Jody Md Vogel

Background: Patients with repeated hospitalizations represent a group with potentially avoidable utilization. Recent publications have begun to highlight the heterogeneity of this group. Latent class analysis provides a novel methodological approach to utilizing administrative data to identify clinically meaningful subgroups of patients to inform tailored intervention efforts. Objective: The objective of the study was to identify clinically distinct subgroups of adult superutilizers. Research Design: Retrospective cohort analysis. Subjects: Adult patients who had an admission at an urban safety-net hospital in 2014 and 2 or more admissions within the preceding 12 months. Measures: Patient-level medical, mental health (MH) and substance use diagnoses, social characteristics, demographics, utilization and charges were obtained from administrative data. Latent class analyses were used to determine the number and characteristics of latent subgroups that best represented these data. Results: In this cohort (N=1515), a 5-class model was preferred based on model fit indices, clinical interpretability and class size: class 1 (16%) characterized by alcohol use disorder and homelessness; class 2 (14%) characterized by medical conditions, MH/substance use disorders and homelessness; class 3 (25%) characterized primarily by medical conditions; class 4 (13%) characterized by more serious MH disorders, drug use disorder and homelessness; and class 5 (32%) characterized by medical conditions with some MH and substance use. Patient demographics, utilization, charges and mortality also varied by class. Conclusions: The overall cohort had high rates of multiple chronic medical conditions, MH, substance use disorders, and homelessness. However, the patterns of these conditions were different between subgroups, providing important information for tailoring interventions.

Early recognition of trauma patients at risk for multiple organ failure (MOF) is important to reduce the morbidity and mortality associated with MOF. The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure, blood urea nitrogen, and white blood cell count, which was designed to predict the development of MOF within 7 days of hospitalization. We performed a prospective multicenter study of adult trauma patients between November, 2011 and March, 2013. The primary outcome was development of MOF within 7 days of hospitalization, assessed using the Sequential Organ Failure Assessment Score. Hierarchical logistic regression analysis was performed to determine associations between the Denver ED TOF Score and MOF. Discrimination was assessed and quantified using a receiver operating characteristics (ROC) curve. The predictive accuracy of the Denver ED TOF score was compared with attending emergency physician estimation of the likelihood of MOF. We included 2,072 patients with a median age of 46 years (interquartile range [IQR] 30 to 61 years); 68% were male. The median Injury Severity Score was 9 (IQR 5 to 17), and 88% of patients had blunt mechanism injury. Among participants, 1,024 patients (49%) were admitted to the ICU, and 77 (4%) died. Multiple organ failure occurred in 120 (6%; 95% CI 5% to 7%) patients and of these, 37 (31%; 95% CI 23% to 40%) died. The area under the ROC curve for the Denver ED TOF Score prediction of MOF was 0.89 (95% CI 0.86 to 0.91) and for physician estimation of the likelihood of MOF was 0.78 (95% CI 0.73 to 0.83). The Denver ED TOF Score predicts development of MOF within 7 days of hospitalization. Its predictive accuracy outperformed attending emergency physician estimation of the risk of MOF.

Objective: To evaluate whether using long-axis or short-axis view during ultrasound-guided internal jugular and subclavian central venous catheterization results in fewer skin breaks, decreased time to cannulation, and fewer posterior wall penetrations. Design: Prospective, randomized crossover study. Setting: Urban emergency department with approximate annual census of 60,000. Subjects: Emergency medicine resident physicians at the Denver Health Residency in Emergency Medicine, a postgraduate year 1–4 training program. Interventions: Resident physicians blinded to the study hypothesis used ultrasound guidance to cannulate the internal jugular and subclavian of a human torso mannequin using the long-axis and short-axis views at each site. Measurements and Main Results: An ultrasound fellow recorded skin breaks, redirections, and time to cannulation. An experienced ultrasound fellow or attending used a convex 8–4 MHz transducer during cannulation to monitor the needle path and determine posterior wall penetration. Generalized linear mixed models with a random subject effect were used to compare time to cannulation, number of skin breaks and redirections, and posterior wall penetration of the long axis and short axis at each cannulation site. Twenty-eight resident physicians participated: eight postgraduate year 1, eight postgraduate year 2, five postgraduate year 3, and seven postgraduate year 4. The median (interquartile range) number of total internal jugular central venous catheters placed was 27 (interquartile range, 9–42) and subclavian was six catheters (interquartile range, 2–20). The median number of previous ultrasound-guided internal jugular catheters was 25 (interquartile range, 9–40), and ultrasound-guided subclavian catheters were three (interquartile range, 0–5). The long-axis view was associated with a significant decrease in the number of redirections at the internal jugular and subclavian sites, relative risk 0.4 (95% CI, 0.2–0.9) and relative risk 0.5 (95% CI, 0.3–0.7), respectively. There was no significant difference in the number of skin breaks between the long axis and short axis at the subclavian and internal jugular sites. The long-axis view for subclavian was associated with decreased time to cannulation; there was no significant difference in time between the short-axis and long-axis views at the internal jugular site. The prevalence of posterior wall penetration was internal jugular short axis 25%, internal jugular long axis 21%, subclavian short axis 64%, and subclavian long axis 39%. The odds of posterior wall penetration were significantly less in the subclavian long axis (odds ratio, 0.3; 95% CI, 0.1–0.9). Conclusions: The long-axis view for the internal jugular was more efficient than the short-axis view with fewer redirections. The long-axis view for subclavian central venous catheterization was also more efficient with decreased time to cannulation and fewer redirections. The long-axis approach to subclavian central venous catheterization is also associated with fewer posterior wall penetrations. Using the long-axis view for subclavian central venous catheterization and avoiding posterior wall penetrations may result in fewer central venous catheter–related complications.

BACKGROUND Multiple-organ failure (MOF) is common among the most seriously injured trauma patients. The ability to easily and accurately identify trauma patients in the emergency department at risk for MOF would be valuable. The aim of this study was to derive and internally validate an instrument to predict the development of MOF in adult trauma patients using clinical and laboratory data available in the emergency department. METHODS We enrolled consecutive adult trauma patients from 2005 to 2008 from the Denver Health Trauma Registry, a prospectively collected database from an urban Level 1 trauma center. Multivariable logistic regression was used to develop a clinical prediction instrument. The outcome was the development of MOF within 7 days of admission as defined by the Sequential Organ Failure Assessment (SOFA) score. A risk score was created from the final regression model by rounding the regression β coefficients to the nearest integer. Calibration and discrimination were assessed using 10-fold cross-validation. RESULTS A total of 4,355 patients were included in this study. The median age was 37 years (interquartile range [IQR], 26–51 years), and 72% were male. The median Injury Severity Score (ISS) was 9 (IQR, 4–16), and 78% of the patients had blunt injury mechanisms. MOF occurred in 216 patients (5%; 95% confidence interval, 4–6%). The final risk score included patient age, intubation, systolic blood pressure, hematocrit, blood urea nitrogen, and white blood cell count and ranged from 0 to 9. The prevalence of MOF increased in an approximate exponential fashion as the score increased. The model demonstrated excellent calibration and discrimination (calibration slope, 1.0; c statistic, 0.92). CONCLUSION We derived a simple, internally valid instrument to predict MOF in adults following trauma. The use of this score may allow early identification of patients at risk for MOF and result in more aggressive targeted resuscitation and improved resource allocation. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.