Improve Outcomes In Trauma Patients Research Articles

Optimisation of mitochondrial function as a novel target for resuscitation in haemorrhagic shock: a systematic review

IntroductionTraumatic injury is one of the leading causes of death worldwide, and despite significant improvements in patient care, survival in the most severely injured patients remains unchanged. There is a...

Efficacy of Trauma Surgery Technical Skills Training Courses

Because open surgical skills training for trauma is limited in clinical practice, trauma skills training courses were developed to fill this gap, The aim of this report is to find supporting evidence for efficacy of these courses. The questions addressed are: What courses are available and is there robust evidence of benefit? We performed a systematic review of the training course literature on open trauma surgery procedural skills courses for surgeons using Kirkpatrick's framework for evaluating complex educational interventions. Courses were identified using Pubmed, Google Scholar and other databases. The review was carried out at the University of Maryland, Baltimore with input from civilian and military trauma surgeons, all of whom have taught and/or developed trauma skills courses. We found 32 course reports that met search criteria, including 21 trauma-skills training courses. Courses were of variable duration, content, cost and scope. There were no prospective randomized clinical trials of course impact. Efficacy for most courses was with Kirkpatrick level 1 and 2 evidence of benefit by self-evaluations, and reporting small numbers of respondents. Few courses assessed skill retention with longitudinal data before and after training. Three courses, namely: Advanced Trauma Life Support (ATLS), Advanced Surgical Skills for Exposure in Trauma (ASSET) and Advanced Trauma Operative Management (ATOM) have Kirkpatrick's level 2-3 evidence for efficacy. Components of these 3 courses are included in several other courses, but many skills courses have little published evidence of training efficacy or skills retention durability. Large variations in course content, duration, didactics, operative models, resource requirements and cost suggest that standardization of content, duration, and development of metrics for open surgery skills would be beneficial, as would translation into improved trauma patient outcomes. Surgeons at all levels of training and experience should participate in these trauma skills courses, because these procedures are rarely performed in routine clinical practice. Faculty running courses without evidence of training benefit should be encouraged to study outcomes to show their course improves technical skills and subsequently patient outcomes. Obtaining Kirkpatrick's level 3 and 4 evidence for benefits of ASSET, ATOM, ATLS and for other existing courses should be a high priority.

The experience and understanding of pain management in recently discharged adult trauma patients: A qualitative study

IntroductionPain following injury is often intense, prolonged and debilitating. If poorly managed, this acute pain has the potential to delay rehabilitation and lead to chronic pain. Recent quantitative Australian research recommends implementing further information and interventions to improve trauma patient outcomes, however, to ensure effectiveness, exploration of the patient perspective is imperative to ensure the success of future pain management strategies. This study aimed to gain understanding about the experience of pain management using prescribed analgesic regimens of recently discharged adult trauma patients. MethodSemi-structured interviews were used to explore the experiences and understandings of trauma patients in managing pain using prescribed analgesic regimens during the initial post-hospital discharge period. Twelve participants were purposively selected over a 6-month period at a level one trauma outpatient clinic based on questionnaire responses indicating pain related concerns. Qualitative data were thematically analysed. ResultsThe overarching finding was that injuries and inadequate pain management incapacitate the patient at home. Four main themes were developed: injury pain is unique and debilitating; patients are uninformed at hospital discharge; patients have low confidence with pain management at home; and patients make independent decisions about pain management. Patients felt they were not given adequate information at hospital discharge to support them to make effective decisions about their pain management practices at home. ConclusionThere is a need for more inclusive and improved hospital discharge processes that includes patient and family education around pain management following injury. To achieve this, clinician education, support and training is essential.

Prognostic effect of different blood transfusion ratios in trauma patients with massive transfusion

Objective To evaluate the prognostic effect of different ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC) in massively transfused trauma patients. Methods A retrospective cohort study was conducted for 210 trauma patients who received more than 10 units of PRBC during the initial 24 hours from January 2007 to June 2015. The patients were divided into four groups: Group A(PRBC ∶FFP≤1, n=41), Group B (1 2, n=76). At 24 hours after admission, blood transfusion amount, blood transfusion ratios, post-transfusion adverse reactions (allergy, non-hemolytic febrile transfusion reaction, hemolysis, congestive heart failure, pulmonary edema, etc) and coagulation changes [hemoglobin (Hb), platelet count (PC), prothrombin time(PT), activated partial thromboplastin time(APTT), international normalized ratio (INR), etc] were compared among groups. Prognostic markers including sequential organ failure assessment(SOFA), hospital stay, ICU stay, 30-day mortality and causes of death were also evaluated. Results Use of PRBC was decreased significantly in Group A than in other groups (P 0.05). The coagulation indices (PT, APTT and INR) in Groups A and B were significantly decreased compared to Group D after transfusion (P 0.05). Group D was associated with higher SOFA and higher 30-day mortality than other groups(P 0.05). Meanwhile, ratio of patients died of massive hemorrhage in Group D was also higher than other groups (P<0.01). Kaplan-Meier survival analysis showed the survival interval was the shortest in Group D, while the longest in Group B and C. Conclusions Modest transfusion ratios(1. 5<PRBC ∶FFP≤2)within 24 hours can substantially improve outcomes in trauma patients. Aggressive ratios may improve coagulation indices and reduce use of PRBC, with no more benefit to the outcomes. Key words: Blood component transfusion; Wounds and injuries; Prognosis

Maryland’s Helicopter Emergency Medical Services Experience From 2001 to 2011: System Improvements and Patients’ Outcomes

Helicopter emergency medical services (EMS) has become a well-established component of modern trauma systems. It is an expensive, limited resource with potential safety concerns. Helicopter EMS activation criteria intended to increase efficiency and reduce inappropriate use remain elusive and difficult to measure. This study evaluates the effect of statewide field trauma triage changes on helicopter EMS use and patient outcomes. Data were extracted from the helicopter EMS computer-aided dispatch database for in-state scene flights and from the state Trauma Registry for all trauma patients directly admitted from the scene or transferred to trauma centers from July 1, 2000, to June 30, 2011. Computer-aided dispatch flights were analyzed for periods corresponding to field triage protocol modifications intended to improve system efficiency. Outcomes were separately analyzed for trauma registry patients by mode of transport. The helicopter EMS computer-aided dispatch data set included 44,073 transports. There was a statewide decrease in helicopter EMS usage for trauma patients of 55.9%, differentially affecting counties closer to trauma centers. The Trauma Registry data set included 182,809 patients (37,407 helicopter transports, 128,129 ambulance transports, and 17,273 transfers). There was an increase of 21% in overall annual EMS scene trauma patients transported; ground transports increased by 33%, whereas helicopter EMS transports decreased by 49%. Helicopter EMS patient acuity increased, with an attendant increase in patient mortality. However, when standardized with W statistics, both helicopter EMS- and ground-transported trauma patients showed sustained improvement in mortality. Modifications to state protocols were associated with decreased helicopter EMS use and overall improved trauma patient outcomes.

Implementation of a surgical intensive care unit service is associated with improved outcomes for trauma patients.

Our trauma service recently transitioned from a pulmonary intensive care unit (ICU) service to a surgical ICU (SICU) service. We hypothesized that a newly formed SICU service could provide comparable outcomes to the existing pulmonary ICU service. A specific aim of this study was to compare outcomes of trauma patients admitted to the ICU before and after implementation of a SICU service. We performed a retrospective study of trauma patients admitted to the ICU of our urban, American College of Surgeons- verified, Level 1 trauma center during a 4-year period (2009-2012). Patients managed by the pulmonary ICU service (2009-2010) were compared with patients managed by a SICU service (2011-2012). The primary outcome was mortality, while secondary outcomes included complications (pulmonary, infectious, cardiac, and thromboembolic), hospital and ICU length of stay, ventilator days, and need for reintubation. There were 2,253 trauma patients admitted to the ICU during the study period, 1,124 and 1,129 managed by the pulmonary ICU and SICU services, respectively. When comparing outcomes for SICU and pulmonary ICU patients, there was no difference in mortality (11% vs. 13%, p = 0.41), but patients managed by the SICU service had fewer pulmonary complications (3% vs. 6%, p < 0.001), fewer days on the ventilator (3 vs. 4, p = 0.002), and less often required reintubation after extubation (4% vs. 9%, p < 0.001). Transition from a pulmonary ICU service to a SICU service at our institution was associated with no change in mortality but an improvement in pulmonary complications, ventilator days, and reintubation rates. Trauma centers currently staffed with a pulmonary ICU service should feel comfortable converting to SICU service and should expect comparable or improved outcomes for trauma patients admitted to the ICU. Therapeutic/care management study, level IV.

Improved trauma patient outcomes after implementation of a dedicated trauma admitting service

Background Regionalised trauma systems have been shown to improve the outcome of seriously injured patients. However, it is not clear which components of these systems have the most impact on patient outcomes. The study evaluates the association between implementation of a single, dedicated trauma admitting service at an urban trauma centre and subsequent patient outcomes. Methods This was a retrospective review of prospectively collected trauma registry data at the St George Public Hospital, a level I urban trauma centre in Sydney, Australia. Two concurrent 18-month periods, before and after implementation of a full-time trauma service, were compared for differences in patient mortality, complication rates, and ED, ICU and hospital lengths of stay. Results There were 962 patients admitted to the hospital in the 18 months immediately preceding the implementation of the trauma service (the PRE group) and 990 patients in the subsequent 18 months (the POST group). There were no significant differences between groups with respect to patient demographics or mechanism of injury, although a higher proportion of patients in the POST group had injury severity scores (ISS) above 15 (30.6% versus 24.8%, p = 0.02). There was an 8% reduction in death rate among the most severely injured patients (ISS > 15), in the POST group as compared to the PRE group (12.2% and 20.2% respectively, p = 0.007). Conclusions The implementation of a full-time trauma service in this hospital was associated with a reduction in death rate among the most severely injured patients, and a decrease in LOS in patients with an ISS < 15.

Does Prehospital RSI Improve Outcomes in Trauma Patients

Rapid sequence intubation (RSI) has been promoted in emergency departments as being safer and more effective than conventional intubation for achieving

341: The Impact of Specialty Trained Emergency Medicine and Trauma Teams on Trauma Mortality Rates at an Academic Level I Trauma Center

Trauma level designation can result in improved patient outcomes after injuries. While the presence of trauma teams has been associated with improved trauma patient outcomes, the contribution of trained specialists, including emergency medicine trained physicians, has not been defined.

An association between Emergency Medicine residencies and improved trauma patient outcome 1

A study was done to compare trauma patient outcome at American College of Surgeons (ACS) Level l Trauma Centers with Emergency Medicine residency programs (EMRP+) to those without (EMRP−). Ten Level l Trauma Centers were reviewed from the ACS National Trauma Database (5 centers with and 5 without EM residency programs). Of 18,591 trauma patient records, 8679 were identified as EMRP−, and 9912 as EMRP+. After deleting incomplete data sets, 6621 EMRP− and 6150 EMRP+ records remained. Comparisons between patient age, gender, TRISS, complications, deaths, hospital, ICU and ventilator days, and numbers of burns, penetrating and blunt trauma were performed using t-test and chi-square analysis. Despite having a statistically significant older patient population, with more burn and penetrating trauma patients requiring longer ICU stays and longer ventilatory support ( p < 0.0001), Emergency Medicine Residency program hospitals had a significantly lower complication rate (5.14% vs. 11.04%, respectively, p < 0.0001), death rate (4.704% vs. 5.479%, respectively, p = 0.0013), and shorter overall hospital stays (Mean 4.94 days, SD ± 8.74 vs. 6.35 days, SD ± 11.22, respectively, p < 0.0001) than EMRP− hospitals. The presence of Emergency Medicine residency programs at ACS Level I Trauma Centers is associated with improved trauma patient outcomes.

Trauma teams in Australia: a national survey.

Trauma teams have been associated with improved trauma patient outcomes. The present study seeks to estimate the use of trauma teams in Australian hospitals and describe their medical composition, leadership and criteria for activation. Australian public hospitals with more than 100 beds, an emergency department and offering surgical services were identified. A survey assessing the presence, composition and means of activation of a trauma team was mailed to the 'Director, Emergency Department' of all identified hospitals. Three months later, all hospitals were contacted by telephone to complete and verify data collection. Questionnaires were distributed to 130 hospitals. After exclusion of hospitals that did not receive patients with traumatic injuries, and dedicated paediatric tertiary referral centres, 111 hospitals remained for analysis. Of these, 56% had an established trauma team, while 71% of hospitals without a trauma team claimed to have insufficient doctors to form one team. Ninety-five per cent of trauma teams were potentially activated by prehospital paramedic data (field triage). For 92% of trauma teams a combination of anatomical, physiological and mechanistic criteria were required for activation. The most common methods of mobilizing a trauma team were by dispatching a common call onto individual pagers (31%) or by paging trauma team members individually (31%). Fifty-eight per cent of trauma team leaders were emergency medicine specialists/registrars, while 8% of trauma teams were led by surgeons/registrars. Consultant surgeons were members of 23% of trauma teams and 74% of trauma teams consisted of more junior members after hours. Some form of trauma audit was engaged in by 64% of hospitals. Trauma teams are yet to be utilized by many Australian hospitals that provide trauma care. Australian surgeons presently have limited leadership roles and membership in trauma teams. Trauma audit can be more widely adopted in Australian hospitals.