Severity Score (severity + score)

Distribution by Scientific Domains
Distribution within Medical Sciences

Kinds of Severity Score

  • disease severity score
  • injury severity score
  • operative severity score
  • symptom severity score


  • Selected Abstracts


    Paediatric and adolescent horse-related injuries: Does the mechanism of injury justify a trauma response?

    EMERGENCY MEDICINE AUSTRALASIA, Issue 4 2008
    John A Craven
    Objective: To identify the frequency, variety and disposition of horse-related injury presentations to the ED and to use this information to evaluate the existing institutional trauma team activation criteria following horse-related injuries. Methods: A retrospective case analysis was performed of all horse-related injury presentations to the ED of Women's and Children's Hospital, Adelaide, Australia, in the 5 year period between January 1999 and December 2003. Results: A total of 186 children presented with horse-related injuries during the 5 year study period. The median age of injury was 9 years (range 1,17 years), with 81% of presentations female and 60% of patients hospitalized. The mechanism of injury was divided into four groups: 148 falls (79%), 28 kicks (15%), 7 tramples (4%) and 5 bites (3%). There was one death. Seven presentations rated an Injury Severity Score >15, with full trauma team activation occurring for two of these presentations. Conclusion: Although horse-related injury presentations are uncommon, severe injuries do occur. Patients presenting with severe horse-related injuries do not always activate a full trauma team response based on current trauma team activation criteria. These severe injury presentations are supported by a limited trauma team response, which activates on the mechanism of injury. The effectiveness of this as a contingency system needs to be evaluated. [source]


    Apolipoprotein E polymorphism interacts with cigarette smoking in progression of multiple sclerosis

    EUROPEAN JOURNAL OF NEUROLOGY, Issue 7 2009
    A. Sena
    Background and purpose:, The influence of apolipoprotein E (ApoE) polymorphism on clinical severity of multiple sclerosis (MS) is still controversial. Cigarette smoking has been suggested to influence the progression of disability in these patients. In this study, we aimed to investigate whether an interaction of smoking with the ApoE polymorphism influences the progression of disability in MS patients. Methods:, Smoking history from 205 female patients with MS was obtained. Clinical data collected include age at onset, disease duration, annual relapse rate, the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Severity Score (MSSS). ApoE polymorphism was examined in all patients and stratified according to smoking status and associations with the clinical data investigated. Results:, There were no significant associations between cigarette smoking and any of the clinical characteristics in the whole group of patients. In women carrying the ApoE E4 isoform, smokers had a lower EDSS (P = 0.033) and MSSS (P = 0.023) in comparison with non-smokers. Conclusion:, Our data suggest that in women with MS carrying the ApoE E4 isoform, cigarette smoking may have a protective influence on disease progression and accumulation of disability. These findings need to be confirmed by future large longitudinal studies. [source]


    The impact of HLA-A and -DRB1 on age at onset, disease course and severity in Scandinavian multiple sclerosis patients

    EUROPEAN JOURNAL OF NEUROLOGY, Issue 8 2007
    C. Smestad
    The human leucocyte antigen (HLA) class II haplotype DRB1*15,DQB1*06 (DR15,DQ6) is associated with susceptibility to multiple sclerosis (MS), and HLA class I associations in MS have also been reported. However, the influence of HLA class I and II alleles on clinical phenotypes in MS has not yet been completely studied. This study aimed at evaluating the impact of HLA-A and -DRB1 alleles on clinical variables in Scandinavian MS patients. The correlation between HLA-A or -DRB1 alleles and age at onset, disease course and Multiple Sclerosis Severity Score (MSSS) were studied in 1457 Norwegian and Swedish MS patients by regression analyses and Kruskal,Wallis rank sum test. Presence of HLA-DRB1*15 was correlated with younger age at onset of disease (corrected P = 0.009). No correlation was found between HLA-A and the variables studied. This study analysed the effect of HLA-A on clinical variables in a large Scandinavian sample set, but could not identify any significant contribution from HLA-A on the clinical phenotype in MS. However, associations between HLA-DRB1*15 and age at onset of MS were reproduced in this extended Scandinavian MS cohort. [source]


    The Association Between Hypothermia, Prehospital Cooling, and Mortality in Burn Victims

    ACADEMIC EMERGENCY MEDICINE, Issue 4 2010
    Adam J. Singer MD
    Abstract Objectives:, Hypothermia is associated with increased morbidity and mortality in trauma victims. The prognostic value of hypothermia on emergency department (ED) presentation in burn victims is not well known. The objective of this study was to determine the incidence of hypothermia in burn victims and its association with mortality and hospital length of stay (LOS). The study also examined the potential causative role of prehospital cooling in hypothermic burn patients. Methods:, This was a retrospective review of a county trauma registry. The county was both suburban and rural, with a population of 1.5 million and with one burn center. Burn patients between 1994 and 2007 who met trauma registry criteria were included. Demographic and clinical data including prehospital cooling, burn size and depth, and presence of inhalation injury were collected. Hypothermia was defined as a core body temperature of less than or equal to 35°C. Data analysis consisted of univariate associations between patient characteristics and hypothermia. Results:, There were 1,215 burn patients from 1994 to 2007. Mean age (±standard deviation [±SD]) was 29 (±24) years, 67% were male, 248 (26.7%) had full-thickness burns, and 24 (2.6%) had inhalation injury. Only 17 (1.8%) had a burn larger than 70% total body surface area (TBSA). A total of 929 (76%) patients had an initial ED temperature recorded. Only 15/929 (1.6%) burn patients had hypothermia on arrival, and all were mild (lowest temperature was 32.6°C). There was no association between sex, year, and presence of inhalation injury with hypothermia. Hypothermic patients were older (44 years vs. 29 years, p = 0.01), and median Injury Severity Score (ISS) was higher (25 vs. 4, p = 0.002) than for nonhypothermic patients. Hypothermia was present in 6/17 (35%) patients with a TBSA of 70% or greater and in 8/869 (0.9%) patients with a TBSA of <70% (p < 0.001). Mortality was higher in hypothermic patients (60% vs. 3%, p < 0.001). None of the hypothermic patients received prehospital cooling. Conclusions:, Hypothermia on presentation to the ED was noted in 1.6% of all burn victims in this trauma registry. Hypothermia was more common in very large burns and was associated with high mortality. In this series, prehospital cooling did not appear to contribute to hypothermia. ACADEMIC EMERGENCY MEDICINE 2010; 17:456,459 © 2010 by the Society for Academic Emergency Medicine [source]


    Interrelation between the Poisoning Severity Score, carboxyhaemoglobin levels and in-hospital clinical course of carbon monoxide poisoning

    INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 12 2006
    A. A. CEVIK
    Summary The aim of the present study is to evaluate the relationship between the Poisoning Severity Score (PSS) and carboxyhaemoglobin (COHb) levels in patients with carbon monoxide poisoning (COP) using outcome as the measure. The study was designed as a retrospective chart review of patients with final diagnosis of COP. Correlation of PSS and COHb levels at presentation was evaluated with collected data. Majority of the cases were grade 1 (minor) PSS (134 cases, 73.6%) and 93.4% of these patients made a complete recovery. There were six deaths (mortality 3.3%) and six in-hospital major complications (IHMCs) (3.3%) (please specify whether the complications were in the patients who died). There is moderate correlation between PSS and outcome (p < 0.001, r = 0.493). Grade 3 (severe) PSS was significantly different from other grades for outcome (six mortalities and three IHMCs). Patients classified as grade 3 and patients who died had a significantly higher mean age (p < 0.05, 41.8 ± 23.6 and p < 0.01, 60.1 ± 20.3, respectively). Mean COHb level of grade 3 (33.2 ± 13.9%) was significantly higher than that of other grades (p < 0.05). COHb levels according to outcome were not different (? within the patients in grade 3). Decreased level of consciousness, acidosis, tachycardia, high glucose and leucocyte levels showed significant relation with higher PSS, COHb level and adverse outcome. We conclude that the PSS is a reliable guide in COP. Value of the PSS in COP may be enhanced if additional factors and investigations are included. [source]


    The Efficacy of Factor VIIa in Emergency Department Patients With Warfarin Use and Traumatic Intracranial Hemorrhage

    ACADEMIC EMERGENCY MEDICINE, Issue 3 2010
    Daniel K. Nishijima MD
    Abstract Objectives:, The objective was to compare outcomes in emergency department (ED) patients with preinjury warfarin use and traumatic intracranial hemorrhage (tICH) who did and did not receive recombinant activated factor VIIa (rFVIIa) for international normalized ratio (INR) reversal. Methods:, This was a retrospective before-and-after study conducted at a Level 1 trauma center, with data from 1999 to 2009. Eligible patients had preinjury warfarin use and tICH on cranial computed tomography (CT) scan. Patients before (standard cohort) and after (rFVIIa cohort) implementation of a protocol for administering 1.2 mg of rFVIIa in the ED were reviewed. Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS), Injury Severity Score (ISS), INR, and Marshall score were collected. Outcome measures included mortality, thromboembolic complications, and INR normalization. Results:, Forty patients (median age = 80.5 years, interquartile range [IQR] = 63.5,85) were included (20 in each cohort). Age, GCS score, ISS, RTS, initial INR, and Marshall score were similar (p > 0.05) between the two cohorts. Survival was identical between cohorts (13 of 20, or 65.0%, 95% confidence interval [CI] = 40.8% to 84.6%). There were no differences in rate of thromboembolic complications in the standard cohort (1 of 20, 5.0%, 95% CI = 0.1% to 24.9%) than the rFVIIa cohort (4 of 20, 20.0%, 95% CI = 5.7% to 43.7%; p = 0.34). Time to normal INR was earlier in the rFVIIa cohort (mean = 4.8 hours, 95% CI = 3.0 to 6.7 hours) than in the standard cohort (mean = 17.5 hours, 95% CI = 12.5 to 22.6; p < 0.001). Conclusions:, In patients with preinjury warfarin and tICH, use of rFVIIa was associated with a decreased time to normal INR. However, no difference in mortality was identified. Use of rFVIIa in patients on warfarin and tICH requires further study to demonstrate important patient-oriented outcomes. ACADEMIC EMERGENCY MEDICINE 2010; 17:244,251 © 2010 by the Society for Academic Emergency Medicine [source]


    Multi-item outcome measures for lateral ligament injury of the ankle: a structured review

    JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 2 2004
    K.L. Haywood BSc(Hons) DPhil MCSP
    Abstract Objective, To identify and review evidence relating to the measurement properties of published multi-item outcome measures for the conservative management of lateral ligament injuries of the ankle. Methods, Systematic literature searches were used to identify measures, which were then assessed against pre-defined criteria relating to development, item content, reliability, validity and responsiveness. Results, Seven disease-specific measures of ankle status [Ankle Joint Functional Assessment Tool, Clinical Trauma Severity Score, Composite Inversion Injury Scale, Kaikkonen Functional Scale (KFS), Karlsson Ankle Function Score (KAFS), Olerud and Molander Ankle Score (OMAS), and the Point System] and two generic measures of health (McGill Pain Questionnaire, Sickness Impact Profile) met the review inclusion criteria. While all measures had been used in acute injuries, only two had also been applied during later stages of recovery (>6 months). The studies covered a comprehensive range of graded ligament injuries. Expert opinion dominated item generation for all measures. All measures lack evidence of test-retest or internal consistency reliability in patients with ankle sprain. Several measures were assessed for validity through comparison with other measures, but there was limited evidence of construct validity and no formal assessment of responsiveness for any measure. Conclusion, The disappointing lack of evidence for measurement properties suggests that any measure should be used with caution until appropriate evidence is provided. On the basis of limited evidence, the KFS offers the most promising approach to a combined clinician- and patient-assessment of ankle function, and the KAFS or OMAS if a patient-assessed evaluation of function is required. [source]


    Validation of Length of Hospital Stay as a Surrogate Measure for Injury Severity and Resource Use Among Injury Survivors

    ACADEMIC EMERGENCY MEDICINE, Issue 2 2010
    Craig D. Newgard MD
    Abstract Objectives:, While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. Methods:, This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD-9), injury diagnosis (years 2005,2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998,2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001,2002). In-hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] , 16 or ICD-9 ISS , 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0,14, 15,64, and ,65 years), hospital type, and hospital annual admission volume. Results:, The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. Conclusions:, Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied. ACADEMIC EMERGENCY MEDICINE 2010; 17:142,150 © 2010 by the Society for Academic Emergency Medicine [source]


    The early IL-6 and IL-10 response in trauma is correlated with injury severity and mortality

    ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2009
    J. STENSBALLE
    Background: Trauma has previously been shown to influence interleukin (IL)-6 and IL-10 levels, but the association of injury severity and mortality with IL-6 and IL-10 responses in the early phase of accidental trauma remains to be investigated. We wished to describe serum levels of IL-6 and IL-10 in the first 24 h after trauma and to assess the relationship with severity of injury and mortality. Methods: Prospective, descriptive cohort study in a Level 1 trauma centre, Copenhagen, Denmark. We included 265 consecutive adult trauma patients admitted directly from the accident scene during an 18-month period. Serum levels of IL-6 and IL-10 were measured upon arrival and at 6, 12, and 24 h after admittance using an enzyme-linked immunosorbent assay. Correlation analysis was used to assess the relationship between Injury Severity Score (ISS) and levels of IL-6 and IL-10. Analysis of variance was used to describe the IL-6 and IL-10 concentrations in relation to 30-day mortality in a mixed-effect model repeated measures analysis. Results: Mortality was 10.9% (29/265) at 30 days. A significant increase of both IL-6 and IL-10 concentrations was found over time, and a significant correlation was found between ISS and the levels of both IL-6 and IL-10 at all sampling points. Serum concentrations of IL-6 and IL-10 were significantly higher in patients not surviving 30 days (P<0.0001). Conclusion: The early systemic inflammatory response measured as IL-6 and IL-10 in serum is correlated with injury severity and 30-day mortality following trauma. [source]


    Overtriage in trauma , what are the causes?

    ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 9 2007
    O. Uleberg
    Background:, Different criteria are employed to activate trauma teams. Because of a growing concern about overtriage, the objective of this study was to investigate the performance of our trauma team's activation protocol. Methods:, Injured patients with trauma team activation (TTA), admission to an intensive care unit or surgical intermediate care unit with a trauma diagnosis, or trauma-related death in the emergency department were investigated retrospectively from 1 January 2004 to 31 December 2005. Different TTA criteria were analysed with respect to sensitivity, positive predictive value (PPV) and overtriage (1 , PPV). Results:, Eight hundred and nine patients were included, 185 (23%) of whom had an Injury Severity Score (ISS) of more than 15. The performance of our protocol showed a sensitivity of 87%, PPV of 22% and overtriage of 78%. The mechanism of injury as a TTA criterion had a sensitivity of 14%, PPV of 7% and overtriage of 93%. Physiological/anatomical criteria and interfacility transfer showed higher PPV and less overtriage. Undertriage (no TTA despite ISS > 15) was identified in 23 patients (13%), 18 of whom were hospital transfers. Conclusion:, A TTA protocol based on physiological, anatomical and interfacility transfer criteria seems to yield a higher precision than, in particular, that based on mechanism of injury criteria. Because of substantial overtriage in our hospital, the TTA protocol needs to be re-evaluated. [source]


    Validation of a composite score for clinical severity of hemophilia

    JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 7 2008
    S. SCHULMAN
    Summary.,Introduction:,Evaluation of modulators of the phenotypic expression of hemophilia may benefit from a scoring system that reflects several aspects of the clinical severity instead of only one dimension. Methods:,We describe here how we constructed a composite Hemophilia Severity Score (HSS) and performed validation. The items in the HSS are annual incidence of joint bleeds, World Federation of Hemophilia Orthopedic joint score, and annual factor consumption. The latter two were adjusted for age at start of prophylaxis and body weight. Data for 100 adolescent or adult patients with hemophilia A or B in the mild, moderate or severe form without inhibitors were collected for the 1990,1999 period. We evaluated the reliability (multidimension property, test,retest) and validity (content, convergent, discriminant and known groups) of the score. Results:,The HSS ranged from 0 to 0.94 and was higher in severe hemophilia A than severe hemophilia B (median 0.50 and 0.24; P = 0.031). The validation indicated that the HSS is reliable and reflective of the clinical severity of hemophilia. The presence of factor V G1691A or prothrombin G20210A polymorphisms was found in 13 patients. The clinical severity, measured as the HSS or each of the three components, appeared to be modified by prothrombin G20210A but not by FV G1691A. Conclusion:,The HSS is a well-defined tool that provides a comprehensive representation of the clinical severity of hemophilia in adults. It would be useful in larger studies on the assessment of modulators of the phenotypic expression of hemophilia. [source]


    Determinants of hospital costs associated with traumatic brain injury in England and Wales,

    ANAESTHESIA, Issue 5 2008
    S. Morris
    Summary Using data from the Trauma Audit Research Network, we investigated the costs of acute care in patients , 18 years of age hospitalised for traumatic brain injury between January 2000 and December 2005 in England and Wales. Traumatic brain injury patients were defined and stratified using the Abbreviated Injury Scale. A total of 6484 traumatic brain injury patients were identified; 22.3% had an Abbreviated Injury Scale score of three, 38.0% of four and 39.7% of five. Median age (IQR) was 42 years (28,59) and 76.7% were men. Primary cause of injury was motor vehicle collisions (42.4%) followed by falls (38.0%). In total 23.7% of the patients died before discharge. Hospitalisation costs averaged £15 462 (SD £16 844). Costs varied significantly by age, Glasgow Coma Score, Injury Severity Score, coexisting injuries of the thorax, spine and lower limb, hospital mortality, availability of neurosurgical services, and specialty of attendants seen in the Accident and Emergency department. [source]


    Effect of Race and Insurance on Outcome of Pediatric Trauma

    ACADEMIC EMERGENCY MEDICINE, Issue 8 2010
    Wael Hakmeh DO
    ACADEMIC EMERGENCY MEDICINE 2010; 17:809,812 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, This study sought to determine if insurance or race status affect trauma outcomes in pediatric trauma patients. Methods:, Using the National Trauma Data Bank (NTDB; v6.2), the following variables were extracted: age (0,17 years), payment type (insured, Medicaid/Medicare, or self-pay), race (white, Black/African American, or Hispanic), Injury Severity Score (ISS > 8), type of trauma (blunt or penetrating), and discharge status (alive or dead). Data were analyzed using logistic regression. Results:, Of the 70,781 patient visits analyzed, 67% were insured, 23% were Medicaid/Medicare, and 10% were self-pay. Self-pay patients had higher mortality (11%, compared to Medicaid/Medicare at 5% and insured at 4%; p < 0.001). African Americans and Hispanics also had higher mortality (7 and 6%) compared to whites (4%; p < 0.001). Self-pay patients more likely suffered penetrating trauma than insured patients (12% vs. 4%; p < 0.001), and mortality for penetrating trauma self-pay patients was 29%, compared to only 11% for penetrating trauma insured patients (p < 0.001). The mortality rate varied from a low of 3% for insured whites, to 18% for self-pay African Americans. Logistic regression (including race, insurance status, injury type, and ISS) revealed that African Americans and Hispanics both had an increased risk of death compared to whites (African American odds ratio [OR] = 1.37, Hispanic OR = 1.20). Medicaid/Medicare patients had a slightly increased risk of death with OR = 1.14, but self-pay patients were almost three times more likely to die (adjusted OR = 2.92). Conclusions:, After controlling for ISS and type of injury, mortality disparity exists for uninsured, African American, and Hispanic pediatric trauma patients. Although the reasons for this are unclear, efforts to decrease these disparities are needed. [source]


    Risk factors of mortality in non-trauma exsanguinating patients that require damage control laparotomy

    ANZ JOURNAL OF SURGERY, Issue 4 2010
    Wen-bo Zhang
    Abstract Background:, Since introduction of damage control (DC) approach to non-trauma setting is relatively late, the risk factors associated with this procedure remain undefined. This study was aimed at identifying factors responsible for the mortality. Methods:, Over a 5-year period (from February 2002 to February 2007), consecutive non-trauma patients who required DC laparotomy (DCL) with gauze packing for control of indomitable abdominal haemorrhage in our institute were included. Clinical, laboratorial and operative factors influencing in-hospital or 30-day mortality were analysed. Results:, A total of 26 patients underwent DCL with packing in an attempt to control severe abdominal haemorrhage. There were seven (26.9%) deaths in hospital or within 30 days of DCL. Increase in age, higher initial physiological score and operative severity score assessed by the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity scoring system, lower initial body temperature, lower initial platelet (PLT) counts, greater intra-operative blood loss, presence of perioperative multiple organ dysfunction syndrome were all associated with increased risk of mortality on univariate analysis (P < 0.05). On multivariate analysis, only decrease in PLT counts (P= 0.042, OR = 0.969, 95% CI = 0.940,0.999) and increase in age (P= 0.035, OR = 1.152, 95% CI = 1.010,1.313) were significant independent factors affecting mortality. Conclusions:, Decrease in PLT counts and increase in age are the independent risk factors related to death in non-trauma series that require DCL with packing. DCL should be performed early as for patients with these risk factors. [source]


    A comparison of severely injured trauma patients admitted to level 1 trauma centres in Queensland and Germany

    ANZ JOURNAL OF SURGERY, Issue 3 2010
    Johanna M. M. Nijboer
    Abstract Background:, The allocation of a trauma network in Queensland is still in the developmental phase. In a search for indicators to improve trauma care both locally as state-wide, a study was carried out comparing trauma patients in Queensland to trauma patients in Germany, a country with 82.4 million inhabitants and a well-established trauma system. Methods:, Trauma patients ,15 years of age, with an Injury Severity Score (ISS) , 16 admitted to the Princess Alexandra Hospital (PAH) and to the 59 German hospitals participating in the Trauma Registry of the German Society for Trauma Surgery (DGU-G) during the year 2005 were retrospectively identified and analysed. Results:, Both cohorts are comparable when it comes to demographics and injury mechanism, but differ significantly in other important aspects. Striking is the low number of primary admitted patients in the PAH cohort: 58% versus 83% in the DGU-G cohort. PAH patients were less physiologically deranged and less severely injured: ISS 25.2 ± 9.9 versus 29.9 ± 13.1 (P < 0.001). Subsequently, they less often needed surgery (61% versus 79%), ICU admission (49% versus 92%) and had a lower mortality: 9.8% versus 17.9% of the DGU-G cohort. Conclusions:, Relevant differences were the low number of primary admissions, the lesser severity of injuries, and the low mortality of the patients treated at the PAH. These differences are likely to be interrelated and Queensland's size and suboptimal organization of trauma care may have played an important role. [source]


    Development and Validation of the Excess Mortality Ratio,adjusted Injury Severity Score Using the International Classification of Diseases 10th Edition

    ACADEMIC EMERGENCY MEDICINE, Issue 5 2009
    Jaiyong Kim MD
    Abstract Objectives:, This study aimed to develop and validate a new method for measuring injury severity, the excess mortality ratio,adjusted Injury Severity Score (EMR-ISS), using the International Classification of Diseases 10th Edition (ICD-10). Methods:, An injury severity grade similar to the Abbreviated Injury Scale (AIS) was converted from the ICD-10 codes on the basis of quintiles of the EMR for each ICD-10 code. Like the New Injury Severity Score (NISS), the EMR-ISS was calculated from three maximum severity grades using data from the Korean National Injury Database. The EMR-ISS was then validated using the Hosmer-Lemeshow goodness-of-fit chi-square (HL chi-square, with lower values preferable), the area under the receiver operating characteristic curve (AUC-ROC), and the Pearson correlation coefficient to compare it with the International Classification of Diseases 9th Edition,based Injury Severity Score (ICISS). Nationwide hospital discharge abstract data (DAD) from stratified-sample general hospitals (n = 150) in 2004 were used for an external validation. Results:, The total number of study subjects was 29,282,531, with five subgroups of particular interest identified for further study: traumatic brain injury (TBI, n = 3,768,670), traumatic chest injury (TCI, n = 1,169,828), poisoning (n = 251,565), burns (n = 869,020), and DAD (n = 26,374). The HL chi-square was lower for EMR-ISS than for ICISS in all groups: 42,410.8 versus 55,721.9 in total injury, 7,139.6 versus 20,653.9 in TBI, 6,603.3 versus 4,531.8 in TCI, 2,741.2 versus 9,112.0 in poisoning, 764.4 versus 4,532.1 in burns, and 28.1 versus 49.4 in DAD. The AUC-ROC for death was greater for EMR-ISS than for ICISS: 0.920 versus 0.728 in total injury, 0.907 versus 0.898 in TBI, 0.675 versus 0.799 in TCI, 0.857 versus 0.900 in poisoning, 0.735 versus 0.682 in burns, and 0.850 versus 0.876 in DAD. The Pearson correlation coefficient between the two scores was ,0.68 in total injury, ,0.76 in TBI, ,0.86 in TCI, ,0.69 in poisoning, ,0.58 in burns, and ,0.75 in DAD. Conclusions:, The EMR-ISS showed better calibration and discrimination power for prediction of death than the ICISS in most injury groups. The EMR-ISS appears to be a feasible tool for passive injury surveillance of large data sets, such as insurance data sets or community injury registries containing diagnosis codes. Additional further studies for external validation on prospectively collected data sets should be considered. [source]


    Age differences in fall-related injury hospitalisations and trauma presentations

    AUSTRALASIAN JOURNAL ON AGEING, Issue 3 2010
    Rebecca Mitchell
    Aim:, To examine fall-related hospitalised morbidity in New South Wales (NSW) and to describe the pattern of fall-related major trauma presentations at a Level 1 Trauma Centre in NSW for younger and older fallers. Methods:, Fall-related injuries were identified in the NSW Admitted Patients Data Collection during 1 July 1999,30 June 2008 and the trauma registry of the NSW St George Public Hospital during 1 January 2006,6 December 2008. Results:, There were 434 138 hospitalisations and 862 fall-related trauma presentations. Older fallers had a higher incidence of hospitalisation, being more likely to fall on the same level during general activities at home, injuring their hip or thigh. Older fallers were also more likely to have an Injury Severity Score > 9, undergo physiotherapy and stay in hospital for >1 day than younger fallers. Conclusion:, Falls, particularly for older individuals, are an important cause of serious injury, representing a considerable burden in terms of hospitalised morbidity. [source]


    Management of blunt injuries to the spleen

    BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 11 2010
    P. Renzulli
    Background: Non-operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM. Methods: All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed. Results: There were 206 patients (146 men) with a mean(s.d.) age of 38·2(19·1) years and an Injury Severity Score of 30·9(11·6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20·9 per cent), grade 2 in 52 (25·2 per cent), grade 3 in 60 (29·1 per cent), grade 4 in 42 (20·4 per cent) and grade 5 in nine (4·4 per cent). Forty-seven patients (22·8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13·72, 95 per cent confidence interval 5·08 to 37·01), Glasgow Coma Scale score below 11 (OR 9·88, 1·77 to 55·16) and age 55 years or more (OR 3·29, 1·07 to 10·08) were associated with primary OM. The rate of primary OM decreased from 33·3 to 11·9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77·2 per cent) qualified for NOM, which was successful in 143 (89·9 per cent). The splenic salvage rate was 69·4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13·58, 2·76 to 66·71). Conclusion: NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]


    Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients

    BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 3 2010
    P. Tran Ba Loc
    Background: Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score,the Elderly (E) POSSUM,has been developed and its accuracy compared with these scores. Methods: From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration. Results: The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0·86) and good calibration (P = 0·178) in predicting mortality and a reasonable discrimination (AUC = 0·77) and good calibration (P = 0·166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (Pc = 0·014 and Pc < 0·001 respectively). Conclusion: The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]


    Evaluation of various POSSUM models for predicting mortality in patients undergoing elective oesophagectomy for carcinoma

    BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 9 2007
    F. Lai
    Background: The aim of the study was to validate the use of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM), Portsmouth (P) POSSUM and upper gastrointestinal (O) POSSUM models in patients undergoing elective thoracic oesophagectomy for carcinoma. Methods: The observed in-hospital mortality rates in 545 patients undergoing elective thoracic oesophagectomy for squamous cell carcinoma of the oesophagus in all public hospitals in Hong Kong was compared with rates predicted by POSSUM, P-POSSUM and O-POSSUM. The discriminatory power of these models was assessed using receiver,operator characteristic (ROC) curve analysis. Results: The observed mortality rate was 5·5 per cent, whereas rates predicted by POSSUM, P-POSSUM and O-POSSUM were 15·0, 4·7 and 10·9 per cent respectively. P-POSSUM showed no lack of fit (P = 0·814), but POSSUM (P < 0·001) and O-POSSUM (P = 0·002) showed lack of fit against observed mortality. POSSUM overpredicted mortality across nearly all risk groups, whereas O-POSSUM overpredicted mortality in patients with low physiological scores and in older patients. POSSUM (area under ROC curve 0·776) and P-POSSUM (0·776) showed equally good discriminatory power but O-POSSUM (0·676) was inferior. Conclusion: P-POSSUM provided the most accurate prediction of in-hospital mortality in this group of patients who had elective oesophagectomy. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]


    Comparative study of left colonic Peritonitis Severity Score and Mannheim Peritonitis Index

    BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 5 2006
    S. Biondo
    Background: Prognostic evaluation of patients with left colonic perforation is useful in predicting mortality. The aims of this prospective study were to determine the prognostic value of the left colonic Peritonitis Severity Score (PSS) and to compare it with the Mannheim Peritonitis Index (MPI). Methods: One-hundred and fifty-six patients underwent emergency operation for distal colonic peritonitis. The PSS and MPI were calculated for each patient. The Spearman rank correlation coefficient was used to measure the association between the two scores. The predictive power of the two scoring systems and their differences were studied using the area under the receiver-operator characteristic (ROC) curve. Results: Forty-one patients died (26·3 per cent). The relationship between scores and mortality was statistically significant for each scoring system (P < 0·001). The Spearman rank correlation coefficient for the correlation between the MPI and PSS was 0·55 (P < 0·001). There was no difference between areas under the ROC curves for the two systems. Conclusion: The PSS and MPI are both well validated scoring systems for left colonic peritonitis. Their routine use might allow stratification of patients according to mortality risk. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]


    Predicting postoperative morbidity by clinical assessment

    BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 1 2005
    P. M. Markus
    Background: The aim of this study was to determine the accuracy of prediction of the surgeon's ,gut-feeling' in estimating postoperative outcome. Methods: A prospective series of 1077 consecutive patients undergoing major hepatobiliary or gastrointestinal surgery were studied. Patients having elective (n = 827) and emergency (n = 250) procedures were included. The surgeon predicted the development of postoperative complications immediately after completion of surgery on a scale from 0 to 100 per cent. These predictions were compared with the actual outcome and with predictions made using the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM). The Portsmouth predictor equation (P-POSSUM) was applied for the estimation of mortality. Results: The observed morbidity and mortality rates were 29·5 and 3·4 per cent respectively. POSSUM predicted a morbidity rate of 46·4 per cent and P-POSSUM a mortality rate of 6·9 per cent. The surgeon's gut-feeling was more accurate in the prediction of morbidity at 32·1 per cent. On the basis of gut-feeling, surgeons overpredicted morbidity in elective surgery, but underestimated the risk of complications in the emergency setting. The (P)-POSSUM scoring system overpredicted morbidity and mortality for elective and emergency operations. Conclusion: The surgeon's gut-feeling is a good predictor of postoperative outcome, especially after elective surgery. (P)-POSSUM overpredicted morbidity and mortality in this series of major gastrointestinal and hepatobiliary operations. Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]


    Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM),,

    BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 9 2004
    P. P. Tekkis
    Background: The aim of the study was to develop a dedicated colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (CR-POSSUM) equation for predicting operative mortality, and to compare its performance with the Portsmouth (P)-POSSUM model. Methods: Data were collected prospectively from 6883 patients undergoing colorectal surgery in 15 UK hospitals between 1993 and 2001. After excluding missing data and 93 patients who did not satisfy the inclusion criteria, 4632 patients (68·2 per cent) underwent elective surgery and 2107 had an emergency operation (31·0 per cent); 2437 operations (35·9 per cent) for malignant and 4267 (62·8 per cent) for non-malignant diseases were scored. Stepwise logistic regression analysis was used to develop an age-adjusted POSSUM model and a dedicated CR-POSSUM model. A 60 : 40 per cent split-sample validation technique was adopted for model development and testing. Observed and expected mortality rates were compared. Results: The operative mortality rate for the series was 5·7 per cent (387 of 6790 patients) (elective operations 2·8 per cent; emergency surgery 12·0 per cent). The CR-POSSUM, age-adjusted POSSUM and P-POSSUM models had similar areas under the receiver,operator characteristic curves. Model calibration was similar for CR-POSSUM and age-adjusted POSSUM models, and superior to that for the P-POSSUM model. The CR-POSSUM model offered the best overall accuracy, with an observed : expected ratio of 1·000, 0·998 and 0·911 respectively (test population). Conclusion: The CR-POSSUM model provided an accurate predictor of operative mortality. External validation is required in hospitals different from those in which the model was developed. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]


    The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) (Br J Surg 2003; 90: 157,165)

    BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 5 2003
    A. L. Tambyraja
    No abstract is available for this article. [source]


    Bayesian Logistic Injury Severity Score: A Method for Predicting Mortality Using International Classification of Disease-9 Codes

    ACADEMIC EMERGENCY MEDICINE, Issue 5 2008
    Randall S. Burd MD
    Abstract Objectives:, Owing to the large number of injury International Classification of Disease-9 revision (ICD-9) codes, it is not feasible to use standard regression methods to estimate the independent risk of death for each injury code. Bayesian logistic regression is a method that can select among a large numbers of predictors without loss of model performance. The purpose of this study was to develop a model for predicting in-hospital trauma deaths based on this method and to compare its performance with the ICD-9,based Injury Severity Score (ICISS). Methods:, The authors used Bayesian logistic regression to train and test models for predicting mortality based on injury ICD-9 codes (2,210 codes) and injury codes with two-way interactions (243,037 codes and interactions) using data from the National Trauma Data Bank (NTDB). They evaluated discrimination using area under the receiver operating curve (AUC) and calibration with the Hosmer-Lemeshow (HL) h-statistic. The authors compared performance of these models with one developed using ICISS. Results:, The discrimination of a model developed using individual ICD-9 codes was similar to that of a model developed using individual codes and their interactions (AUC = 0.888 vs. 0.892). Inclusion of injury interactions, however, improved model calibration (HL h-statistic = 2,737 vs. 1,347). A model based on ICISS had similar discrimination (AUC = .855) but showed worse calibration (HL h-statistic = 45,237) than those based on regression. Conclusions:, A model that incorporates injury interactions had better predictive performance than one based only on individual injuries. A regression approach to predicting injury mortality based on injury ICD-9 codes yields models with better predictive performance than ICISS. [source]


    End-tidal Carbon Dioxide Measurements in Children with Acute Asthma

    ACADEMIC EMERGENCY MEDICINE, Issue 12 2007
    Bridgette D. Guthrie MD
    Objectives A noninvasive method to assess ventilation may aid in management of children with acute asthma. The purpose of this study was to evaluate the association between end-tidal carbon dioxide (EtCO2) values and disease severity among children with acute asthma. Methods This was a prospective, blinded, observational study of children 3,17 years old treated for acute asthma in a pediatric emergency department (ED). EtCO2 measurements were taken before the initiation of therapy and after each nebulization treatment (maximum of three). Peak expiratory flow rate (PEFR), Pediatric Asthma Severity Score (PASS), oxygen saturation, and disposition were recorded. Treating physicians, unaware of the EtCO2 results, made all treatment decisions, including disposition. Results One hundred children were enrolled. The mean initial EtCO2 value was 35 mm Hg (95% confidence interval = 34.3 to 36.1 mm Hg). The mean disposition EtCO2 value was 33.3 mm Hg (95% confidence interval = 32.6 to 34.4 mm Hg). PEFR measures were completed on 43 patients and PASS recorded on 100 patients. There was an overall trend toward lower EtCO2 values during treatment (p < 0.01). Sixteen patients were admitted. Initial EtCO2 values were lower among children admitted to the hospital (35.6 mm Hg vs. 32.9 mm Hg; Mann-Whitney U test; p < 0.02). EtCO2 values at disposition did not differ between groups based on PEFR, PASS, or hospital admission. Conclusions Noninvasive bedside measurement of EtCO2 values among children with acute asthma is feasible. EtCO2 values did not distinguish children with mild disease from those with more severe disease. Further data are needed to clarify the association between EtCO2 values and other indicators of disease severity, particularly in children with more severe disease. [source]


    Prospective Evaluation of Two Clinical Scores for Acute Asthma in Children 18 Months to 7 Years of Age

    ACADEMIC EMERGENCY MEDICINE, Issue 6 2010
    FRCPC, Serge Gouin MDCM
    Abstract Objectives:, The objective was to evaluate the discriminatory ability of two clinical asthma scores, the Preschool Respiratory Assessment Measure (PRAM) and the Pediatric Asthma Severity Score (PASS), during an asthma exacerbation. Methods:, This was a prospective cohort study in an academic pediatric emergency department (ED; 60,000 visits/year) conducted from March 2006 to October 2007. All patients 18 months to 7 years of age who presented for an asthma exacerbation were eligible. The primary outcome was a length of stay (LOS) of >6 hours in the ED or admission to the hospital. Clinical findings and components of the PRAM and the PASS were assessed by a respiratory therapist (RT) at the start of the ED visit and after 90 minutes of treatment. Results:, During the study period, 3,845 patients were seen in the ED for an asthma exacerbation. Of these, 291 were approached to participate, and eight refused. Moderate levels of discrimination were found between a LOS of >6 hours and/or admission and PRAM (area under the receiver-operating characteristic curve [AUC] = 0.69, 95% confidence interval [CI] = 0.59 to 0.79) and PASS (AUC = 0.70, 95% CI = 0.60 to 0.80) as calculated at the start of the ED visit. Significant similar correlations were seen between the physician's judgment of severity and PRAM (r = 0.54, 95% CI = 0.42 to 0.65) and PASS (r = 0.55, 95% CI = 0.43 to 0.65). Conclusions:, The PRAM and PASS clinical asthma scores appear to be measures of asthma severity in children with discriminative properties. ACADEMIC EMERGENCY MEDICINE 2010; 17:598,603 © 2010 by the Society for Academic Emergency Medicine [source]


    Utility of Base Deficit for Identifying Major Injury in Elder Trauma Patients

    ACADEMIC EMERGENCY MEDICINE, Issue 9 2007
    Shahriar Zehtabchi MD
    Background: Early identification of serious injuries is especially important in elders. Base deficit (BD) is an indicator of serious injury in trauma patients. There are limited data to support the utility of BD in elders who have sustained trauma. Objectives: To assess the diagnostic performance of BD in identifying major injury in elders. Methods: This was a prospective, observational, preliminary study. Elder (age 65 years and older) patients with significant injury mechanisms had BD analyzed during initial emergency department resuscitation. Major injury was defined by an Injury Severity Score ,15, a decrease in hematocrit of more than ten points, or blood transfusion. Patients were stratified into two groups of minor and major injuries. Data were reported as means (±SD). Receiver operating characteristic (ROC) curves tested the diagnostic ability of BD to identify major injury. Results: Seventy-four patients were enrolled; the mean (±SD) age was 75 (±7) years, and 57% were male. Twenty-four patients (32%) had major injury. The mean (±SD) for BD in the major injury group (,2.9 [±6] mmol/L) was significantly different from that in the minor injury group (0.8 [±3] mmol/L), with a mean difference of 3.7 (95% confidence interval = 1.4 to 5.9). ROC curves revealed that BD was able to identify major injury in elder patients (area under the ROC curve, 0.72; 95% confidence interval = 0.60 to 0.85; p = 0.0003). Conclusions: The preliminary data from this study indicate that in trauma patients aged 65 years and older, increased BD at emergency department arrival can predict life-threatening injury. [source]


    Efficacy and tolerability of EPs 7630 in patients (aged 6,18 years old) with acute bronchitis

    ACTA PAEDIATRICA, Issue 4 2010
    A randomized, double-blind, placebo-controlled clinical dose-finding study
    Abstract Aim:, For EPs-7630, a herbal drug preparation from Pelargonium sidoides roots, therapeutic effects in respiratory tract infections outside the strict indication for antibiotics have already been demonstrated in adults. Now, a dose-finding study for EPs-7630 was performed in children and adolescents. Methods:, A total of 400 patients (aged 6,18 years) were randomized to receive either 30 mg, 60 mg or 90 mg EPs-7630 or placebo daily. Primary outcome criterion was the change in the Bronchitis Severity Score (BSS) from day 0 to day 7. Results:, After 7 days of treatment, the change in the BSS total score was significantly better in the 60 mg and 90 mg groups compared with placebo that of the without relevant differences between these two dosages. Especially ,coughing', ,sputum' and ,rales at auscultation' improved under EPs-7630. Onset of effect was faster, time of bed rest shorter and treatment outcome and satisfaction with treatment were rated better. Tolerability was comparable with placebo in all treatment groups. Conclusion:, EPs-7630 is effective in acute bronchitis outside the strict indication for antibiotics in 6,18 years old patients, with a dose of 60 mg or 90 mg daily offering the best benefit/risk ratio. EPs-7630 significantly reduces the severity of symptoms, leads to a more favourable course of the disease and a faster recovery from acute bronchitis compared with the placebo, and is well tolerated. [source]


    Trauma Center Utilization for Children in California 1998,2004: Trends and Areas for Further Analysis

    ACADEMIC EMERGENCY MEDICINE, Issue 4 2007
    N. Ewen Wang MD
    Abstract Background: While it is known that trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma system function amid changes in policies and health care financing that affect emergency medical systems for children. Objectives: To describe the trends in the proportion of pediatric trauma patients acutely hospitalized in trauma-designated versus non,trauma-designated hospitals. Methods: This was a retrospective observational study of a population-based cohort obtained by secondary analysis of a publicly available data set: the California Office of Statewide Health Planning and Development Patient Discharge Database from 1998 to 2004. Patients were included in the analysis if they were 0,19 years old, had International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes and E-codes indicative of trauma, had an unscheduled admission, and were discharged from a general acute care hospital (N= 111,566). Proportions of patients hospitalized in trauma-designated hospitals versus non,trauma-designated hospitals were calculated for Injury Severity Score and death. Injury Severity Scores were calculated from ICD-9 codes. Primary outcomes were hospitalization in a trauma center and death two or more days after hospitalization. Results: Over the study period, the proportion of children aged 0,14 years with acute trauma requiring hospitalization and who were cared for in trauma-designated hospitals increased from 55% (95% confidence interval [CI] = 54% to 56%) in 1998 to 66% (95% CI = 65% to 67%) in 2004 (p < 0.01). For children aged 15,19 years, the proportion increased from 55% (95% CI = 54% to 57%) in 1998 to 74% (95% CI = 72% to 75%) in 2004 (p < 0.0001). When trauma discharges were stratified by injury severity, the proportion of children with severe injury who were hospitalized in trauma-designated hospitals increased from 69% (95% CI = 66% to 72%) in 1998 to 84% (95% CI = 82% to 87%) in 2004, a rate higher than in children with moderate injury (59% [95% CI = 58% to 61%] in 1998 and 75% [95% CI = 74% to 76%] in 2004) and mild injury (51% [95% CI = 50% to 52%] in 1998 and 63% [95% CI = 62% to 64%] in 2004) (p < 0.0001 for each injury severity category and both age groups). Of the hospitalized children who died two or more days after injury (n= 502), 18.1% died in non,trauma-designated hospitals (p < 0.002 for children aged 0,14 years; p = 0.346 for children aged 15,19 years). Conclusions: An increasing majority of children with trauma were cared for in trauma-designated hospitals over the study period. However, 23% of children with severe injuries, and 18.1% of pediatric deaths more than two days after injury, were cared for in non,trauma-designated hospitals. These findings demonstrate an important opportunity for improvement. If we can characterize those children who do not access the trauma system despite severe injury or death, we will be able to design clinical protocols and implement policies that ensure access to appropriate regional trauma care for all children in need. [source]