Injury and Trauma
Stephen M. Bowman, PhD, MHA University of Arkansas for Medical Sciences
Injury Impact
• Leading cause of death for age 1-44 • About ¼ of all years of potential life lost before age 75 are due to injury (U.S. 2004) • Lifetime medical costs for children 0-14 who were injured in 2000 are estimated to be nearly $12 billion (Finkelstein, 2006). • But…injury research funding from NIH ranks 67th!
Injury as Leading Cause of Death (Ages 0 to 19, 2004, U.S.)
12000 10000 8000 6000 4000 2000 0
Deaths
0-
4
o 5t
9 0t 1
14 o
5t 1
Suicide
19 o
Unintentional
Homicide
16,807 deaths in 2004
Source: CDC WISQARS
Injury as Leading Cause of Death (Ages 0 to 19, 2004)
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
% of All Deaths
<1
to 1
4
to 5
9 1
14 o 0t
Suicide
5t 1
19 o
Unintentional
Homicide
16,807 deaths in 2004
Source: CDC WISQARS
Injury Deaths – All Cause (Ages 0 to 19)
60 55 50 45 40 35 30 25 20 15 10 5 0
198 1 198 2 198 3 198 4 198 5 198 6 198 7 198 8 198 9 199 0 199 1 199 2 199 3 199 4 199 5 199 6 199 7 199 8 199 9 200 0 200 1 200 2
Rate per 100,000
Year White Black Native American Asian/PI
Source: CDC WISQARS
200 3 200 4
All
Homicide
(15-19 year olds)
60 50 40 30 20 10 0 1996 1997 1998 1999 2000 Year White Black Native American Asian/PI
Source: CDC WISQARS
Rate per 100,000
2001
2002
2003
2004
All
Suicide (15-19 year olds)
25
Rate per 100,000
20 15 10 5 0 1996 1997 1998 1999 2000 Year White Black Native American Asian/PI
Source: CDC WISQARS
2001
2002
2003
2004
All
Motor Vehicle Traffic Deaths (ages 15 to 19)
40 35 30 25 20 15 10 5 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year Males Females
Source: CDC WISQARS
Rate per 100,000
Motorcycle Injury Deaths
3
Rate per 100,000
2.5 2 1.5 1 0.5 0 1999 2000 2001 Year U.S. Deaths 15-19 yo deaths
Source: CDC WISQARS
2002
2003
2004
ATV Injury Trends
Consumer Product Safety Commission, 2004
Trauma Systems
• Meta-analysis and systematic review reports 15% reduction in mortality (Celso, 2006). • Wide variability by state –
– 15 states have no formal system. – Success of implementation variable
• In states with formal systems, the number of trauma center varies from 0.37 to 42.04 per million population (MacKenzie, 2003).
Timely Access to a Level I or II Trauma Center
(<45 minute response by ground or air, source: American Trauma Society)
Pediatric mortality by ISS and year
(Washington State, Age<15)
25%
Mortality (%)
20% 15% 10% 5% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year 0-8 9 to 15 16-75
Pediatric Spleen Management
Clinical Decision-Making in Blunt Spleen Injury
mortality blood loss multiple injuries delayed rupture pseudoaneurysm infection OPSI transfusions LOS economics
Splenectomy
NOM
The Washington State Experience: Pediatric Blunt Spleen Injury
Substantial variability in management lead to the development of a state-wide action plan:
• Data to trauma providers • Educate trauma providers on the guidelines and ‘Liver/Spleen Injury in Children Algorithm’ • Target specific care providers for follow-up
Impact of a Statewide Quality Improvement Initiative in Improving the Management of Pediatric Splenic Injuries in Washington State
Stephen M. Bowman, PhD, Sam R. Sharar, MD, Linda Quan, MD University of Arkansas for Medical Sciences and University of Washington
Accepted for publication – Journal of Trauma
Objectives
• To evaluate the effect of a statewide quality improvement initiative on splenectomy rates in children.
• To examine splenectomy rates before and after implementation of the quality improvement initiative.
• To examine the likelihood of children with splenic injuries receiving care at pediatric trauma hospitals before and after the initiative, compared to general trauma hospitals located in both urban and rural settings.
Methods
• Design: Retrospective cohort study using Washington Trauma Registry for years 1999-2001 (pre-intervention) and 2003-2005 (post-intervention). • Inclusion criteria: Children ages 0-14 years who were hospitalized with a traumatic (non-iatrogenic) splenic injury. • Dependent variable: Splenectomy • Independent variable: Pediatric trauma designation • Control and confounding variables: Patient and injury characteristics • Analysis: Multivariable logistic regression, clustering on hospital identifier
Results
Splenectomies were more common in the preintervention period compared to the postintervention period (13.6% vs. 7.8%, p=.027).
Spleen Injury Management by Hospital Type and Intervention Period
(Washington State Trauma Registry)
Factors associated with splenectomy in children 0-14 years, excluding pediatric designation
Risk Factor
Adjusted Logistic Regression† OR (95% CI) P Value__
Accepted for publication – Journal of Trauma
Factors associated with splenectomy in children 0-14 years, including pediatric designation Risk Factor
Adjusted Logistic Regression† OR (95% CI) P Value
Accepted for publication – Journal of Trauma
Factors associated with the likelihood of receiving definitive care at pediatric designated hospitals Risk Factor
Adjusted Logistic Regression† OR (95% CI) P Value
Accepted for publication – Journal of Trauma
Thanks!
bowmanstephenm@uams.edu (501) 364-3357