title: Quadrimodal distribution of death after trauma suggests that critical injury is a potentially terminal disease.
abstract: BACKGROUND
  Patterns of death after trauma are changing due to advances in critical care. We examined mortality in critically injured patients who survived index hospitalization.
  
  
  METHODS
  Retrospective analysis of adults admitted to a Level-1 trauma center (1/1/2000-12/31/2010) with critical injury was conducted comparing patient characteristics, injury, and resource utilization between those who died during follow-up and survivors.
  
  
  RESULTS
  Of 1,695 critically injured patients, 1,135 (67.0%) were discharged alive. As of 5/1/2012, 977/1,135 (86.0%) remained alive; 75/158 (47.5%) patients who died during follow-up, died in the first year. Patients who died had longer hospital stays (24 vs. 17 days) and ICU LOS (17 vs. 8 days), were more likely to undergo tracheostomies (36% vs. 16%) and gastrostomies (39% vs. 16%) and to be discharged to rehabilitation (76% vs. 63%) or skilled nursing (13% vs. 5.8%) facilities than survivors. In multivariable models, male sex, older age, and longer ICU LOS predicted mortality. Patients with ICU LOS >16 days had 1.66 odds of 1-year mortality vs. those with shorter ICU stays.
  
  
  CONCLUSIONS
  ICU LOS during index hospitalization is associated with post-discharge mortality. Patients with prolonged ICU stays after surviving critical injury may benefit from detailed discussions about goals of care after discharge.
authors.affiliation: Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA. Electronic address: heena.santry@umassmemorial.org.
authors.forename: Heena P
authors.initials: HP
authors.lastname: Santry
authors.affiliation: Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Psoinos
authors.affiliation: Department of Emergency Medicine, MedStar Harbor Hospital, Baltimore, MD, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Wilbert
authors.affiliation: Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Flahive
authors.affiliation: Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: Aimee R
authors.initials: AR
authors.lastname: Kroll-Desrosiers
authors.affiliation: Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Emhoff
authors.affiliation: Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: Catarina I
authors.initials: CI
authors.lastname: Kiefe
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D003422:Critical Care; D005260:Female; D006760:Hospitalization; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010351:Patient Discharge; D012047:Rehabilitation Centers / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data*; D014139:Tracheostomy / Q000706:statistics & numerical data*; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000401:mortality*
keywords: Critical injury; Goals of care; Injury mortality; Trauma mortality