Metropolitan Trauma Center Research Articles

Survivor's remorse.

In urban, large metropolitan trauma centers, we are accustomed to seeing the most gruesome morbidity and mortality in medicine. By far, the most devastating morbidity and mortality to observe are those inflicted on one human being to another. Gun violence is pervasive in this industrialized country, and it impacts us all. Staff, residents, and faculty in trauma centers bear the brunt of this trauma, second only to the families and communities that suffer the loss of loved ones. This burden is especially heavy for health care workers who share the same ethnic background of those who are disproportionately affected by interpersonal gun violence. Survivors of gun violence exist on a spectrum of chronic illness that ranges in physical and mental morbidity and social disruption in loss of wages and capabilities. This disease not only infects those wounded or killed but also transmits through communities and generations. Urban violence exists because of historic and systematic racism. It continues to persist because racism creates inequities in the quality of education, housing, and investment in urban environments, exacerbated by residential segregation. For two providers, a trainee and a faculty member of African descent, conscious of the determinants that create gun violence, it is overwhelming. We, as health care providers, must tell our stories and the stories of those whose voices are not empowered. We can hope that, by sharing these experiences, we stimulate action and change by raising the moral consciousness of those unaware of the tragedies we witness every day.

COVID-19 and emergency department volume: The patients return but have different characteristics.

BackgroundThe COVID-19 pandemic has altered behaviors in the general population, as well as processes in the healthcare industry. Patients may be afraid to pursue care in the emergency department (ED) due to perceived risk of infection. The objective of this study was to determine the impact of COVID-19 on ED metrics.MethodsAt one metropolitan trauma center ED, we conducted a review of all visits from February to May in 2020 and compared findings with the same months from 2019.ResultsA total of 34,213 ED visits occurred during the study periods (18,471 in 2019 and 15,742 in 2020), with a decline in patient visits occurring after state emergency declarations. In 2020, patients were less likely to be female and more likely to arrive by ambulance. Diagnoses in the musculoskeletal, neurologic, and genitourinary categories occurred in lower proportions in 2020; toxicology, psychiatry, and infectious diseases occurred in higher proportions. In contrast to other insurance categories, Medicare patients comprised a larger share of ED visits in 2020 compared to 2019.DiscussionDespite relatively low local prevalence of COVID-19, we report decreases in ED volume for some medical diagnosis categories. A volume rebound occurred in May 2020, but did not reach 2019 levels. Public health officials should encourage local populations to seek emergency care when concerned, and could consider programs to provide transportation. Patients should continue to protect themselves with social distancing and masks.

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure. To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure. This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019. Standard- or low-dose WBCT. The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy. Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, -2.0% [95% CI, -7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001). Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.

The Impact of Hemodialysis on Mortality and Personal Independence After Hip Fracture. A Prospective Matched Cohort Study.

To determine the cumulative 30-day and 1-year mortality as well as personal independence after hip fracture in patients on hemodialysis. Prospective, observational cohort study with matched controls. One teaching hospital, one metropolitan trauma center, one peripheral hospital. Study group: a consecutive cohort of 64 patients with end-stage renal disease receiving chronic hemodialysis who had undergone surgery for a trochanteric or femoral neck fracture from June 2008 to November 2016. subjects without end-stage renal disease who underwent surgery for similar hip fractures. One-year mortality, activities of daily living, and ambulatory activity. The 30-day and 1-year mortality rate in patients with a hip fracture undergoing hemodialysis was 25.0% and 57.8%, respectively. Hemodialysis was independently associated with increased 30-day (Hazard ratio 2.933; 95% confidence interval 1.270-6.770; P = 0.018) and 1-year (hazard ratio 2.535; 95% confidence interval, 1.494-4.299; P < 0.001) mortality compared with the matched controls. At the 1-year follow-up, loss of personal independence in comparison with the prefracture status was detected. Hemodialysis was associated with increased mortality after hip fracture. A worse prefracture functional status predicted the loss of functional independence at follow-up. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of In-Hospital Ambulatory Status Following Low-Energy Hip Fracture Surgery.

Introduction:Twenty-five percent to seventy-five percent of independent patients do not walk independently after hip fracture (HF), and many patients experience functional loss. Early rehabilitation of functional status is associated with better long-term outcomes; however, predictors of early ambulation after HF have not been well described.Purposes:To assess the impact of perioperative and patient-specific variables on in-hospital ambulatory status following low-energy HF surgery.Methods:This is a retrospective analysis of 463 geriatric patients who required HF surgery at a metropolitan level-1 trauma center. The outcomes were time to transfer (out of bed to chair) and time to walk.Results:Three hundred ninety-two (84.7%) patients were able to transfer after surgery with a median time of 43.8 hours (quartile range: 24.7-53.69 hours), while 244 (52.7%) patients were able to walk with a median time of 50.86 hours (quartile range: 40.72-74.56 hours). Preinjury ambulators with aids (hazard ratio [HR]: 0.70, confidence interval [CI]: 0.50-0.99), age >80 years (HR: 0.66, CI: 0.52-0.84), peptic ulcer disease (HR: 0.57, CI: 0.57-0.82), depression (HR: 0.66, CI: 0.49- 0.89), time to surgery >24 hours (HR: 0.77, CI: 0.61-0.98), and surgery on Friday (HR: 0.73, CI: 0.56-0.95) were associated with delayed time to transfer. Delayed time to walk was observed in patients over 80 years old (HR: 0.74, CI: 0.56-0.98), females (HR: 0.67, CI: 0.48-0.94), peptic ulcer disease (HR: 0.23, CI: 0.84-0.66), and depression (HR: 0.51, CI: 0.33-0.77).Conclusions:Operative predictors of delayed time to transfer were surgery on Friday and time to surgery >24 hours after admission. Depression is associated with delayed time to transfer and time to walk. These data suggest that is important to perform surgeries within 24 hours of admission identify deficiencies in care during the weekends, and create rehabilitation programs specific for patient with depression. Improving functional rehabilitation after surgery may facilitate faster patient discharge, decrease inpatient care costs, and better long-term functional outcomes.

Simulation-based multidisciplinary team training decreases time to critical operations for trauma patients

BackgroundSimulation has been promoted as a platform for training trauma teams. However, it is not clear if this training has an impact on health service delivery and patient outcomes. This study evaluates the association between implementation of a simulation based multidisciplinary trauma team training program at a metropolitan trauma centre and subsequent patient outcomes. MethodThis was a retrospective review of trauma registry data collected at an 850-bed Level 1 Adult Trauma Centre in Sydney, Australia. Two concurrent four-year periods, before and after implementation of a simulation based multidisciplinary trauma team training program were compared for differences in time to critical operations, Emergency Department (ED) length of stay (LOS) and patient mortality. ResultsThere were 2389 major trauma patients admitted to the hospital during the study, 1116 in the four years preceding trauma team training (the PREgroup) and 1273 in the subsequent 4 years (the POST group). There were no differences between the groups with respect to gender, body region injured, incidence of polytrauma, and pattern of arrival to ED. The POST group was older (median age 54 versus 43 years, p < 0.001) and had a higher incidence of falls and assaults (p < 0.001). There was a reduction in time to critical operation, from 2.63 h (IQR 1.23–5.12) in the PRE-group to 0.55 h (IQR 0.22–1.27) in the POST-group, p < 0.001. The overall ED LOS increased, and there was no reduction in mortality. Post-hoc analysis found LOS in ED was reduced in the cohort requiring critical operations, p < 0.001. ConclusionThe implementation of trauma team training was associated with a reduction in time to critical operation while overall ED length of stay increased. Simulation is promoted as a platform for training teams; but the complexity of trauma care challenges efforts to demonstrate direct links between multidisciplinary team training and improved outcomes. There remain considerable gaps in knowledge as to how team training impacts health service delivery and patient outcomes. Level of evidenceRetrospective comparative therapeutic/care management study, Level III evidence.

Change in Care Transition Practice for Patients With Nonspecific Chest Pain After Emergency Department Evaluation 2006 to 2012.

From 2005 to 2010 health care financing shifts in the United States may have affected care transition practices for emergency department (ED) patients with nonspecific chest pain (CP) after ED evaluation. Despite being less acutely ill than those with myocardial infarction, these patients' management can be challenging. The risk of missing acute coronary syndrome is considerable enough to often warrant admission. Diagnostic advances and reimbursement limitations on the use of inpatient admission are encouraging the use of alternative ED care transition practices. In the setting of these health care changes, we hypothesized that there is a decline in inpatient admission rates for patients with nonspecific CP after ED evaluation. We retrospectively used the Nationwide ED Sample to quantify total and annual inpatient hospital admission rates from 2006 to 2012 for patients with a final ED diagnosis of nonspecific CP. We assessed the change in admission rates over time and stratified by facility characteristics including safety-net hospital status, U.S. geographic region, urban/teaching status, trauma-level designation, and hospital funding status. The admission rate for all patients with a final ED diagnosis of nonspecific CP declined from 19.2% in 2006 to 11.3% in 2012. Variability across regions was observed, while metropolitan teaching hospitals and trauma centers reflected lower admission rates. There was a 41.1% decline in inpatient hospital admission for patients with nonspecific CP after ED evaluation. This reduction is temporally associated with national policy changes affecting reimbursement for inpatient admissions.

4:03 PMAbstract No. 300 - Initial experience with trans radial artery access for management of high-grade splenic trauma at a major metropolitan trauma center

4:03 PMAbstract No. 300 - Initial experience with trans radial artery access for management of high-grade splenic trauma at a major metropolitan trauma center

Civilian cerebral gunshot wounds: a South African experience.

Cerebral gunshot wounds represent one of the most lethal forms of traumatic brain injury, but there is a paucity of literature on the topic, especially from the developing world. We reviewed our experience and describe the spectrum and outcome of civilian cerebral gunshot wounds in a major metropolitan trauma centre in South Africa. This was a retrospective study of all patients with isolated cerebral gunshot wounds managed by the Pietermaritzburg Metropolitan Trauma Service over a 5-year period from 2010 to 2014. One hundred and two patients were included, 92% (94/102) were male and the mean age was 29 years. Fifty-four per cent (55/102) of all patients were from urban areas. The mean time from injury to arrival was 6 h (standard deviation: 5) for urban patients and 15 h (standard deviation: 5.2) for rural patients (P < 0.001). Ninety-four per cent (94/102) of all injuries were related to interpersonal violence and involved low velocity firearms. Twenty per cent of all patients (20/102) had a Glasgow Coma Scale 3-8, 20% (20/102) 9-12 and 61% (61/102) 12-15. All 102 patients underwent computed tomography scans. Thirty per cent (31/102) required neurosurgical interventions. The overall mortality rate was 22% (22/102). There was a significant difference in mortality between urban and rural patients (9% versus 36%, P < 0.001). Cerebral gunshot wounds are associated with significant mortality and protracted delay to definitive care is common in our setting. Those who survive the delayed transfer to definitive care generally do well and have reasonably good clinical outcomes.

Management of paediatric splenic injury in the New South Wales trauma system

Since the 1980’s, paediatric surgeons have increasingly managed blunt splenic injury (BSI) in children non-operatively. However, studies in North America have shown higher operation rates in non-paediatric centres and by adult surgeons. This association has not been examined elsewhere. ObjectiveTo investigate the management of BSI in New South Wales (NSW) children, to determine the patient and hospital factors related to the odds of operation. Secondarily, to investigate whether the likelihood of operation varied by year. MethodsChildren age 0–16 admitted to a NSW hospital between July 2000 and December 2011 with a diagnosis of BSI were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages, and Bureau of Statistics. The operation rate was calculated and compared between different hospital types. Univariable analysis was used to determine patient and hospital factors associated with operative management. The difference in the odds of operation between the oldest data (July 2000–December 2005) and most recent (January 2006–December 2011) was also examined. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of operative management according to hospital category and era, adjusting for potential confounders. Results955 cases were identified, with 101(10.6%) managed operatively. On multivariable analysis, factors associated with operation included age (OR 1.11, 95% CI 1.01–1.18, p<0.05), massive splenic disruption (OR 3.10, 95% CI 1.61–6.19, p<0.001), hollow viscus injury (OR 11.03, 95% CI 3.46–34.28, p<0.001) and transfusion (OR 7.70, 95% CI 4.54–13.16, p<0.001). Management outside a paediatric trauma centre remained significantly associated with operation, whether it be metropolitan adult trauma centre (OR 4.22 95% CI 1.70–10.52, p<0.01), rural trauma centre (OR 3.72 95% CI 1.83–7.83, p<0.001) or metropolitan local hospital (OR 5.23, 95% CI 1.22–18.93 p<0.05). Comparing the 2 eras, the overall operation rate fell, although not significantly, from 12.9% to 8.7% (OR 1.3, 95% CI 0.89–243 p=0.13) ConclusionWhile Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, children in NSW are still being operated on for BSI unnecessarily. While the factors at play may be complex, further evaluation of the management and movement of injured children within the broad NSW trauma system is required.

Association between perception of fault for the crash and function, return to work and health status 1 year after road traffic injury: a registry-based cohort study

ObjectivesTo establish the association between the patient's perception of fault for the crash and 12-month outcomes after non-fatal road traffic injury.SettingTwo adult major trauma centres, one regional trauma centre and...

Orthopaedic firearm injuries in children and adolescents: An eight-year experience at a major urban trauma center.

The purpose of this study is to describe the epidemiology of orthopaedic injuries incurred secondary to firearms among children and adolescents at a major metropolitan trauma center and to identify risk factors for complications and long-term morbidity. A retrospective review was performed of consecutive patients 17 years of age and younger who sustained a firearm injury and required orthopaedic treatment at a major trauma center from 2006 to 2013. Patient demographics, injury mechanism, fracture classification, neurovascular injury, antibiotic administration, and length of hospitalization were recorded. Radiographic studies were used to determine fracture pattern, methods of stabilization, and time to union. Primary clinical outcomes include fracture nonunion, infection, and physeal arrest. 46 patients with a mean age of 12.7 years were treated for firearm related orthopaedic injuries. 72% of the patients were ages 13-17, while 28% were 12 years of age and younger. There were 28 violent injuries (21 assaults, 7 innocent bystanders) and 16 non-violent injuries (15 unintentional discharges and 1 self-inflicted). There was a bimodal distribution of violent versus nonviolent mechanisms, with the majority of children 12 years of age and under sustaining non-violent injuries and adolescents more commonly injured with a violent mechanism. There were 44 fractures and 6 traumatic arthrotomies, with eight associated neurovascular injuries. Twenty-five patients had an orthopaedic procedure, with a total of 43 surgeries. Mean hospital length of stay was 6.8 days. There were five deep infections. Four patients developed non-unions and all of these patients had deep infections. The timing and duration of antibiotic therapy was not significantly different between those who did and did not develop infection. Of the non-operatively treated fractures, there were no infections or non-unions at long-term follow-up. Morbidity and mortality related to firearms is a growing public health problem in the United States. Results of this study suggest that gunshot related fractures had higher than anticipated morbidity, including permanent neurologic deficits, infection (11%) and fracture non-union (9%). More than half of patients underwent surgery and experienced long hospital stays secondary to the complexity of the injury. This epidemiological data on firearm injuries in children and adolescents is an impetus for prospective study, with the goal to increase awareness and develop treatment strategies for firearm-related fractures.

Incidence of depression, anxiety and stress following traumatic injury: a longitudinal study.

BackgroundTraumatic injury and mental health disorders are co-associated. Early identification of depression, anxiety and stress following injury, and subsequent preventive intervention, may reduce the long-term symptoms and negative impacts associated with depression and anxiety. The purpose of the study was to determine the incidence, severity and predictors of depression, anxiety and stress in injured patients in the acute phase of care, and at six months following injury, as well as the effectiveness of an in-hospital screening tool.MethodsThis descriptive longitudinal study of trauma patients was conducted at a Level 1 Metropolitan Trauma Centre in Australia over 14 months. Participants were interviewed using the Depression Anxiety Stress Scale short-form version (DASS-21) during hospital admission then at 3 and 6 months after injury. Descriptive statistics were performed to evaluate participant characteristics and incidence of depression, anxiety and stress. Correlations and logistic regression were conducted to investigate the ability of the DASS-21 to predict symptoms of depression, anxiety and stress and to investigate factors associated with depression, anxiety and stress 6 months after injury.Results201 participants ranging in age (18–94 years) and injury severity participated in the baseline interview and 109 completed all 3 interviews over 6 months. Over half (54%) reported above normal scores for depression, anxiety and/or stress in at least one of the 3 time points. Intensive care unit admission and high levels of depression, anxiety and stress at 3 months post injury were predictors for high levels of depression, anxiety and stress at 6 months. Low scores for depression, anxiety and stress during admission were correlated with low scores for depression, anxiety and stress at 3 and 6 months.ConclusionDepression, anxiety and stress in patients hospitalised following injury is common and should be anticipated in patients who have had an intensive care admission. Screening at 3 months following injury identifies patients at risk of long-term symptoms of depression, anxiety and stress.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma

Contrast-enhanced whole-body computed tomography (also called "pan-scanning") is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7-490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%-8.0%). We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Poster 72: Maxillofacial Trauma Treatment of Medicaid Patients at a Level One Trauma Center: Financial and Epidemiologic Cross-Sectional Analysis for 2010

Last year we postulated a connection between the economic recession and a shift of maxillofacial trauma payer status patients from private and commercial to federal insurers. Medicaid patients at Vanderbilt Medical Center, treated by OMS for facial trauma increased from 10% to 18%, while the reimbursement from these patients decreased from 26% to 22% from 2007 to 2009. Medicaid cost sharing problems are projected with attempts to enroll more low-income patients amidst nationwide attempts to control budget costs. In 2009 state Medicaid programs spent $7.9 billion on dental services, but the cost of maxillofacial trauma in Medicaid patients by OMS has not been recently well documented. This survey details Medicaid patients presenting to a metropolitan trauma center, and the important role OMS plays in providing services for this vulnerable population. Deidentified data were collected from all facial trauma patients treated by OMS at a level one trauma center during 2010. Patients with an isolated dentoalveolar injury were excluded. Demographic parameters of interest included patient age, race, sex, length of stay, maxillofacial injury (ICD-9 code), maxillofacial procedures performed (CPT); and charges, collections, and contractuals per procedure. All patients meeting inclusion criteria (n = 335) and the procedures performed (n = 611) were analyzed with summary statistics compared across different groups with the use of independent T-test where appropriate. The variance in reimbursement of professional charges across payers was calculated with a charge recovery ratio (collections/charges). Tests of association and variance between demographics, procedures, and financial variables were assessed using correlation coefficients and χ2 tests. In 2010, 335 patients presented for facial trauma and 50 (14.9%) of these patients were classified as Medicaid, with an average age of 23.1 (SD 18.9). Males made up 66% of the Medicaid sample, and average length of stay was 5.3 days (SD 10.4). Median hospital bill for Medicaid patients was $42,400. Overall OMS professional fees averaged $6,632, while Medicaid patient bills averaged $5,913, but this difference was not significant (P = .05). Average charges for individual maxillofacial procedures based on ICD-9 was $2,825, and average collections were $739, compared to average Medicaid charges and collections of $2,712 and $566, respectively. The percent reimbursement (collections/charges) for professional fees was 20.9% in the Medicaid group. The percent was significantly greater than the Medicare group at 13.8% (P < .05). Interestingly, average soft tissue procedure reimbursement (31%) was highest in the Medicaid group when compared with Medicaid reimbursement for mid-face (20%) and mandible procedures (22%). The calendar year data showed a statistically significant 5.5% increase (P < .05) in Medicaid contractuals after fiscal year renegotiation. There was also a significant increase in collections (16%) from patients after the contractual changes, and significant difference between contractuals for those under age 19 ($1,807) (state Medicaid age limit), and over 19 ($2,459). This study shows that Medicaid patients make up an important percentage of the OMS trauma cases at our metropolitan trauma center; and percent reimbursement continues to decline from previous estimates in 2009 despite increases in contractuals. Hospitals can use these data to advocate for increased Medicaid reimbursement for maxillofacial trauma patients, and for the continued involvement of OMS in providing care to this growing patient population.

Scope of emergency nurse practitioner practice: where to beyond clinical practice guidelines?

Aim: The aim of this paper is to discuss some of the issues around continuing development of the Emergency Nurse Practitioner (ENP) role in a Victorian metropolitan Emergency Department (ED) setting. More specifically the discussion will consider the evolving clinical practice of the ENP in relation to clinical practice guidelines (CPG) and optimal utilisation of ENP skills and expertise. Background: Internationally the mainstay of ENP practice is predominantly minor injury/minor illness models of care. This trend reflects traditional areas of need, or service gap. It is recognised however, that for a service to be sustainable and effective, it must be flexible, dynamic and prepared for future challenges.The development of CPGs to inform ‘scope of practice’, has become contentious. The restrictive nature of ENP specific guidelines has become evident over time, and together with the labour intensive nature of their development, continuing use is questionable. The trend towards the use of multidisciplinary clinical practice guidelines that utilise existing clinical protocols has gained support for future nurse practitioner (NP) role development. These guidelines are generally of a robust, evidence based nature, with regular review and update and don’t apply to any specific clinician group. Method: An exploration of the progression of the ENP role and service model at a large metropolitan hospital ED was undertaken. An examination of the ongoing changes in demand for ENP service within this organisation was carried out together with the strategies in place, or required, for ENP role expansion and flexibility. Setting: The setting for this discussion is a large metropolitan Emergency and Trauma centre in Melbourne, Victoria, Australia. The ENP team consists of endorsed ENP and those in training, generally referred to as Emergency Nurse Practitioner Candidates (ENPC). This ENP/C team is employed and cover sixteen hours per day, seven days per week, primarily in the ‘fast-track’ area of the department. ‘Fast-track’ is an area within the ED specifically treating patients presenting with minor injury and minor illness deemed likely to be seen, treated and discharged within a four hour time frame. Conclusion: The ENP model of care at this organisation confirms ongoing evolvement and expansion of the role in terms of increasing numbers of ENP/C. Questions continue as to the most efficient utilisation of the role to best benefit the ED as a whole and more specifically, patient outcomes. The need for a continued, cooperative and collaborative approach by stakeholders to inform role progression and continuing clinical practice expansion is paramount for continuing department improvements and better patient outcomes.

Poster Board Number: 73: Recent Trends and Financial Impact of Facial Injury Treatment by Oral and Maxillofacial Surgeons at a Metropolitan Trauma Center

Statement of the Problem: Emergency departments and hospital trauma centers are essential U.S. health care safety nets that generally face frightening financial shortcomings due to poor service reimbursement and overutilization.1,2 Oral and maxillofacial surgeons (OMFS) provide valuable manpower and technical skills for facial trauma patients presenting to both rural and metropolitan hospitals. An appreciation for the financial impact of maxillofacial trauma on hospitals is essential to respond to the recent economy and health reform dialogue. We analyzed the trends in reimbursement, payer distribution, and injury incidence for OMFS emergency patients at a regional trauma center to highlight relations between the evolving economy and patient, hospital, and provider resources.

Addressing scope of practice issues from an organisational perspective

Aim: This paper aims to explore the transition and role expansion of Emergency Nurse Practitioner (ENP) role in Emergency Departments (EDs). Given the infancy of this model of care in Victoria, the progression from project to sustainable and effective main stream care delivery in a metropolitan Emergency & Trauma Centre is of interest.

Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective

Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI. A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted. One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations. This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

The effect of compensation on health care utilisation in a trauma cohort

To determine whether there is an association between compensation factors and health care utilisation following major trauma. Retrospective cohort study within a major metropolitan trauma centre in New South Wales. Major trauma patients aged > or = 18 years, admitted between May 1999 and April 2004. Patients were included if they had an accidental injury and an Injury Severity Score > 15. In total, 355 of 582 potentially contactable patients returned completed questionnaires (response rate, 61%). Health care utilisation, defined as the number of times patients visited specified health care professionals (general practitioners, medical specialists, psychiatrists, physiotherapists, chiropractors and massage therapists) in the previous 3 months. For statistical analysis, health care utilisation was dichotomised into low and high (0-3 or > or = 4 health care visits over the previous 3 months). Health care utilisation was significantly higher for patients engaging the services of a lawyer (odds ratio, 3.3; 95% CI, 2.0-5.5; P < 0.001) after allowing for time since injury, chronic illness, presence of a head injury and employment status. Having a head injury and increased time since injury were significantly associated with lower health care utilisation, whereas being unemployed and having a chronic illness were associated with higher health care utilisation. Compensation-related factors are significant predictors of health care utilisation in a major trauma population.