Care Of Trauma Patients Research Articles

The Effect of a Multidisciplinary Trauma Team Leader Paradigm at a Tertiary Trauma Center: 10-Year Experience.

Background To illustrate the impact of the implementation of a multidisciplinary TTL program in 2005 on the mortality of trauma patients in a level 1 trauma center as well as admission rates and length of stay. Methods Retrospective observational study of all trauma patients included in the provincial trauma database at the Montreal General Hospital between 1998 and 2015. The primary outcome studied was in-hospital mortality. The secondary outcomes studied were hospital and intensive care unit (ICU) rates of admission and hospital and ICU length of stay. Results 24,107 patients were included. We observed a statistically significant reduction in mortality of 1.25% or a relative reduction of 16% (p value = 0.0058; rate ratio 0.844 (95% CI 0.747–0.952)). ICU admissions were also significantly reduced where we observed a statistically significant absolute reduction of 4.46% or a relative reduction of 14% (p value = 8.38 × 10−7; rate ratio 0.859 (95% CI 0.808–0.912)). The ICU length of stay was increased by 0.91 days or 19.03% (p value = 0.016 (95% CI 0.167–1.655)). There was no observed change in overall length of stay (13.97 days pre-TTL and 12.91 post-TTL (p value = 0.13; estimate −1.053 (95% CI −2.424–0.318))). Conclusions This article suggests that multidisciplinary TTL model may be beneficial in the care of trauma patients. Further subgroup analysis may help determine which patients could benefit more.

Electronic trauma resuscitation documentation and decision support using T6 Health Systems Mobile Application: A combat trauma center pilot program.

The care of trauma patients in combat operations is handwritten on a five-page flow sheet. The process requires the manual scanning and uploading of paper documents to bridge the gap between electronic and paper record management. There is an urgent operational need for an information technology solution that will enable medics to better capture patient treatment information, which will improve long-term health care without impacting short-term care responsibilities. We conducted a process improvement project to evaluate the ability of T6 Health Systems Mobile Application to improve combat casualty care data collection at a deployed trauma hospital. We performed a head-to-head comparison of the completeness and accuracy of data capture of electronic versus handwritten records to determine noninferiority. During the 90-day pilot, there were 131 trauma evaluations of which 53 casualty resuscitations (40.5%) were also documented in the electronic application. We compared completeness and accuracy of admit, prehospital, primary survey, secondary survey, interventions, and trends data. We found an overall 13% increase in data capture at 96% accuracy compared with the written record, suggesting that the electronic record was superior. Completion of electronic documentation compared with paper by section was statistically significantly higher for admitting data, 119.7% (p < 0.0001); prehospital, 116.2% (p = 0.0039); primary, 109.6% (p < 0.001); and secondary, 125.5% (p < 0.001). We also had the medical evacuation teams document prehospital and en route care and then synchronize the record in the trauma bay, allowing the trauma teams there to continue documenting on the same casualty record, likely contributing to superiority because teams did not have to redocument based on an oral report. Our pilot program in the deployed environment demonstrated a mobile technology that actually enhanced the completeness and accuracy of paper trauma documentation that has the capability of providing patient-specific decision support and real-time data analysis. Care Management, level IV.

Combat Facial Fractures Sustained During Operation Resolute Support and Operation Freedom's Sentinel in Afghanistan.

Facial fractures sustained in combat are generally unrepresentative of those commonly experienced in civilian practice. In the US military, acute trauma patient care is guided by the Joint Trauma System Clinical Practice Guidelines but currently none exists for facial trauma. All casualties that underwent surgery to facial fractures between January 01, 2016 and September 15, 2019 at a US deployed Military Treatment Facility in Afghanistan were identified using the operating room database. Surgical operative records and outpatient records for local Afghan nationals returning for follow-up were reviewed to determine outcomes. 55 casualties underwent treatment of facial fractures; these were predominantly from explosive devices (27/55, 49%). About 46/55 (84%) were local nationals, of which 32 (70%) were followed up. Length of follow-up ranged between 1 and 25months. About 36/93 (39%) of all planned procedures developed complications, with the highest being from ORIF mandible (18/23, 78%). About 8/23 (35%) casualties undergoing ORIF mandible developed osteomyelitis, of which 5 developed nonunion. Complications were equally likely to occur in those procedures for "battlefield type" events such as explosive devices and gunshot wounds (31/68, 46%) as those from "civilian type" events such as falls or motor vehicle collisions (5/11, 45%). Complications Rates from facial fractures were higher than that reported in civilian trauma. This likely reflects factors such as energy deposition, bacterial load, and time to treatment. Load sharing osteosynthesis should be the default modality for fracture fixation. External fixation should be considered in particular for complex high-energy or infected mandible fractures where follow-up is possible.

Training to identify red flags in the acute care of trauma: who are the patients at risk for early death despite a relatively good prognosis? An analysis from the TraumaRegister DGU\xae

BackgroundIn the acute care of trauma, some patients with a low estimated risk of death die suddenly and unexpectedly. In this study, we aim to identify predictors for early death within 24 h following hospital admission in low-risk patients.MethodsThe TraumaRegister DGU® was used to collect records of patients who were primarily treated in a participating hospital between 2004 and 2013 with a RISC II score below 10%.ResultsDuring the study period, 64,379 patients met the inclusion criteria. The mean RISC II score was 2.0%, and the mean ISS was 16 ± 9. The overall hospital mortality rate was 2.1%, and 0.5% of patients (n = 301) died within the first 24 h. A SPB of ≤ 90 mmHg was associated with an increased risk of death (p < 0.001). An AIS abdomen score of ≥ 3 was associated with increased risk of death within the first 24 h (p < 0.001). A high risk of early death was also seen in patients with an AIS score (thorax) ≥ 3; 51% of those who died died within the first 24 h (p < 0.005). Death in patients over 60 years was more common after 24 h (p < 0.001). Patients with an ASA score of ≥ 3 were more likely to die after the first 24 h (p < 0.001).ConclusionsIndicators predicting a high risk of early death in patients with a low RISC II score include a SPB ≤ 90 mmHg and severe chest and abdominal trauma. Emergency teams involved in the acute care of trauma patients should be aware of these “red flags” and treat their patients accordingly.

Time to definitive care among severely injured farmers compared to other work-related injuries in a Midwestern state

BackgroundFarming is a high risk occupation that predisposes workers to injury, but may also lead to barriers in reaching trauma care. Little is known about emergency and trauma care for patients with farm-related injuries. The purpose of this study was to determine whether severely injured farmers presenting to a statewide trauma system faced delays in reaching definitive care compared to other severely injured workers.MethodsA population-based observational study was performed using the Iowa State Trauma Registry from 2005 to 2011. The registry was used to identify a multiply imputed sample of severe occupational injuries. Time to definitive care for farm- and non-farm-related injuries was compared using Kaplan-Meier curves and an extended, stratified Cox model censoring at 4 h. An interaction with time was included in the Cox model to generate hazard ratios for each hour after injury.ResultsSeven-hundred forty-eight severe occupational injuries were identified; 21% of these were farm-related. The overall median time to definitive care was nearly an hour longer for farmers compared to other workers (2h46m vs. 1h48m, p < 0.05). When adjusted for confounders, farm status remained a significant predictor of delay in reaching definitive care, but only in the first hour after injury (HR = 0.44, 95%CI = 0.24–0.83).ConclusionsFarm-related injuries accounted for more than 1 of every 5 severe occupational injuries entered into the Iowa trauma system. We found that severely injured farmers had delays in reaching definitive trauma care, even when adjusted for confounding variables such as rurality. This effect was most pronounced in the first hour.

Development of an enhanced acute care surgery service in response to the COVID-19 global pandemic

BackgroundAs the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions. MethodsAn enhanced ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed. ResultsThere were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 min) and time from surgery to discharge (2.4-hours). The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised. ConclusionIn healthcare systems not overwhelmed by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients.

Nasal Bone Fractures: Differences Amongst Sub-Specialty Consultants.

Nasal fractures constitute the largest proportion of facial trauma each year, however, there is no consensus management. In this study, we investingated the role of the consultant and the functional and aesthetic outcomes of procedures performed to address nasal bone fractures. A retrospective chart review of patients who sustained nasal bone fractures was conducted from 8/1/14 through 1/23/18. Categorical variables were analyzed using chi-squared testing and Fisher's exact test, where appropriate, while continuous variables were compared using Mann-Whitney U testing. During the study period, 136 patients met inclusion criteria for full analysis. The mean age of this cohort was 47.6 ± 20.2 years with the majority identifying as African-American (53.7%) and male (67.2%). Otolaryngologists were significantly more likely to assess pre-operative nasal obstruction (100%) compared to plastic surgeons (24.1%) (P < .001). Otolaryngology elected operative management (53.3%) at a significantly higher rate than plastic surgery (24.1%) (P = .005). Additionally, otolaryngology was significantly more likely to manage patients in an outpatient setting (91.2%), whereas plastic surgery more commonly performed inpatient management (57.1%) (P = .006). Plastic surgery averaged a significantly shorter amount of time from presentation to operative management (7.3 ± 10.7 days) compared to otolaryngology (20 ± 27.7) (P = .019). Consulting service was not associated with a need for revision surgery. Consultants across subspecialties differ in the management of nasal bone trauma. A more standardized approach is warranted by all individuals involved in the care of maxillofacial trauma patients.

Evaluation of quality of care in trauma patients using international scoring systems

ObjectiveTo evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DesignA retrospective observational study was carried out over a 66-month period. BackgroundThe study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PatientsAll severe trauma patients (Injury Severity Score≥16 and/or Revised Trauma Score<12) aged >14 years were included. Variables of interestMedical care data were prospectively recorded. The “W” statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer–Lemeshow test and GiViTI calibration belt, respectively. ResultsA total of 1240 patients were included. Survival at hospital discharge was 81.9%. The “W” scores for the TRISS, TRISS 2010 and PS14 models were +6.72 (P<.01), +1.48 (P=.08) and +2.74 (P<.01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P>.05). Both the Hosmer–Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. ConclusionsThese models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed.

Prehospital care of trauma patients in Tanzania: medical knowledge assessment and proposal for safe transportation of neurotrauma patients.

A descriptive, cross-sectional survey of individuals involved in prehospital transportation of neurotrauma patients was performed. Little is known about prehospital care of neurotrauma patients in low- and middle-income countries. This study sought to assess the knowledge of prehospital transporters in Tanzania and propose an educational intervention to help identify patients with severe neurotrauma. Dar es Salaam, Tanzania. Surveys assessed demographic information and medical knowledge with three outcomes of identifying signs of a deceased, sick, or clinically deteriorating patient. Predictors of increased medical knowledge were investigated with univariate and multivariate logistic regression (MLR). The survey included 501 participants, who were predominantly young (mean: 36.7 years) and male (84.0%). More than 70% of participants self-reported being able to recognize a deceased or sick patient, yet fewer than 20% correctly listed more than two signs of a deceased, sick, or clinically deteriorating patient. MLR showed that first aid training (Odds ratio (OR): 2.3; 95% confidence interval (CI): 1.3, 3.9; p = 0.002) was predictive of identifying a deceased patient, being employed (OR: 0.5; 95% CI: 0.3, 0.9; p = 0.021) was a negative predictor of identifying a sick patient, and higher education level (OR: 2.3; 95% CI: 1.1, 4.8; p = 0.032) was predictive of identifying a clinically deteriorating patient. In a survey of prehospital transporters of neurotrauma patients in Tanzania, higher education level and first aid training were associated with higher medical knowledge scores. An educational flier was created to identify severe neurotrauma patients. Additional education of prehospital transporters in Tanzania may improve morbidity and mortality of neurotrauma patients.

Abstract 1: Is Chief Resident Operative Volume Associated with Milestone Competency Achievement?

Background: The Milestone program in Plastic Surgery was established to promote competency-based achievement in resident education. However, despite the widespread belief that clinical exposure is fundamental to competency achievement, little is known about the association between Plastic Surgery Milestone achievement and resident operative volume. The authors sought to build upon prior investigation that highlighted the absence of a significant association between chief resident cosmetic case volume and respective Milestone achievement by exploring the relationship between chief resident case volume and respective reconstructive and general Milestone competencies. Methods: A retrospective review of operations performed by eight chief residents at a single training program graduating from 2015 to 2018. Reconstructive cases were isolated and classified by type of operation, and total cosmetic and reconstructive operative volumes were calculated for each resident. The association between operative volume and levels of achievement in respective Milestone competencies was performed using Spearman’s rank correlation coefficient (p < 0.05). Results: Chief residents performed an average of 139.3 (29.0) operations at our primary training center, which was comprised of 94.6 (21.0) reconstructive operations and 44.6 (11.6) cosmetic operations. No significant association existed between chief year reconstructive case volume and patient care or medical knowledge Milestone achievements in the following areas: tissue transfer, congenital anomalies, head and neck, maxillofacial trauma, breast reconstruction, trunk and perineum, non-trauma hand, and lower extremity (p > 0.05). While upper extremity trauma patient care was also not significantly associated with relevant operative volume (r = -0.42, p = 0.31), upper extremity trauma medical knowledge had a significant negative association with relevant operative volume (r = -0.86, p = 0.01). Furthermore, there was no significant association between surgical care, wound care, or general practice competencies and total number of reconstructive and cosmetic cases (p > 0.05). Conclusion: With the exception of upper extremity trauma medical knowledge, the present study found no significant association between operative volume and Milestone achievements, suggesting that attainment of Milestone competencies relies on factors beyond operative volume alone. Further investigation is needed to evaluate the relationship between operative volume and competency achievement as residents progress through earlier years of training.

Emerging hemorrhage control and resuscitation strategies in trauma: Endovascular to extracorporeal.

This article reviews four emerging endovascular hemorrhage control and extracorporeal perfusion techniques for management of trauma patients with profound hemorrhagic shock including hemorrhage-induced traumatic cardiac arrest: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, extracorporeal life support, and emergency preservation and resuscitation. The preclinical and clinical studies underpinning each of these techniques are summarized. We also present an integrated conceptual framework for how these emerging technologies may be used in the future care of trauma patients in both resource-rich and austere environments.

Beyond the Crossroads: Who Will be the Caretakers of Vascular Injury Management?

Beyond the Crossroads: Who Will be the Caretakers of Vascular Injury Management?

Brief report on combat trauma surgical training using a perfused cadaver model.

Surgical combat casualty care presents difficult training challenges. Although several high-fidelity simulation (SIM) techniques have emerged, none are able to fully integrate the many intricacies involved in the care of a complex trauma patient. Herein, we report the use of perfused fresh human cadaver model for training and assessment of forward surgical teams (FSTs). Forward surgical teams attend a 4-day combat trauma surgical skills course including focused on trauma exposures. A half-day SIM involves the entire surgical team in four sequential surgical scenarios that involve the neck, chest, abdomen, and extremities, as well as airway management and resuscitation. Teams undergo immediate debriefing and videotape review of team dynamics and technical skills, as well as times to completion of critical interventions. The data evaluated include five initial demonstration courses in which training metrics were available. Each team included both a junior and experienced surgeon, anesthesiologists, and surgical scrub technicians. As FSTs progressed through SIMs, they demonstrated improvements in team dynamics and technical skills evaluations. There was considerable variability in the times to completion of critical intervention, particularly for control of cardiac and vascular injuries. Initial evaluations support the use of this novel perfused cadaver model for the training and evaluation of military FSTs. Preliminary data highlight the utility for open vascular, thoracic, and other high-acuity/low-volume procedures critical to combat casualty care. Larger studies are needed for model optimization and further validation of an objective structured technical assessment tool. Care management, level V.

Unlocked yet untapped: The ubiquitous smartphone and utilization of emergency medical identification technology in the care of the injured patient

BackgroundSmartphones allow users to store health and identification information that is accessible without a passcode—conceivably invaluable information for care of unresponsive trauma patients. We sought to characterize the use of smartphone emergency medical identification applications and hypothesized that these are infrequently used but positively perceived. MethodsWe surveyed a convenience sample of adult trauma patients/family members (nonproviders) and providers from an urban Level I trauma center during July 2018 on their demographics and smartphone emergency medical identification application usage. Descriptive and chi-square/Fisher exact analyses were performed to characterize the use of smartphone emergency medical identification applications and compare groups. Results338 subjects participated; most were female (52%) with median age of 36 (29–48). 182 (54%) were providers and 306 (91%) owned smartphones. 157 (51%) owners were aware smartphone emergency medical identification existed, but only 94 (31%) used it. 123 providers encountered unresponsive patients with smartphones, but only 26 (21%) queried smartphone emergency medical identification, with 19 (73%) finding smartphone emergency medical identification helpful. All 8 (100%) nonproviders who reported to have had their smartphone emergency medical identification queried believed it was beneficial. There were no differences between groups in smartphone emergency medical identification awareness and utilization. ConclusionSmartphone emergency medical identification technology is underused despite its potential benefits. Future work should focus on improving education to use this technology in trauma care.

Discussion on the Valuable application of Healthy Education Nursing Care before Ultrasound Examination

Objective To analyze the effect of health education on the nursing care for ophthalmic trauma patients. Methods Our hospital randomly selected 80 patients who underwent ultrasound examination from September 2017 to September 2018. According to the patients' consultation sequence numbers, they were divided into control group and observation group, with 40 cases per group. The patients in control group were only given ultrasound examination and routine guidance. The patients in observation group were given health education nursing care before ultrasound examination. The ultrasound examination time, anxiety and depression, as well as compliance of examination, health knowledge and nursing satisfaction were compared between the two groups. Result Compared with the data of the patients in the control group, the anxiety and depression of the patients in the observation group were significantly improved after health education. In the observation, the patients' mastery of health knowledge, compliance of examination and examination nursing satisfaction were all higher and the ultrasound examination time was shorter than that in the control group. The difference between the two groups was statistically significant (P &lt; 0.05). Conclusion Healthy education nursing care can effectively improve the anxiety and depression of patients undergoing ultrasound examination, enhance the compliance of patients and shorten the ultrasound examination time, making the quality of clinical ultrasound examination recognized and satisfied by patients.

The timeline of information exchange: a service evaluation of London Ambulance Service NHS Trust's front line communication and emergency response to Exercise Unified Response.

Introduction:Exercise Unified Response, Europe’s largest major incident training exercise to date, provided a rich environment for the emergency services to test their multi-agency crisis response capabilities. Supported by the London Ambulance Service NHS Trust, this service evaluation examined London Ambulance Service NHS Trust front line communication and decision-making via body-worn camera footage.Methods:Twenty London Ambulance Service NHS Trust front line responders and evaluators were each equipped with a body-worn camera during Exercise Unified Response. The service evaluation aimed to: (a) produce timelines of the London Ambulance Service NHS Trust’s response in order to identify key events and actions during the ‘golden hour’ (the crucial first hour in the care of trauma patients), the proceedings of command meetings and the multi-agency response; and (b) develop recommendations for future training and evaluations.Results:The service evaluation identified that, within the golden hour, London Ambulance Service NHS Trust first responders rightly and rapidly declared the event a major incident, requested resources and assigned roles. Triage crews were tasked quickly, though it was identified that their efficiency may be further enhanced through more detailed triage briefings prior to entering the scene. The command meetings (led by the Metropolitan Police) lacked efficiency, and all agencies could make more effective use of the multi-agency shared radio network to address ongoing matters. Finally, London Fire Brigade and London Ambulance Service NHS Trust teams demonstrated clear communication and co-ordination towards casualty extraction.Conclusion:Successful multi-agency working requires clear communication, information sharing and timely command meetings. It is recommended that Joint Emergency Services Interoperability Principles multi-agency talk groups should be utilised more frequently and used to complete a joint METHANE report. In addition, training in areas such as communication skills and detailed briefings will enhance the front line response. Finally, body-worn cameras are shown to be an effective service evaluation tool, as a basis for promoting best practice as well as highlighting areas for future training and evaluations.

Does Caring for Trauma Patients Admitted to Emergency Departments Need Advanced Communication Skills? A Quasi-Experimental Study of Nurses' Communication Audit

Background: Communication increases awareness of patient problems, productivity and job satisfaction, improving decision-making in patient discharge and transfer, and reducing hospital stay duration, medical costs, and nurses’ stress and burnout. Objectives: This study aimed to audit the communication of nurses with trauma patients in the emergency department. Methods: This quasi‑experimental study was conducted at the Baqiyatallah University of Medical Sciences in 2018. The data collection tool was a valid and reliable checklist for nurses' communication skills with trauma patients with 3 subscales and 31 items. Before the intervention, 35 nurses who were randomly selected were evaluated based on the communication checklist, and then the collected data was analyzed. Based on the results and the assessment of weaknesses, the necessary training was provided to the nurses. After the intervention, the participants' communication skills were analyzed using the same checklist and the results were compared. Descriptive statistics and parametric tests such as paired T-test were used to analyze the data. Results: The means age of participants was 39.5±9.3 years, and the majority of them were males.The mean scores of communication status before and after intervention were (10.00±3.29) and (26.26±2.30), respectively, among the 35 participating nurses. There was a significant difference between pre-and post-intervention (p <0/001) in terms of total communication skills scores, indicating the effectiveness of the intervention. Conclusion: The audit of nurses' communications with patients in the emergency department as well as training based on the improvement of weaknesses may be effective in improving nurses’ communication skills, and this may promote the level of communication skills, behavioral changes, and positive effects on the clinical situation of trauma patients.

103: Treatment of placenta accreta spectrum (PAS) utilizing a standardized multidisciplinary approach: The Obstetrics-Trauma Team

To describe the impact of implementing an obstetrics-trauma multidisciplinary surgical team on Placenta Accreta Syndrome (PAS) outcomes among patients seen at a high-risk Maternal Care Facility and Level I Trauma Center within a safety net community hospital in Florida. A retrospective chart review of patients, between the ages of 22 and 43 years old, with a confirmed diagnosis of PAS who were seen between the years 2013 and 2019 was conducted. Blood transfusion, hospital readmission within 6 weeks, maternal and fetal survival, estimated blood loss and common risk factors were examined pre- and post-implementation. Twenty-one patients were included in this study; ten in the pre-period and eleven in the post-period. The average maternal age at birth was 32 and 35 years old in the pre and post period, respectively. All patients in the pre-period had a history of cesarean section (CS) compared to 82% in the post-period. The average number of prior CS was similar between the two periods (mean=2). When examining outcome measures, results showed that after implementation of the multidisciplinary team approach, a reduction in the proportion of blood transfusions were observed (63.6% vs. 77.8%; p=0.64). There was also a reduction in estimated blood loss (-2212.7; p=0.14). In terms of survival, maternal survival increased from 90% in the pre-period to 100% in the post-period (p=0.48), and fetal survival remained at 100%. PAS-related critical illness shares several similarities to the care of trauma patients. In the setting of a community hospital where Gynecologic Oncology or surgically trained Maternal Fetal Medicine physicians are not available, Trauma surgeons involvement can be vital in reducing morbidity and mortality in a team setting. Results of our study suggest the benefit of a multidisciplinary surgical team in a PAS program. Incorporation of the multidisciplinary team may prove beneficial for centers dedicated to caring for these high risk deliveries in a community setting; however, further research is warranted.

Variations in Revenue Generation for the Care of Orthopaedic Trauma Patients

In the background of increasing competition between trauma centers, this study investigated the relative reimbursement of trauma care provided in an urban trauma setting, comparing patients previously unknown (new) to the system, representing potential sources of new revenue, and those who were known (established), having received medical care previously in the same system. A retrospective review of 440 patients with high-energy fractures at a single level 1 trauma center was conducted. Payment to charge (P/C) ratios for professional and facilities services within 6 months of injury were calculated. Mean professional charges per patient were $35,522 and $30,639 (P = 0.11), between new and established patients, respectively, whereas mean professional payments were statistically different, $7,894 and $4,365 (P < 0.001). Mean differences in P/C for facilities payments for new and established patients were not statistically significant, but professional P/C was higher in new patients (P < 0.001), consistent with better insured patients. Insurance companies reimburse for professional or facilities services with statistically different P/C ratios. Treating new patients at our institution likely benefits our institution by offering exposure to a more favorable payer mix and more complex patients. Retrospective level III.

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients

Hospital-based care of pediatric trauma patients includes transitions between units that are critical for quality of care and patient safety. Using a macroergonomics approach, we identify work system barriers and facilitators in care transitions. We interviewed eighteen healthcare professionals involved in transitions from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU. We applied the Systems Engineering Initiative for Patient Safety (SEIPS) process modeling method and identified nine dimensions of barriers and facilitators – anticipation, ED decision making, interacting with family, physical environment, role ambiguity, staffing/resources, team cognition, technology and characteristic of trauma care. For example, handoffs involving all healthcare professionals in the OR to PICU transition created a shared understanding of the patient, but sometimes included distractions. Understanding barriers and facilitators can guide future improvements, e.g., designing a team display to support team cognition of healthcare professionals in the care transitions.