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Calculating Trauma Mortality Risk

The Answer May Already Exist

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000470673.39939.e3
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When patients come to the emergency department with severe injuries or trauma, what are the chances they will survive to leave the hospital? What about living another month? The answer may rest with two commonly ordered blood tests and a special computerized tool called the Intermountain Risk Score.

A retrospective study of more than 9,500 patients treated at the Intermountain Health Center in Murray, UT, determined that the blood tests could identify patients as much as 58 percent more likely to die than others, regardless of the severity of the original injury.

“We are hopeful that having the quantitative risk information will help the clinicians better evaluate the patient and get the right care to that person in the right time frame,” said Benjamin Horne, PhD, the director of cardiovascular and genetic epidemiology at the Intermountain Medical Center Heart Institute and a senior author of a report that appeared in PLoS One. (2013;8[7]:e69160.)

The Intermountain Risk Score, long used to predict outcome for cardiac conditions, uses a computer to combine factors like age, gender, complete blood count (CBC), and basic metabolic profile to determine a person's mortality risk. Between October 2005 and December 2011, admitted trauma patients with CBCs and basic metabolic profiles were evaluated. Sex-specific 30-day and one-year Intermountain Risk Score values were calculated using multivariate modeling of components of the two sets of blood tests and age. The researchers established three risk thresholds: high, medium, and low, and they used the medical record and Social Security Administration data to determine whether the patient died.

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Surprising Results

“The results were very surprising. As surgeons, we don't often use all of the CBC results in evaluating a patient who needs surgery for a bleeding spleen or after a motor vehicle accident, Sarah Majercik, MD, a general and trauma surgeon at Intermountain Medical Center and part of the team that developed the risk score, said in a news statement.

“There are certain values, such as hemoglobin, hematocrit, and platelets that we scrutinize closely as part of good clinical care, but then other parts, such as the red blood cell distribution width (RDW) that we pay no attention to at all in the acute setting. These factors are generally overlooked, even though they are part of the CBC that every trauma patient gets when he or she arrives in the emergency room,” she said.

An ongoing clinical study is seeking to determine whether the risk score's delivery is helpful in reducing 30-day and one-year mortality, according to Dr. Horne. The researchers are also looking for whether it could affect resource utilization. “We are hopeful that having the quantitative risk information will help the clinicians better evaluate the patient and get the right care to them in the right time frame,” he said.

He said the researchers have approached it as though individuals who are in the lower-to-moderate risk range get standard of care. “People who fall into the high-risk range based on the risk score may get care that takes more time and expends more resources.”

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A Gray Area

Some patients usually fall into a gray area, however, without the use of the risk score, he said. “If you are in the high-risk zone, it may bump you as a physician into taking that greater action,” Dr. Horne said, adding that he is interested in determining how useful the risk score is in clinical practice. His team is still researching how it could be applied, perhaps in heart failure and palliative care, as other studies have.

“As far as clinical implementation, its use in a trauma population is quite well advanced,” he said. But he also added there has been some resistance.

“It's almost too simple for some people. When we first started to try publishing on the risk/mortality score, some reviewers said, ’I don't believe this to be true. Someone should have thought about this already.’ This is the first risk score, however, we have made using a complete blood count,” he said.

Dr. Horne and his colleagues studied the coronary catheterization population in 2007, and found that red cell distribution predicted mortality. “Now we are looking at every parameter. In particular, the red blood cell distribution width is not being used in medicine in this time. It's so popular and exciting to use new biotechnology — genomics, proteomics, and metabolomics — yet when we get down to the point, is it clinically valuable? Does it produce the outcome we want? Is it cost-effective?

“When you have something like this, it's essentially free. Trauma surgeons are already getting this information. They run it stat on all the patients coming into the emergency department. You can run the mortality score, and the computer can compute that value as well,” he said.

Dr. Horne added that emergency physicians don't have to change the way they practice to get the information, nor is the patient charged extra. “When I talk to physicians, their faces light up. How do I get this for my practice? I want to add in pulmonary testing parameters. Can we do that?” he said. In fact, they have already done that, he said. He said he and his colleagues have already tested the risk score in populations of patients who are part of large studies. “Wherever we apply it, it seems to work.”

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