Community Trauma Center Research Articles

Cost Savings of Whole Blood Versus Component Therapy at a Community Level 1 Trauma Center.

Blood product component-only resuscitation (CORe) has been the standard of practice in both military and civilian trauma care with a 1:1:1 ratio used in attempt to recreate whole blood (WB) until recent data demonstrated WB to confer a survival advantage, leading to the emergence of WB as the contemporary resuscitation strategy of choice. Little is known about the cost and waste reduction associated with WB vs CORe. This study is a retrospective single-center review of adult trauma patients admitted to a community trauma center who received WB or CORe as part of their massive transfusion protocol (MTP) resuscitation from 2017 to 2021. The WB group received a minimum of one unit WB while CORe received no WB. Univariate and multivariate analyses were completed. Statistical analysis was conducted using a 95% confidence level. Non-normally distributed, continuous data were analyzed using the Wilcoxon rank sum test. 576 patients were included (201 in WB and 375 in CORe). Whole blood conveyed a survival benefit vs CORe (OR 1.49 P < .05, 1.02-2.17). Whole blood use resulted in an overall reduction in products prepared (25.8%), volumes transfused (16.5%), product waste (38.7%), and MTP activation (56.3%). Cost savings were $849923 annually and $3399693 over the study period. Despite increased patient volumes over the study period (43.7%), the utilization of WB as compared to CORe resulted in an overall $3.39million cost savings while improving mortality. As such, we propose WB should be utilized in all resuscitation strategies for the exsanguinating trauma patient.

Whole Blood Trauma Resuscitation in Community Trauma Centers Confers Survival Benefit Over Component Therapy.

Whole blood (WB) for trauma resuscitation in civilian populations has become more common. The utilization of WB in community trauma centers has not been reported. Previous studies have centered around large academic medical centers. We hypothesized that WB-based resuscitation compared to component-only resuscitation (CORe) would demonstrate a survival benefit and that WB resuscitation is safe, feasible, and benefits trauma patients regardless of setting. Our results indicate that receiving whole blood during resuscitation conferred a clear survival benefit to discharge, and this benefit was independent of ISS, age, gender, and initial SBP. We conclude WB should be incorporated into all resuscitation protocols for exsanguinating trauma patients and preferred over component therapy in all centers treating trauma patients.

Computed Tomography Autopsy: A 12 Year Experience at a Community Trauma Center

Introduction: Post-mortem computed tomography (CT) has failed to gain traction in the United States. CT is readily available and well understood by all surgeons who take care of trauma patients. To our knowledge, there are no published reports on the routine use of post-mortem CT for performance improvement. Methods: Beginning in 2008, trauma patients who expire in our ED have undergone whole body non-contrast CT. These studies are reviewed immediately to evaluate our resuscitation efforts. They are all presented at our monthly trauma conference. Results: Seventy-two patients had CT autopsies and 35 of these had autopsies (47%): 66% were blunt and 33% were penetrating injuries. Probable cause of death was established by CT in 70 of the patients and 2 appeared to have non-fatal injuries suggesting a medical cause. Fifty-six of sixty-two (90%) chest tubes placed were in functional position; 4 were in the subcutaneous tissue, 1 in the lung and 1 below the diaphragm. Of the 31 needle decompressions present on CT, 27 (88%) did not reach the pleura, including one death from tension pneumothorax. One needle, from a lateral attempt, was in the liver. Seventy patients had airways placed; of these, one ET tube was in the right main stem bronchus and one king airway was in the subcutaneous space of the hypopharynx. Conclusion: Post-mortem CT is easy to obtain, carries no risk of communicable disease and is free of cultural objections. The information obtained is the only practical way to assess our efforts in these most critically injured patients.

Implementation of a Provider in Triage and Its Effect on Left without Being Seen Rate at a Community Trauma Center.

IntroductionEmergency department (ED) overcrowding is a nationally recognized problem and multiple strategies have been proposed and implemented with varying levels of success. It has caused patients to present to the ED but leave without being seen (LWBS). These patients suffer delayed diagnosis, delayed treatment, and ultimately increased morbidity and mortality. In efforts to decrease the number of patients who leave without being seen, one proposed solution is to place a provider in triage to evaluate these patients at the initial point of contact.MethodsA retrospective chart review was conducted on patient’s presenting to the Emergency Department from October through January for the years 2013 through 2017. A list of all patient dispositions for each study month was analyzed and compared for the 4 consecutive years with the implementation of an Advanced Practice Provider (APP) in triage.ResultsA total of 2162 patients dispositioned as LWBS during the entire study period of October 2013 through January 2017 were enrolled in the analysis. After implementation of a provider in triage, there was a 39% overall decrease (95% CI 0.005) in patients who left the ED before completion of treatment. There was a 69% reduction (95% CI 0.005) in patients who left before seeing the provider in triage. After seeing the provider, we saw an 83% reduction (95% CI<0.001) in LWBS. Overall, our initial LWBS rate was found to be 5%, and after implementation of a provider in triage that rate decreased to 1%.DiscussionThe addition of a provider in triage decreased our LWBS rate from 5% to 1%. The addition of a provider in triage also helped identify sick patients in the waiting room and helped facilitate more rapid assessment of ED patients on arrival.

Burnout and Anxiety Among Trauma Nursing Specialties in a Rural Level I Trauma Center.

Burnout and anxiety compromise physical and mental well-being of nurses and jeopardize patient safety. Personal, professional, and workplace characteristics have been associated with burnout and anxiety across diverse practice settings, yet none in rural, community trauma centers. We sought to identify the severity and predictors of burnout and anxiety in the trauma nursing staff of a rural Level I trauma center. A convenience sample of trauma nurses from the emergency department (ED), intensive care unit (ICU), and trauma ward was voluntarily surveyed using a demographic questionnaire, the Maslach Burnout Inventory (MBI) subscales: depersonalization (DP), emotional exhaustion (EE), and reduced personal accomplishment, as well as the Generalized Anxiety Disorder seven-item (GAD-7) scale. Multivariable linear regression identified the significant predictors of burnout and anxiety. Ninety-six nurses completed surveys (response rate: 83.5%). Married or divorced status, and ICU or trauma ward job assignments were associated with significantly lower adjusted DP scores. Thus, the model-predicted score for a single ED nurse was 15 versus a predicted score of 7 for a divorced ICU or trauma ward nurse, p < .001 for each group. The GAD-7 model demonstrated that race/ethnicity (Asian compared with White, coefficient: -5.06, p = .03), number of children (2 compared with 0, coefficient: -2.54, p = .02), and job tenure (5-10 years vs. <2, coefficient: -3.18, p = .01) were each associated with fewer GAD-7 points. Depersonalization and anxiety vary across the trauma nursing workforce based on identifiable personal and work-related risk factors. Group-specific, targeted interventions are needed to effectively reduce burnout and anxiety in trauma nursing staff.

Institutional differences in management of compartment syndrome at academic and community-based trauma centers: A survey of Orthopaedic Trauma Association (OTA) members.

Objectives:The purpose of this study was to compare management of compartment syndrome at academic and community trauma centers and to identify any institutional variables that influence the number of adverse events reported to the hospital's peer review process.Design:Web-based survey.Setting:N/A.Participants:Orthopedic Trauma Association (OTA) members.Methods:A link to a 9-item web-based questionnaire was sent to members of the OTA.Results:Two hundred twenty-four (21%) of 1031 OTA members completed the survey. Respondents indicated that residents were primarily responsible for checking compartments at academic trauma centers (91%), while community trauma centers reported higher utilization rates of ortho attendings (81%), trauma attendings (26%), and nurses (27%). Seventy-five percent of respondents at academic trauma centers relied on intra-compartmental pressure monitoring to make the diagnosis in intubated/obtunded patients as opposed to just 56% of respondents at community centers. Seventy percent of all respondents utilizing prophylactic fasciotomies practiced at community trauma centers. Forty-four percent indicated that they had submitted cases involving management of compartment syndrome to their hospital peer review process. While most submitted only 1 or 2 cases (75% of positive replies), 5% had submitted 5 or more cases for peer review. Use of a pressure monitor and orthopaedic surgeons performing all fasciotomies were associated with a lower number of cases submitted to peer review (P < .02 and P < .04, respectively).Conclusion:Academic and community trauma centers differ in their utilization of in-house staff for early assessment, in the diagnostic modalities employed in obtunded patients, and in their threshold for fasciotomy. Adverse events are regularly reported for peer review at both academic and community trauma centers. As there is great variability between institutions in terms of clinical practice as demonstrated by the responses to this survey, it is recommended that institutions devise their own written protocol based on the resources they have available to reduce adverse events.Level of Evidence:Therapeutic Level V.

Assessment of the “Wisconsin Criteria” for Obtaining Maxillofacial Computed Tomography in Trauma Patients at a Community Trauma Center

Assessment of the “Wisconsin Criteria” for Obtaining Maxillofacial Computed Tomography in Trauma Patients at a Community Trauma Center

Implementation of a Comprehensive Geriatric Pathway in a Community Trauma Center Facilitates Discharge Home

Rich, Preston B. MD, FACS, MBA; Donley, Dustin K. MD; Harbour, Lori F. BS, NRP; Marcum, Stephanie R. PAC; Guilford, Kelly M. BSN, RN, CSTR; Watts, Dorraine PhD, RN; Davies, Caitlyn J. DPT, PT; Cundiff, Ashley BSN, RN, CCRN, TCRN; Hanrahan, Brian W. MD; Torbert, Jesse T. MD Author Information

Effect of a 6 am-9 am Dedicated Orthopaedic Trauma Room on Hip Fracture Outcomes in a Community Level II Trauma Center.

To assess the outcomes of elderly hip fracture surgeries performed 12 months before and 12 months after the implementation of a daily 6 am-9 am dedicated orthopaedic trauma room (DOTR) at a Level II community trauma center. Retrospective cohort study. Level II academic trauma center. A total of 431 consecutive trauma patients undergoing surgical management of isolated low-energy hip fractures from January 1, 2018, to December 31, 2019. Implementation of a 6 am-9 am DOTR Monday through Friday. Time to surgery, number of cases performed after hours, surgical time, 90-day morbidity and mortality, and time to therapy. Retrospective analysis showed that despite a 24% increase in surgical hip fracture volume, implementation of a part-time DOTR led to a decrease in after-hours surgery (32.4% vs. 19.6%; P = 0.008) and patients requiring the intensive care unit postoperatively (7% vs. 3.8%; P = 0.036). Surgeries performed after hours were longer than that of surgeries performed during the daytime (82.0 vs. 68 minutes; P = 0.003) and had more complications (pneumonia, pulmonary embolism, and surgical site infection; P = 0.002, 0.047, 0.024, respectively). Our results show that a part-time DOTR in a community Level II hospital is associated with improvement in patient care. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Implementation of an Alcohol Screening, Brief Intervention, and a Referral Program at a Community Level II Trauma Center.

Trauma is the leading cause of years of potential life lost in the United States. Alcohol and drug use is a significant contributing factor. In 2017, a Level II community trauma center was achieving less than 80% screening rate compliance utilizing blood alcohol level as a screening method for trauma patients. The purpose of this article is to evaluate the implementation of a screening, brief intervention, and a referral-to-treatment service program. In 2018, the trauma program adopted structured interviews as a screening method for trauma patients. The injury prevention coordinator conducted structured interviews as a screening method for trauma patients who met inclusion criteria. High-risk patients were referred to the social worker, who conducted a brief evaluation with subsequent referral to treatment. One year after the implementation of a structured interview approach, 1,021 trauma patients met inclusion criteria for this retrospective evaluation. From 2017 to 2018, the program observed an 86% statistically significant increase in screening using the structured interview SBIRT program (p < .0001) compared with the prior alcohol-level screening approach. On the basis of these data, a structured interview screening method demonstrated a significant improvement in screening compliance rates.

Establishing a Geriatric Hip Fracture Program at a Level 1 Community Trauma Center.

Establishing a Geriatric Hip Fracture Program at a Level 1 Community Trauma Center.

Establishing a Geriatric Hip Fracture Program at a Level 1 Community Trauma Center.

Traditional care of patients with geriatric hip fracture has been fragmented with patients admitted under various specialty services and to different units within a hospital. This produces inconsistent care and leads to varying outcomes that can be associated with increased length of stay, delays in time from admission to surgery, and higher readmission rates. The purpose of this article is to describe the process taken to establish a successful geriatric hip fracture program (GFP) and the initial results observed in a single institution after its implementation. All patients 60 years or older, with an osteoporotic hip fracture sustained from a low energy mechanism (defined as a fall from 3-ft height or less), were included in our program. Fracture patterns include femoral neck, intertrochanteric, pertrochanteric, and subtrochanteric femur fractures including displaced, nondisplaced, and periprosthetic fractures. Preprogram data included all patients admitted from January 1, 2012, through December 31, 2014; postprogram data were collected on patients admitted between May 1, 2016, and May 1, 2018. Demographic characteristics of the populations were similar. After the GFP was implemented, the proportion of patients who were treated surgically within 24 and 48 hours increased. The average number of hours between admission and surgery significantly reduced from 35.2 to 23.2 hours. Overall length of stay was decreased by 1.8 days and readmission within 30 days of discharge was lower. Reasons for readmission were similar in both timeframes. The rate of inpatient death was similar in the two groups. Mortality within 30 days of surgery appeared somewhat higher in the post-GFP period. Our program found that, with the utilization of a multidisciplinary approach, we could positively influence the care of patients with geriatric hip fracture through the implementation of evidence-based practice guidelines. In the first 2 years after initiation of the GFP, our institution saw a decrease in time from admission to surgery, length of stay, and blood transfusion requirements.

Hospital-based Hip fracture programs: Clinical need and effectiveness

Hospital-based hip fracture programs are essential for effective, efficient care of elderly patients who have sustained hip fractures. Many of the gains in outcomes and patient survival are a result of such integrated care models. We review the rationale, elements, and benefits of such programs across the spectrum of inpatient centers, including low-volume and high-volume community hospitals and trauma centers.

End-tidal carbon dioxide on emergency department arrival predicts trauma patient need for transfusion, vasopressors, and operative hemorrhage control in the first 24 hours

Introduction: Predicting early need for trauma resuscitation is an important goal of trauma systems. Aim/Hypothesis: We sought to compare the predictive value of end-tidal carbon dioxide (EtCO2) compared to hemoglobin, shock index, systolic blood pressure, heart rate, and respiratory rate in determining transfusion requirement, need for operative hemorrhage control, or pressor use in the first 24 h after trauma alert activation. Materials and Methods: A convenience sample of trauma patients at a Level 1 community trauma center were enrolled. EtCO2 was measured via nasal cannula upon arrival, in addition to initial hemoglobin levels and vital signs. Once stable and competent, patients or families were consented. EtCO2 average over three measurements 3 min apart was used as the EtCO2 value. The electronic medical record was reviewed by a trained research associate who was not involved in the care of the patient to determine the need for transfusion, pressor use, or operative hemorrhage control within the first 24 h of hospitalization. Results: Fifty patients were enrolled, with a median age of 52 years. Seven patients required transfusion, pressor use, and/or surgical hemorrhage control. Vital signs between groups were statistically no different. The mean EtCO2 in patients requiring transfusion was 26.8 (19.5–34.1) versus 34.1 (31.8–36.3) in those who did not (P = 0.027). A cutoff value of EtCO2 ≤33 mmHg was 100% sensitive and 62.8% specific, with an area under the curve of 0.889. Conclusion: EtCO2 has a high sensitivity in predicting the need for intervention in trauma patients. Additional research is needed to determine further utility of this value in the triage and treatment of trauma patients. The following core competency statement: Patient care and Systems-based practice.

Implementing a REBOA Program Outside Large Academic Trauma Centers: Initial Case Series and Lessons Learned at a Busy Community Trauma Program

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an established adjunct to hemorrhage control. Prospective data sets are being collected, primarily from large high-volume trauma centers. There are limited data and guidelines, to direct the implementation and use of REBOA outside these highly resourced environments. Smaller centers interested in adopting a REBOA program could benefit from closing this knowledge gap. Methods: A clinical series of cases utilized REBOA at a busy community trauma center (ACS Level 2) from January 2017 to May 2018. Seven cases are identified and reported, including outcomes. Considerations and ‘lessons learned’ from this early institutional experience are discussed. Results: REBOA was performed by trauma and acute care surgeons for hemorrhage and shock (blunt trauma n = 3, penetrating trauma n = 2, no trauma n = 2). All were placed in Zone 1 (one was placed initially in Zone 3 then advanced). The mean (SD) systolic pressure (mmHg) before REBOA was 43 (30); post-REBOA pressure was 104 (19). Four of the patients were placed via an open approach, and three were percutaneous (n = 2 with ultrasound). All with arrest before placement expired (n = 3) and all others survived. Complications are described.Conclusions: REBOA can be a feasible adjunct for shock treatment in the community hospital environment, with outcomes comparable to large centers, and can be implemented by acute care and trauma surgeons. A rigorous process of improvement programs and critical appraisal are critical in maximizing the benefit in these centers.

Successful Interprofessional Approach to Development of a Resuscitative Endovascular Balloon Occlusion of the Aorta Program at a Community Trauma Center

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a relatively innovative procedure designed to control critical non-compressible torso hemorrhage. In the United States, this procedure is currently in active use at only a small number of trauma centers. ObjectiveWe describe how we developed our REBOA program at an independent academic-affiliated community trauma center. DiscussionThrough a close interprofessional and multidisciplinary collaboration led by emergency physicians and trauma surgeons, we were able to successfully develop our program. ConclusionsSuccessful implementation of a REBOA program requires close attention to multimodal training, interprofessional roles, team dynamics, financial considerations, and quality assurance processes to safely deliver this potentially life-saving procedure to our trauma patient population.

Does a Staged Posterior Approach Have a Negative Effect on OTA 43C Fracture Outcomes?

To determine whether multiple approaches pose an increased risk to fracture healing when compared with a standard single approach in the treatment of pilon (OTA 43C) fractures. Retrospective review of a prospective database. Level I academic trauma center and level II community trauma center. From January 1, 2005 to December 31, 2011, all records of patients treated for OTA 43C fractures of the distal tibia were reviewed. Patients were grouped according to multiple (posterior-anterior) and single (anterior-alone) approaches. Medical charts and surgical documentation were reviewed and postoperative computed tomography (CT) scans were examined for residual articular displacement and quantified. Ultimate union rate was correlated with approach strategy. Articular reduction was subdivided into 3 groups (<1, 1-2, and >2 mm). A total of 116 patients were identified as having had 43C fractures treated surgically with postoperative CT scans completed. Twenty-six fractures presented as an open injury. Of these 116 patients, 35 underwent staged fixation of the posterior malleolar component at an average of 2 days postinjury, followed by delayed anterior fixation at an average of 14 days postinjury. The remaining 81 patients underwent anterior fixation alone, on average 17 days postinjury. Twenty-one patients were lost to follow-up before 12 months. Of the 95 patients with sufficient follow-up (≥12 months), there were 24 nonunions. There was a statistically significant association of nonunion with staged posterior approach (40% vs. 19%, P = 0.015). CT reduction for staged posterior versus anterior-alone approach was not significantly different for any of the 3 categories (63% vs. 57% <1 mm, 31% vs. 26% 1-2 mm, and 6% vs. 17% >2 mm). In this series, there was no statistically proven benefit to combined surgical approaches to tibial pilon fractures with regard to the quality of articular reduction. It appears from this investigation that there may be a significantly higher risk of nonunion associated with the addition of the staged posterior approach. Although articular reduction is of paramount importance, multiple approaches for direct reduction and fixation of all fragments may lead to further complications. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Experience gained by emergency medicine residents as members of the rapid response team

Objectives: Rapid response teams (RRTs) are multidisciplinary teams designed to respond to unstable patients within the hospital. Given the acuity of these patient encounters, this offers an opportunity to expose emergency medicine (EM) residents to a high concentration of experiences that are important for their training. This study was a retrospective observational study quantifying the value to an EM resident performing primary airway assessments while participating on the RRT. Methods: The study site is a community trauma center that hosts an EM residency. All RRT logs from 2008 to 2013 were reviewed by trained data abstractors. Abstractors recorded interventions performed by EM residents, which we a priori identified as endotracheal intubation, ordering of noninvasive positive pressure ventilation (NIPPV), placement of central vascular access, placement of intraosseous access, and/or ordering of resuscitative medications. Data were entered into a standardized Excel spreadsheet where abstractors chose from a closed list of possibilities and were analyzed with descriptive statistics. Results: One thousand nine hundred and eighty-four encounters were reviewed. 53.9% of patients had advancement in their level of care. 29.2% of rapid responses resulted in patient intubation and 17.8% of patients required initiation of NIPPV. In addition, 1.6% of patients required immediate placement of a central line and 0.4% required placement of intraosseous access. EM residents involved in the RRT ordered resuscitative medications in 17.2% of encounters. Conclusions: EM resident involvement on RRTs provides them exposure to a number of critical encounters and advanced procedures that are essential for their EM training. The following core competencies are addressed in this article: This article addresses the ACGME milestones pertaining to patient care as well as procedural skills.

Dabigatran Use Does Not Increase Intracranial Hemorrhage in Traumatic Geriatric Falls When Compared with Warfarin

Patients on anticoagulation are at increased risk for intracranial hemorrhage (ICH) after trauma. This is important for geriatric trauma patients, who are increasing in number, frequently fall, and often take anticoagulants. This study sought to evaluate whether prehospital use of dabigatran, a newer anticoagulant, is associated with outcome differences in geriatric trauma patients suffering falls when compared with warfarin. The registry of a Level II community trauma center was used to identify 247 patients aged 65 and older who sustained a fall while taking prehospital dabigatran or warfarin admitted between December 2010 and March 2014. Patients on warfarin were included if their International Normalized Ratio was therapeutic (2-3). About 176 of the 247 patients were then compared using coarsened exact matching. In the matched analysis, overall population means for age, Glasgow Coma Score, and Injury Severity Score were 83.5, 14.7, and 5.1, respectively. The overall rate of ICH was 12.5 per cent, with a mortality rate of 16.1 per cent for patients who sustained an ICH. There were no observed differences in ICH, hospital length of stay, intensive care unit length of stay, or mortality between patients taking prehospital warfarin or dabigatran.

Elderly fall patients triaged to the trauma bay: age, injury patterns, and mortality risk

BackgroundFalls in the elderly are a significant cause of morbidity and mortality. We sought to better categorize this patient population and describe factors contributing to their falls. MethodsThis is a retrospective review of geriatric patients presenting to a level 1 community trauma center. We queried our trauma database for all patients 65 years and older presenting with fall and triaged to the trauma bay from 2008 to 2013. Researchers reviewed the patients' trauma intake paperwork to assess mechanism, injury, and location of fall, whereas discharge summaries were reviewed to determine disposition, morbidity, and mortality. ResultsA total of 650 encounters were analyzed. Five hundred thirty-nine resided at home (82.9%), 110 presented from nursing homes or assisted living (16.9%), and 1 came from hospice (0.15%). Ninety-five patients died or were placed on hospice as a result of their falls (14.7%), of which 88 came from home. Controlling for Injury Severity Score, living at home was an independent risk factor for fall-related mortality (odds ratio, 3.0).Comparing the elderly (age 65-79 years; n = 274) and the very elderly (age ≥80 years; n = 376), there were no differences in Injury Severity Score (P = .33), likelihood of death (P = .49), likelihood of C-spine injury (P = 1.0), or likelihood of other axial or long bone skeletal injury (P = .23-1.0). There was a trend for increased likelihood of head injury in very elderly patients (P = 0.06). ConclusionPrevention measures to limit morbidity and mortality in elderly fall patients should be aimed at the home setting, where most severe injuries occur. Very elderly patients may be at increased risk for intracranial fall-related injuries.