title: Early tracheostomy in trauma patients saves time and money.
abstract: BACKGROUND
  Patients suffering traumatic brain and chest wall injuries are often difficult to liberate from the ventilator yet best timing of tracheostomy remains ill-defined. While prior studies have addressed early versus late tracheostomy, they generally suffer from the use of historical controls, which cannot account for variations in management over time. Propensity scoring can be utilized to identify controls from the same patient population, minimizing impact of confounding variables. The purpose of this study was to determine outcomes associated with early versus late tracheostomy by application of propensity scoring.
  
  
  METHODS
  Patients requiring intubation within 48h and receiving tracheostomy from January 2010 to June 2012 were identified. Early tracheostomy (ET) was a tracheostomy performed by the fifth hospital day. ET patients were matched to late tracheostomy patients (LT, tracheostomy after day 5) using propensity scoring and compared for multiple outcomes. Cost for services was calculated using average daily billing rates at our institution.
  
  
  RESULTS
  One hundred and six patients were included, 53 each in the ET (mean day tracheostomy=4) and the LT (mean day tracheostomy=10) cohorts. The average age was 47 years and 94% suffered blunt injury, with an average NISS of 23.7. Patients in the ET group had significantly shorter TICU LOS (21.4 days vs. 28.6 days, p<0.0001) and significantly fewer ventilator days (16.7 days vs. 21.9, p<0.0001) compared to the LT group. ET patients also had significantly less VAP (34% vs. 64.2%, p=0.0019).
  
  
  CONCLUSIONS
  In the current era of increased health-care costs, early tracheostomy significantly decreased both pulmonary morbidity and critical care resource utilization. This translates to an appreciable cost savings, at minimum $52,173 per patient and a potential total savings of $2.8million/year for the entire LT cohort. For trauma patients requiring prolonged ventilator support, early tracheostomy should be performed.
authors.affiliation: University of Tennessee at Chattanooga, Chattanooga, TN, USA. Electronic address: ghyde@uthsc.edu.
authors.forename: Glendon A
authors.initials: GA
authors.lastname: Hyde
authors.affiliation: University of Tennessee Health Sciences Center, 910 Madison Ave, Suite 220, Memphis, TN 38163, USA. Electronic address: ssavage1@uthsc.edu.
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Savage
authors.affiliation: Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA. Electronic address: bzarzaur@iupui.edu.
authors.forename: Ben L
authors.initials: BL
authors.lastname: Zarzaur
authors.affiliation: University of Tennessee Health Sciences Center, 910 Madison Ave, Suite 220, Memphis, TN 38163, USA. Electronic address: jhart27@uthsc.edu.
authors.forename: Jensen E
authors.initials: JE
authors.lastname: Hart-Hyde
authors.affiliation: University of Tennessee Health Sciences Center, 910 Madison Ave, Suite 220, Memphis, TN 38163, USA. Electronic address: cschaefe@uthsc.edu.
authors.forename: Candace B
authors.initials: CB
authors.lastname: Schaefer
authors.affiliation: University of Tennessee Health Sciences Center, 910 Madison Ave, Suite 220, Memphis, TN 38163, USA. Electronic address: mcroce@uthsc.edu.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Croce
authors.affiliation: University of Tennessee Health Sciences Center, 910 Madison Ave, Suite 220, Memphis, TN 38163, USA. Electronic address: tfabian@uthsc.edu.
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Fabian
mesh_terms: D000328:Adult; D003422:Critical Care; D016638:Critical Illness; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment; D013898:Thoracic Injuries / Q000150:complications / Q000628:therapy*; D014139:Tracheostomy / Q000379:methods*; D016896:Treatment Outcome; D015300:Ventilator Weaning / Q000379:methods*
keywords: Medical costs; Thoracic trauma; Tracheostomy; Traumatic brain injury; Ventilator associated pneumonia