2016 Annual Trauma Program Report

OREGON HEALTH & SCIENCE UNIVERSITY 2016 Trauma Program Report Transforming Trauma Care Summary• In 2016, the Trauma Service at OHSU treated 3,003 Table of contents OHSU trauma system background 4 patients. Trauma stati sti cs 6 • Of those patients, 1,959 (65 percent) were brought to County of origin OHSU directly from the scene of injury, and 1,044 (35 percent) were transferred from another hospital. Trauma team response • The mean injury severity score of admitted patients Mechanism of injury was 12.2. Dispositi on and outcome 12 • The number of patients increased in every age group except for those aged 15–24 and 56–64. Mortality 14 • Injury Prevention: ThinkFirst and Matter of Balance Care for pati ents older than 64 16 Fall Prevention had another successful year, serving more than 36,000 community members. Pati ents 14 and younger 18 • The Trauma Laboratory had another productive year, 2016 preventi on acti viti es 20 publishing 38 research papers and receiving more ThinkFirst Oregon than $8 million in new and continued funding. Matter of Balance Trauma faculty 22 Research 24 Appendix A 28 The OHSU Trauma Service Team. W WW.OHSU.EDU/ TRAUMA 3 20152016 ANNUAL REPORT OHSU trauma system background Oregon’s area trauma advisory board regions Oregon’s statewide trauma system is based on landmark H legislation. Statutory authority was passed in 1985 by the CLATSOP H H state legislature as ORS 431.607 – 431.633 under the leadership COLUMBIA of the president of the Oregon Senate, John Kitzhaber, M.D., UMATILLA and signed into law by Governor Victor Atiyeh. With the HOOD WALLOWA TILLAMOOK H implementation of the trauma system in May 1988, only two WASHINGTON MULTNOMAH RIVER SHERMAN WASCO MORROW Oregon hospitals, OHSU and Legacy Emanuel Hospital, were designated as Level I trauma centers. Injured individuals in YAMHILL UNION CLACKAMAS GILLIAM the four-county metropolitan region identifi ed by pre-hospital rescue personnel or emergency medical technicians as meeting the criteria for severe injury are transported to one of these POLK MARION Level I centers. BAKER JEFFERSON WHEELER LINCOLN Published research comparing inter-hospital transfer practices GRANT LINN BENTON before and after implementation showed improvement in rapid transfer of critically injured patients to Level 1 and 2 trauma centers as well as improved outcomes. CROOK LANE DESCHUTES H DOUGLAS HARNEY MALHEUR COOS LAKE KLAMATH JACKSON JOSEPHINE CURRY MAP COURTESY OF OREGON DHS: http://egov.oregon.gov/DHS/ph/ems/trauma/docs/hosp-map.pdf 4 2016 ANNUAL REPORT | TRANSFO RMING TRAUMA CARE W WW.OHSU.EDU/ TRAUMA 5 2016 ANNUAL REPORT Trauma stati sti cs In 2016, the OHSU Trauma Program total patient volume increased by 234 patients from 2015, an 8 percent increase. Distribution of patients by month 350 315 319 291 300 266 244 248 223 221 231 234 231 250 180 Patient volume 2014–2016 200 150 100 2016 1,959 1,044 SCENE/ED 50 TRANSFERS 0 2015 1,820 9,52 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 1,668 840 Distribution of patients by day of week 487 442 462 500 419 416 409 368 0 500 1,000 1,500 2,000 2,500 3,000 3,500 400 300 200 Gender distribution of patients treated Patients treated by the OHSU Trauma Program: 100 by the OHSU trauma program blunt versus penetrating injuries 0 Sun Mon Tue Wed Thur Fri Sat Distribution of patients by time of arrival FEMALE 8% BLUNT 789 800 706 33% MALE PENETRATING 600 566 403 67% 92% 328 400 211 200 0 00:00–03:59 04:00–07:59 08:00–11:59 12:00–15:59 16:00–19:59 20:00–23:59 Age distribution of patients treated by the OHSU trauma program Total hospital length of stay of admitted patients 900 800 2014 6.4 6.1 700 5.9 SCENE/ED 700 5.8 5.8 5.8 600 2015 500 TRANSFER 400 2016 350 300 200 100 0 0 age ≤ 4 age 5–14 age 15–24 age 25–44 age 55–64 age 65–74 age ≥ 75 2014 2015 2016 6 2016 ANNUAL REPORT | TRANSFO RMING TRAUMA CARE W WW.OHSU.EDU/ TRAUMA 7 2016 ANNUAL REPORT County of origin, patients treated by the OHSU trauma team BAKER 1 BENTON 2 CLACKAMAS 626 CLARK 31 CLATSOP 68 COLUMBIA 21 COOS 47 COWLITZ 29 CROOK 2 CURRY 20 DEL NORTE 1 DESCHUTES 18 DOUGLAS 25 GILLIAM 2 GRANT 3 HARNEY 1 HOOD RIVER 26 Trauma team response JACKSON 22 JEFFERSON 5 The OHSU Trauma Program uses a three-tiered system to evaluate injured patients. The level of activation JOSEPHINE 18 is based on information provided by pre-hospital personnel (Tables I and II). In the Portland metropolitan 1 KING area, paramedics evaluate patients at the scene of injury and enter them into the trauma system if they meet KLAMATH 10 KLICKITAT 9 established triage criteria for serious injury. Since OHSU implemented a three-tiered system in 2004, we LANE 37 have noted a high proportion of injured patients meeting criteria for Level 2 or 3 activation (Figure 10). LINCOLN 19 Our analyses indicate patients can be safely and effi ciently treated with a limited team response, saving our LINN 22 full trauma team activations for those truly critically injured patients. MARION 98 MODOC 1 MORROW 8 OHSU trauma team configuration based on triage criteria MULTNOMAH 931 PACIFIC 12 Level 1 Level 2 Level 3 PIERCE 1 POLK 19 Staff trauma surgeon Staff trauma surgeon SAN DIEGO 1 Staff anesthesiologist SHERMAN 3 SISKIYOU 3 Staff ED physician Staff ED physician Staff ED physician SKAMANIA 2 TILLAMOOK 22 Trauma chief resident Trauma chief resident Trauma chief resident UMATILLA 17 Emergency medicine resident Emergency medicine resident Emergency medicine resident UNION 4 4 WAHKIAKUM Respiratory care practitioner Respiratory care practitioner Respiratory care practitioner WALLOWA 3 WASCO 31 Primary trauma nurse Primary trauma nurse Primary trauma nurse WASHINGTON 573 Trauma recording nurse WHEELER 2 YAKIMA 1 Procedure nurse Procedure nurse Procedure nurse YAMHILL 125 Transportation aide ED = EMERGENC Y DEPARTMENT 8 2016 ANNUAL REPORT | TRANSFO RMING TRAUMA CARE W WW.OHSU.EDU/ TRAUMA 9 2016 ANNUAL REPORT Mechanism of Injury Causes of injury for patients seen by the OHSU trauma team OHSU trauma team response by level of activation Although motor vehicle crashes remain the most common 8% mechanism of injury overall, falls continue to be a 3% VEHICLE COLLISIONS signifi cant source of trauma. Falls continue to be the leading 8% NO ACTIVATION 10% mechanism of injury for older adults. NON‐INTENTIONAL LEVEL 1 FALLS 36% 7% 44.5% LEVEL 2 SUICIDE AND 18% SELF‐INFLICTED LEVEL 3 64% 46% HOMICIDE & INJURY PURPOSELY INFLICTED BY OTHERS OTHER Three-tiered response triage criteria Injury severity scores for patients treated by OHSU trauma team Level 1 Criteria Level 2 Criteria Level 3 Criteria Anatomic Mechanism of Injury Injury Severity Score is an estimate of the overall severity of the patient’s injuries. Scores can range from 0 to 75. An ISS of 15 or more denotes a serious injury (see Appendix A). GCS < 9 and not intubated Intubated patient Fall > 20 feet Inadequate airway/need for emergency Two or more long-bone Death in same passenger 75 3 airway control or presence of supraglottic fractures compartment 50–74 11 airway (KING, combitube, etc.) 41–49 18 Shock, defined as: Penetrating injury to head, Extrication > 20 minutes 25–40 229 Systolic BP < 90 (> 11 years to adult) neck or torso 15–24 366 Systolic BP < 80 (5–11 years) Systolic BP < 70 (2–4 years) 9–14 941 Systolic BP < 60 (0–2 years) 0–8 1,435 Immediate need for operating room or Crush injury to torso or Rollover motor vehicle crash planned direct admission to the upper thigh 0200400 600800 1,000 1,200 1,400 1,600 operating room Patients receiving blood transfusion to Amputation proximal to wrist Ejection from motor vehicle Mean injury severity score of patients admitted to OHSU hospital maintain blood pressure > 90 or ankle Pelvic instability Auto vs. pedestrian > 5 mph Patients transferred in from other hospitals are more injured on average than those admitted directly from the scene. 15.8 Paralysis Special considerations, age < 5 15.1 15.1 14.8 16 SCENE/ED 12.6 Flail chest Paramedic discretion: 12.1 MCC, ATV, bicycle crash 12 TRANSFER Presence of a tourniquet Significant intrusion/impact Hostile environment (cold/heat) 8 Respirations > 22 (age ≥ 15) Preexisting medical issues AND suspected blunt chest Presence of intoxicants 4 injury Pregnancy 0 Emergency medicine discretion Emergency medicine Emergency medicine discretion 2014 2015 2016 discretion 10 2016 ANNUAL REPORT | TRANSFO RMING TRAUMA CARE W WW.OHSU.EDU/ TRAUMA 11 2016 ANNUAL REPORT Dispositi on and outcome Emergency Observation Unit Hospital admissions via OHSU trauma program for pati ents treated by Faculty from the Department of Emergency Medicine are In 2016, we admitted 2,179 patients (73 percent) to OHSU OHSU trauma team responsible for managing patients with minor injuries Hospital (Figure 15). Patients at the extremes of age were more admitted to the Observation Unit in the Emergency Department. likely to require hospital admission. Most of these patients Of the hundreds of trauma patients sent to ED OBS in 2016, were able to return home after admission (Figure 16). 12 percent required subsequent hospital admission (Figure 14). The decrease in OBS unit usage for trauma patients is likely due to the increase in the elderly trauma population, which Patients requiring hospitalization after trauma team care requires more intensive service and care. The ED OBS unit continues to be an effective way to ensure effi cient use 600 of inpatient beds while providing quality medical care for 2014 injured patients.

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