Objective: To examine the effect of the “after-hours” (18:00–07:00) model of trauma care on a high-risk subgroup — patients presenting with acute traumatic coagulopathy (ATC).
Design, participants and setting: Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011.
Main outcome measure: Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality.
Results: There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10–2.87).
Conclusion: The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.
- 1. Di Bartolomeo S. The “off-hour” effect in trauma care: a possible quality indicator with appealing characteristics. Scand J Trauma Resusc Emerg Med 2011; 19: 33.
- 2. Carmody IC, Romero J, Velmahos GC. Day for night: should we staff a trauma center like a nightclub? Am Surg 2002; 68: 1048-1051.
- 3. Busse JW, Bhandari M, Devereaux PJ. The impact of time of admission on major complications and mortality in patients undergoing emergency trauma surgery. Acta Orthop Scand 2004; 75: 333-338.
- 4. Arbabi S, Jurkovich GJ, Wahl WL, et al. Effect of patient load on trauma outcomes in a level I trauma center. J Trauma 2005; 59: 815-818; discussion 9-20.
- 5. Laupland KB, Ball CG, Kirkpatrick AW. Hospital mortality among major trauma victims admitted on weekends and evenings: a cohort study. J Trauma Manag Outcomes 2009; 3: 8.
- 6. Cameron PA, Gabbe BJ, Cooper DJ, et al. A statewide system of trauma care in Victoria: effect on patient survival. Med J Aust 2008; 189: 546-550. <MJA full text>
- 7. Twijnstra MJ, Moons KG, Simmermacher RK, Leenen LP. Regional trauma system reduces mortality and changes admission rates: a before and after study. Ann Surg 2010; 251: 339-343.
- 8. Curtis KA, Mitchell RJ, Chong SS, et al. Injury trends and mortality in adult patients with major trauma in New South Wales. Med J Aust 2012; 197: 233-237. <MJA full text>
- 9. Kim SJ, Lee SW, Han GS, et al. Acute traumatic coagulopathy decreased actual survival rate when compared with predicted survival rate in severe trauma. Emerg Med J 2012; 29: 906-910.
- 10. Gruen RL, Brohi K, Schreiber M, et al. Haemorrhage control in severely injured patients. Lancet 2012; 380: 1099-1108.
- 11. Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care 2007; 13: 680-685.
- 12. Mitra B, Cameron PA, Mori A, Fitzgerald M. Acute coagulopathy and early deaths post major trauma. Injury 2012; 43: 22-25.
- 13. MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma 2003; 55: 39-44.
- 14. Mitra B, Tullio F, Cameron PA, Fitzgerald M. Trauma patients with the “triad of death”. Emerg Med J 2012; 29: 622-625.
- 15. Kashuk JL, Moore EE, Johnson JL, et al. Postinjury life threatening coagulopathy: is 1:1 fresh frozen plasma: packed red blood cells the answer? J Trauma 2008; 65: 261-270; discussion 270-271.
- 16. Nardi G, Agostini V, Rondinelli BM, et al. Prevention and treatment of trauma induced coagulopathy (TIC). An intended protocol from the Italian trauma update research group. J Anesthesiol Clin Sci 2013; 2 (1): 22.
- 17. Zatta AJ, McQuilten ZK, Mitra B, et al. Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion. Vox Sang 2014; 107: 60-70.
- 18. McNab A, Burns B, Bhullar I, et al. An analysis of shock index as a correlate for outcomes in trauma by age group. Surgery 2013; 154: 384-387.
- 19. Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med 2008; 3: 17.
- 20. Cuzick J. A Wilcoxon-type test for trend. Stat Med 1985; 4: 87-90.
- 21. Luchette F, Kelly B, Davis K, et al. Impact of the in-house trauma surgeon on initial patient care, outcome, and cost. J Trauma 1997; 42: 490-495; discussion 495-497.
- 22. Helling TS, Nelson PW, Shook JW, et al. The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients. J Trauma 2003; 55: 20-25.
- 23. Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW. Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA 1988; 260: 3446-3450.
- 24. Arabi Y, Alshimemeri A, Taher S. Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage. Crit Care Med 2006; 34: 605-611.
- 25. Carr BG, Jenkins P, Branas CC, et al. Does the trauma system protect against the weekend effect? J Trauma 2010; 69: 1042-1047; discussion 1047-1048.
- 26. Schwartz DA, Medina M, Cotton BA, et al. Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg 2014; 76: 134-139.
- 27. Mitra B, Cameron PA, Gruen RL. Aggressive fresh frozen plasma (FFP) with massive blood transfusion in the absence of acute traumatic coagulopathy. Injury 2012; 43: 33-37.
- 28. Deasy C, Bray J, Smith K, et al. Traumatic out-of-hospital cardiac arrests in Melbourne, Australia. Resuscitation 2012; 83: 465-470.
- 29. Mitra B, Mori A, Cameron PA, et al. Massive blood transfusion and trauma resuscitation. Injury 2007; 38: 1023-1029.
- 30. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. J Trauma 1987; 27: 370-378.
- 31. Olaussen A, Blackburn T, Mitra B, Fitzgerald M. Shock index for prediction of critical bleeding post-trauma: a systematic review. Emerg Med Australas 2014; 26: 223-228.
- 32. Epstein DS, Mitra B, O'Reilly G, et al. Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: A systematic review and meta-analysis. Injury 2014; 45: 819-824.
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