Community Trauma Center Research Articles

Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls.

Elderly patients, with considerable fall risk, are increasingly anticoagulated to prevent thromboembolic disease. We hypothesized that a policy of prophylactic fresh frozen plasma (FFP) infusion in patients having falls would reverse vitamin K antagonists (VKAs) and that reversal would decrease delayed intracranial hemorrhage (ICH). A retrospective review of patients with trauma admitted to a level 2 community trauma center was performed from January 2010 until November 2012. Inclusion criteria were: ground level fall (GLF) with suspected head trauma, on VKA, an international normalized ratio (INR) of >1.5, and a negative head computed tomography (CT). Patients were transfused with FFP to a goal INR of <1.5 while observed. Patients were classified as reversed (REV) if the lowest INR achieved within 4 to 24 hours after initial INR was <1.5 or unreversed (NREV) if lowest INR achieved was >1.5. Chi-square and logistic regression were performed. A total of 194 patients met the criteria. In all, 43 (22%) patients were able to be REV, and 151 (78%) patients remained NREV. Unreversed patients were male and younger (P < .05). There was no difference in mean FFP received. Unreversed patients had a higher initial INR of 3.0 compared to REV patients (2.5; P = .018). One patient developed a delayed ICH and belonged to the REV group. The incidence of delayed hemorrhage was 0.5%. A strategy of prophylactic FFP infusion was ineffective in VKA reversal. We recommend against prophylactic infusion of FFP during a period of observation for patients on VKA with suspected head trauma and a negative initial CT.

Communication gaps in nursing home transfers to the ED: impact on turnaround time, disposition, and diagnostic testing

IntroductionThis study aims to determine the source of communication gaps in history of present illness (HPI), medical history, and advanced directives in nursing home (NH) patients transferred to the emergency department (ED). We also attempt to determine if these gaps create differences in patient turnaround time (TAT), disposition decision, or diagnostic testing. MethodsA convenience sample of patients transferred from NHs to a level 1 community trauma center was enrolled by the physicians caring for them. The physicians assessed the adequacy and source of the history for each patient. The patient's chart was then retrospectively reviewed to determine disposition, ED TAT, and diagnostic tests ordered. ResultsOne hundred patients were enrolled. Physicians found that NH paperwork contained adequate HPI 35% of the time. Patients could provide their own HPI 28% of the time. In 32% of patients, adequate HPI could not be obtained from the patient, NH paperwork, or NH personnel. Comparing patients in whom adequate HPI was available (n = 68) to those in whom HPI was not available (n = 32), there was no difference in TAT (146 vs 173 minutes, P = .22), admissions (60% vs 66%, P = .66), or diagnostic testing (P = .89-1.0). ConclusionEmergency department physicians often do not have adequate HPI in patients transferred from NHs. The absence of adequate information does not affect patient TAT, disposition decision, or ED diagnostic testing.

Shock index and early recognition of sepsis in the emergency department: pilot study.

Introduction:Screening for severe sepsis in adult emergency department (ED) patients may involve potential delays while waiting for laboratory testing, leading to postponed identification or over-utilization of resources. The systemic inflammatory response syndrome (SIRS) criteria are inaccurate at predicting clinical outcomes in sepsis. Shock index (SI), defined as heart rate / systolic blood pressure, has previously been shown to identify high risk septic patients. Our objective was to compare the ability of SI, individual vital signs, and the systemic inflammatory response syndrome (SIRS) criteria to predict the primary outcome of hyperlactatemia (serum lactate ≥ 4.0 mmol/L) as a surrogate for disease severity, and the secondary outcome of 28-day mortality.Methods:We performed a retrospective analysis of a cohort of adult ED patients at an academic community trauma center with 95,000 annual visits, from February 1st, 2007 to May 28th, 2008. Adult patients presenting to the ED with a suspected infection were screened for severe sepsis using a standardized institutional electronic order set, which included triage vital signs, basic laboratory tests and an initial serum lactate level. Test characteristics were calculated for two outcomes: hyperlactatemia (marker for morbidity) and 28-day mortality. We considered the following covariates in our analysis: heart rate >90 beats/min; mean arterial pressure < 65 mmHg; respiratory rate > 20 breaths/min; ≥ 2 SIRS with vital signs only; ≥2 SIRS including white blood cell count; SI ≥ 0.7; and SI ≥ 1.0. We report sensitivities, specificities, and positive and negative predictive values for the primary and secondary outcomes.Results:2524 patients (89.4%) had complete records and were included in the analysis. 290 (11.5%) patients presented with hyperlactatemia and 361 (14%) patients died within 28 days. Subjects with an abnormal SI of 0.7 or greater (15.8%) were three times more likely to present with hyperlactatemia than those with a normal SI (4.9%). The negative predictive value (NPV) of a SI ≥ 0.7 was 95%, identical to the NPV of SIRS.Conclusion:In this cohort, SI ≥ 0.7 performed as well as SIRS in NPV and was the most sensitive screening test for hyperlactatemia and 28-day mortality. SI ≥ 1.0 was the most specific predictor of both outcomes. Future research should focus on multi-site validation, with implications for early identification of at-risk patients and resource utilization.

Orthopaedic Trauma Career and Employment Horizons

The trauma opportunities: The numbers are 260 verified sites (American College of Surgeons), 1100 Centers performing as Regional or Community Trauma Centers currently in the continental 48 states, and 3256 hospitals performing in-patient orthopaedic surgery. Orthopaedic trauma surgeons still represent <10% of the total national surgeon complement. This component speaks to the demand side. Presently, there are >60 Traumatology Fellows annually. This represents the supply side that has the potential to graduate in 2013 and beyond. These individuals face a wide variety of career options not previously available to past generations, but one has to know the business model differentiators to be successful: employed-employee (most common, least sustainable historically); employed-partner; partner-contract for service; partner-private practice; private practice-hospital partner (least common, most productive).

The Effect of Education in Hospice and Palliative Care on Emergency Medicine Residents' Knowledge and Referral Patterns

To determine: (1) residents' knowledge base in key concepts in hospice and palliative care, (2) residents' comfort level in discussing end-of-life (EOL) care and managing EOL symptoms, and (3) if a brief educational intervention improves residents' knowledge of and comfort in dealing with EOL issues both immediately following and six months after the intervention. This prospective cohort study was performed at a level-1 community trauma center. A survey was developed regarding knowledge of palliative care and its emergency department (ED) utilization and administered to emergency medicine (EM) residents. Subsequently, residents underwent four hours of palliative care training. An identical post-education survey was administered immediately and then six months later. Education improved knowledge of hospice qualifying diagnoses which was maintained at six months. Improvement in residents' ability to convert between oral and intravenous formulations of opioids was not retained at six months. Education was not shown to improve EM residents' comfort in managing pain or dyspnea but it was shown to improve their comfort level in discussing EOL care with patients and families Inpatient hospice admissions from the ED increased 88% after the education. Identified barriers to providing palliative care in the ED decreased. There are gaps in EM residents' hospice and palliative care knowledge. Education is shown to improve and maintain knowledge of hospice qualifying diagnoses, comfort level in discussing EOL care with patients and families, and to increase inpatient hospice admissions from the ED.

A Systematic Approach to Very Important Person Preparedness for a Trauma Center

Hospitals across the United States are more involved in disaster/rapid response planning than ever. This collaboration is often driven by continuing federal and state preparedness and all-hazards planning efforts that provide cooperative agreement and/or grant support. These efforts currently include programs administered by the US assistant secretary for preparedness and response, the US Centers for Disease Control and Prevention, the US Department of Defense, and the US Department of Homeland Security. Beyond legislated support or mandates, key emergency management regulations governing hospital-specific disaster planning and response activities are required of hospitals by The Joint Commission, the largest national hospital accrediting body. Despite this ongoing, heightened awareness and inclusion of health care in local and regional emergency response planning, there is 1 partnership to yet strengthen: the relationship between community trauma centers and US Secret Service staff responsible for White House travel and health care contingency plans. One Michigan hospital system designed a program that has made preevent communications and preparedness for rapid very important person response with the Secret Service as important as other local all-hazards planning; the evolution of this partnership is the focus of this article.

Level I Verification Is Associated with a Decreased Mortality Rate after Major Torso Vascular Injuries

Major torso vascular injuries (MTVIs) are frequently fatal. Our purpose was to determine whether the American College of Surgeons' (ACS) trauma center level of verification was associated with reduced mortality rates in a rural population-based community trauma center. Patients with blunt and penetrating MTVIs were retrospectively reviewed. Mortality rates were compared between Level II and Level I verification time periods. The primary outcome measured was death from MTVIs. Two hundred seventy-four patients (blunt, 167 [61%]; penetrating, 107 [39%]) representing 1.5 per cent of all trauma admissions were studied. Mortality decreased from 41 of 80 (51%) (Level II) to 60 of 194 (31%) (Level I) (P = 0.002) for the entire group. Mortality reduction occurred primarily in the subgroup with blunt and penetrating thoracic injuries (Level II, 24 of 33 [73%] vs Level I, 25 of 82 [30%]; P < 0.001). A significant reduction was not observed in patients with major abdominal vascular injuries (Level II, 17 of 47 [36%] vs Level I, 35 of 112 [31%]; P = 0.581). Level I status was associated with an overall decreased mortality rate from MTVIs despite low patient numbers. The commitment of hospital resources that are required to achieve Level I ACS verification in a community hospital improves survival, particularly in patients with blunt and penetrating thoracic injuries.

Field Triage and Patient Maldistribution in a Mass-Casualty Incident

Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005. A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident. The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 "Immediate" patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 "Immediate" patients, two patients per center, while the 25 closest community hospitals offered to accept 75 "Immediate" patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients. The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for "Immediates", and that they were distributed about equally between community hospitals and trauma centers.

Identifying risk factors for medical injury

To examine multiple risk factors for medical injury using administrative data. This cross-sectional study used logistic regression models to examine associations among patient characteristics such as age, sex, and insurance payer status and hospital characteristics such as ownership, teaching status and trauma level, and comorbidities and presence of a medical injury diagnosis. Data were from the Bureau of Health Information: Wisconsin hospital in-patient discharge records and hospital characteristics for the year 2001. All Wisconsin non-federal, acute-care hospitals. A total of 556 899 patients discharged from 132 Wisconsin hospitals, excluding newborns, participated. None. Main outcome measure. Medical injury, defined as untoward harm to a patient as a result of a medical intervention, was determined using discharge diagnosis criteria. Medical injuries were found in 13.3% of 556 899 hospital discharge records. Covariates associated with increased risk of a recorded medical injury code included age 45-84 years, female sex, comorbidities, non-profit religious order ownership, proportion of cardiac intensive care in-patient days to total in-patient days, percent of board-certified medical staff, and community trauma center or regional trauma resource. This article describes an innovative analysis of risk factors for medical injury that controlled for numerous potential confounding factors, including hospital coding characteristics. The associations we found, such as increased risk of medical injury in women, can be used to generate hypotheses for further testing through other methods and suggest intervention points for patient safety efforts.

Establishing a collaborative trauma training program with a community trauma center for military nurses.

A mission of the Navy Nurse Corps is to deploy medical support for military forces on short notice. Navy nurses must possess a working knowledge of trauma management, but meeting this clinical experience is a challenge. Peacetime military hospitals do not routinely care for severely injured patients. This article describes how the Navy established a partnership with a Level 1 Trauma Center, the role and expectations for both Navy and civilian nurses, and an evaluation of the experience.

Nonoperative Management of Blunt Splenic and Hepatic Trauma in the Pediatric Population: Significant Differences between Adult and Pediatric Surgeons?

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.

Hot air balloon crash: An unusual incident in Oregon

O n a clear August Sunday morning, a hot air balloon crashed into a spruce tree during a landing attempt at a designated landing field in rural Donald, Ore. The balloon, carrying 1 pilot and 7 passengers, was on a commercial recreational flight. One passenger was pronounced dead at the scene, and the pilot and all the other passengers were transported to level I trauma centers with a variety of injuries. The pilot and 5 passengers were transported to our academic trauma center, and 1 passenger was transported to the community trauma center. This crash demonstrated that the mechanism of injury, estimated to be a 75-foot fall, predisposed the injured to spinal cord and other orthopedic injuries. Limited research is available about hot-air balloon crashes; however, it appears that more injuries are sustained during descent in recreational flights than during ascent or in professional flights and races. In the future, emergency nurses are likely to have more opportunities to care for patients injured in balloon crashes. Hot-air ballooning is one of the fastest-growing recreational and professional sports in America (for more information about this sport, see the following Web sites: Hot Air Balloons USA at www.hot-air balloons.com and World Balloon at www.worldballoon.com). The number of balloons registered with the Federal Aviation Administration in the United States increased from 6 in 1964 to 7123 in 1995, and between 1964 and 1995, 495 balloon crashes were reported. Ballooning takes place year-round; however, the peak season in North America occurs from March through October. Published data on hot-air balloon crashes are very limited. In this article, we report on one balloon crash. Hot Air Balloon Crash: An Unusual Incident in Oregon

Profile of pediatric bicycle injuries.

Bicycle injury data from local communities are important for developing injury prevention and control programs. This study represents the efforts of one community trauma center to describe bicycle injuries. We conducted a retrospective analysis of bicycle injury data from hospital charts, emergency medical services reports, and medical examiner reports. The review encompassed a 4-year period. The study sample included 211 trauma alert patients, ages 1 through 15 years, who were treated for bicycle-related injuries at our level II pediatric trauma center. Bicycle injuries accounted for 18% of all pediatric trauma alert patients. The mean age of injured children was 10 years, and 79% were males. Bicycle-motor vehicle collisions caused 84% of injuries. Only 3 children (1.4%) wore bicycle helmets. Resulting injuries included external wounds (86%), head injuries (47%), fractures (29%), and internal organs (9%). Six children died. Bicycle injuries are a significant cause of mortality and morbidity for children in our community. Use of safety helmets by child bicyclists is inadequate. The data from this study can be used as a baseline in testing the effectiveness of local and state interventions, including new legislation mandating helmet use by children in our state.

Reuse of external skeletal fixator components: effects on costs and complications.

Although many community hospitals and trauma centers reuse external fixator components, no published studies have examined the cost-effectiveness or the effect on the rate of complications of reuse. This study reports the preliminary results of a program for the reuse of selected components of external fixators at a trauma center. After removal from the patient, fixators were cleaned and examined by a single nurse responsible for the program. Components in good repair were returned to the operating room stock for reuse, whereas those showing specific signs of wear were discarded. No component was used more than three times. The medical center charged patients a loaner fee equal to the hospital's cost for reusable components of external fixators. Data were collected for all fixators applied in the 15 months before and after institution of the program (69 and 65 fixators, respectively). The overall mean hospital charge for a fixator decreased 32% as a result of the reuse program (from $4,067 to $2,791). For the two fractures most commonly treated with external fixation, the distal radius and tibial plafond fractures, the mean charge decreased 44 and 29%, respectively. The mean hospital cost for a fixator decreased 34% as a result of the program (from $1,864 to $1,238). There were no differences in the rates of reoperation or complications before and after institution of the reuse program. No patient had mechanical failure of a new or reused fixator body. The preliminary results of this program are encouraging. We recommend that institutions reusing these devices develop specific programs outlining criteria for reuse and guidelines for reprocessing devices for reuse. The results of this study represent an important first step in the validation of the efficacy and safety of reuse of external fixator components.

Alcohol Interventions in Trauma Centers

To the Editor. —Dr Gentilello and colleagues1focus on a major public health problem, alcohol-related injuries. is the third leading cause of death in the United States, most often the result of alcohol-related trauma. Survivors of alcohol-related injuries are common in community hospitals and trauma centers. Few health care institutions screen patients for alcohol, and many reasons and excuses are offered. Today these beliefs and attitudes must be addressed in each hospital considering starting to screen for alcohol. With that in mind, and as a direct result of American Medical Association (AMA) Resolution 190,2which states that the AMA encourages the development of alcohol screening programs for injured patients admitted to hospitals, the Center for Substance Abuse Treatment developed a treatment improvement protocol (TIP) entitled Alcohol and Other Drug Screening of Hospitalized Trauma Patients. A TIP is a series of documents the goals of which are to

THE FINANCIAL IMPACT OF INTENTIONAL VIOLENCE ON COMMUNITY HOSPITALS

The purpose of this study was to examine the financial impact of assault-related penetrating trauma. We specifically reviewed hospital charges and reimbursement data. Two hundred eleven patients were identified from our Trauma Registry in a 4-year period: 108 with firearm injuries and 103 with injuries related to cutting or piercing instruments. Assault-related penetrating injuries generated more than $2,000,000 in hospital charges. Sixty-seven percent of this amount was incurred by patients who had no source of third-party payment. Reimbursement covered only 30% of charges. There were no differences in demographics, procedures, or in insurance status, mean charges, and unpaid balances between patients directly admitted and those transferred from other hospitals. Financial losses incurred by community hospitals from the care of penetrating injuries are substantial, and must be borne by cost shifting or other strategies. No evidence of "dumping" was found among this group of patients. The specter of injury caused by intentional violence extends beyond urban trauma centers, and has a serious negative financial impact on community trauma centers.

Trauma Care Reimbursement:

Concern exists that per case payment using Diagnosis Related Groups (DRGs) inadequately pays trauma centers. In this study, 45 Trauma Resource Groups (TRGs), an alternative patient classification system based on the Injury Severity Score and patient age, is developed and compared to 172 Diagnosis Related Groups (DRGs) that include trauma diagnoses. TRGs were developed using 1983 Maryland trauma patient hospital discharge abstracts (n= 34,702), the same source used to assign a DRG. We compared estimated TRG and DRG payments to actual charges for 17,398 trauma cases treated during 1986 at five trauma centers and 18 community hospitals in the Central Maryland Metropolitan Statistical Area. The unexpected findings of this study are that an anatomic severity-based classification of hospital trauma discharges (TRGs) does not perform as well as DRGs in: 1) explaining variations in length of stay for trauma cases, or 2) assuring an appropriate distribution of revenues to regional trauma centers and community hospitals. Solutions discussed include segregating community hospital and trauma center costs in computation of average per case rate setting, and inclusion of physiologic and mechanism of injury parameters in prospective payment classification systems to increase explained variance of resource use.

Trauma Case Manager Development and Implementation as a Nursing Role in a Community Trauma Center

Trauma Case Manager Development and Implementation as a Nursing Role in a Community Trauma Center

The Management of Splenic Trauma in a Trauma System

Large teaching centers have reported splenic salvage rates of 40% to 50% in adults after splenic trauma. It is unknown whether similar salvage rates can be achieved safely in community trauma centers with a lower volume of patients and less experience. Between August 1984 and August 1988, 117 patients with splenic injury were treated at a level I center and 311 were treated at four level II centers. Splenectomy was performed in 252 patients (59%), splenorrhaphy was performed in 160 patients (37%), and 16 patients (4%) were observed. While the splenic salvage rate was higher at the level I center (50% vs 38%), selective splenorrhaphy was successful in the level II centers where the volume of splenic injury was lower (15 to 25 cases per year).