education. We believe this should be a standard part of undergraduate medical education.
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http://dx.doi.org/10.1177/2382120520973214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682227PMC
November 2020

Chest imaging representing a COVID-19 positive rural U.S. population.

Sci Data 2020 11 24;7(1):414. Epub 2020 Nov 24.

Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

As the COVID-19 pandemic unfolds, radiology imaging is playing an increasingly vital role in determining therapeutic options, patient management, and research directions. Publicly available data are essential to drive new research into disease etiology, early detection, and response to therapy. In response to the COVID-19 crisis, the National Cancer Institute (NCI) has extended the Cancer Imaging Archive (TCIA) to include COVID-19 related images. Rural populations are one population at risk for underrepresentation in such public repositories. We have published in TCIA a collection of radiographic and CT imaging studies for patients who tested positive for COVID-19 in the state of Arkansas. A set of clinical data describes each patient including demographics, comorbidities, selected lab data and key radiology findings. These data are cross-linked to SARS-COV-2 cDNA sequence data extracted from clinical isolates from the same population, uploaded to the GenBank repository. We believe this collection will help to address population imbalance in COVID-19 data by providing samples from this normally underrepresented population.
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http://dx.doi.org/10.1038/s41597-020-00741-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686304PMC
November 2020

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

Injury 2021 Mar 16;52(3):443-449. Epub 2020 Sep 16.

Trauma Services, 640 Jackson St, Saint Paul, MN 55101 USA. Electronic address:

Objectives: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample.

Methods: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005.

Results: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar.

Conclusions: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.
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http://dx.doi.org/10.1016/j.injury.2020.09.027DOI Listing
March 2021

Toolkit to Compute Time-Based Elixhauser Comorbidity Indices and Extension to Common Data Models.

Healthc Inform Res 2020 Jul 31;26(3):193-200. Epub 2020 Jul 31.

Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Objective: The time-dependent study of comorbidities provides insight into disease progression and trajectory. We hypothesize that understanding longitudinal disease characteristics can lead to more timely intervention and improve clinical outcomes. As a first step, we developed an efficient and easy-to-install toolkit, the Time-based Elixhauser Comorbidity Index (TECI), which pre-calculates time-based Elixhauser comorbidities and can be extended to common data models (CDMs).

Methods: A Structured Query Language (SQL)-based toolkit, TECI, was built to pre-calculate time-specific Elixhauser comorbidity indices using data from a clinical data repository (CDR). Then it was extended to the Informatics for Integrating Biology and the Bedside (I2B2) and Observational Medical Outcomes Partnership (OMOP) CDMs.

Results: At the University of Arkansas for Medical Sciences (UAMS), the TECI toolkit was successfully installed to compute the indices from CDR data, and the scores were integrated into the I2B2 and OMOP CDMs. Comorbidity scores calculated by TECI were validated against: scores available in the 2015 quarter 1-3 Nationwide Readmissions Database (NRD) and scores calculated using the comorbidities using a previously validated algorithm on the 2015 quarter 4 NRD. Furthermore, TECI identified 18,846 UAMS patients that had changes in comorbidity scores over time (year 2013 to 2019). Comorbidities for a random sample of patients were independently reviewed, and in all cases, the results were found to be 100% accurate.

Conclusion: TECI facilitates the study of comorbidities within a time-dependent context, allowing better understanding of disease associations and trajectories, which has the potential to improve clinical outcomes.
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http://dx.doi.org/10.4258/hir.2020.26.3.193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438698PMC
July 2020

Measles immunity in emergency medical providers.

Vaccine 2020 09 11;38(41):6350-6351. Epub 2020 Aug 11.

Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA. Electronic address:

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http://dx.doi.org/10.1016/j.vaccine.2020.08.012DOI Listing
September 2020

Collecting data on organizational structures of trauma centers: the CAFE web service.

Trauma Surg Acute Care Open 2020 29;5(1):e000473. Epub 2020 Jul 29.

Surgery, UAMS, Little Rock, Arkansas, USA.

Background: During the past several decades, the American College of Surgeons has led efforts to standardize trauma care through their trauma center verification process and Trauma Quality Improvement Program. Despite these endeavors, great variability remains among trauma centers functioning at the same level. Little research has been conducted on the correlation between trauma center organizational structure and patient outcomes. We are attempting to close this knowledge gap with the Comparative Assessment Framework for Environments of Trauma Care (CAFE) project.

Methods: Our first action was to establish a shared terminology that we then used to build the Ontology of Organizational Structures of Trauma centers and Trauma systems (OOSTT). OOSTT underpins the web-based CAFE questionnaire that collects detailed information on the particular organizational attributes of trauma centers and trauma systems. This tool allows users to compare their organizations to an aggregate of other organizations of the same type, while collecting their data.

Results: In collaboration with the American College of Surgeons Committee on Trauma, we tested the system by entering data from three trauma centers and four trauma systems. We also tested retrieval of answers to competency questions.

Discussion: The data we gather will be made available to public health and implementation science researchers using visualizations. In the next phase of our project, we plan to link the gathered data about trauma center attributes to clinical outcomes.
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http://dx.doi.org/10.1136/tsaco-2020-000473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394144PMC
July 2020

Demographics, Treatment, and Cost of Periprosthetic Femur Fractures: Fixation Versus Revision.

Geriatr Orthop Surg Rehabil 2020 19;11:2151459320939550. Epub 2020 Jul 19.

Department of Orthopaedic Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Introduction: Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost.

Methods: Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost.

Results: Differences in gender (66% vs 83.7% female, < .01), comorbidities (fewer in hips, < .01), and costs (US$30 979 vs US$27 944, < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs ( < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost.

Conclusion: Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.
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http://dx.doi.org/10.1177/2151459320939550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372608PMC
July 2020

Opioid exposure after injury in United States trauma centers: A prospective, multicenter observational study.

J Trauma Acute Care Surg 2020 06;88(6):816-824

From the Department of Surgery and the Center for Translational Injury Research (J.A.H., V.T.T.T., C.E.G., C.E.W., L.S.K.), McGovern Medical School, University of Texas, Houston, Texas; Department of Surgery (L.A., J.M.), University of Texas Health Tyler, Tyler, Texas; Department of Surgery (J.J.R., J.N.B.), St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Surgery (P.B.M., B.B.P.-J., B.L.Z.), Indiana University, Indianapolis, Indiana; Department of Surgery (J.R.T., K.WS.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and Department of Surgery (C.D., T.J.S.), University of Colorado Health Memorial Hospital Central, Colorado Springs, Colorado.

Background: Efforts to reduce opioid use in trauma patients are currently hampered by an incomplete understanding of the baseline opioid exposure and variation in United States. The purpose of this project was to obtain a global estimate of opioid exposure following injury and to quantify the variability of opioid exposure between and within United States trauma centers.

Study Design: Prospective observational study was performed to calculate opioid exposure by converting all sources of opioids to oral morphine milligram equivalents (MMEs). To estimate variation, an intraclass correlation was calculated from a multilevel generalized linear model adjusting for the a priori selected variables Injury Severity Score and prior opioid use.

Results: The centers enrolled 1,731 patients. The median opioid exposure among all sites was 45 MMEs per day, equivalent to 30 mg of oxycodone or 45 mg of hydrocodone per day. Variation in opioid exposure was identified both between and within trauma centers with the vast majority of variation (93%) occurring within trauma centers. Opioid exposure increased with injury severity, in male patients, and patients suffering penetrating trauma.

Conclusion: The overall median opioid exposure was 45 MMEs per day. Despite significant differences in opioid exposure between trauma centers, the majority of variation was actually within centers. This suggests that efforts to minimize opioid exposure after injury should focus within trauma centers and not on high-level efforts to affect all trauma centers.

Level Of Evidence: Epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802946PMC
June 2020

Association of Insurance Status With Treatment and Outcomes in Pediatric Patients With Severe Traumatic Brain Injury.

Crit Care Med 2020 07;48(7):e584-e591

Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR.

Objective: To determine whether a health insurance disparity exists among pediatric patients with severe traumatic brain injury using the National Trauma Data Bank.

Design: Retrospective cohort study.

Setting: National Trauma Data Bank, a dataset containing more than 800 trauma centers in the United States.

Patients: Pediatric patients (< 18 yr old) with a severe isolated traumatic brain injury were identified in the National Trauma Database (years 2007-2016). Isolated traumatic brain injury was defined as patients with a head Abbreviated Injury Scale score of 3+ and excluded those with another regional Abbreviated Injury Scale of 3+.

Interventions: None.

Measurement And Main Results: Procedure codes were used to identify four primary treatment approaches combined into two classifications: craniotomy/craniectomy and external ventricular draining/intracranial pressure monitoring. Diagnostic criteria and procedure codes were used to identify condition at admission, including hypotension, Glasgow Coma Scale, mechanism and intent of injury, and Injury Severity Score. Children were propensity score matched using condition at admission and other characteristics to estimate multivariable logistic regression models to assess the associations among insurance status, treatment, and outcomes. Among the 12,449 identified patients, 91.0% (n = 11,326) had insurance and 9.0% (n = 1,123) were uninsured. Uninsured patients had worse condition at admission with higher rates of hypotension and higher Injury Severity Score, when compared with publicly and privately insured patients. After propensity score matching, having insurance was associated with a 32% (p = 0.001) and 54% (p < 0.001) increase in the odds of cranial procedures and monitor placement, respectively. Insurance coverage was associated with 25% lower odds of inpatient mortality (p < 0.001).

Conclusions: Compared with insured pediatric patients with a traumatic brain injury, uninsured patients were in worse condition at admission and received fewer interventional procedures with a greater odds of inpatient mortality. Equalizing outcomes for uninsured children following traumatic brain injury requires a greater understanding of the factors that lead to worse condition at admission and policies to address treatment disparities if causality can be identified.
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http://dx.doi.org/10.1097/CCM.0000000000004398DOI Listing
July 2020

Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009-2013).

Jt Comm J Qual Patient Saf 2020 09 19;46(9):493-500. Epub 2020 Apr 19.

Background: Patients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours).

Methods: National Inpatient Sample (NIS) data 2009-2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS.

Results: Utilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization.

Conclusions: Among surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.
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http://dx.doi.org/10.1016/j.jcjq.2020.03.011DOI Listing
September 2020

Systematic approach for content and construct validation: Case studies for arthroscopy and laparoscopy.

Int J Med Robot 2020 Aug 4;16(4):e2105. Epub 2020 Apr 4.

Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Background: In minimally invasive surgery, there are several challenges for training novice surgeons, such as limited field-of-view and unintuitive hand-eye coordination due to performing the operation according to video feedback. Virtual reality (VR) surgical simulators are a novel, risk-free, and cost-effective way to train and assess surgeons.

Methods: We developed VR-based simulations to accurately assess and quantify performance of two VR simulations: gentleness simulation for laparoscopy and rotator cuff repair for arthroscopy. We performed content and construct validity studies for the simulators. In our analysis, we systematically rank surgeons using data mining classification techniques.

Results: Using classification algorithms such as K-Nearest Neighbors, Support Vector Machines, and Logistic Regression we have achieved near 100% accuracy rate in identifying novices, and up to an 83% accuracy rate identifying experts. Sensitivity and specificity were up to 1.0 and 0.9, respectively.

Conclusion: Developed methodology to measure and differentiate the highly ranked surgeons and less-skilled surgeons.
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http://dx.doi.org/10.1002/rcs.2105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980497PMC
August 2020

ROTEM as a Predictor of Mortality in Patients With Severe Trauma.

J Surg Res 2020 07 28;251:107-111. Epub 2020 Feb 28.

Division of Trauma and Acute Care Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Electronic address:

Background: Hemorrhage, especially when complicated by coagulopathy, is the most preventable cause of death in trauma patients. We hypothesized that assessing hemostatic function using rotational thromboelastometry (ROTEM) or conventional coagulation tests can predict the risk of mortality in patients with severe trauma indicated by an injury severity score greater than 15.

Methods: We retrospectively reviewed trauma patients with an injury severity score >15 who were admitted to the emergency department between November 2015 and August 2017 in a single level I trauma center. Patients with available ROTEM and conventional coagulation data (partial thromboplastin time [PTT], prothrombin time [PT], and international normalized ratio) were included in the study cohort. Logistic regression was performed to assess the relationship between coagulation status and mortality.

Results: The study cohort included 301 patients with an average age of 47 y, and 75% of the patients were males. Mortality was 23% (n = 68). Significant predictors of mortality included abnormal APTEM (thromboelastometry (TEM) assay in which fibrinolysis is inhibited by aprotinin (AP) in the reagent) parameters, specifically a low APTEM alpha angle, a high APTEM clot formation time, and a high APTEM clotting time. In addition, an abnormal international normalized ratio significantly predicted mortality, whereas abnormal PT and PTT did not.

Conclusions: A low APTEM alpha angle, an elevated APTEM clot formation time, and a high APTEM clotting time significantly predicted mortality, whereas abnormal PT and PTT did not appear to be associated with increased mortality in this patient population. Viscoelastic testing such as ROTEM appears to have indications in the management and stabilization of trauma patients.
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http://dx.doi.org/10.1016/j.jss.2020.01.013DOI Listing
July 2020

Mandated 30-minute Scene Time Interval Correlates With Improved Return of Spontaneous Circulation at Emergency Department Arrival: A Before and After Study.

J Emerg Med 2019 Oct 28;57(4):527-534. Epub 2019 Aug 28.

Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Background: Conflicting ideas exist about whether or not Emergency Medical Service (EMS) personnel should treat a cardiac arrest on scene or transport immediately.

Objective: Our aim was to examine patient outcomes before and after an urban EMS system implemented a protocol change mandating a 30-min scene time interval (STI) for out-of-hospital cardiac arrest (OHCA).

Methods: This was a retrospective, single-center, observational study of OHCA patients before and after an EMS protocol change mandating resuscitation on scene. Data were retrieved from an EMS cardiac arrest database for all adults with non-traumatic OHCA between January 2015 and August 2016. Descriptive statistics were used to summarize the study population, and a regression model was used to determine the associations of the protocol with the return of spontaneous circulation (ROSC).

Results: A total of 633 patients were included in the study population, which was primarily male (61.3%) with a mean age of 65 years. After the 30-min STI was implemented, ROSC from OHCA increased to 40.1% of cases compared to 27.3% before the protocol change (p = 0.001; 95% confidence interval [CI] 0.053-0.203). The STI increased from 19 min 23 s to 29 min 40 s in the pre and post periods, respectively (p < 0.001). Regression indicated that the protocol change was independently associated with an improved chance of ROSC (OR 1.81; 95% CI 1.23-2.64).

Conclusions: A protocol change mandating a 30-min STI in OHCA correlated with increased STI and increased ROSC. While increased ROSC may not always equate with positive neurologic outcome, logistic regression indicated that the protocol change was independently associated with improved ROSC at emergency department arrival.
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http://dx.doi.org/10.1016/j.jemermed.2019.06.021DOI Listing
October 2019

Barriers to and facilitators of a screening procedure for PTSD risk in a level I trauma center.

Trauma Surg Acute Care Open 2019 12;4(1):e000345. Epub 2019 Aug 12.

Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Background: Patients admitted to the hospital after an injury are at a greater risk for developing post-traumatic stress disorder (PTSD) due to the nature of the injury and the traumatic nature of necessary medical interventions. Many level I trauma centers have yet to implement screening protocols for PTSD risk. The goal of the study was to characterize the barriers to and facilitators of implementation of a screening procedure for PTSD risk in a level I trauma center.

Methods: We conducted semistructured qualitative interviews with multidisciplinary academic medical center stakeholders (N=8) including those with clinical, research, teaching, and administrative roles within an urban academic medical center's Department of Surgery, Division of Acute Care Surgery. We analyzed the qualitative data using summative template analysis to abstract data related to participants' opinions about implementation of a screener for PTSD.

Results: Participants' general perception of screening for PTSD risk after injury was positive. Identified challenges to implementation included timing of screening, time burden, care coordination, addressing patients with traumatic brain injury or an altered mental status, and ensuring appropriate care after screening. Reported facilitators included existing psychosocial screening tools and protocols that would support inclusion of a PTSD screener, a patient-centered culture that would facilitate buy-in from providers, a guideline-driven culture, and a commitment to continuity of care.

Conclusions: This study offers concrete preliminary information on barriers to and facilitators of PTSD screening that can be used to inform planning of implementation efforts within a trauma center.

Level Of Evidence: Level V, qualitative.
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http://dx.doi.org/10.1136/tsaco-2019-000345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699788PMC
August 2019

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

J Trauma Acute Care Surg 2019 09;87(3):658-665

From the Division of Trauma, Critical Care, & Acute Care Surgery (J.W.R.-F., N.R.R., M.L.F.), Baylor University Medical Center at Dallas, Dallas, Texas; Children's Minnesota Research Institute (A.L.Z.), Children's Minnesota, Minneapolis, Minnesota; Division of Acute Care Surgery (K.W.S., W.C.B.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Centura Health Trauma System (C.M., R.A.C.), Colorado Springs, Colorado; St. Anthony Hospital (A.R.B.), Lakewood, Colorado; Center for Trauma and Critical Care (J.H., B.S.B.S.), George Washington University, Washington, District of Columbia; Penn State Hershey Children's Hospital (J.C.H.), Hershey. Pennsylvania; Trauma Department, Children's Hospital of Dallas (C.G.), Dallas, Texas; Rhode Island Hospital (C.A.A., S.N.L.); Warren Alpert Medical School of Brown University (C.A.A., S.N.L.), Providence, Rhode Island; Division of Trauma (M.W.), Cook Children's Medical Center, Forth Worth, Texas Clinical Research Institute, Methodist Health System (V.A.); Associates of Surgical Acute Care (J.D.A.), Methodist Dallas Medical Center, Dallas, Texas; University of North Carolina HealthCare (C.F.W.), Chapel Hill, North Carolina; Division of Trauma and Acute Care Surgery (D.J.M.), Medical College of Wisconsin; Froedtert Memorial Luthern Hospital (A.B.), Milwaukee, Wisconsin; University of Colorado Health Medical Center of the Rockies (W.D., M.J.W.), Loveland, Colorado; Department of Surgery (J.C.), Greenville Health System, Greenville, South Carolina; Trauma & Acute Care Services (C.A.L.), John Peter Smith Health Network, Forth Worth, Texas; Division of Trauma & Acute Care Surgery (J.L.R.), Baylor Scott & White Medical Center, Temple, Grapevine, Texas; Regions Hospital (M.D.M.), St. Paul, Minnesota, Pediatric Trauma (S.D.F.), Helen Devos Children's Hospital, Grand Rapids, Michigan; Aspirus Wausau Hospital (S.S.), Wausau, Wisconsin; Children's Hospital of Philadelphia (M.L.N., M.C.), Philadelphia, Pennsylvania; Division of Trauma (B.P., D.S.), Baylor Scott & White Medical Center at Grapevine, Grapevine, Texas; and Department of Surgery (T.J.S.), University of Colorado School of Medicine; Division of Trauma (T.J.S.), University of Colorado Health-Memorial Hospital, Aurora, Colorado.

Background: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.

Methods: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).

Results: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84.

Conclusion: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.

Level Of Evidence: Prognostic, level IV.
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September 2019
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