Trauma Center Hospital Research Articles

Diagnostic Outcome of Bone Marrow Aspiration in a Tertiary Hospital in Ondo State, Nigeria

Bone marrow examination is a vital study carried out to attain a positive diagnosis of hematological disorders in a resource low income country like Nigeria specifically in Ondo state. Bone marrow is a main spot of hematopoiesis. It is also a major tool used in diagnosis of non-hematological disorders. The main aim of this study is to examine the outcome of bone marrow aspiration in Ondo state. A retrospective 8 years study was carried out between 2012 till 2020 at the University of medical sciences (former Kidney care center, Trauma center and State specialist hospital, Akure) Ondo state. Age, sex, location of patients, bleeding disorders, various indications and diagnosis were analysed using SPSS version 23. A total of 115 bone marrow aspirations were done at University of medical sciences, Ondo. Majority of the patients were male (58.3%) while 41.7% were females. Most are aged above 45 (46.1%). The most common indication was Anaemia specifically the moderate anaemia (52.2%). Commonest diagnostic findings in our study was Leukemia (42%) followed by Megaloblastic anaemia and Multiple myeloma (12.1%). Given the increase in the prevalence of Megaloblastic anaemia and Iron deficiency anemia globally, our study showed high prevalence rate of leukemia specifically chronic myeloid leukemia. The predominance of leukemia among diagnostic findings in our study has been related to the proximity to tertiary health facility. Low number of cases of other diagnostic findings can be due to lack of accessibility to an improved health center especially those in the rural areas and low population of people in the state. Early diagnosis should be done for effective management of these hematological disorders. Good family support and improved health care system with well trained personnel will help in management of the disease.

The impact of COVID-19 lockdown on acute trauma patients seen at the National Hospital Trauma Centre Abuja, Nigeria.

Introductiontrauma is the leading cause of mortality in individuals less than 45 years. The principles of Advanced Trauma Life Support (ATLS) which is used around the world in resuscitation of trauma patients have been considered to be safe. However, the outbreak of corona virus disease 2019 (COVID-19) has affected the processes and characteristics of acute trauma patients seen around the world. This study is intended to determine the impact of COVID-19 lockdown on the acute trauma patients seen in a Nigerian trauma centre.Methodsthis is a cross-sectional observational study of trauma patients seen in the resuscitation room of the National Hospital trauma centre in Abuja, Nigeria, from 24th February,2020 to 3rd May, 2020. The participants were consecutive acute trauma patients who were grouped into two: five weeks preceding total lockdown and five weeks of total lockdown. Statistical analysis was done using the statistical package for social sciences (SPSS) version 24.0 while results were presented in tables and a figure.Resultsa total of 229 patients were recruited into the study with age range 1 to 62 years, mean age of 28 ± 13 and male to female ratio of 3.87. The patient volume reduced by 41.31% during the lockdown. Though motor vehicular crash (MVC) was the predominant mechanism of injury in both groups making up 37.65% and 23.88% respectively, penetrating assault was more during the lockdown period (17.91% versus 6.17%). The lockdown was further associated with more delayed presentation (52.24% versus 48.15%), more referrals (53.73% versus 32.72%), less severe injury score (29.6% versus 56.7%) and no death in the resuscitation room (0% versus 1.85%).Conclusiondespite the reduction in the volume of trauma presentations by 41.31%, patients got the required care with less mortality. Efforts should be directed at sustaining access to acute trauma care in all circumstances to reduce preventable trauma deaths.

A Cross-sectional Survey of Job Stress Among Nurses Working at National Hospital Trauma Centre, Abuja, Nigeria

Background: Job stress is recognized world-wide as a major challenge to workers’ health and their organizations. This study is intended to determine the work stress among nurses working in a Nigerian dedicated trauma centre. Methods: This is a cross-sectional study carried out at the trauma centre of a Nigerian tertiary institution from August to November 2017. All the nurses working in the trauma centre were included in the study. A structured, self administered questionnaire was used as the survey instrument. Data analysis was carried out using SPSS version 20.0. Results were presented in tables and figures. Results: A total of 80 nurses were enrolled in the survey with male to female ratio of 0.1, mean age of 34±2.3 and modal age group of 31-40years. The mean PSS was high (28.2). The major identified stressors were work load (50%) and lack of consumables (22.5%). Depression (2.5%) was recorded only in female respondents. Despite the high PSS, none of the respondents has had any psychological counselling in the past year. Conclusion: The perceived stress scale among the studied population was high, with virtually no formal Psychological support. Efforts should be made to include regular psychological counseling in this group of people. A follow up study is strongly recommended.

Trends in head injury associated mortality in Malawi.

To address the problem of surgical workforce deficiencies in Malawi, we partnered with local institutions to establish a surgical residency-training and educational program for local surgeons in 2009. While this program has improved trauma-associated outcomes, it is unclear whether, without additional system improvements, the management of traumatic brain injury (TBI) has similarly advanced. This study sought to describe trends of TBI-associated in-hospital trauma mortality at a tertiary trauma center in sub-Saharan Africa. We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi, from 2012 through 2017. Modified Poisson regression modeling was used to compare the risk ratio of TBI associated in-hospital death each year compared to the year 2012, after adjusting for relevant covariates. 87,295 patients were recorded into the KCH Trauma Registry. 3,393 patients with TBI were identified, and most TBI patients were young males. In 2013 (RR 0.66, 95% CI 0.48, 0.92) and 2014 (RR 0.57, 95% CI 0.41, 0.79), the adjusted risk ratio of in-hospital death decreased compared to 2012 when adjusted for age, sex, initial AVPU score, transfer status, and multisystem trauma. However, the adjusted risk ratio of mortality in 2015 (0.73, 95% CI 0.53, 1.02) plateaued, with relatively minor improvements in 2016 (0.72, 95% CI 0.54, 0.97) and 2017 (0.71, 95% CI 0.53, 0.96). A decrease in TBI associated mortality was associated with the establishment of a residency and educational training program for general surgery. This program increased available surgeons, improved critical care and trauma training, and integrated some neurosurgical training. However, improvements in outcomes plateaued in the last few years of the study, despite these enhancements to surgical care. The general surgery workforce must be supplemented with improved neurosurgical services and neurocritical care to decrease TBI-related mortality.

Impact of the COVID-19 pandemic on a trauma center of a university hospital in Japan

BackgroundThe Coronavirus disease 2019 pandemic caused the Japanese government to declare a State of Emergency on April 7, 2020. The aim of this study is to provide an overview of the effects of the pandemic on surgical cases at a university hospital trauma center. MethodsAn observational study was performed at a trauma center in a tertiary hospital in Tokyo, Japan. The number of surgeries was compared between two periods: a historical control period (Tuesday April 9 to Monday May 27, 2019) and the period of the Japan State of Emergency due to COVID-19 (Tuesday April 7–Monday May 25, 2020). Information on patient age, gender, and surgical diagnosis, site, and procedure was collected for cases operated on in each period. The number of trauma surgeries was compared between the two periods. Data from the two periods were compared statistically. ResultsThe total number of surgical cases was 151 in the control period and 83 in the COVID-19 period (including no cases with COVID-19), a decrease of 45.0%. There were significantly more surgeries for patients with hip fractures in the COVID-19 period (9 vs. 19, P < 0.001 by Fisher exact test). ConclusionsDuring the State of Emergency in Japan, the number of operations for trauma patients at the trauma center decreased, but surgeries for hip fracture increased.

Unplanned Reoperation Rate at a Government-Designated Regional Trauma Center in Gangwon Province

Purpose Determining appropriate ways to assess health care quality within the National Health Insurance System is of interest to both the Korean government and the medical community. However, in the trauma field, the number of indicators used to evaluate surgical quality is limited. Using data collected over 5 years at Wonju Severance Christian Hospital Trauma Center in Korea, this study aimed to determine whether the unplanned reoperation rate in the field of trauma surgery could be used to assess the quality of an institution’s surgical care. Methods In total, 665 general surgical procedures were performed at the Trauma Center in 453 patients with abdominopelvic injuries from January 2015 to December 2019. Data were collected from the Trauma Center’s data registry and medical records, and included information regarding patients’ demographic characteristics, the type of index operation, and the reason for unplanned reoperations. Results A total of 453 index operations were evaluated. The proportion of patients with an Injury Severity Score (ISS) >15 was 48–70% over the 5-year period, with an unplanned reoperation rate of 2.1–9.3%. Patients had an average ISS score of 17.5, while the average Abbreviated Injury Scale score was 2.87. Unplanned reoperations were required in about 7% of patients. The most common complications requiring reoperation were recurrent bleeding (26.9%), wound problems (26.9%), intestinal infarction (15.4%), and anastomosis site leakage (7.7%). The procedures most frequently requiring unplanned reoperations were bowel surgery (segmental resection, primary repair, enterostomy, etc.) (24.5%) and preperitoneal pelvic packing (10.6%). Conclusions The proportion of reoperations was confirmed to be affected by injury severity. Keywords: Wounds and injuries; Reoperation; Quality of health care

Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study.

We studied the safety of immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) after open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of 2 or more of the malleoli or syndesmosis without articular comminution) and attempted to identify risk factors for complications. Retrospective case-control study. Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area. Of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013 to 2018, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity score matching to identify 172 controls who were non-weight-bearing (NWB) and no range of motion for 6 weeks postoperatively. The groups did not differ significantly in age, body mass index, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, P = 0.85). IWBAT and IROM after ankle ORIF versus NWB for 6 weeks. Postoperative complications, including delayed wound healing, superficial or deep infection, and loss of reduction. There was no significant difference in total complications (P = 0.41), nonoperative complications (P = 0.53), or operative complications, including a loss of reduction (P = 0.89). We did not identify any factors associated with an increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or preinjury-assisted ambulation. We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight-bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight-bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Provider Perspectives on Early Psychosocial Interventions after Pediatric Severe Traumatic Brain Injury: An Implementation Framework.

This study created a framework incorporating provider perspectives of best practices for early psychosocial intervention to improve caregiver experiences and outcomes after severe pediatric traumatic brain injury (TBI). A purposive sample of 23 healthcare providers from the emergency, intensive care, and acute care departments, was selected based on known clinical care of children with severe TBI at a level 1 trauma center and affiliated children's hospital. Semistructured interviews and directed content analysis were used to assess team and caregiver communication processes and topics, prognostication, and recommended interventions. Providers recommended a dual approach of institutional and individual factors contributing to an effective framework for addressing psychosocial needs. Healthcare providers recommended interventions in three domains: (1) presenting coordinated, clear messages to caregivers, (2) reducing logistical and emotional burden of care transitions, and (3) assessing and addressing caregiver needs and concerns. Specific family-centered and trauma-informed interventions included: (1) creating and sharing interdisciplinary plans with caregivers, (2) coordinating prognostication meetings and communications, (3) tracking family education, (4) improving institutional coordination and workflow, (5) training caregivers to support family involvement, (6) performing biopsychosocial assessment, and (7) using systematic prompts for difficult conversations and to address family needs at regular intervals. Healthcare workers from a variety of disciplines want to incorporate certain trauma-informed and family-centered practices at each stage of treatment to improve experiences for caregivers and outcomes for pediatric patients with severe TBI. Future research should test the feasibility and effectiveness of incorporating routine psychosocial interventions for these patients.

Factors associated with delays in discharge for trauma patients at an urban county hospital

BackgroundDischarge delays for non-medical reasons put patients at unnecessary risk for hospital-acquired infections, lead to loss of revenue for hospitals and reduce hospital capacity to treat other patients. The objective...

The Use of a Urinary Balloon Catheter to Control Hemorrhage From Penetrating Torso Trauma: A Single-Center Experience at a Major Inner-City Hospital Trauma Center.

Use of a urinary catheter balloon tamponade (UCBT) in controlling traumatic hemorrhage is a frequently employed but infrequently described technique. We aim to discuss the experience of balloon tamponade as a bridge to definitive hemorrhage control in the operating room. This is retrospective review at a single institution from January 2008 to December 2018. We identified patients with active bleeding from penetrating torso trauma in whom UCBT was used to tamponade bleeding. We used revised trauma score (RTS), injury severity score (ISS), and new trauma and injury severity score (TRISS) to quantify injury severity. All surviving patients required definitively hemorrhage control in the operating room. Primary endpoint was mortality at 24 hours and 30 days. Twenty-nine patients were managed with UCBT. Nine had hemorrhage controlled in the trauma bay, including 4 with neck trauma and 5 with cardiac trauma. Twenty patients had hemorrhage controlled in the operating room, including 15 with cardiac trauma and 5 with intra-abdominal hemorrhage. Mean RTS, ISS, and TRISS in this population were: 5.93, 19.31, and 83.78, respectively. Of the 9 patients treated in the trauma bay, 1 (11.1%) died in the first 24 hours and 2 died in the first 30 days (22.2%). Of the 20 patients treated in the operating room, 0 (0%) patients died in the first 24 hours and 3 died in the first 30 days (15.0%). UCBT is an effective tool that can be used to stabilize and bridge an actively bleeding patient to definitive hemorrhage control in the operating room.

Unnecessary Preoperative Cardiology Evaluation and Transthoracic Echocardiogram Delays Time to Surgery for Geriatric Hip Fractures.

Delays to surgery for patients with geriatric hip fracture are associated with increased morbidity and mortality. The American Heart Association (AHA) and American College of Cardiology (ACC) Clinical Practice Guidelines (CPG) were created to standardize preoperative cardiology consultation and transthoracic echocardiogram (TTE). This study's purpose is to determine if these practices are over used and delay time to surgery at a safety net hospital. Retrospective review. Level 1 trauma center and safety net hospital. Charts were reviewed for indications of preoperative cardiology consultation or TTE per AHA and ACC CPG in 412 patients admitted with geriatric hip fracture. Criteria meeting the AHA/ACC guidelines for preoperative TTE and cardiac consultations. Time to surgical intervention. Despite 17.7% of patients meeting criteria, 44.4% of patients received cardiology consultation. Of those patients, 33.8% met criteria for receiving preoperative TTE but 89.4% received one. Time to surgery was greater for patients receiving cardiology consultation (25.42 ± 14.54 hours, P-value <0.001) versus those who did not (19.27 ± 13.76, P-value <0.001) and for those receiving preoperative TTE (26.00 ± 15.33 hours, P-value <0.001) versus those who did not (18.94 ± 12.92, P-value <0.001). Cardiology consultation and TTE are frequently used against AHA/ACC CPG. These measures are expensive and delay surgery, which can increase morbidity and mortality. These findings persisted despite limited resources available in a safety net hospital. Hospitals should improve adherence to CPG, or modify protocols. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

TIMING PREOSPEDALIERI E SERVIZI DI EMERGENZA MEDICA: STUDIO PRELIMINARE PRESSO IL TRAUMA SYSTEM EMILIA EST

Introduction: The time factor in prehospital rescue is taken a reference to evaluate the efficiency of the emergency medical services (EMS). The scientific community agrees that the survival of a victim of a major trauma increase following a reduction of the pre-hospital time. The hypothesis of the importance of the prehospital time remains, in terms of trauma, although controversial. The purpose of the study is to determine the prehospital time and related subintervals in the victims of trauma, transported by ambulance in the Trauma System Emilia Est (region Emilia Romagna) and to check whether the injured person arrives at the hospital in a time ≤ 60 minutes and if the on-scene time is ≤ 15 minutes. The two times, taken as a comparison target, represent reference values in the United States, respectively: (1) the golden hour; (2) the ambulance’s average prehospital on-scene time in US. Materials and Methods: Retrospective observational study on all transports that had as a return code 2 or 3, which occurred by ambulance, of patients suffering trauma in the prehospital phase between 2016 and 2018. Results: The 74.6% ( 833/1116 cases) met the inclusion criteria. The average prehospital time an ambulance spent managing trauma was of 56.3 minutes. The average duration of the relevant sub-range was found to be: response time 9.4 minutes; on-scene time 30.1 minutes; transport time 16.4 minutes. In 62.1% (No.517) of cases, hospitalization took place in a time ≤ 60 minutes. In 14.8% (No.123) of the cases, the rescue crew remained at the scene for a time ≤ 15 minutes. Patients were transported in 35.9% (No.299) of cases to a Hub hospital (Trauma Center). Discussion: More than half of the transports, by ambulance, took place while respecting the golden hour. On-scene time is twice as long as the US reality (30.1 minutes instead of 15 minutes). The indications suggested by the authors to reduce prehospital times are: (1) increased training/simulations; (2) increased efficiency of hospital networks; (3) rapid centralization “Hub”; (4) increased data collection/analysis.

169 Emergency Department Utilization Trends during the COVID-19

With COVID-19 cases and fatalities increasing globally, health officials implemented many policies and restrictions to slow the rate of infection. In California, a statewide stay-at-home order was issued on March 19, 2020. Subsequently, individuals avoided gatherings and public places, which potentially increased their risk of contracting the virus, including emergency departments. There is concern that delaying preventive and emergent care could have negative health consequences, especially among those managing chronic conditions and the elderly. The objective of this study was to assess patterns of ED utilization during the initial COVD-19 pandemic, as compared to utilization during the prior year. We conducted a multi-center, retrospective study among adult patients (>=18 years) presenting to two emergency departments (urban level 1 trauma center and suburban academic hospital with combined annual census of ∼83,000). We compared weekly ED utilization between two distinct time periods: March 1 to May 30 in 2019 (n=21,226 visits) and 2020 (n=15,927 visits). We calculated the percent change in ED utilization from 2019 to 2020 for each of the 13 weeks, assessing trends over time by patient age, sex, race/ethnicity, homelessness, presence of chronic conditions, and primary reason for ED visit. Compared to 2019, weekly ED volume and admissions in 2020 decreased by as much as 41.8% and 37.2%, respectively. While weekly ED volume in 2020 did not return to 2019 levels (-17.0% at the highest), admissions did (-0.8% at the highest). Patients 65-74 year of age saw the highest weekly decrease at 50.8% below 2019, and while weekly admissions also decreased for this group by up to 48.3%, admissions spiked to an average of 23.0% above the previous year during the last two weeks of the study period. On average, ED visits by females decreased in 2020 by 30.1%, compared to 20.2% for males. ED visits by Non-Hispanic Asians were at least 30% below the prior year for 9/13 weeks, compared to Non-Hispanic Blacks who only surpassed a 30% decrease during one week. ED volume was relatively unaffected among patients experiencing homelessness, with an average weekly decrease of 4.5%. Patients with diabetes saw a high of 45.1% decrease in admission compared to 2019, but were within 5% of the previous year during 3 of the final 4 weeks of the study period. Psychiatric-related visits and alcohol and substance-related visits decreased as much as 50.6% and 32.0%, respectively; however, alcohol and substance-related visits averaged only 6.8% below 2019 volumes during the last 4 weeks of the study period compared to -26.0% among psychiatric visits. Visits for skin and subcutaneous tissue infections decreased up to 44.4%, but also saw volume above 2019 levels for 5 different weeks (range +2.2% to +34.1%). Similarly, weekly sepsis-related and cardiac dysrhythmia visits were at least 15% higher than 2019 for 2 of the last 4 weeks, and, 3 out of the last 4 weeks, respectively. This study of ED utilization trends during the COVID-19 pandemic demonstrated that ED volume and admissions decreased dramatically compared to the prior year. However, there was much variation among the patient population, and unfortunately elderly patients and those with chronic conditions may be paying the price for initially avoiding the ED. Further study with a longer follow-up period is needed to evaluate potential health consequences for patients who may be delaying care.

In-home interpersonal violence: Sex based prevalence and outcomes.

IntroductionThere is a shortage of data on intimate partner and interpersonal violence in sub-Saharan Africa. We, therefore, sought to characterize patterns of sex-based risk of in-home interpersonal violence in Malawi.MethodsWe performed a retrospective analysis of the Kamuzu Central Hospital Trauma Registry data from 2009 to 2017 on adult patients presenting the emergency room following assault. Data variables collected include basic demographics, injury characteristics, and outcomes. We performed a bivariate analysis for covariates based on sex and Poisson regression analysis to estimate the risk of domestic violence and sex-based mortality.ResultsThe in-home assault interpersonal violence was 37.1% (n = 10,854) of the total assault cohort and 37.4% (n = 4056) were female. Women were more likely to be assaulted at home (n = 4065, 69.6%)compared to men. The overall prevalence of in-home interpersonal violence over eight years was 9.09%, with the prevalence in men and women being 7.85 and 12.38%, respectively. Women injured following in-home interpersonal violence assaults were less severely injured. Women were more likely to be injured following slaps, punches, or kicks (n = 950, 41.2%) and men were more likely to be injured by an object, 41.0% with a blunt object (n = 1658) and 37.9% by a knife or another sharp object (n = 1532). For patients experiencing in-home interpersonal violence, overall mortality is 1.8% and 0.5% for men and women, respectively (p < 0.001). After controlling for covariates, the relative risk for In-home interpersonal violence was 2.25 (p < 0.001) times higher for women. Still, men had a 3.3 times risk of mortality following in-home interpersonal violence (p < 0.001).ConclusionInterpersonal violence is a global problem. In Malawi, women are more likely to be victims of in-home interpersonal violence. However, men are more likely to die following in-home interpersonal violence. Prevalence of in-home interpersonal violence is likely an underestimation.

Challenges of diagnosis of COVID-19 in trauma patients: A case series.

BackgroundDiagnosis of COVID-19 can be challenging in trauma patients, especially those with chest trauma and lung contusion.MethodsWe present a case series of patients from February and March 2020 who were admitted to our trauma center at Rajaee Hospital Trauma Center, in Shiraz, Iran and had positive SARS-CoV-2 PCR test or chest CT scan suggestive of COVID-19 and were admitted to the specific ICU for COVID-19.ResultsEight COVID-19 patients (6 male) with mean age of 40 (SD = 16.3) years old, were presented. All patients were cases of trauma injuries, with multiple injuries including chest trauma and lung contusion, admitted to our trauma center for management of their injuries, but they were diagnosed with COVID-19 as well. Two of them had coinfection of influenza type-B and SARS-CoV-2. All patients were treated for COVID-19 and three of them died; the rest were discharged from hospital.ConclusionSince PCR for SARS-CoV-2 is not always sensitive enough to confirm the cause of pneumonia, chest CT manifestations can be helpful, though, they are not always differentiable from lung contusion. Therefore, both the CT scan and the clinical and paraclinical presentation and course of improvement can be beneficial in diagnosing COVID-19 in the trauma setting.

Frequency and severity of general surgical emergencies during the COVID-19 pandemic: single-centre experience from a large metropolitan teaching hospital.

The COVID-19 pandemic has put significant stress on healthcare systems globally. This study focuses on emergency general surgery services at a major trauma centre and teaching hospital. We aimed to identify whether the number of patients and the severity of their presentation has significantly changed since the implementation of a national lockdown. This study is a retrospective review of acute referrals (from general practice and accident and emergency) to the emergency general surgery team over a 14-day period before (group 1) and during (group 2) lockdown. A total of 151 patients were reviewed by the general surgical team in group 1 and 75 in group 2 (a 50.3% reduction). The number of days with symptoms prior to presentation was significantly shorter in group 1 compared with group 2 (3 vs 4, p = 0.04). There was no significant difference in the National Early Warning Score, white blood cell count, lymphocytes and C-reactive protein on admission between the two groups of patients. There were significantly fewer patients admitted after lockdown compared with pre-lockdown (66% vs 48%, p = 0.01). Length of hospital stay was significantly shorter during lockdown compared with pre-lockdown (5 days vs 4 days, p = 0.04). Fewer patients were referred and admitted during lockdown compared with pre-lockdown, and the length of stay was also significantly reduced. There was also a delay in presentation to hospital, although these patients were not more unwell based on the scoring criteria used within this study.

Interprofessional barriers in patient flow management: an interview study of the views of emergency department staff involved in patient admissions

ABSTRACT Patient flow in emergency departments (EDs) is notoriously difficult to manage efficiently. While much of the attention has focused on the procedures, protocols and pathways in which patients receive their first hours of care, less attention has been paid to the relational factors that make it happen. Our study is the first, to our knowledge, to consider the role of interprofessional barriers, defined as suboptimal ways of working, as perceived by ED staff in patient flow management. Drawing on 19 interviews with hospital staff in an acute tertiary trauma center hospital in England, we established three flow-related types of interprofessional barriers: ED teamwork barriers, performance-driven coordination barriers, and referral-related collaborative barriers. Knotworking was recognized as a form of interactions and asset to teamworking, coordination, and collaboration. Identifying processes such as chasing, escalating, and advocating enabled our investigation to highlight a very complex set of interprofessional interactions, and signpost what the suboptimal practices of flow management are. Our analysis holds promise for hospitals beyond the National Health Service in England.

The Inter-Relationship Between Employment Status and Interpersonal Violence in Malawi: A Trauma Center Experience.

As a proportion of the overall population, sub-Saharan Africa (SSA) has the highest youth demographic, composing 60% of Africa's unemployed. With the worsening economic crisis in low- and middle-income countries, unengaged youth are susceptible to gang violence and anti-government demonstrations, resulting in political instability. We performed a retrospective review of the Kamuzu Central Hospital Trauma Registry from 2008-2018. All adult patients (>14years) injured by interpersonal violence (IPV) were included. Age was categorized as 15-24 (youth), 25-45, and >45years. A bivariate analysis (IPV versus unintentional injury), and Poisson multivariable analysis were performed to identify factors increasing the risk of IPV. During the study, 87,338 trauma patients presented; 30,532 (35.0%) were injured following IPV. Patients injured following IPV (28years, IQR 23-34) were younger than those unintentionally injured (30years, IQR 23-39, p < 0.001). More patients injured following IPV were unemployed (n = 7,178, 23.6% vs. n = 10,148, 17.9%, p < 0.001), injured at night (n = 19,346, 63.7% vs. n = 10,148, 17.9%, p < 0.001), and reported alcohol use (n = 4.973, 16.4% vs n = 2,461, 4.4%, p < 0.001). Being unemployed (RR 1.25, 95% CI 1.22-1.27), youth compared to age >45years (RR 1.72, 1.66-1.79), and those injured at night (RR 2.18, 95% CI 2.14-2.23) had increased the risk of being victims of IPV. In Malawi, there is an interrelationship between unemployment and IPV, particularly in the youth population. Given impending demographic realities, government and non-government organizations should prioritize youth employment to help defer political instability in vulnerable nation-states.

Effect of Surgery vs Functional Bracing on Functional Outcome Among Patients With Closed Displaced Humeral Shaft Fractures

Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without high-quality evidence to justify the trend. To compare the effectiveness of surgical treatment with open reduction and internal plate fixation to nonsurgical treatment with functional bracing in the treatment of closed humeral shaft fractures. Randomized clinical trial conducted at 2 university hospital trauma centers in Finland, enrollment between November 2012 and January 2018 with a final follow-up of January 2019. A total of 82 adult patients with closed, unilateral, displaced humeral shaft fracture met criteria for inclusion. Patients were excluded if they had cognitive disabilities preventing them from following the protocol or had multimorbidity or multiple trauma. Patients were randomly assigned to surgical treatment with open reduction and internal plate fixation (n = 38) or to nonsurgical treatment with functional bracing (n = 44). The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (range, 0 to 100 points, 0 denotes no disability and 100 extreme disability; minimal clinically important difference, 10 points). Among 82 patients who were randomized (mean age, 48.9 years; 38 women [46%]; 44 men [54%]), 78 (95%) completed the trial. Thirteen (30%) of the patients assigned to functional bracing underwent surgery during the 12-month follow-up period to promote healing of the fracture. At 12 months, the mean DASH score was 8.9 (95% CI, 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group (between-group difference, -3.1 points; 95% CI, -9.6 to 3.3; P = .34). Eleven patients (25%) allocated to functional bracing developed fracture nonunion. Three patients (8%) allocated to surgery developed a temporary radial nerve palsy. Among patients with closed humeral shaft fracture, internal fixation surgery, compared with nonoperative functional bracing, did not significantly improve functional outcomes at 12 months. However, the substantial amount of treatment crossover from nonoperative to surgical treatment should be considered when interpreting the trial results. ClinicalTrials.gov Identifier: NCT01719887.

Impact of the Closure of a Large, Urban Safety-Net Hospital on a Neighboring Academic Center: A Philadelphia Case Study.

We examined how the closure of 496-bed Hahnemann University Hospital (HUH), a level I trauma and stroke center and safety-net hospital in Philadelphia, Pennsylvania, impacted the emergency department (ED) and radiology workflow in our neighboring hospital (Thomas Jefferson University Hospital) located <1 mile away. On June 30, 2019, HUH announced its imminent closure and began diverting trauma patients, with its ED officially closing in mid-August. Trends of our ED and radiology workflow were analyzed using QlikView analytics software for 3 months before and after the closure. Data were compared to workflow from the same time period in2018. The average monthly number of patients presenting to our ED after the closure increased 20.2% with a corresponding 16% increase in ED imaging studies, primarily in radiographs (+16%) and CT (+20%). Radiology orders by advanced practice providers increased 74%. Turnaround time from imaging order placed to final diagnostic radiology report did not change substantially after the closure. Workflow in our ED and radiology department was significantly impacted by the closure of HUH. This study provides insight into how our practice patterns changed and compensated after the closure of a neighboring, large, urban safety-net hospital; it is important for radiologists to be aware of citywide practice patterns to adapt to acute change.